Association of a younger age with an increased risk of angiographic and symptomatic vasospasms following subarachnoid hemorrhage

Association Between High Preoperative White Blood Cell-to-Hemoglobin Ratio and Postoperative Symptomatic Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (ASAH) is a serious complication and has a strong relationship with systemic inflammatory responses. Given previously reported relationships between leukocytosis and anemia with ASAH-related cerebral vasospasm, this study examined the association between the preoperative white blood cell-to-hemoglobin ratio (WHR) and postoperative symptomatic cerebral vasospasm (SCV) in patients with ASAH.

METHODS

Demographic, preoperative (comorbidities, ASAH characteristics, laboratory findings), intraoperative (operation and anesthesia), and postoperative (SCV, other neurological complications, clinical course) data were retrospectively analyzed in patients with ASAH who underwent surgical or endovascular treatment of the culprit aneurysm. Patients were divided into high-WHR (n=286) and low-WHR (n=257) groups based on the optimal cutoff value of preoperative WHR (0.74), and stabilized inverse probability weighting was performed between the 2 groups. The predictive power of the WHR and other preoperative systemic inflammatory indices (neutrophil-to-albumin, neutrophil-to-lymphocyte, platelet-to-lymphocyte, platelet-to-neutrophil, platelet-to-white blood cell ratios, and systemic immune-inflammation index) for postoperative SCV was evaluated.

RESULTS

Postoperative SCV was more frequent in the high-WHR group than in the low-WHR group before (33.2% vs. 12.8%; P<0.001) and after (29.4% vs. 19.1%; P=0.005) inverse probability weighting. Before weighting, the predictive power for postoperative SCV was the highest for the WHR among the preoperative systematic inflammatory indices investigated (area under receiver operating characteristics curve 0.66, P<0.001). After weighting, preoperative WHR ≥0.74 was independently associated with postoperative SCV (odds ratio 1.76; P=0.006).

CONCLUSIONS

High preoperative WHR was an independent predictor of postoperative SCV in patients with ASAH.

A nomogram for predicting the risk of cerebral vasospasm after neurosurgical clipping in patients with aneurysmal subarachnoid hemorrhage

Purpose

Cerebral vasospasm (CVS) is a common complication that occurs after neurosurgical clipping of intracranial aneurysms in patients with aSAH. This complication can lead to clinical deterioration and a poor prognosis. The aim of this study is to explore the risk factors for CVS in aSAH patients who have undergone neurosurgical clipping, develop a nomogram for CVS, and evaluate its performance.

Methods

Patients with aSAH who underwent neurosurgical clipping in the Department of Neurosurgery from January 2018 to January 2023 were selected as the subjects of this research. The clinical data of these patients were retrospectively analyzed. Logistic multivariate regression analysis was employed to identify the independent risk factors of CVS. A clinical prediction model in the form of a nomogram for CVS was developed using the R programming language and subsequently evaluated for its performance and quality.

Results

A total of 156 patients with aSAH were included in the analysis, comprising 109 patients in the training set and 47 patients in the validation set. In the training cohort, 27 patients (24.77%) developed CVS after neurosurgical clipping, while in the validation cohort, 15 patients (31.91%) experienced CVS. Multivariate regression analysis revealed that age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade were independent risk factors for CVS. The nomogram exhibited excellent discriminative performance in both the training set (AUC = 0.885) and the validation set (AUC = 0.906).

Conclusion

CVS was a prevalent complication following neurosurgical clipping in patients with aSAH, with a highly intricate pathogenesis and pathophysiological course. Early prediction of CVS represented a significant challenge in clinical practice. In this study, age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade emerged as independent risk factors for CVS. The resulting nomogram demonstrated substantial predictive value.

Paracentral Acute Middle Maculopathy Following Acute Primary Angle Closure and Acute Primary Angle Closure Glaucoma

Purpose

To report the prevalence, clinical characteristics and risk factors for paracentral acute middle maculopathy (PAMM) following acute primary angle closure (APAC) and acute primary angle closure glaucoma (APACG).

Methods

This retrospective study consecutively recruited patients diagnosed with APAC or APACG. Based on the spectral domain optical coherence tomography characteristics, PAMM eyes were divided into three stages. Characteristics of different stages such as the time from symptoms to treatment (TST), retinal thickness and BCVA improvement were analyzed. The risk factors of PAMM were evaluated by binary logistic regression models.

Results

A total of 781 eyes of 781 APAC or APACG patients were included, and PAMM was found in 22 (2.9%) of them. Stage III eyes had a significantly longer TST than stage I eyes (P = 0.008) while exhibiting significantly thinner retinal thicknesses (P < 0.0001). The BCVA improvement was significantly worse in the eyes treated in stage III than in those treated in stage I (P = 0.008). Older age, longer axial length and without type 2 diabetes were associated with a lower risk of incident PAMM (OR = 0.95, P = 0.028; OR = 0.52, P = 0.019; OR = 3.92, P = 0.022).

Conclusion

PAMM can be secondary to APAC or APACG at a rate of 2.9%. Different visual outcomes were observed in patients who received the intervention at different stages of PAMM. Younger patients with a shorter axial length and type 2 diabetes were found to be more susceptible to PAMM.

Prognostic significance of fibrinogen and neutrophil/lymphocyte ratio score and D-dimer/Albumin ratio for prognosis in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Recent research indicates that systemic inflammation significantly affects the overall prognosis of individuals with aneurysmal subarachnoid hemorrhage. To delve deeper into this issue, a retrospective study was undertaken. The study aimed to investigate the relationship between fibrinogen and neutrophil/lymphocyte ratio scores, D-dimer/Albumin ratios, and the Glasgow Outcome Scale at 6 months post-discharge for patients with aSAH.

METHODS

A retrospective analysis was conducted on 321 patients who experienced aneurysmal subarachnoid hemorrhage. These patients were monitored using the Glasgow Outcome Scale six months after being discharged from Huizhou Central People's Hospital. Patients with GOS scores between 1 and 3 were classified as having a poor prognosis, while those with scores ranging from 4 to 5 were considered to have a good prognosis. To create distinct sets, patients were randomly divided into both training and validation groups. The best cut-off value for the D-dimer/Albumin ratio was established through ROC curves, and the scores for fibrinogen and the neutrophil/lymphocyte ratio were calculated. Utilizing multivariate logistic regression analysis, independent risk factors linked to an unfavorable prognosis in aSAH patients were identified. A nomogram model was developed and validated based on these findings, providing an improved approach for evaluating the prognostic influence of risk factors. To gauge the model's predictive performance, several analytical tools such as ROC curves, calibration curves, and decision curve analysis were employed. This comprehensive approach ensured a thorough assessment of the prognostic prediction capabilities of the model.

RESULTS

Multivariate regression analysis revealed that Age (OR=3.87, 95%CI=1.54-9.73, p=0.004), Pneumonia (OR=3.54, 95%CI=1.41-8.86, p=0.007), WFNS (OR=3.24, 95%CI=1.23-8.54, p=0.017), DAR (OR=2.88, 95%CI=1.13-7.34, p=0.027), and F-NLR (OR=3.12, 95%CI=1.22-7.97, p=0.017) were identified as independent risk factors influencing the prognosis of patients with aSAH. Additionally, the area under the ROC curve was 0.866 (95%CI=0.805-0.927) for the training set and 0.924 (95%CI=0.849-0.999) for the validation set. The calibration curve analysis demonstrated a minor error of 0.02 for the training set and 0.051 for the validation set. Furthermore, both the training set and validation set displayed significant clinical benefits according to the DCA curves, underscoring the meaningful utility of the developed nomogram.

CONCLUSIONS

Fibrinogen and neutrophil/lymphocyte ratio scores, and the D-dimer/Albumin ratio emerged as significant independent risk factors for prognosticating the outcomes of patients with aSAH. Leveraging these factors, a robust nomogram model was meticulously developed, showcasing its impressive precision in prognostic predictions. These results underscore the promising clinical applicability of these biomarkers as effective prognostic indicators for individuals afflicted by aSAH.

The Role of VASOGRADE as a Simple Grading Scale to Predict Delayed Cerebral Ischemia and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The VASOGRADE is a simple aneurysmal subarachnoid hemorrhage (aSAH) grading scale that combines the modified Fisher scale (mFisher) and the World Federation of Neurological Societies (WFNS) grading system, allowing the stratification of delayed cerebral ischemia (DCI) risk. However, the VASOGRADE accuracy in predicting functional outcomes is still to be determined.

METHODS

We retrospectively evaluated a multiethnic cohort of consecutive patients with aSAH admitted to a high-volume center in Brazil from January 2016 to January 2019. Patients were classified according to the severity of the clinical presentation (WFNS), the amount of blood in the initial head computerized tomography (mFisher) scan, and the VASOGRADE (green, yellow, red). The primary outcome was to detect DCI-related cerebral infarction, and the secondary outcome was the functional outcome at hospital discharge according to the modified Rankin scale (mRs). Univariate and multivariate logistic regression models were employed.

RESULTS

A total of 212 patients (71.7% female, mean age 52.7 ± 12.8) were included. Sixty-nine patients were classified as VASOGRADE-Green (32.5%), 98 patients as VASOGRADE-Yellow (46.9%), and 45 patients as VASOGRADE-Red (20.6%). DCI-related infarction was present in 39 patients (18.9%). The proportions of patients in the VASOGRADE-Green, VASOGRADE-Yellow, and VASOGRADE-Red categories with DCI-related infarction were 7.7, 61.5, and 30.8%, respectively. After a multivariable analysis including age, sex, aneurysm location, and the VASOGRADE classification as variables, both VASOGRADE-Yellow and VASOGRADE-Red were independently associated with DCI-related infarction (odds ratio [OR] 7.69, 95% confidence interval [CI] 2.13-27.8, and OR 8.07, 95% CI 2.03-32.11, respectively) and unfavorable outcome (OR 4.16, 95% CI 1.33-13.03, and OR 25.57, 95% CI 4.45-147.1, respectively). The VASOGRADE discrimination performance for DCI-related infarction (area under the receiver operating characteristic curve) was 0.67 ± 0.04 (95% CI 0.58-0.75; p = 0.001). VASOGRADE-Red had 97.5% specificity for predicting an unfavorable mRs score at discharge (95% CI 92.8-99.5%). Conversely, VASOGRADE-Green had an excellent specificity for predicting favorable outcome at discharge (mRs score 0-2, 95% CI 82.6-95.5%).

CONCLUSIONS

In conclusion, in a multiethnic cohort of patients with aSAH, VASOGRADE-Green predicted the absence of DCI and good clinical outcome at discharge with very high specificity, and patients in this category might be selected for early intensive care unit (ICU) discharge, minimizing costs and medical complications associated with prolonged hospital stay. On the other hand, patients categorized as VASOGRADE-Yellow and VASOGRADE-Red were at the highest risk for DCI. They should, therefore, be selected as a priority for care in high-volume aSAH centers, being aggressively monitored for DCI at the ICU. Such stratification methods are crucial, especially in countries with low financial resources and high health care services demand.

Effect of intra-arterial nimodipine on iatrogenic vasospasms during endovascular stroke treatment - angiographic resolution and infarct growth in follow-up imaging

PURPOSE

The treatment of vasospasms during endovascular stroke treatment (EST) with intra-arterial nimodipine (NM) is routinely performed. However, the efficacy of resolving iatrogenic vasospasms during the angiographic intervention and the infarct development in follow-up imaging after EST has not been studied yet.

METHODS

Retrospective single-center analysis of patients receiving EST for anterior circulation vessel occlusion between 01/2015 and 12/2021. The primary endpoint was ASPECTS in follow-up imaging. Secondary endpoints were the clinical outcome (combined endpoint NIHSS 24 h after EST and difference between modified Rankin Scale (mRS) before stroke and at discharge (delta mRS)) and intracranial hemorrhage (ICH) in follow-up imaging. Patients with vasospasms receiving NM (NM+) or not (NM-) were compared in univariate analysis.

RESULTS

Vasospasms occurred in 79/1283 patients (6.2%), who consecutively received intra-arterial NM during EST. The targeted vasospasm angiographically resolved in 84% (66/79) under NM therapy. ASPECTS was lower in follow-up imaging after vasospasms and NM-treatment (NM - 7 (6-9), NM + 6 (4.5-8), p = 0.013) and the clinical outcome was worse (NIHSS 24 h after EST was higher in patients treated with NM (median, IQR; NM+: 14, 5-21 vs. NM-: 9, 3-18; p = 0.004), delta-mRS was higher in the NM + group (median, IQR; NM+: 3, 1-4 vs. NM-: 2, 1-2; p = 0.011)). Any ICH (NM+: 27/79, 34.2% vs. NM-: 356/1204, 29.6%; p = 0.386) and symptomatic ICH (NM+: 2/79, 2.5% vs. NM-: 21/1204, 1.7%; p = 0.609) was equally distributed between groups.

CONCLUSION

Intra-arterial nimodipine during EST resolves iatrogenic vasospasms efficiently during EST without increasing intracranial hemorrhage rates. However, patients with vasospasms and NM treatment show higher infarct growth resulting in lower ASPECTS in follow-up imaging.

The Supratrochlear Artery Sign—A New Piece in the Puzzle of Cerebral Vasospasm

Background: Cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) has been extensively investigated, but the impact of collateralization remains unclear. We investigated the predictive value of collateral activation for delayed cerebral ischemia (DCI)-related infarctions and functional outcome. Methods: Data from 43 patients with CVS (January 2014 to August 2021) were evaluated for the angiographic presence of leptomeningeal and ophthalmic collaterals (anterior falcine artery (AFA), supratrochlear artery (STA), dorsal nasal artery (DNA)) on internal carotid artery angiograms. Vasospasm-related infarction and the modified Rankin Scale (mRS) score after six months were chosen as the endpoints. Results: 77% of the patients suffered from DCI-related infarctions. In 233 angiograms (at hospitalization, before spasmolysis, after six months), positive vessel signs were observed in 31 patients for STA, 35 for DNA, and 31 for AFA. The STA sign had the highest positive (84.6%) and negative (85.7%) predictive value for unfavorable outcome (mRS 4–6) in patients aged ≥50 years. DNA and AFA signs were not meaningful predictors for either endpoint. Leptomeningeal collaterals showed a positive Pearson’s correlation with the STA sign in 87.5% (p = 0.038) without providing any prediction for either endpoint. Conclusions: The STA sign is associated with clinical outcome in patients with CVS after SAH aged ≥50 years, and was correlated with the occurrence of leptomeningeal collaterals.

Risk Factors for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Tertiary Care Center Experience

Objectives  Cerebral vasospasm in subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. There is a lack of consensus on the risk factors leading to cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this retrospective study, our objective was to determine the association of risk factors for cerebral vasospasm aSAH.

Methods  A total of 259 charts of aSAH patients consecutively admitted to the surgical intensive care unit of Hamad General Hospital from January 2007 to December 2016 were reviewed and included. The patient's demographic data, including comorbidities like hypertension (HTN), was recorded. Variables of interest included measurements of the neurological deficit on admission, the severity of SAH, treatment modality, and the initial computerized tomography scan of the head for intraventricular hemorrhage, intracerebral hemorrhage, or hydrocephalus. Multivariate analysis and multiple logistic regression analyzed the relationship to identify the association of independent variables.

Results  Out of the 259 patients, 34% ( n  = 87) suffered from cerebral vasospasm. The severity of SAH was associated with the development of cerebral vasospasm ( p  < 0.05). The presence of HTN and neurological deficits on admission were associated with an increased risk of cerebral vasospasm ( p  < 0.05, p  < 0.01, respectively). Hydrocephalus requiring treatment using external ventricular drains decreased the risk of cerebral vasospasm ( p  < 0.05). Intraventricular and intracerebral hemorrhage were not associated with cerebral vasospasm ( p  = 0.25, p  = 0.16). The endovascular treatment of cerebral aneurysms was associated with an increased risk of cerebral vasospasm ( p  < 0.05).

Conclusion  Cerebral vasospasm is common among patients admitted with aSAH. It is significantly associated with the history of HTN, the neurological deficit on admission that corelates more strongly to the motor deficit on admission, the severity of hemorrhage (modified Fischer score), and endovascular treatment. External ventricular drainage was associated with a decrease in cerebral vasospasm. The present study's findings shed light on cerebral vasospasm's risk factors in the country and the region.

Treatment of octogenarians and nonagenarians with aneurysmal subarachnoid hemorrhage: a 17-year institutional analysis

BACKGROUND

Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines the neurologic outcomes of patients ≥ 80 years of age treated for aSAH.

METHOD

A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2.

RESULTS

During the study period, 1418 patients were treated for aSAH. The mean (standard deviation) age was 55.1 (13.6) years, the mean follow-up was 24.6 (40.0) months, and the rate of functional independence (mRS 0-2) at follow-up was 54% (751/1395). Logistic regression analysis found increasing age strongly associated with declining functional independence (R² = 0.929, p < 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67% [n = 29] vs 33% [n = 14], p < 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly.

CONCLUSIONS

Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.

Prognostic factors varying with age in patients with aneurysmal subarachnoid hemorrhage

With the advent of an aging society, more elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) have been treated. We investigated if prognostic factors differ with age in aSAH patients. In a prospectively maintained aSAH database at multiple institutions from 2013 to 2016, 238 patients who underwent clipping or coiling for a ruptured aneurysm within 48 h of onset were divided into elderly (≥75 years; 57 patients) and non-elderly groups, or categorized into 4-age groups (<54, 55-64, 65-74, and ≥75 years). Prognostic factors and clinical characteristics were retrospectively analyzed. The elderly group had a higher incidence of pre-morbidities, co-morbidities, poor admission World Federation of Neurological Surgeons (WFNS) grades, modified Fisher grade 4, and resultantly 90-day poor outcomes (modified Rankin scale [mRS] 3-6). Multivariate logistic regression analyses revealed that independent determinants for poor outcomes were hypertension and modified Fisher grade 4 in the elderly group, and admission WFNS grades IV-V, systemic complications, non-procedural cerebral infarction and shunt-dependent chronic hydrocephalus in the non-elderly group. The 4-age group analyses showed that higher age group was more frequently associated with the prognostic factors. As higher age itself causes poor outcomes and more association of prognostic factors, prognostic factors in elderly patients may be rather limited.

Susceptibility of the cerebral cortex to spreading depolarization in neurological disease states: The impact of aging

Secondary injury following acute brain insults significantly contributes to poorer neurological outcome. The spontaneous, recurrent occurrence of spreading depolarization events (SD) has been recognized as a potent secondary injury mechanism in subarachnoid hemorrhage, malignant ischemic stroke and traumatic brain injury. In addition, SD is the underlying mechanism of the aura symptoms of migraineurs. The susceptibility of the nervous tissue to SD is subject to the metabolic status of the tissue, the ionic composition of the extracellular space, and the functional status of ion pumps, voltage-gated and other cation channels, glutamate receptors and excitatory amino acid transporters. All these mechanisms tune the excitability of the nervous tissue. Aging has also been found to alter SD susceptibility, which appears to be highest at young adulthood, and decline over the aging process. The lower susceptibility of the cerebral gray matter to SD in the old brain may be caused by the age-related impairment of mechanisms implicated in ion translocations between the intra- and extracellular compartments, glutamate signaling and surplus potassium and glutamate clearance. Even though the aging nervous tissue is thus less able to sustain SD, the consequences of SD recurrence in the old brain have proven to be graver, possibly leading to accelerated lesion maturation. Taken that recurrent SDs may pose an increased burden in the aging injured brain, the benefit of therapeutic approaches to restrict SD generation and propagation may be particularly relevant for elderly patients.

Vasospasm-related complications after subarachnoid hemorrhage: the role of patients' age and sex

BACKGROUND

Outcome of aneurysmal subarachnoid hemorrhage (SAH) depends strongly on occurrence of symptomatic vasospasm (SV) leading to delayed cerebral ischemia (DCI). Various demographic, radiographic, and clinical predictors of SV have been reported so far, partially with conflicting results. The aim of this study was to analyze the role of patients' age and sex on SV/DCI risk, especially to identify age and sex-specific risk groups.

METHODS

All patients admitted with acute SAH during a 14-year-period ending in 2016 were eligible for this study. The study endpoints were the following: SV requiring spasmolysis, occurrence of DCI in follow-up computed tomography scans and unfavorable outcome at 6 months (modified Rankin scale > 2).

RESULTS

Nine hundred ninety-four patients were included in this study. The majority was female (666; 67%). SV, DCI, and unfavorable outcomes were observed in 21.5, 21.8, and 43.6% of the patients, respectively. Younger age (p < 0.001; OR = 1.03 per year decrease) and female sex (p = 0.025; OR = 1.510) were confirmed as independent predictors of SV. Regarding the sex differences, there were three age groups for SV/DCI risk ≤ 54, 55-74, and ≥ 75 years. Male patients showed earlier decrease in SV risk (at ≥ 55 vs. ≥ 75 years in females). Therefore, SAH females aged between 55 and 74 years were at the highest risk for DCI and unfavorable outcome, as compared to younger/older females (p = 0.001, OR = 1.77/p = 0.001, OR = 1.80). In contrast, their male counterparts did not show these risk alterations (p = 0.445/p = 0.822).

CONCLUSION

After acute SAH, female and male patients seem to show different age patterns for the risk of SV and DCI. Females aged between 55 and 74 years are at particular risk of vasospasm-related SAH complications, possibly due to onset of menopause.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS, Unique identifier: DRKS00008749.

Early Hemodynamic Changes Based on Initial Color-Coding Angiography as a Predictor for Developing Subsequent Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage

INTRODUCTION

Prediction of vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) remains imperfect and currently relies on clinical and radiographic characteristics. Whether early hemodynamic changes may refine risk stratification for delayed vasospasm (DV) after aSAH was analyzed.

METHODS

Patients with aSAH (n = 53) and a control group with unruptured intracranial aneurysms (UIA) (n = 12) with initial color-coding angiography at admission were included in this study (n = 65). Clinical and radiologic data were collected, and uni- and multivariate analysis was used to correlate the occurrence of DV (manifesting clinically or detected with transcranial Doppler or angiography) with hemodynamic features of the initial angiography including Tmax and mean transit times (MTTs).

RESULTS

In the aSAH patient cohort, 37 of 53 patients with aSAH (70%) developed DV. After we controlled for the effects of age, Hunt and Hess grade, and modified Fisher grade, patients with DV had a shorter mean region of interest peak time (Tmax) of the anterior cerebral artery A2 segment (P = 0.036) and the middle cerebral artery M1 (P = 0.045) and M3 (P = 0.013) segments. Mean MTTs between internal carotid artery to middle cerebral artery M3 segment (P = 0.026) was also significantly shorter in patients with DV when compared with controls.

CONCLUSIONS

Tmax and MTT on angiography within 48 hours of aneurysm rupture before treatment provide an early quantitative assessment in patients with aSAH and in this small study were predictive for the development of subsequent symptomatic DV. Early identification of patients with aSAH at greatest risk of DV may ameliorate clinical outcome through timely, selective implementation of aggressive prophylactic therapy to prevent the effects of DV.

External validation of the Practical Risk Chart for the prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage

OBJECTIVE Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) occurs in approximately 30% of patients. The Practical Risk Chart was developed to predict DCI based on admission characteristics; the authors seek to externally validate and critically appraise this prediction tool. METHODS A prospective cohort of aSAH patients was used to externally validate the previously published Practical Risk Chart. The model consists of 4 variables: clinical condition on admission, amount of cisternal and intraventricular blood on CT, and age. External validity was assessed using logistic regression. Model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). RESULTS In a cohort of 125 patients with aSAH, the Practical Risk Chart adequately predicted DCI, with an AUC of 0.66 (95% CI 0.55-0.77). Clinical grade on admission and amount of intracranial blood on CT were the strongest predictors of DCI and clinical vasospasm. The best-fit model used a combination of the Hunt and Hess grade and the modified Fisher scale to yield an AUC of 0.76 (95% CI 0.675-0.85) and 0.70 (95% CI 0.602-0.8) for the prediction of DCI and clinical vasospasm, respectively. CONCLUSIONS The Practical Risk Chart adequately predicts the risk of DCI following aSAH. However, the best-fit model represents a simpler stratification scheme, using only the Hunt and Hess grade and the modified Fisher scale, and produces a comparable AUC.

Identification of specific age groups with a high risk for developing cerebral vasospasm after aneurysmal subarachnoid hemorrhage

The impact of age on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a matter of ongoing discussion. The aim of this study was to identify age groups with a higher risk for developing vasospasm, delayed ischemic neurological deficit (DIND), or delayed infarction (DI) and to identify a cut-off age for a better risk stratification. We defined six age groups (<30, 30-39, 40-49, 50-59, 60-69, and >70 years). ROC analysis was performed to determine a cutoff age with the highest positive predictive value (PPV) for developing vasospasm, defined as a blood-flow-velocity-increase >120 cm/s in transcranial-Doppler-sonography (TCD). Multivariate binary-logistic-regression-analysis was then performed to evaluate differences in the incidence of cerebral vasospasm, DIND, and DI among the different age groups. A total of 753 patients were included in the study. The highest incidence (70 %) of TCD-vasospasm was found in patients between 30 and 39 years of age. The cutoff age with the highest PPV (65 %) for developing TCD-vasospasm was 38 years. Multivariate analysis revealed that age <38 years (OR 3.6; CI 95 % 2.1-6.1; p < 0.001) best predicted vasospasm, followed by the need for cerebrospinal fluid drainage (OR 1.5; CI 95 % 1.0-2.3; p = 0.04). However, lower age did not correlate with higher rates of DIND or infarcts. The overall vasospasm-incidence after aSAH is age-dependent and highest in the age group <38 years. Surprisingly, the higher incidence in the younger age group does not translate into a higher rate of DIND/DI. This finding may hint towards age-related biological factors influencing the association between arterial narrowing and cerebral ischemia.

Risk Factors for Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature

OBJECTIVE

To examine the literature on risk factors for cerebral vasospasm (CV), one of the most serious complications following aneurysmal subarachnoid hemorrhage (SAH), with special reference to the definition of CV.

METHODS

Using standard search engines, including PubMed, the medical literature on risk factors for CV after SAH was reviewed, and the best definition representative of CV was searched.

RESULTS

Severe SAH evident on computed tomography scan was the only consistent risk factor for CV after SAH. Effects of risk factors on CV, including age, clinical grade, rebleeding, intraventricular or intracerebral hemorrhage on computed tomography scan, acute hydrocephalus, aneurysm site and size, leukocytosis, interleukin-6 level, and cardiac abnormalities, appeared to be associated with the severity of SAH rather than each having a direct effect. Cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram were associated with CV without any relationship to SAH severity. With regard to parameters representative of CV, the grade of angiographic vasospasm (i.e., the degree of arterial narrowing evident on angiography) was the most adequate. Nevertheless, few reports on the risk factors associated with angiographic vasospasm grade have been reported to date.

CONCLUSIONS

Severe SAH evident on computed tomography scan appears to be a definite risk factor for CV after SAH, followed by cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram. To understand the pathogenesis of CV, further studies on the relationships between risk factors, especially factors not related to the severity of SAH, and angiographic vasospasm grade are necessary.

The VASOGRADE: A Simple Grading Scale for Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Patients are classically at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. We validated a grading scale-the VASOGRADE-for prediction of DCI.

METHODS

We used data of 3 phase II randomized clinical trials and a single hospital series to assess the relationship between the VASOGRADE and DCI. The VASOGRADE derived from previously published risk charts and consists of 3 categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale [WFNS] 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1-3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade). The relation between the VASOGRADE and DCI was assessed by logistic regression models. The predictive accuracy of the VASOGRADE was assessed by receiver operating characteristics curve and calibration plots.

RESULTS

In a cohort of 746 patients, the VASOGRADE significantly predicted DCI (P<0.001). The VASOGRADE-Yellow had a tendency for increased risk for DCI (odds ratio [OR], 1.31; 95% CI, 0.77-2.23) when compared with VASOGRADE-Green; those with VASOGRADE-Red had a 3-fold higher risk of DCI (OR, 3.19; 95% CI, 2.07-4.50). Studies were not a significant confounding factor between the VASOGRADE and DCI. The VASOGRADE had an adequate discrimination for prediction of DCI (area under the receiver operating characteristics curve=0.63) and good calibration.

CONCLUSIONS

The VASOGRADE results validated previously published risk charts in a large and diverse sample of subarachnoid hemorrhage patients, which allows DCI risk stratification on presentation after subarachnoid hemorrhage. It could help to select patients at high risk of DCI, as well as standardize treatment protocols and research studies.

Extent of collateralization predicting symptomatic cerebral vasospasm among pediatric patients: correlations among angiography, transcranial Doppler ultrasonography, and clinical findings

OBJECT

Although the development and prevalence of cerebral vasospasm (CV) has been extensively investigated in adults, little data exist on the development of CV in children. The authors hypothesized that even though children have highly vasoreactive arteries, because of a robust cerebral collateral blood flow, they rarely develop symptomatic CV.

METHODS

The authors retrospectively reviewed their university hospital's neurointerventional database for children (that is, patients ≤ 18 years) who were examined or treated for aneurysmal or traumatic subarachnoid hemorrhage (SAH) during the period 1990-2013. Images from digital subtraction angiography (DSA) were analyzed for the extent of CV and collateralization of the cerebral circulation. Results from transcranial Doppler (TCD) ultrasonography were correlated with those from DSA. Cerebral vasospasm on TCD ultrasonography was defined according to criteria developed for adults. Clinical outcomes of CV were assessed with the pediatric modified Rankin Scale (mRS).

RESULTS

Among 37 children (21 boys and 16 girls ranging in age from 8 months to 18 years) showing symptoms of an aneurysmal SAH (comprising 32 aneurysms and 5 traumatic pseudoaneurysms), 17 (46%) had CV confirmed by DSA; CV was mild in 21% of these children, moderate in 50%, and severe in 29%. Only 3 children exhibited symptomatic CV, all of whom had poor collateralization of cerebral vessels. Among the 14 asymptomatic children, 10 (71%) showed some degree of vessel collateralization. Among 16 children for whom TCD data were available that could be correlated with the DSA findings, 13 (81%) had CV according to TCD criteria. The sensitivity and specificity of TCD ultrasonography for diagnosing CV were 95% and 59%, respectively. The time to CV onset detected by TCD ultrasonography was 5 ± 3 days (range 2-10 days). Twenty-five (68%) of the children had good long-term outcomes (that is, had mRS scores of 0-2).

CONCLUSIONS

Children have a relatively high incidence of angiographically detectable, moderate-to-severe CV. Children rarely develop symptomatic CV and have good long-term outcomes, perhaps due to robust cerebral collateral blood flow. Criteria developed for detecting CV with TCD ultrasonography in adults overestimate the prevalence of CV in children. Larger studies are needed to define TCD ultrasonography-based CV criteria for children.

Haptoglobin phenotype predicts the development of focal and global cerebral vasospasm and may influence outcomes after aneurysmal subarachnoid hemorrhage

Cerebral vasospasm (CV) and the resulting delayed cerebral ischemia (DCI) significantly contribute to poor outcomes following aneurysmal subarachnoid hemorrhage (aSAH). Free hemoglobin (Hb) within the subarachnoid space has been implicated in the pathogenesis of CV. Haptoglobin (Hp) binds free pro-oxidant Hb, thereby modulating its harmful effects. Humans can be of three Hp phenotypes: Hp1-1, Hp2-1, or Hp2-2. In several disease states, the Hp2-2 protein has been associated with reduced ability to protect against toxic free Hb. We hypothesized that individuals with the Hp2-2 phenotype would have more CV, DCI, mortality, and worse functional outcomes after aSAH. In a sample of 74 aSAH patients, Hp2-2 phenotype was significantly associated with increased focal moderate (P = 0.014) and severe (P = 0.008) CV and more global CV (P = 0.014) after controlling for covariates. Strong trends toward increased mortality (P = 0.079) and worse functional outcomes were seen for the Hp2-2 patients with modified Rankin scale at 6 wk (P = 0.076) and at 1 y (P = 0.051) and with Glasgow Outcome Scale Extended at discharge (P = 0.091) and at 1 y (P = 0.055). In conclusion, Hp2-2 phenotype is an independent risk factor for the development of both focal and global CV and also predicts poor functional outcomes and mortality after aSAH. Hp phenotyping may serve as a clinically useful tool in the critical care management of aSAH patients by allowing for early prediction of those patients who require increased vigilance due to their inherent genetic risk for the development of CV and resulting DCI and poor outcomes.

Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand?

Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 persons in the United States each year. Around 30 percent of patients with aneurysmal subarachnoid hemorrhage suffer from cerebral ischemia and infarction due to cerebral vasospasm, a leading cause of treatable death and disability following aneurysmal subarachnoid hemorrhage. Methods used to predict, diagnose, and manage vasospasm are the topic of recent active research. This paper utilizes a comprehensive review of the recent literature to address controversies surrounding these topics. Evidence regarding the effect of age, smoking, and cocaine use on the incidence and outcome of vasospasm is reviewed. The abilities of different computed tomography grading schemes to predict vasospasm in the aftermath of subarachnoid hemorrhage are presented. Additionally, the utility of different diagnostic methods for the detection and visualization of vasospasm, including transcranial Doppler ultrasonography, CT angiography, digital subtraction angiography, and CT perfusion imaging is discussed. Finally, the recent literature regarding interventions for the prophylaxis and treatment of vasospasm, including hyperdynamic therapy, albumin, calcium channel agonists, statins, magnesium sulfate, and endothelin antagonists is summarized. Recent studies regarding each topic were reviewed for consensus recommendations from the literature, which were then presented.

Long-term impact of perfusion CT data after subarachnoid hemorrhage

INTRODUCTION

Dynamic perfusion computed tomography (PCT) has been established as a diagnostic instrument for the detection of vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to assess the prognostic impact of PCT parameters after SAH on the long-term outcome of patients.

METHODS

Three hundred twelve patients were retrospectively interrogated with a questionnaire 23.06 ± 14.33 months after spontaneous subarachnoid hemorrhage. The modified Rankin scale (mRS) was determined, respectively. Scheduled PCT data sets from the first days after ictus were available for all patients.

RESULTS

The maximum mean transit time over several examinations per hemisphere (MTTPEAK) values were significantly correlated (p ≤ 0.001, r = 0.422) with the clinical long-term outcome (mRS). Corresponding to our linear regression analysis, MTTPEAK is the second most important regressor (behind clinical severity of the initial hemorrhage) for the prediction of long-term mRS. An MTTPEAK threshold of 3.98 s (identified by receiver operating characteristic analysis, area under the curve = 0.75) predicted an unfavorable long-term outcome (mRS ≥ 2) with a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 67.3, 74.3, 84.5, 52.1, and 69.6 %, respectively.

CONCLUSION

The presented data corroborate the relevance of PCT data for the clinical long-term outcome of SAH patients. By identification of patients who are at risk for a bad outcome and may need escalation of therapy, risk-benefit analysis is supported.

Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Background and Purpose—

Established predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage are large amounts of extravasated blood and poor clinical condition on admission. The predictive value of other factors is uncertain.

Methods—

We searched MEDLINE (1960–2012) for clinical, laboratory, and radiological predictors routinely available within 72 hours after subarachnoid hemorrhage. The studies were categorized according to methodological quality. Crude data and effect estimates (odds ratio [OR], hazard ratios, and risk ratio) with 95% CI were extracted, (re-)calculated and pooled if possible. For every potential predictor we assessed all effect estimates on consistency (point estimates in equal direction) and clinical relevance (size and 95% CI).

Results—

Fifty-two studies on 33 potential predictors were included. There was strong evidence (≥3 high-quality studies) for a higher risk of delayed cerebral ischemia in smokers (pooled OR, 1.2; 95% CI, 1.1–1.4), and moderate evidence (2 high-quality studies) for an increased risk in patients with hyperglycemia (OR, 3.2; 1.8–5.8 and hazard ratios, 1.7; 1.1–2.5), hydrocephalus (OR, 1.3; 1.1–1.5 and OR, 2.6; 1.2–5.5), history of diabetes mellitus (pooled OR, 6.7; 1.7–26), and early systemic inflammatory response syndrome (pooled OR, 2.1; 1.4–3.3). Evidence was limited for increased risk in women (pooled OR, 1.3; 1.1–1.6) and in patients with history of hypertension (pooled OR, 1.5; 1.3–1.7). The evidence on initial loss of consciousness, history of migraine, previous use of selective serotonin reuptake inhibitors, hypomagnesemia, low hemoglobin, or high blood flow on early transcranial Doppler was also limited.

Conclusions—

There is strong evidence that smoking is a predictor of delayed cerebral ischemia. For several other potential predictions the evidence is moderate, limited, or inconsistent.

The relationship between subarachnoid hemorrhage volume and development of cerebral vasospasm

Objective

The objective of this study is to verify the relationship between subarachnoid hemorrhage (SAH) volume (not Fisher grade) and development of cerebral vasospasm prospectively.

Methods

Patients who visited our hospital with a diffuse or localized thick subarachnoid blood clot seen on computed tomography (CT), taken within 48 hours after SAH and the aneurysm was confirmed by CT Angiogram (CTA) from March 2010 to July 2011 were enrolled in this study. CTA was checked at least twice after admission. Angiographic vasospasm (AVS) on CTA was defined as irregularity or narrowing of intracranial vessels on follow up CTA compared with initial CTA. Total intracranial hemorrhage (ICH) volume (subdural, SAH, intracerebral and intraventricular) was calculated and SAH volume (all supratentorial and infratentorial cisterns) was also calculated using the MIPAV software package.

Results

A total of 55 patients were included in our study. Thirty six patients did not show AVS on CTA or clinical deterioration (non vasospasm group: NVS). AVS without ischemic neurologic symptoms was observed in four patients and development of symptomatic vasospasm (SVS), defined as AVS with ischemic symptoms, was observed in 15 patients. SAH volume in SVS patients was statistically larger than that in NVS patients (p < 0.05). Total ICH volume in SVS patients was larger than that in NVS patients. However, the difference was not statistically significant.

Conclusion

Results of this study indicate an association of development of vasospasm with the SAH volume, not intracranial hemorrhage.

Transcranial Doppler ultrasonography for diagnosis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: mean blood flow velocity ratio of the ipsilateral and contralateral middle cerebral arteries

BACKGROUND

Transcranial Doppler (TCD) is widely accepted to monitor cerebral vasospasm after subarachnoid hemorrhage (SAH); however, its predictive value remains controversial.

OBJECTIVE

To investigate the predictive reliability of an increase in the mean blood flow velocity (mBFV) ratio of the ipsilateral to contralateral middle cerebral arteries (I/C mBFV) compared with the conventional absolute flow velocity.

METHODS

We retrospectively investigated the clinical and radiologic data of consecutive patients with SAH admitted from July 2003 to August 2009 who underwent TCD ultrasonography. The highest mBFV value in bilateral middle cerebral arteries was recorded, while delayed cerebral ischemia (DCI) was defined as neurological deficits or computed tomographic evidence of cerebral infarction caused by vasospasm. The ipsilateral side was defined as the side with higher mBFV value when evaluating the I/C mBFV. We thus elucidated the reliability of this rate in comparison with the conventional method for predicting DCI with receiver operating characteristic (ROC) analysis.

RESULTS

One hundred and forty-two patients were retrospectively analyzed with specific data from 1262 TCD studies. The ROC curve showed that the overall predictive value for DCI had an area under the curve of 0.86 (95% confidence interval: 0.76-0.96) when the I/C mBFV was used vs 0.80 (0.71-0.88) when the absolute flow velocity was used. The threshold value that best discriminated between patients with and without DCI was I/C mBFV of 1.5.

CONCLUSION

In patients with SAH, the I/C mBFV demonstrated a more significant correlation to vasospasm than the absolute mean flow velocity.

Predicting the lack of development of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Patients with aneurysmal subarachnoid hemorrhage are typically kept in the intensive care unit to be monitored for signs of delayed cerebral ischemia (DCI). Identifying patients at lower risk for DCI could have a positive financial impact by allowing earlier transfer from the intensive care unit.

METHODS

We analyzed 307 consecutive patients admitted to the intensive care unit. Demographic, clinical, and neuroimaging data were recorded. The relationship with absent DCI was analyzed using univariate and multivariate logistic regression models.

RESULTS

DCI did not develop in 169 patients (57.9%). Among factors at admission, age 68 years or older (P=0.0003; OR, 3.16; 95% CI, 1.66-6.39), World Federation of Neurological Surgeons (WFNS) I to III at presentation (P=0.0003; OR, 2.73; 95% CI, 1.57-4.79), WFNS I to III at worst (P=0.0003; OR, 2.39; 95% CI, 1.48-3.87), WFNS I to III after resuscitation (P=0.0006; OR, 2.85; 95% CI, 1.56-5.32), modified Fisher grade 1 to 2 (P=0.0021; OR, 2.43; 95% CI, 1.37-4.47), absence of intracranial hematoma (P=0.0042; OR, 2.26; 95% CI, 1.29-4.01), and aneurysm in the posterior circulation (P=0.025; OR, 1.74; 95% CI, 1.07-2.87) were associated with absence of DCI. On multivariate analysis, a model including age 68 years or older, WFNS I to III at presentation and a modified Fisher grade 1 to 2 were independently predictive of the absence of DCI, with a specificity of 100% and a positive predictive value of 100%.

CONCLUSIONS

We propose a new model that can reliably identify patients with aneurysmal subarachnoid hemorrhage who are at very low risk for DCI. These patients could be candidates for early transfer to the general ward.

Lower Incidence of Transcranial Doppler and Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Aneurysm Clipping in the Elderly Patient?

BACKGROUND:

Vasospasm is the major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. It is well known that the vasoreactivity decreases with advancing age, but it is not well investigated in a large patient cohort whether, as a consequence, the incidence of vasospasm is lower in elderly patients.

OBJECTIVE:

To investigate whether transcranial Doppler vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are less frequent in older patients.

METHODS:

Seven hundred fifty-eight patients who suffered from subarachnoid hemorrhage were included in this study. Clinical presentation, Hunt and Hess score, Fisher grade, incidence of vasospasm, neurological deficits and ischemic lesions on radiographic imaging, transcranial Doppler blood flow velocities, medical complications, and outcome were registered.

RESULTS:

Four hundred seventy-eight patients &lt; 60 years of age and 280 patients ≥ 60 years of age were identified; 55.2% of the younger and 25.7% of the older age group developed post-hemorrhagic vasospasm (P &lt; .001). Older patients developed less vasospasm (P = .00), fewer neurological deficits (P &lt; .001), and fewer ischemic lesions on computed tomography imaging (P = .06). On the other hand, older patients had significantly worse outcomes than younger patients (P = .01) and more frequently died of medical complications (P = .01).

CONCLUSION:

Vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are more likely to occur in patients &lt; 60 years of age than in older patients. The lower incidence of vasospasm and vasospasm-related ischemia in the elderly patient does not translate into better outcome because of the higher rate of fatal medical complications in patients ≥ 60 years of age.