Type 2 diabetes and risk of rupture of saccular intracranial aneurysm in eastern Finland

Prediction of small intracranial aneurysm rupture status based on combined Clinical-Radiomics model

Background

Accumulating small unruptured intracranial aneurysms are detected due to the improved quality and higher frequency of cranial imaging, but treatment remains controversial. While surgery or endovascular treatment is effective for small aneurysms with a high risk of rupture, such interventions are unnecessary for aneurysms with a low risk of rupture. Consequently, it is imperative to accurately identify small aneurysms with a low risk of rupture. The purpose of this study was to develop a clinically practical model to predict small aneurysm ruptures based on a radiomics signature and clinical risk factors.

Methods

A total of 293 patients having an aneurysm with a diameter of less than 5 mm, including 199 patients (67.9 %) with a ruptured aneurysm and 94 patients (32.1 %) without a ruptured aneurysm, were included in this study. Digital subtraction angiography or surgical treatment was required in all cases. Data on the clinical risk factors and the features on computed tomography angiography images associated with the aneurysm rupture status were collected simultaneously. We developed a clinical-radiomics model to predict aneurysm rupture status using multivariate logistic regression analysis. The combined clinical-radiomics model was constructed by nomogram analysis. The diagnostic performance, clinical utility, and model calibration were evaluated by operating characteristic curve analysis, decision curve analysis, and calibration analysis.

Results

A combined clinical-radiomics model (Area Under Curve [AUC], 0.85; 95 % confidence interval [CI], 0.757-0.947) showed effective performance in the operating characteristic curve analysis. In the validation cohort, the performance of the combined model was better than that of the radiomics model (AUC, 0.75; 95 % CI, 0.645-0.865; Delong's test p-value = 0.01) and the clinical model (AUC, 0.74; 95 % CI, 0.625-0.851; Delong's test p-value <0.01) alone. The results of the decision curve, nomogram, and calibration analyses demonstrated the clinical utility and good fitness of the combined model.

Conclusion

Our study demonstrated the effectiveness of a clinical-radiomics model for predicting rupture status in small aneurysms.

Associations Between Drug Treatments and the Risk of Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-analysis

There is increasing interest in drug therapy for preventing aneurysmal subarachnoid hemorrhage (aSAH). We aimed to comprehensively evaluate the association between drug use and the risk of aSAH. We searched PubMed and Scopus from the databases' inception until December 2021. Observational studies reporting the association between any drug therapy and aSAH were included. The odds ratios (ORs) for each drug used in aSAH were meta-analyzed with a random-effect model. According to the systematic review, 25 observational studies were eligible for the present study. Four therapeutic purpose-based classes (e.g., lipid-lowering agents) and 14 mechanism-based classes (e.g., statins) were meta-analyzed. Anti-hypertensive agents (OR, 0.50; 95% confidence interval [95% CI], 0.33-0.74), statins (OR, 0.55; 95% CI, 0.35-0.85), biguanides (OR, 0.57; 95% CI, 0.34-0.96), and acetylsalicylic acid (ASA) (OR, 0.62; 95% CI, 0.41-0.94) were inversely associated with the risk of aSAH. Non-ASA non-steroidal anti-inflammatory drugs (OR, 1.73; 95% CI, 1.07-2.79), selective cyclooxygenase-2 inhibitors (OR, 2.04; 95% CI, 1.24-3.35), vitamin K antagonists (OR, 1.50; 95% CI, 1.18-1.91), and dipyridamole (OR, 1.77; 95% CI, 1.23-2.54) were positively associated with the incidence of aSAH. There was also a trend toward a positive association between glucocorticoids (OR, 1.38; 95% CI, 0.97-1.94) and aSAH. The present study suggests that anti-hypertensive agents, statins, biguanides, and ASA are candidate drugs for preventing aSAH. By contrast, several drugs (e.g., anti-thrombotic drugs) may increase the risk of aSAH. Thus, the indications of these drugs in patients with intracranial aneurysms should be carefully determined.

Long-term Risk of Epilepsy in Subarachnoid Hemorrhage Survivors With Positive Family History: A Population-Based Follow-up Study

BACKGROUND AND OBJECTIVES

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating form of stroke affecting the working-age population, where epilepsy is a common complication and major prognostic factor for increased morbidity in aSAH survivors. The objective of this analysis was to assess whether epilepsy in first-degree relatives is a risk of developing epilepsy after aSAH.

METHODS

We used a region-specific database that includes all cases of unruptured and ruptured saccular intracranial aneurysm admitted to Kuopio University Hospital from its defined Eastern Finnish catchment population. We also retrieved data from Finnish national health registries for prescription drug purchases and reimbursement, hospital discharge, and cause of death and linked them to patients with aSAH, their first-degree relatives, and population controls matched 3:1 by age, sex, and birth municipality. Cox regression modeling and Kaplan-Meier survival curves were used for analysis.

RESULTS

We examined data for 760 consecutive 12-month survivors of aSAH, born in 1950 or after, with a first aSAH from January 1, 1995, to December 31, 2018. Of the 760 patients (median age, 47 years; 53% female; median follow-up, 11 years), 111 (15%) developed epilepsy at a median of 7 months (interquartile range, 2-14 months) after admission for aSAH. Of the 2,240 population controls and 4,653 first-degree relatives of patients with aSAH, 23 (0.9%) and 80 (1.7%), respectively, developed epilepsy during the follow-up period. Among 79 patients with epilepsy in first-degree relatives, 22 (28%) developed epilepsy after aSAH; by contrast, among 683 patients with no epilepsy in first-degree relatives, 89 (13%) developed epilepsy after aSAH. Having at least 1 relative with epilepsy was an independent risk factor of epilepsy after aSAH (hazard ratio, 2.44; 95% CI 1.51-3.95). Cumulative 1-year rates by first-degree relationship were 40% with 1 or more children with epilepsy, 38% with 1 or more affected parents, 5% with 1 or more affected siblings, and 10% with no relatives with epilepsy.

DISCUSSION

Patients who developed epilepsy after aSAH were significantly more likely to have first-degree relatives with epilepsy than those who did not develop epilepsy after the aSAH.

Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving Sulfonylureas: A Propensity-Adjusted Analysis

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased blood-brain barrier permeability, disrupted tight junctions, and increased cerebral edema. Sulfonylureas are associated with reduced tight-junction disturbance and edema and improved functional outcome in aSAH animal models, but human data are scant. We analyzed neurological outcomes in aSAH patients prescribed sulfonylureas for diabetes mellitus.

METHODS

Patients treated for aSAH at a single institution (August 1, 2007-July 31, 2019) were retrospectively reviewed. Patients with diabetes were grouped by presence or absence of sulfonylurea therapy at hospital admission. The primary outcome was favorable neurologic status at last follow-up (modified Rankin Scale score ≤2). Variables with an unadjusted P-value of <0.20 were included in a propensity-adjusted multivariable logistic regression analysis to identify predictors of favorable outcomes.

RESULTS

Of 1013 aSAH patients analyzed, 129 (13%) had diabetes at admission, and 16 of these (12%) were receiving sulfonylureas. Fewer diabetic than nondiabetic patients had favorable outcomes (40% [52/129] vs. 51% [453/884], P = 0.03). Among diabetic patients, sulfonylurea use (OR 3.90, 95% CI 1.05-15.9, P = 0.046), Charlson Comorbidity Index <4 (OR 3.66, 95% CI 1.24-12.1, P = 0.02), and absence of delayed cerebral infarction (OR 4.09, 95% CI 1.20-15.5, P = 0.03) were associated with favorable outcomes in the multivariable analysis.

CONCLUSIONS

Diabetes was strongly associated with unfavorable neurologic outcomes. An unfavorable outcome in this cohort was mitigated by sulfonylureas, supporting some preclinical evidence of a possible neuroprotective role for these medications in aSAH. These results warrant further study on dose, timing, and duration of administration in humans.

Effect of Comorbidities on the Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Study

Background The pathophysiological changes following aneurysmal subarachnoid hemorrhage (aSAH) lead to a varied degree of neurological deficit and cognitive decline. The presence of comorbidities can contribute to the progression and course of the disease resulting in high morbidity and mortality.

Methods A total of 140 patients with aSAH, scheduled for surgical clipping or endovascular coiling were included. The patients' comorbidities were recorded. The postoperative outcome was evaluated using Glasgow Outcome Scale at 1 month following discharge. Multiple logistic regression analysis was performed to identify variables predicting poor outcome, taking into consideration those variables which were significant in univariate analysis.

Results Sixty-six percent of these patients with aSAH had associated comorbidities. In our patient cohort, we found that smoking and hypertension were associated with worse outcome (odds ratio [OR] = 4.63 [confidence interval [CI] = 1.83–11.7] and OR = 2.92 [CI = 1.41–6.01], respectively). Hypothyroidism, diabetes mellitus, coronary artery disease, and asthma did not influence the neurological outcome because of their small number.

Conclusion Presence of comorbidities like smoking and hypertension significantly worsen the outcome of these patients with aSAH.

Effect of Renin-Angiotensin-Aldosterone System Inhibitors on the Rupture Risk Among Hypertensive Patients With Intracranial Aneurysms

BACKGROUND

Mounting experimental evidence supports the concept that the RAAS (renin-angiotensin-aldosterone system) is involved in the pathogenesis of intracranial aneurysm rupture. However, whether RAAS inhibitors could reduce the rupture risk of intracranial aneurysms remains unclear.

METHODS

We performed a chart review of a multicenter, prospectively maintained database of 3044 hypertensive patients with intracranial aneurysms from 20 medical centers in China. The patients were separated into ruptured and unruptured groups. Univariable and multivariable logistical regression analyses were performed to determine the association between the use of RAAS inhibitors and the rupture risk. Sensitivity analyses and subgroup analyses were performed to verify the robustness of the results.

RESULTS

In multivariable analyses, female sex, passive smoking, uncontrolled, or unmonitored hypertension, use of over 2 antihypertensive medications, RAAS inhibitors use, antihyperglycemic agents use, hyperlipidemia, ischemic stroke, and aneurysmal location were independently associated with the rupture risk. The use of RAAS inhibitors was significantly associated with a reduced rupture risk compared with the use of non-RAAS inhibitors (odds ratio, 0.490 [95% CI, 0.402-0.597]; P=0.000). Compared with the use of non-RAAS inhibitors, the use of ACE (angiotensin-converting enzyme) inhibitors (odds ratio, 0.559 [95% CI, 0.442-0.709]; P=0.000) and use of ARBs (angiotensin receptor blockers; odds ratio, 0.414 [95% CI, 0.315-0.542]; P=0.000) were both significantly associated with a reduced rupture risk. The negative association of the rupture risk with RAAS inhibitors was consistent across 3 analyzed data and the predefined subgroups (including controlled hypertension).

CONCLUSIONS

The use of RAAS inhibitors was significantly associated with a decreased rupture risk independent of blood pressure control among hypertensive patients with intracranial aneurysms.

Numerical Assessment of the Risk of Abnormal Endothelialization for Diverter Devices: Clinical Data Driven Numerical Study

Numerical modeling is an effective tool for preoperative planning. The present work is devoted to a retrospective analysis of neurosurgical treatments for the occlusion of cerebral aneurysms using flow-diverters and hemodynamic factors affecting stent endothelization. Several different geometric approaches have been considered for virtual flow-diverters deployment. A comparative analysis of hemodynamic parameters as a result of computational modeling has been carried out basing on the four clinical cases: one successful treatment, one with no occlusion and two with in stent stenosis. For the first time, a quantitative assessment of both: the limiting magnitude of shear stresses that are necessary for the occurrence of in stent stenosis (MaxWSS > 1.23) and for conditions in which endothelialization is insufficiently active and occlusion of the cervical part of the aneurysm does not occur (MaxWSS < 1.68)—has been statistacally proven (p < 0.01).

Nonlinear Association of Glycosylated Hemoglobin With Single Intracranial Aneurysm Rupture in Patients With Diabetes Mellitus: A Cross-Sectional Study

Background

The published literature linking diabetes mellitus (DM) to intracranial aneurysm (IA) ruptured has been controversial and limited by methodology. Thus, this study was performed to examine whether hyperglycemia control status is independently associated with single IA rupture in patients with DM.

Methods

We conducted a cross-sectional study on two Chinese hospitals between January 2010 and November 2017. Medical records of 223 patients with single IA and DM were reviewed and analyzed. We used glycosylated hemoglobin (GHB) as the independent variable of interest, and the outcome variable was ruptured status of IA. Covariates included data on demographics, morphological parameters, lifestyle habits, clinical features, and comorbidities.

Results

Multivariable adjusted binary logistic regression and sensitivity analyses indicated that GHB was not associated with IA rupture (odds ratio OR, = 1.07, 95% CI 0.84-1.35). A nonlinear association between GHB and IA rupture was observed, whose inflection points were 5.5 and 8.9. The OR values (95% confidence intervals) were 0.38 (0.16-0.9) at the range of 1.88-5.5% of GHB, 1.6 (1.03, 2.5) at the range of 5.5-8.9%, and 0.56 (0.06-5.34) at the range of 8.9-10.1, respectively.

Conclusion

The independent correlation between GHB and risk of IA rupture presented is nonlinear. The good glycemic control in single IA patients with DM can reduce the risk of IA rupture, and vice versa.

Development and External Validation of a Dynamic Nomogram With Potential for Risk Assessment of Ruptured Multiple Intracranial Aneurysms

Background and Purpose

About 20.1% of intracranial aneurysms (IAs) carriers are multiple intracranial aneurysms (MIAs) patients with higher rupture risk and worse prognosis. A prediction model may bring some potential benefits. This study attempted to develop and externally validate a dynamic nomogram to assess the rupture risk of each IA among patients with MIA.

Method

We retrospectively analyzed the data of 262 patients with 611 IAs admitted to the Hunan Provincial People's Hospital between November 2015 and November 2021. Multivariable logistic regression (MLR) was applied to select the risk factors and derive a nomogram model for the assessment of IA rupture risk in MIA patients. To externally validate the nomogram, data of 35 patients with 78 IAs were collected from another independent center between December 2009 and May 2021. The performance of the nomogram was assessed in terms of discrimination, calibration, and clinical utility.

Result

Size, location, irregular shape, diabetes history, and neck width were independently associated with IA rupture. The nomogram showed a good discriminative ability for ruptured and unruptured IAs in the derivation cohort (AUC = 0.81; 95% CI, 0.774–0.847) and was successfully generalized in the external validation cohort (AUC = 0.744; 95% CI, 0.627–0.862). The nomogram was calibrated well, and the decision curve analysis showed that it would generate more net benefit in identifying IA rupture than the “treat all” or “treat none” strategies at the threshold probabilities ranging from 10 to 60% both in the derivation and external validation set. The web-based dynamic nomogram calculator was accessible on https://wfs666.shinyapps.io/onlinecalculator/.

Conclusion

External validation has shown that the model was the potential to assist clinical identification of dangerous aneurysms after longitudinal data evaluation. Size, neck width, and location are the primary risk factors for ruptured IAs.

Modifiable risk factors for intracranial aneurysms: Evidence from genetic studies

Background:

Intracranial aneurysm (IA) is a crucial health concern with limited strategies for prevention and treatment.

Aim:

To identify potentially modifiable risk factors, such as socioeconomic, behaviors, dietary, and cardiometabolic factors, for IA and its subtypes.

Methods:

Summary statistics for IA were derived from a genome-wide association study with an overall 79,429 participants. Single nucleotide polymorphisms associated with modifiable risk factors at genome-wide significance ( P = 5 × 10–8) were used as instrumental variables. The inverse-variance-weighted method, weighted-median method, Mendelian randomization (MR)-Egger regression, MR-Pleiotropy RESidual Sum and Outlier, and multivariable MR analyses were performed to evaluate the effect estimates.

Results:

Genetically predicted educational attainment, insomnia, smoking, and systolic and diastolic blood pressure (SBP and DBP) were significantly associated with the risk of IA. The odds ratios (ORs) were 0.44 (95% confidence interval (CI): 0.37–0.52) for educational attainment, 1.15 (95% CI: 1.08–1.23) for insomnia, 1.56 (95% CI: 1.38–1.75) for smoking initiation, 2.69 (95% CI: 1.77–4.07) for cigarette per day, 2.65 (95% CI: 1.72–4.08) for lifetime smoking, 1.07 (95% CI: 1.06–1.09), and 1.06 (95% CI: 1.04–1.10) for SBP and DBP, respectively. Similar effect estimates were observed for unruptured IAs and aneurysmal subarachnoid hemorrhage.

Conclusions:

This study provided genetic evidence that several modifiable risk factors, including blood pressure, smoking, educational attainment, and insomnia were associated with the risk of IA.

Shunt performance in 349 patients with hydrocephalus after aneurysmal subarachnoid hemorrhage

Background

Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequelae leading to poorer neurological outcomes and predisposing to various complications.

Methods

A total of 2191 consecutive patients with aSAH were acutely admitted to the Neurointensive Care at the Kuopio University Hospital between 1990 and 2018 from a defined population. A total of 349 (16%) aSAH patients received a ventriculoperitoneal shunt, 101 with an adjustable valve (2012–2018), 232 with a fixed pressure valve (1990–2011), and 16 a valveless shunt (2010–2013). Clinical timelines were reconstructed from the hospital records and nationwide registries until death (n = 120) or June 2019.

Results

Comparing the adjustable valves vs. the fixed pressure valves vs. the valveless shunts, intraventricular hemorrhage was present in 61%, 44% and 100%, respectively. The median times to the shunt were 7 days vs. 38 days vs. 10 days. The rates of the first revision were 25% vs. 32% vs. 69%. The causes included infection in 11% vs. 7% vs. 25% and overdrainage in 1% vs. 4% vs. 31%. The valveless shunt was the only independent risk factor (HR 2.9) for revision. After the first revision, more revisions were required in 48% vs. 52% vs. 45%.

Conclusions

The protocol to shunt evolved over time to favor earlier shunt. In post-aSAH hydrocephalus, adjustable valve shunts, without anti-siphon device, can be installed at an early phase after aSAH, in spite of intraventricular blood, with a modest risk (25%) of revision. Valveless shunts are not recommendable due to high risk of revisions.

Association Between Body Mass Index and Intracranial Aneurysm Rupture: A Multicenter Retrospective Study

Background and Aims: It has recently emerged the concept of “obesity paradox,” a term used to describe an inverse association between obesity and clinical outcomes in cardiovascular diseases and stroke. The purpose of this study was to investigate the association between body mass index (BMI) and the risk of intracranial aneurysm rupture.

Methods: In this study, we conducted a retrospective analysis of a prospectively maintained database of patients with intracranial aneurysms from 21 medical centers in China. A total of 3,965 patients with 4,632 saccular intracranial aneurysms were enrolled. Patients were separated into unruptured (n = 1,977) and ruptured groups (n = 1,988). Univariable and multivariable logistic regression analyses were performed to determine the association between BMI and intracranial aneurysm rupture.

Results: Compared to the patients with normal BMI (18.5 to < 24.0 kg/m²), the odds of intracranial aneurysm rupture were significantly lower in patients with BMI 24.0 to < 28.0 kg/m² (OR = 0.745, 95% CI = 0.638–0.868, P = 0.000) and patients with BMI ≥ 28.0 kg/m² (OR = 0.628, 95% CI = 0.443–0.890, P = 0.009). Low BMI (<18.0 kg/m²) was not associated with intracranial aneurysm rupture (OR = 0.894, 95% CI = 0.483–1.657, P = 0.505). For males, both the BMI 24.0 to < 28.0 kg/m² (OR = 0.606, 95% CI = 0.469–0.784, P = 0.000) and the BMI ≥ 28.0 kg/m² (OR = 0.384, 95% CI = 0.224–0.658, P = 0.001) were associated with a lower rupture risk, whereas the inverse association was not observed in females. Both the BMI 24.0 to < 28.0 kg/m² (OR = 0.722 for aged 50–60y, 95% CI = 0.554–0.938, P = 0.015; OR = 0.737 for aged >60y, 95% CI = 0.586–0.928, P = 0.009) and the BMI ≥ 28.0 kg/m² (OR = 0.517 for aged 50–60y, 95% CI = 0.281–0.950, P = 0.0034; OR = 0.535 for aged >60y, 95% CI = 0.318–0.899, P = 0.0018) was associated with a lower rupture risk in patients aged ≥50 years, whereas the association was not significant in patients aged <50 years.

Conclusions: Increased BMI is significantly and inversely associated with saccular intracranial aneurysm rupture in males and patients aged ≥50 years.

Development and validation of an institutional nomogram for aiding aneurysm rupture risk stratification

Rupture risk stratification is critical for incidentally detected intracranial aneurysms. Here we developed and validated an institutional nomogram to solve this issue. We reviewed the imaging and clinical databases for aneurysms from January 2015 to September 2018. Aneurysms were reconstructed and morphological features were extracted by the Pyradiomics in python. Multiple logistic regression was performed to develop the nomogram. The consistency of the nomogram predicted rupture risks and PHASES scores was assessed. The performance of the nomogram was evaluated by the discrimination, calibration, and decision curve analysis (DCA). 719 aneurysms were enrolled in this study. For each aneurysm, twelve morphological and nine clinical features were obtained. After logistic regression, seven features were enrolled in the nomogram, which were SurfaceVolumeRatio, Flatness, Age, Hyperlipemia, Smoker, Multiple aneurysms, and Location of the aneurysm. The nomogram had a positive and close correlation with PHASES score in predicting aneurysm rupture risks. AUCs of the nomogram in discriminating aneurysm rupture status was 0.837 in a separate testing set. The calibration curves fitted well and DCA demonstrated positive net benefits of the nomogram in guiding clinical decisions. In conclusion, Pyradiomics derived morphological features based institutional nomogram was useful for aneurysm rupture risk stratification.

Relationship between peroxisome proliferator-activated receptor-γ mRNA expression and intracranial aneurysm rupture

It has been reported that the normal adults can suffer from an intracranial aneurysm (IA) that might present the risk of rupture and cause the subarachnoid hemorrhage. Peroxisome proliferator-activated receptor-γ (PPAR-γ) as a nuclear hormone receptor has been identified to involve in the progress of the formation and rupture of IAs. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used to detect PPAR-γmRNA expression in the macrophages of the patients with IAs. The information including fasting blood glucose (FBG), interleukin-6 (IL-6), and systolic blood pressure (SBP) were collected. The aneurysm parameters of all the participants were obtained through the cerebral angiography. Establishing the receiver-operating characteristic curve (ROC curve) evaluated the clinical significances of PPAR-γmRNA for IAs rupture. In this study, we observed that the rupture of IAs was caused by the maximum height of aneurysm ⩾7 mm, the location of aneurysm in posterior communicating artery (PCOM) or anterior communicating artery (ACOM), and the increase of aneurysm size ratio (SR). The levels of SBP and IL-6 in the rupture group were higher than those in the unrupture group, and PPAR-γmRNA expression in the rupture group was also significantly reduced. In addition, heavy drinking was statistically significant between the ruptured and unruptured groups. There was no significant difference in serum FBG level between the two groups. The evidences of this study showed that PPAR-γmRNA was negatively correlated with SBP, SR, and IL-6 levels in rupture group, respectively. The AUC of PPAR-γmRNA in ROC curve was 0.867, indicating that the change of PPAR-γmRNA level had obvious effect on IAs rupture. The aim of this study was to evaluate the potential of PPAR-γ in macrophages to prevent IAs rupture.

Clinical condition of 120 patients alive at 3 years after poor-grade aneurysmal subarachnoid hemorrhage

Background

To study the clinical condition of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients alive at 3 years after neurointensive care.

Methods

Of the 769 consecutive aSAH patients from a defined population (2005–2015), 269 (35%) were in poor condition on admission: 145 (54%) with H&H 4 and 124 (46%) with H&H 5. Their clinical lifelines were re-constructed from the Kuopio Intracranial Aneurysm Database and Finnish nationwide registries. Of the 269 patients, 155 (58%) were alive at 14 days, 125 (46%) at 12 months, and 120 (45%) at 3 years.

Results

The 120 H&H 4–5 patients alive at 3 years form the final study population. On admission, 73% had H&H 4 but only 27% H&H 5, 59% intracerebral hematoma (ICH; median 22 cm³), and 26% intraventricular blood clot (IVH). The outcome was favorable (mRS 0–1) in 45% (54 patients: ICH 44%; IVH clot 31%; shunt 46%), moderate (mRS 2–3) in 30% (36 patients: ICH 64%; IVH clot 19%; shunt 42%), and unfavorable (mRS 4–5) in 25% (30 patients: ICH 80%; IVH clot 23%; shunt 50%). A total of 46% carried a ventriculoperitoneal shunt. ICH volume was a significant predictor of mRS at 3 years.

Conclusions

Of poor-grade aSAH patients, 45% were alive at 3 years, even 27% of those extending to pain (H&H 5). Of the survivors, 75% were at least in moderate condition, while only 2.6% ended in hospice care. Consequently, we propose non-selected admission to neurointensive care (1) for a possibility of moderate outcome, and (2), in case of brain death, possibly improved organ donation rates.

Lower risk of subarachnoid haemorrhage in diabetes: a nationwide population-based cohort study

Background and purpose

Diabetes mellitus (DM) is a common metabolic disorder with increased risk of cardiovascular and cerebrovascular complications. However, its relationship with risk of subarachnoid haemorrhage (SAH), the most devastating form of stroke, remains controversial.

Methods

To evaluate the relationship between DM and risk of SAH, we performed a retrospective cohort study using a nationwide, population‐based, health screening database in Korea. We included participants without history of stroke who underwent a nationwide health screening programme between 2003 and 2004. Primary outcome was occurrence of SAH. Participants were followed up until development of SAH or December 2015. Multivariate Cox proportional hazards regression analysis was performed with adjustments for age, sex, systolic blood pressure, total cholesterol, body mass index, physical activity, smoking status, alcohol habit, household income and treatment with antihypertensive agents and statins.

Results

Among 421 768 study participants, prevalence of DM was 9.6%. During a mean follow-up period of 11.6±1.9 years, 1039 patients developed SAH. Presence of DM was significantly associated with decreased risk of SAH (adjusted HR 0.68; 95% CI 0.53 to 0.86; p<0.001). Elevated level of fasting blood glucose was also negatively associated with risk of SAH (adjusted HR per 1 mmol/L increase 0.90; 95% CI 0.86 to 0.95; p<0.001).

Conclusion

DM and elevated level of fasting blood glucose were inversely associated with risk of SAH. Further studies may elucidate the possibly protective, pathophysiological role played by hyperglycaemia in patients at risk of SAH.

Intracranial aneurysm's association with genetic variants, transcription abnormality, and methylation changes in ADAMTS genes

Purpose

The development of intracranial aneurysm (IA) has been linked to genetic factors. The current study examines the potential role of genes encoding disintegrin and metalloproteinase using thrombospondin motifs (ADAMTS) in IA development.

Material and Methods

High-throughput whole-genome and whole-exome sequencing were used when screening for deleterious single-nucleotide variants (SNVs) in ADAMTS genes using samples from 20 Han Chinese patients: 19 with familial IA and one patient with sporadic IA. The variant frequencies in these subjects were compared to those in control individuals found in the Genome Aggregation Database. Transcriptome sequencing and methylation sequencing data were retrieved from the Gene Expression Omnibus (GEO) database to identify differentially expressed ADAMTS genes and their methylation sites. We predicted the network of interactions among proteins encoded by the overlapping set of ADAMTS genes showing deleterious variants and both differential expression and abnormal methylation in IA. Possible candidate proteins linked to IA were validated using Western blot analysis. The associations between IA and SNVs rs11750568 in ADAMTS2, as well as rs2301612 and rs2285489 in ADAMTS13, were verified using the Sequenom MassArray system on a separate sample set of 595 Han Chinese patients with sporadic IA and 600 control individuals.

Results

A total of 16 deleterious variants in 13 ADAMTS genes were identified in our patients, and seven of these genes overlapped with the genes found to be differentially expressed and differentially methylated in the GEO database. Protein–protein interaction analysis predicted that ADAMTSL1 was at the center of the seven genes. ADAMTSL1 protein was lower expressed in IA tissue than in the control cerebral artery. Frequencies of the IA-related SNVs rs11750568 in ADAMTS2 and rs2301612 and rs2285489 in ADAMTS13 were not significantly different between sporadic IA patients and controls.

Conclusion

IA is associated with genetic variants, differential expression, and abnormal methylation in ADAMTS genes, ADAMTSL1 in particular.

Bifurcation Configuration Is an Independent Risk Factor for Aneurysm Rupture Irrespective of Location

Background: Bifurcation and sidewall aneurysms have different rupture risks, but whether this difference comes from the location of the aneurysm is not clear. The objective of this study is to illustrate the rationality of ranking bifurcation configuration as an independent risk factor for aneurysm rupture.

Methods: Morphological features of 719 aneurysms (216 ruptured) were automatically extracted from a consecutive cohort of patients via PyRadiomics. Rupture risks and morphological features were compared between bifurcation and sidewall aneurysms, and lasso regression was applied to explore the morphological determinants for rupture in bifurcation and sidewall aneurysms. Rupture risks and morphological features of bifurcation aneurysms in different locations were analyzed. Multivariate regression was performed to explore the risk factors for aneurysm rupture.

Results: Twelve morphological features were automatically extracted from PyRadiomics implemented in Python. The rupture risks were higher in bifurcation aneurysms (P < 0.01), and morphological features Elongation and Flatness were much lower in ruptured bifurcation than sidewall aneurysms (P = 0.036, 0.011, respectively). Elongation and Flatness were the morphological determinants for rupture in bifurcation aneurysms, whereas Elongation and SphericalDisproportion were determinants for sidewall aneurysms. Different rupture risks and morphological features were found between sidewall and bifurcation aneurysms of the same location, and among bifurcation aneurysms of different locations. In multivariate regression, bifurcation configuration was an independent risk factor for aneurysm rupture (OR 3.007, 95% CI 1.752–5.248, P < 0.001).

Conclusions: Sidewall and bifurcation aneurysms and bifurcation aneurysms of different locations have different rupture risks and morphological features. Bifurcation configuration is an independent risk factor for aneurysm rupture irrespective of location.

Prediction of Aneurysm Stability Using a Machine Learning Model Based on PyRadiomics-Derived Morphological Features

Background and Purpose- Discrimination of the stability of intracranial aneurysms is critical for determining the treatment strategy, especially in small aneurysms. This study aims to evaluate the feasibility of applying machine learning for predicting aneurysm stability with radiomics-derived morphological features. Methods- Morphological features of 719 aneurysms were extracted from PyRadiomics, of which 420 aneurysms with Maximum3DDiameter ranging from 4 mm to 8 mm were enrolled for analysis. The stability of these aneurysms and other clinical characteristics were reviewed from the medical records. Based on the morphologies with/without clinical features, machine learning models were constructed and compared to define the morphological determinants and screen the optimal model for predicting aneurysm stability. The effect of clinical characteristics on the morphology of unstable aneurysms was analyzed. Results- Twelve morphological features were automatically extracted from PyRadiomics implemented in Python for each aneurysm. Lasso regression defined Flatness as the most important morphological feature to predict aneurysm stability, followed by SphericalDisproportion, Maximum2DDiameterSlice, and SurfaceArea. SurfaceArea (odds ratio [OR], 0.697; 95% CI, 0.476-0.998), SphericalDisproportion (OR, 1.730; 95% CI, 1.143-2.658), Flatness (OR, 0.584; 95% CI, 0.374-0.894), Hyperlipemia (OR, 2.410; 95% CI, 1.029-5.721), Multiplicity (OR, 0.182; 95% CI, 0.082-0.380), Location at middle cerebral artery (OR, 0.359; 95% CI, 0.134-0.902), and internal carotid artery (OR, 0.087; 95% CI, 0.030-0.211) were enrolled into the final prediction model. In terms of performance, the area under curve of the model reached 0.853 (95% CI, 0.767-0.940). For unstable aneurysms, Compactness1 (P=0.035), Compactness2 (P=0.036), Sphericity (P=0.035), and Flatness (P=0.010) were low, whereas SphericalDisproportion (P=0.034) was higher in patients with hypertension. Conclusions- Morphological features extracted from PyRadiomics can be used for aneurysm stratification. Flatness is the most important morphological determinant to predict aneurysm stability. Our model can be used to predict aneurysm stability. Unstable aneurysm is more irregular in patients with hypertension.

Antipsychotic Use Among 1144 Patients After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

At acute phase and neurointensive care, patients with aneurysmal subarachnoid hemorrhage (aSAH) may become agitated or delirious. We found no previous studies on psychotic disorders or antipsychotic drug (APD) use by long-term aSAH survivors. We defined the APD use and its risk factors among 12-month survivors of aSAH in an Eastern Finnish population–based cohort with long-term follow-up.

Methods—

We analyzed APD use in 1144 consecutive patients with aSAH alive at 12 months of the Kuopio intracranial aneurysm patient and family database and their age, sex, and birth municipality matched controls (3:1; n=3432) from 1995 to 2013 and median follow-up of 9 years. Using the Finish nationwide health registries, we obtained drug purchase and hospital discharge data.

Results—

In total, 140 (12%) of the 1144 patients started APD use first time after aSAH (index date), in contrast to 145 (4%) of the 3432 matched population controls. The cumulative rate of starting APD was 6% at 1 year and 9% at 5 years, in contrast to 1% and 2% in the controls, respectively. The rates at 1 and 5 years were only 1% and 2% in the 489 patients with a good condition (modified Rankin Scale score, 0 or 1 at 12 months; no shunt, intracerebral hemorrhage, or intraventricular hemorrhage). Instead, the highest rate of APD use, 23% at 5 years was among the 192 patients shunted for hydrocephalus after aSAH. Eighty-eight (63%) of the 140 aSAH patients with APD use had also concomitant antidepressant or antiepileptic drug use.

Conclusions—

The 12-month survivors of aSAH were significantly more likely to be started on APD after aSAH than their matched population controls. These patients often used antidepressant and antiepileptic drugs concomitantly. The use of APDs strongly correlated with signs of brain injury after aSAH, with low use if no signs of significant brain injury were present.

Characteristics of Intracranial Aneurysms According to Levels of Coronary Artery Calcium

Background and Purpose- Several vascular risk factors are known to be associated with the occurrence of intracranial aneurysms (IAs). Coronary artery calcium (CAC), which reflects the atherosclerotic burden of the coronary arteries, is a known predictor of cardiovascular events and stroke. We investigated the relationship between IA and CAC. Methods- We retrospectively enrolled Korean subjects at a single university hospital who had both brain magnetic resonance angiography and cardiac computed tomography as part of health examinations from January 2010 to July 2017. Subjects were categorized into 4 groups according to CAC score as assessed by cardiac computed tomography: zero (0), low (1-99), intermediate (100-399), or high (≥400). Then, the prevalence of IA in each CAC score group was assessed. We also performed subgroup analysis by age, sex, and location of IA. Results- A total of 4934 subjects (mean age, 54.1±9.8 years; %women, 42.2%) were included for analysis. IAs were detected in 258 subjects (5.23%). The prevalence of IA significantly increased as the CAC score increased (4.8%, 5.4%, 6.4%, and 11.1%, respectively; P for trend, 0.004). In subjects over the age of 50 years, this correlation was more prominent in women than in men (7.1% versus 3.7%, 8.8% versus 4.4%, 8.6% versus 6.3%, and 21.1% versus 10.0%, respectively). Subgroup analysis for the aneurysm location showed that nonbifurcation aneurysm was associated with a high CAC score but bifurcation aneurysm was not. Multivariate logistic regression showed high CAC score was an independent risk factor for the presence of IA compared with zero CAC score (adjusted odds ratio, 2.16; 95% CI, 1.18-3.95). Conclusions- A high CAC score was associated with the presence of IA. This relationship was more prominent in females and nonbifurcation aneurysms.

Secondary hypertension in patients with saccular intracranial aneurysm disease: A population based study

Background

Secondary hypertension is a serious form of hypertension, involving 5% to 10% of all hypertension patients. Hypertension is a risk factor of the saccular intracranial aneurysm (sIA) disease and subarachnoid hemorrhage from ruptured sIA (aSAH), but the impact of secondary hypertension on sIA disease is poorly known. In a defined Eastern Finnish sIA population we studied the prevalence of secondary hypertension and its impact on sIA disease phenotype.

Methods

We included 2704 consecutive sIA patients first admitted to Kuopio University Hospital from 1995 to 2014. Their clinical data from Kuopio Intracranial Aneurysm patient and Family Database was fused with prescription drug usage data, hospital diagnoses and causes of death, retrieved from nationwide registries. Medical records of hypertensive sIA patients were reviewed to confirm or exclude secondary hypertension. Prevalence of secondary hypertension and associated diagnoses were calculated. Logistic regression was used to identify clinical characteristics of sIA disease that associated with secondary hypertension.

Results

We identified 2029 (75%) sIA patients with hypertension and 208 (10%) of them had secondary hypertension. Most frequent conditions associated with secondary hypertension were kidney and renovascular diseases (45%), sleep apnea (27%) and hypothyroidism (19%); 46 (22%) of the 208 patients had more than one such condition. In multivariate logistic regression analyses of 1561 aSAH patients, secondary hypertension significantly associated with the number of sIAs (p = 0.003; OR 1.32; 95% CI 1.10–1.58) and male gender (p = 0.034; OR 1.59; 95% CI 1.04–2.43).

Conclusions

Secodary hypertension was relatively common (10%) among hypertensive sIA patients. Secondary causes for hypertension should be taken into account in hypertensive sIA patients, especially in aSAH patients with multiple intracranial aneurysms. Further research is indicated to evaluate the impact of secondary hypertension on the long-term rupture risk of unruptured sIA carriers and long-term outcome after aSAH.

Aneurysm Size is the Strongest Risk Factor for Intracranial Aneurysm Growth in the Eastern Finnish Population

BACKGROUND

Saccular intracranial aneurysm (sIA) growth during follow-up is associated with high risk for subsequent rupture. Finnish patients have been suggested to have higher risk for subarachnoid hemorrhage, but follow-up studies of sIA growth in the Finnish population are scarce.

OBJECTIVE

To identify the strongest risk factors for sIA growth in Eastern Finnish population by studying 205 patients with 350 unruptured sIAs with angiographic follow-up imaging.

METHODS

In this population-based cohort study, we included unruptured sIA patients from the Kuopio University Hospital Intracranial Aneurysm Patient and Family database with at least 6 mo of angiographic follow-up after the diagnosis of sIAs. Angiograms were re-evaluated to detect aneurysms with growth of at least 1.0 mm. Cox regression analysis with patient- and aneurysm-related risk factors was used to calculate hazard ratios with 95% confidence intervals for growth. In addition, we tested the diagnostic value of previously introduced PHASES score for the prediction of sIA growth in Eastern Finnish population.

RESULTS

Of the 350 unruptured aneurysms, 36 (10.3%) showed growth during median follow-up of 1.7 yr and total follow-up of 790 yr. In the multivariate Cox regression analysis, sIA size and location in the middle cerebral artery were significant risk factors for sIA growth. In receiver operator characteristic curves, both PHASES score and sIA size had relatively low areas under the curve.

CONCLUSION

Our study indicates that aneurysm size is the strongest risk factor for aneurysm growth in Eastern Finnish population. Further studies are required to identify new risk factors for aneurysm growth.

Adverse lipid profile elevates risk for subarachnoid hemorrhage: A prospective population-based cohort study

BACKGROUND AND AIMS

Studies report that both high and low total cholesterol (TC) elevates SAH risk. There are few prospective studies on high-density lipoproteins (HDL-C) and low-density lipoproteins (LDL-C), and apparently none concerns apolipoproteins A and B. We aimed to clarify the association between lipid profile and SAH risk.

METHODS

The National FINRISK study provided risk-factor data recorded at enrolment between 1972 and 2007. During 1.52 million person-years of follow-up until 2014, 543 individuals suffered from incident hospitalized SAH or outside-hospital-fatal SAH. Cox proportional hazards model was used to calculate the hazard ratios and multiple imputation predicted ApoA1, ApoB, and LDL-C values for cohorts from a time before apolipoprotein-measurement methods were available.

RESULTS

One SD elevation (1.28 mmol/l) in TC elevated SAH risk in men (hazard ratio (HR) 1.15 (95% CIs 1.00-1.32)). Low HDL-C levels increased SAH risk, as each SD decrease (0.37 mmol/l) in HDL-C raised the risk in women (HR 1.29 (95% CIs 1.07-1.55)) and men (HR 1.20 (95% CIs 1.14-1.27)). Each SD increase (0.29 g/l) in ApoA1 decreased SAH risk in women (HR 0.85 (95% CIs 0.74-0.97)) and men (HR 0.88 (95% CIs 0.76-1.02)). LDL-C (SD 1.07 mmol/l) and ApoB (SD 0.28 g/l) elevated SAH risk in men with HR 1.15 (95% CIs 1.01-1.31) and HR 1.26 (95% CIs 1.10-1.44) per one SD increase. Age did not change these findings.

CONCLUSIONS

An adverse lipid profile seems to elevate SAH risk similar to its effect in other cardiovascular diseases, especially in men. Whether SAH incidence diminishes with increasing statin use remains to be studied.

Management of Small Incidental Intracranial Aneurysms

Advances in neuroimaging and its widespread use for screening have increased the diagnosis of unruptured intracranial aneurysms (UIAs), including small-sized UIAs. The clinical management of these small-sized UIAs requires a patient-specific judgment of the risk of aneurysm rupture, if not treated, versus the risk of complications from surgical or endovascular treatment. Experienced cerebrovascular teams recommend treating small UIAs in young patients or in patients with more than one aneurysm rupture risk factor who also have a reasonable life expectancy. However, individual overall assessment of risk is critical for patients with UIAs to decide the next steps of care.

Risk factors analysis of mirror aneurysms: A multi-center retrospective study based on clinical and demographic profile of patients

As a special subgroup of multiple intracranial aneurysms, mirror aneurysms are located bilaterally on the corresponding intracranial arteries. The current study sought to compare the clinical and demographic features of patients harboring mirror aneurysm, and to elucidate the corresponding risk factors. We performed a retrospective cohort study of 2641 intracranial aneurysms patients, who were admitted to our hospitals between January 2005 and June 2014. Patients were subdivided into three groups based on the inclusion criteria: (i) single (n=2250); (ii) non-mirror multiple (n=285); and (iii) mirror aneurysms (n=106). Clinical and demographic files of the three groups were collected and compared, and medical histories including stroke, hyperlipemia, hypertension, hyperglycemia, valvular heart disease were considered as potential risk factors. Potential morphological reasons for mirror cerebral aneurysms rupture, including aneurysms size, irregular walls and cerebral hemispheric dominance, were also compared. Our data showed that the male to female ratio of mirror aneurysms patients was 1:3.61, which was significantly different from that of single aneurysm (1:1.27) and multiple aneurysms (1:2.00). The prevalence of mirror aneurysms in women is higher than that in men (P<0.001). Older patients (especially 60-69 years old) also appear to be more vulnerable to mirror aneurysm than single aneurysm (P<0.001). In 84 mirror aneurysm patients the aneurysms were located on the internal carotid arteries (79.2%), most typically at the PComA or in the Cavernous ICA. Patients with medical history of hyperlipemia appear to have an increased risk of harboring mirror aneurysms. Larger aneurysm size and presence of an irregular aneurysm wall appear to be the morphological factors that predispose for mirror aneurysms rupture.

Elevated glycated hemoglobin level and hyperglycemia after aneurysmal subarachnoid hemorrhage

OBJECTIVES

Elevated blood glucose is frequently detected early after aneurysmal subarachnoid hemorrhage (aSAH) and is considered a risk factor for poor neurological outcome. However it remains unclear whether hyperglycemia is caused by the SAH ictus or reflects a pre-existing hyperglycemic metabolism. In a prospective register we analysed glycated haemoglobin levels (HbA1c) in patients with aSAH and its influence on outcome.

PATIENTS AND METHODS

Between July 2012 and July 2014, 87 patients with confirmed aSAH were included (NCT02081820). Within 72h HbA1c levels were assessed as a measure for hyperglycemic metabolism preceding aSAH. Blood glucose levels were recorded upon admission. Patient outcome was recorded after 6 months using modified Rankin scale (mRS).

RESULTS

HbA1c levels did not correlate with initial neurological status (p=0.338, r=0.104). On the contrary, initial blood glucose levels correlated significantly with neurological status at admission (p=0.001, r=0.341). Additionally, HbA1c levels failed to show a significant influence on the occurrence of delayed cerebral ischemia (DCI) (p=0.400) or outcome after 6 months (p=0.790).

CONCLUSION

A pre-existing hyperglycemic metabolism does not contribute to the severity of aSAH or influences the quality of neurological recovery. Hyperglycemia after aSAH correlates with initial neurological status and patient outcome and is potentially attributable to the metabolic changes induced by the brain injury after the hemorrhage.

Polycystic kidney disease among 4,436 intracranial aneurysm patients from a defined population

OBJECTIVE

To define the association of autosomal dominant polycystic kidney disease (ADPKD) with the characteristics of aneurysmal subarachnoid hemorrhage (aSAH) and unruptured intracranial aneurysm (IA) disease.

METHODS

We fused data from the Kuopio Intracranial Aneurysm database (n = 4,436 IA patients) and Finnish nationwide registries into a population-based series of 53 IA patients with ADPKD to compare the aneurysm- and patient-specific characteristics of IA disease in ADPKD and in the general IA population, and to identify risks for de novo IA formation.

RESULTS

In total, there were 33 patients with ADPKD with aSAH and 20 patients with ADPKD with unruptured IAs. The median size of ruptured IAs in ADPKD was significantly smaller than in the general population (6.00 vs 8.00 mm) and the proportion of small ruptured IAs was significantly higher (31% vs 18%). Median age at aSAH was 42.8 years, 10 years younger than in the general IA population. Multiple IAs were present in 45% of patients with ADPKD compared to 28% in the general IA population. Cumulative risk of de novo IA formation was 1.3% per patient-year (vs 0.2% in the general IA population). Hazard for de novo aneurysm formation was significantly elevated in patients with ADPKD (Cox regression hazard ratio 7.7, 95% confidence interval 2.8-20; p < 0.0005).

CONCLUSIONS

Subarachnoid hemorrhage occurs at younger age and from smaller IAs in patients with ADPKD and risk for de novo IAs is higher than in the general Eastern Finnish population. ADPKD should be considered as an indicator for long-term angiographic follow-up in patients with diagnosed IAs.

Epilepsy-associated long-term mortality after aneurysmal subarachnoid hemorrhage

Objective:

To elucidate the epilepsy-associated causes of death and subsequent excess long-term mortality among 12-month survivors of subarachnoid hemorrhage from saccular intracranial aneurysm (SIA-SAH).

Methods:

The Kuopio SIA Database (kuopioneurosurgery.fi) includes all SIA-SAH patients admitted to the Kuopio University Hospital from its defined catchment population in Eastern Finland. The study cohort consists of 779 patients, admitted from 1995 to 2007, who were alive at 12 months after SIA-SAH. Their use of reimbursable antiepileptic drugs and the causes of death (ICD-10) were fused from the Finnish national registries from 1994 to 2014.

Results:

The 779 12-month survivors were followed up until death (n = 197) or December 31, 2014, a median of 12.0 years after SIA-SAH. Epilepsy had been diagnosed in 121 (15%) patients after SIA-SAH, and 34/121 (28%) had died at the end of follow-up, with epilepsy as the immediate cause of death in 7/34 (21%). In the 779 patients alive at 12 months after SIA-SAH, epilepsy was an independent risk factor for mortality (hazard ratio 1.8, 95% confidence interval 1.1–3.0).

Conclusions:

Comorbid epilepsy in 12-month survivors of SIA-SAH is associated with increased risk of death in long-term follow-up. Survivors of SIA-SAH require long-term dedicated follow-up, including identification and effective treatment of comorbid epilepsy to prevent avoidable deaths.

Diabetes mellitus and the risk of aneurysmal subarachnoid haemorrhage: A systematic review and meta-analysis of current evidence

Objective

This systematic review aimed to define the relationship between diabetes mellitus (DM) and the risk of aneurysmal subarachnoid haemorrhage (aSAH).

Methods

Studies associated with DM and aSAH published until March 2016 were retrieved from Pubmed, Embase, Web of Science, and Cochrane Library databases. A random-effects model was used to calculate the relative risks (RRs) with 95% confidence intervals (CIs).

Results

Eighteen observational studies were retrieved. The overall RRs for DM and aSAH were RRs = 0.59 (0.44, 0.79), with moderate heterogeneity (I²= 55.7%, P_{heterogeneity} = 0.000). Subgroup analysis by study quality revealed a reduced association between DM and aSAH risk in high quality studies only (RRs = 0.40, 95% CI: 0.29, 0.56; I²= 0.0%, P_{heterogeneity} = 0.549), therefore study quality may be a source of heterogeneity.

Conclusion

A potential decreased risk of aSAH in DM patients was found in high quality studies. Further studies are required to confirm this causal relationship and to investigate the biological mechanisms.

Antidepressant Use After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

To elucidate the predictors of antidepressant use after subarachnoid hemorrhage from saccular intracranial aneurysm (sIA-SAH) in a population-based cohort with matched controls.

Methods—

The Kuopio sIA database includes all unruptured and ruptured sIA cases admitted to the Kuopio University Hospital from its defined catchment population in Eastern Finland, with 3 matched controls for each patient. The use of all prescribed medicines has been fused from the Finnish national registry of prescribed medicines. In the present study, 2 or more purchases of antidepressant medication indicated antidepressant use. The risk factors of the antidepressant use were analyzed in 940 patients alive 12 months after sIA-SAH, and the classification tree analysis was used to create a predicting model for antidepressant use after sIA-SAH.

Results—

The 940 12-month survivors of sIA-SAH had significantly more antidepressant use (odds ratio, 2.6; 95% confidence interval, 2.2–3.1) than their 2676 matched controls (29% versus 14%). Classification tree analysis, based on independent risk factors, was used for the best prediction model of antidepressant use after sIA-SAH. Modified Rankin Scale until 12 months was the most potent predictor, followed by condition (Hunt and Hess Scale) and age on admission for sIA-SAH.

Conclusions—

The sIA-SAH survivors use significantly more often antidepressants, indicative of depression, than their matched population controls. Even with a seemingly good recovery (modified Rankin Scale score, 0) at 12 months after sIA-SAH, there is a significant risk of depression requiring antidepressant medication.

Diabetes may affect intracranial aneurysm stabilization in older patients: Analysis based on intraoperative findings

BACKGROUND

Only a small proportion of aneurysms progress to rupture. Previous studies have focused on predicting the rupture risk of intracranial aneurysms. Atherosclerotic aneurysm wall appears resistant to rupture. The purpose of this study was to evaluate clinical and morphological factors affecting atherosclerosis of an aneurysm and identify the parameters that predict aneurysm stabilization.

METHODS

We conducted a retrospective analysis of 253 consecutive patients with 291 unruptured aneurysms who underwent clipping surgery in a single institution between January 2012 and October 2013. Aneurysms were categorized based on intraoperative video findings and assessed morphologic and demographic data. Aneurysms which had the atherosclerotic wall without any super thin and transparent portion were defined as stabilized group and the others as a not-stabilized group.

RESULTS

Of the 207 aneurysms, 176 (85.0%) were assigned to the not-stabilized group and 31 (15.0%) to the stabilized group. The relative proportion of stabilized aneurysms increased significantly as the age increased (P < 0.001). Univariate logistic analysis showed that age ≥65 years (P < 0.001), hypertension (P = 0.012), diabetes (P = 0.007), and height ≥3 mm (P = 0.007) were correlated with stabilized aneurysms. Multivariate logistic analysis showed that age ≥65 years (P = 0.009) and hypertension (P = 0.041) were strongly correlated with stable aneurysms. In older patients (≥65 years of age), multivariate logistic regression revealed that only diabetes was associated with stabilized aneurysms (P = 0.027).

CONCLUSIONS

In patients ≥65 years of age, diabetes mellitus may highly predict the stabilized aneurysms. These results provide useful information in determining treatment and follow-up strategies, especially in older patients.

De Novo Aneurysm Formation in Carriers of Saccular Intracranial Aneurysm Disease in Eastern Finland

BACKGROUND AND PURPOSE

Formation of new (de novo) aneurysms in patients carrying saccular intracranial aneurysm (sIA) disease has been published, but data from population-based cohorts are scarce.

METHODS

Kuopio sIA database (http://www.uef.fi/ns) contains all unruptured and ruptured sIA patients admitted to Kuopio University Hospital from its Eastern Finnish catchment population. We studied the incidence and risk factors for de novo sIA formation in 1419 sIA patients with ≥5 years of angiographic follow-up, a total follow-up of 18 526 patient-years.

RESULTS

There were 42 patients with a total of 56 de novo sIAs, diagnosed in a median of 11.7 years after the first sIA diagnosis. The cumulative incidence of de novo sIAs was 0.23% per patient-year and that of subarachnoid hemorrhage from a ruptured de novo sIA 0.05% per patient-year. The risk of de novo sIA discovery per patient-year increased with younger age at the first sIA diagnosis: 2.2% in the patients aged <20 years and 0.46% in the patients aged between 20 and 39 years. In Cox regression analysis, smoking history and younger age at the first sIA diagnosis significantly associated with de novo sIA formation, but female sex, multiple sIAs, and sIA family did not.

CONCLUSIONS

Patients aged < 40 years at the first sIA diagnosis are in a significant risk of developing de novo sIAs, and they should be scheduled for long-term angiographic follow-up. Smoking increases the risk of de novo sIA formation, suggesting long-term follow-up for smokers. Antismoking efforts are highly recommended for sIA patients.

Impact of Comorbidity on Early Outcome of Patients with Subarachnoid Hemorrhage Caused by Cerebral Aneurysm Rupture

BACKGROUND

One of the complications aneurysms subarachnoid hemorrhage is the development of vasospasm, which is the leading cause of disability and death from ruptured cerebral aneurysm.

AIM

To evaluate the significance of previous comorbidities on early outcome of patients with subarachnoid hemorrhage caused by rupture of a cerebral aneurysm in the prevention of vasospasm.

PATIENTS AND METHODS

The study had prospective character in which included 50 patients, whose diagnosed with SAH caused by the rupture of a brain aneurysm in the period from 2011to 2013. Two groups of patients were formed. Group I: patients in addition to the standard initial treatment and "3H therapy" administered nimodipine at a dose of 15-30 mg / kg bw / h (3-10 ml) for the duration of the initial treatment. Group II: patients in addition to the standard initial treatment and "3H therapy" administered with MgSO4 at a dose of 12 grams in 500 ml of 0.9% NaCl / 24 h during the initial treatment.

RESULTS

Two-thirds of the patients (68%) from both groups had a good outcome measured with values according to GOS scales, GOS IV and V. The poorer outcome, GOS III had 20% patients, the GOS II was at 2% and GOS I within 10% of patients. If we analyze the impact of comorbidity on the outcome, it shows that there is a significant relationship between the presence of comorbidity and outcomes. The patients without comorbidity (83.30%) had a good outcome (GOS IV and V), the same outcome was observed (59.4%) with comorbidities, which has a statistically significant difference (p = 0.04). Patients without diabetes (32%) had a good outcome (GOS IV and V), while the percentage of patients with diabetes less frequent (2%) with a good outcome, a statistically significant difference (p = 0.009).

CONCLUSION

The outcome of treatment 30 days after the subarachnoid hemorrhage analyzed values WFNS and GOS, is not dependent on the method of prevention and treatment of vasospasm. Most concomitant diseases in patients with SAH which, requiring additional treatment measures are arterial hypertension and diabetes mellitus. The best predictors in the initial treatment of patients with subarachnoid hemorrhage caused by rupture of a cerebral aneurysm has the presence of comorbidity, which has statistical significance.

Hypertension predisposes to the formation of saccular intracranial aneurysms in 467 unruptured and 1053 ruptured patients in Eastern Finland

OBJECTIVE

Hypertension associates with subarachnoid hemorrhage from saccular intracranial aneurysm (sIA-SAH) when compared to matched controls or general population. Few series compare hypertension in unruptured sIA versus sIA-SAH, so its impact on the sIA disease remains uncertain.

METHODS

Kuopio sIA Database ( www.uef.fi/ns ) contains all cases of unruptured and ruptured sIAs admitted to Kuopio University Hospital from its Eastern Finnish catchment population. We compared the age-adjusted incidence of drug-treated hypertension in 467 unruptured and 1053 ruptured sIA patients admitted to Kuopio University Hospital from 1995 to 2007, using the national registry of prescribed medicines.

RESULTS

Antihypertensive medication was more frequent in the unruptured (73% versus 62%) with higher age-adjusted incidence. At sIA diagnosis, the sIA-SAH group had more often untreated hypertension (29% versus 23%). The size of unruptured sIAs increased with age at sIA diagnosis, independently of hypertension. Multiple sIAs, familial sIA, and sIA-SAH were not associated with hypertension in multivariate analysis. Results indicate that drug-treated hypertension associates with the formation of sIAs rather than their growth or rupture.

CONCLUSION

Hypertension is highly prevalent in the carriers of unruptured sIAs when compared to those with ruptured sIA. Hypertension may associate with the sIA formation, and may predispose to the rupture of sIA if untreated.