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Lee KS, Chari A, Motiwala M, Khan NR, Arthur AS, Lawton MT. Effectiveness of Cerebrospinal Fluid Lumbar Drainage Among Patients with Aneurysmal Subarachnoid Hemorrhage: An Updated Systematic Review and Meta-Analysis. World Neurosurg 2024; 183:246-253.e12. [PMID: 38246528 DOI: 10.1016/j.wneu.2024.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH. METHODS Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality. RESULTS A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99). CONCLUSIONS For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, King's College Hospital, London, United Kingdom; Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Aswin Chari
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mustafa Motiwala
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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Lumbar Drainage After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:261-267.e9. [PMID: 35868504 DOI: 10.1016/j.wneu.2022.07.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study reviews the use of lumbar drains (LDs) after aneurysmal subarachnoid hemorrhage (aSAH) and compares the outcomes to those associated with external ventricular drains (EVDs) and controls. METHODS A comprehensive search of the literature was performed. English language studies with a sample size of more than 10 patients were included. One-arm and 2-arm meta-analyses were designed to compare external drainage groups. Random-effects models, heterogeneity measures, and risk of bias were calculated. RESULTS Seventeen studies were included in the meta-analysis. The 2-arm meta-analysis comparing the LD to no drainage after aSAH found a significant improvement in the postoperative modified Rankin Scale (mRS) score (0-2) within 1 month of hospital discharge in the LD group (P = 0.003), a lower mortality rate (P = 0.03), fewer cases of clinical vasospasm (P = 0.007), and a lower incidence of ischemic stroke or delayed ischemic neurological deficits (P = 0.003). When the LD was compared to EVDs, a significant improvement in the postoperative mRS score (0-2) within 1 month of discharge was found in the LD group (P < 0.001). In the LD group, rebleeding occurred in 15 (3.4%) cases and meningitis occurred in 50 (4.7%) cases. CONCLUSIONS Compared with patients without cerebrospinal fluid drainage, patients with the LD after aSAH had lower mortality rates, lower risk of clinical vasospasm, and lower risk of ischemic stroke, and they were more likely to have an mRS score of 0-2 within 1 month of discharge. Compared with patients with EVDs, patients with the LD were more likely to have an mRS score of 0-2 within 1 month of discharge.
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Al-Mistarehi AH, Elsayed MA, Ibrahim RM, Elzubair TH, Badi S, Ahmed MH, Alkhaddash R, Ali MK, Khader YS, Alomari S. Clinical Outcomes of Primary Subarachnoid Hemorrhage: An Exploratory Cohort Study from Sudan. Neurohospitalist 2022; 12:249-263. [PMID: 35419154 PMCID: PMC8995598 DOI: 10.1177/19418744211068289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Although Subarachnoid Hemorrhage (SAH) is an emergency condition, its epidemiology and prognosis remain poorly understood in Africa. We aim to explore the clinical presentations, outcomes, and potential mortality predictors of primary SAH patients within 3 weeks of hospitalization in a tertiary hospital in Sudan. Methods We prospectively studied 40 SAH patients over 5 months, with 3 weeks of follow-up for the symptomatology, signs, Glasgow coma scale (GCS), CT scan findings, and outcomes. The fatal outcome group was defined as dying within 3 weeks. Results The mean age was 53.5 years (SD, 6.9; range, 41–65), and 62.5% were women. One-third (30.0%) were smokers, 37.5% were hypertensive, two-thirds (62.5%) had elevated blood pressure on admission, 37.5% had >24 hours delayed presentation, and 15% had missed SAH diagnosis. The most common presenting symptoms were headache and neck pain/stiffness, while seizures were reported in 12.5%. Approximately one-quarter of patients (22.5%) had large-sized Computed Tomography scan hemorrhage, and 40.0% had moderate size. In-hospital mortality rate was 40.0% (16/40); and 87.5% of them passed away within the first week. Compared to survivors, fatal outcome patients had significantly higher rates of smoking (50.0%), hypertension (68.8%), elevated presenting blood pressure (93.8%), delayed diagnosis (56.2%), large hemorrhage (56.2%), lower GCS scores at presentation, and cerebral rebleeding ( P < 0.05 for each). The primary causes of death were the direct effect of the primary hemorrhage (43.8%), rebleeding (31.3%), and delayed cerebral infarction (12.5%). Conclusions SAH is associated with a high in-hospital mortality rate in this cohort of Sudanese SAH patients due to modifiable factors such as delayed diagnosis, hypertension, and smoking. Strategies toward minimizing these factors are recommended.
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Affiliation(s)
- Abdel-Hameed Al-Mistarehi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Muaz A. Elsayed
- Department of Neurology, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Omdurman Teaching Hospital / Sudan Medical Specialization Board, Khartoum, Sudan
| | | | - Tarig Hassan Elzubair
- Department of Psychiatry, Faculty of Medicine, University of Science and Technology (UST), Khartoum, Sudan
| | - Safaa Badi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Khartoum, Sudan
| | - Mohamed H. Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital, NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK
| | - Raed Alkhaddash
- Department of Neurology, The University of Tennessee Health Science Center (UTHSC), Memphis, TN, USA
| | - Musaab K. Ali
- Department of Emergency Medicine, King Abdullah University Hospital, Irbid, Jordan/Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan
| | - Yousef S. Khader
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ding CY, Wang FY, Cai HP, Chen XY, Zheng SF, Yu LH, Lin YX, Lin ZY, Kang DZ. Can admission lipoprotein-associated phospholipase A2 predict the symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage? Chin Neurosurg J 2020; 6:9. [PMID: 32922938 PMCID: PMC7398414 DOI: 10.1186/s41016-020-00188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Inflammation has been believed to be related to the development of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH). A potential biomarker for vascular inflammation that is well recognized is the lipoprotein-associated phospholipase A2 (Lp-PLA2). However, whether Lp-PLA2 can predict the occurrence of symptomatic cerebral vasospasm (SCV) in aSAH patients is still unknown. Thus, this study aimed to assess the value of Lp-PLA2 for predicting SCV in patients with aSAH. Methods Between March 2017 and April 2018, we evaluated 128 consecutive aSAH patients who were admitted in the First Affiliated Hospital of Fujian Medical University. Their Lp-PLA2 level was obtained within 24 h of the initial bleeding. Factors might be related to SCV were analyzed. Results Compared to patients without SCV, those with SCV (9.4%, 12/128) had significantly higher Lp-PLA2 level. Multivariate logistic analysis revealed that worse modified Fisher grade (OR = 10.08, 95% CI = 2.04-49.86, P = 0.005) and higher Lp-PLA2 level (OR = 6.66, 95% CI = 1.33-3.30, P = 0.021) were significantly associated with SCV, even after adjustment for confounders. Based on the best threshold, Lp-PLA2 had a sensitivity of 83.3% and a specificity of 51.7% for predicting SCV, as shown by the receiver operating characteristic curve analysis. In the poor World Federation of Neurosurgical Societies grade patient sub-group, patients with Lp-PLA2 > 200 μg/L had significantly higher SCV rate than that of patients having Lp-PLA2 ≤ 200 μg/L. Conclusion The admission Lp-PLA2 level might be a helpful predictor for SCV in aSAH.
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Affiliation(s)
- Chen-Yu Ding
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Fang-Yu Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Han-Pei Cai
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Xiao-Yong Chen
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Shu-Fa Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Liang-Hong Yu
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - Zhang-Ya Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian People's Republic of China
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Aldrich EF, Higashida R, Hmissi A, Le EJ, Macdonald RL, Marr A, Mayer SA, Roux S, Bruder N. Thick and diffuse cisternal clot independently predicts vasospasm-related morbidity and poor outcome after aneurysmal subarachnoid hemorrhage. J Neurosurg 2020; 134:1553-1561. [PMID: 32442971 DOI: 10.3171/2020.3.jns193400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. The presence of thick, diffuse subarachnoid blood may portend a worse clinical course and outcome, independently of other known prognostic factors such as age, aneurysm size, and initial clinical grade. METHODS In this post hoc analysis, patients with aSAH undergoing surgical clipping (n = 383) or endovascular coiling (n = 189) were pooled from the placebo arms of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS)-2 and CONSCIOUS-3 randomized, double-blind, placebo-controlled phase 3 studies, respectively. Patients without and with thick, diffuse SAH (≥ 4 mm thick and involving ≥ 3 basal cisterns) on admission CT scans were compared. Clot size was centrally adjudicated. All-cause mortality and vasospasm-related morbidity at 6 weeks and Glasgow Outcome Scale-Extended (GOSE) scores at 12 weeks after aSAH were assessed. The effect of the thick and diffuse cisternal aSAH on vasospasm-related morbidity and mortality, and on poor clinical outcome at 12 weeks, was evaluated using logistic regression models. RESULTS Overall, 294 patients (51.4%) had thick and diffuse aSAH. Compared to patients with less hemorrhage burden, these patients were older (median age 55 vs 50 years) and more often had World Federation of Neurosurgical Societies (WFNS) grade III-V SAH at admission (24.1% vs 16.5%). At 6 weeks, all-cause mortality and vasospasm-related morbidity occurred in 36.1% (95% CI 30.6%-41.8%) of patients with thick, diffuse SAH and in 14.7% (95% CI 10.8%-19.5%) of those without thick, diffuse SAH. Individual event rates were 7.5% versus 2.5% for all-cause death, 19.4% versus 6.8% for new cerebral infarct, 28.2% versus 9.4% for delayed ischemic neurological deficit, and 24.8% versus 10.8% for rescue therapy due to cerebral vasospasm, respectively. Poor clinical outcome (GOSE score ≥ 4) was observed in 32.7% (95% CI 27.3%-38.3%) and 16.2% (95% CI 12.1%-21.1%) of patients with and without thick, diffuse SAH, respectively. CONCLUSIONS In a large, centrally adjudicated population of patients with aSAH, WFNS grade at admission and thick, diffuse SAH independently predicted vasospasm-related morbidity and poor 12-week clinical outcome. Patients with thick, diffuse cisternal SAH may be an important cohort to target in future clinical trials of treatment for vasospasm.
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Affiliation(s)
- E François Aldrich
- 1Department of Neurosurgery, University of Maryland, Baltimore, Maryland
| | - Randall Higashida
- 2Department of Neurointerventional Radiology, University of California San Francisco Medical Center, San Francisco, California
| | - Abdel Hmissi
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Elizabeth J Le
- 1Department of Neurosurgery, University of Maryland, Baltimore, Maryland
| | - R Loch Macdonald
- 4Department of Neurological Surgery, University of California San Francisco, Fresno, California.,5Department of Surgery, University of Toronto, Ontario, Canada
| | - Angelina Marr
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Stephan A Mayer
- 6Department of Neurology, Henry Ford Neuroscience Institute, Wayne State School of Medicine, Detroit, Michigan; and
| | - Sébastien Roux
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Nicolas Bruder
- 7Department of Anesthesia and Critical Care, Hôpital de la Timone, Aix-Marseille Université, Marseille, France
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Starnoni D, Maduri R, Hajdu SD, Pierzchala K, Giammattei L, Rocca A, Grosfilley SB, Saliou G, Messerer M, Daniel RT. Early Perfusion Computed Tomography Scan for Prediction of Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e743-e752. [PMID: 31284055 DOI: 10.1016/j.wneu.2019.06.213] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We investigated the ability of early alteration of cerebral perfusion-computed tomography (PCT) parameters to predict the risk of vasospasm, delayed cerebral ischemia (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective cohort study of 38 aSAH patients investigated with PCT within 48 hours after hemorrhage. Cerebral blood flow (CBF), cerebral blood volume, and mean transit time (MTT) values were recorded. Mean values were compared with clinical data. Vasospasm and DCI were determined by imaging and clinical criteria. Neurologic outcome was assessed by the modified Rankin Scale at discharge and 1-year follow-up visit. RESULTS More than a third (39.5%) of patients developed DCI, of whom 86.7% presented moderate-severe vasospasm. There was a significant correlation between perfusion parameters in the early phase and occurrence of DCI and vasospasm. The occurrence of DCI and vasospasm correlated significantly with lower mean early PCT values. DCI was correlated with lower mean early CBF values (P = 0.049) and vasospasm with lower mean CBF (P = 0.01) and MTT (P < 0.00001) values. MTT values of 5.5s were shown to have 94% specificity and 100% sensitivity for predicting the risk of developing vasospasm. The severity of the SAH according to the Barrow Neurological Institute scale correlated significantly with the risk of developing DCI and vasospasm, both significantly associated with unfavorable neurologic outcome (modified Rankin Scale score 3-6) (P = 0.0002 and P = 0.02, respectively). CONCLUSIONS Early alterations in PCT parameters and high Barrow Neurological Institute grade may identify a subgroup of patients at high risk of developing DCI and vasospasm after aSAH, thus prompting more robust preventative measures and treatment in this subgroup.
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Affiliation(s)
- Daniele Starnoni
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - Steven David Hajdu
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Lorenzo Giammattei
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alda Rocca
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Sarah Beatrice Grosfilley
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
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8
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Maduri R, Starnoni D, Rocca A, Bervini D, Zumofen DW, Stienen MN, Schatlo B, Fung C, Robert T, Seule MA, Burkhardt JK, Maldaner N, Rothlisberger M, Blackham KA, Marbacher S, D’Alonzo D, Remonda L, Machi P, Gralla J, Bijlenga P, Saliou G, Ballabeni P, Levivier M, Messerer M, Daniel RT. Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry. Acta Neurochir (Wien) 2019; 161:769-779. [PMID: 30680461 DOI: 10.1007/s00701-019-03812-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/12/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques. OBJECTIVE To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes. METHODS This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined. RESULTS From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1 year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1 year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1 year. CONCLUSIONS In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.
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Hemorrhagic burden in poor-grade aneurysmal subarachnoid hemorrhage: a volumetric analysis of different bleeding distributions. Acta Neurochir (Wien) 2019; 161:791-797. [PMID: 30790092 DOI: 10.1007/s00701-019-03846-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Volumetric assessment of aneurysmal bleeding has been evaluated in few studies and emerged as a promising outcome predictor. There is a lack of studies evaluating its impact in the poor-grade population. METHODS Retrospective review of 63 consecutive poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients, defined as grade IV and V according to the World Federation of Neurological Surgeons (WFNS) classifications. Global intracranial bleeding volume was calculated with its subarachnoid, intracerebral (ICH), and intraventricular (IVH) portions by means of analytical software. Univariate and multivariate analyses were performed in order to identify independent predictors of outcome. Good outcome was defined as modified Rankin Scale (mRS) 0-2 and mortality as mRS 6. The cutoff values of bleeding volumes were derived by receiver operating curve (ROC) analysis. RESULTS Mean follow-up was of 12.5 (± 1.5) months. Thirty (47.7%) patients achieved good outcome, whereas 19 (30.2) patients out of 63 died. Global intracranial bleeding resulted as an independent predictor of good outcome (cutoff 24 mL). Furthermore, ICH relative percentage of global volume (10% of total) and pure SAH (64% of total) emerged respectively as independent predictors of worsened and improved outcome. Global bleeding volume (cutoff 51 mL) along with global cerebral edema showed to independently predict mortality in the examined poor-grade aSAH population. CONCLUSIONS Volumetric assessment of aneurysmal bleeding has the potential for identifying cutoff values that independently predict outcome. Further insights into the relative importance of different bleeding volumes may be implicated in better tailoring the management of this dismal aSAH population.
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van der Steen WE, Leemans EL, van den Berg R, Roos YBWEM, Marquering HA, Verbaan D, Majoie CBLM. Radiological scales predicting delayed cerebral ischemia in subarachnoid hemorrhage: systematic review and meta-analysis. Neuroradiology 2019; 61:247-256. [PMID: 30693409 DOI: 10.1007/s00234-019-02161-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Delayed cerebral ischemia (DCI) is a severe complication of aneurysmal subarachnoid hemorrhage (aSAH). The extent of subarachnoid blood is a strong predictor of DCI and is frequently estimated with the Fisher scale, modified Fisher scale, or Hijdra sum score. It is unclear which scale has the strongest association with clinical DCI. To evaluate this, we performed a systematic review of the literature. METHODS We performed a MEDLINE and EMBASE search from 1980 to 20th of June 2017. Radiological grade and occurrence of clinical DCI were extracted along with odds ratios (ORs) for DCI. When possible, pooled ORs with 95% confidence intervals were calculated per grade increase on the radiological scale. RESULTS Fifty-three studies were included. The Fisher scale was significantly associated with DCI in 62% of the studies compared to 88-100% for the other scales. In studies using the Fisher scale, Fisher 3 had the strongest association with DCI (pooled OR 3.21 (1.87-5.49)). In studies using the modified Fisher score, DCI occurred most frequently (42%) in modified Fisher 4. No pooled OR could be calculated for the other scales. CONCLUSION The Fisher scale, modified Fisher scale, and Hijdra sum score are all associated with clinical DCI. The risk of DCI, however, does not increase with increasing Fisher grade as opposed to the modified Fisher scale. Furthermore, the modified Fisher scale was more commonly significantly associated with DCI than the Fisher scale, which may advocate using the modified Fisher in future SAH-related studies.
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Affiliation(s)
- Wessel E van der Steen
- Department of Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Room L0-106, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva L Leemans
- Department of Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Room L0-106, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Room L0-106, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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11
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Duan Y, Wright J, Wright C, Shammassian B, Tatsuoka C, Bambakidis N. Reliable Identification of Benign Clinical Course in Aneurysmal Subarachnoid Hemorrhage: A Simple and Qualitative Algorithm. Neurosurgery 2018; 83:948-956. [PMID: 29136224 DOI: 10.1093/neuros/nyx548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 10/02/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A reliable method to specifically identify low vasospasm risk in aneurysmal subarachnoid hemorrhage (aSAH) patients has not been previously proposed. OBJECTIVE To develop a clinical algorithm using admission aSAH clinical severity and subarachnoid blood distribution to identify patients at low risk of clinical vasospasm. METHODS Clinical severities, admission noncontrasted head computerized tomography (CT) scan, and incidences of vasospasm among 291 aSAH patients treated at our institution were evaluated. Admission head CTs were assessed for distributions of cisternal and ventricular blood. Patients with the following 4 criteria experienced considerably lower risk of vasospasm: (1) Hunt Hess grade 1 to 2, (2) Lack of thick subarachnoid blood filling 2 adjacent cisterns, (3) Lack of thick interhemispheric blood, and (4) Lack of biventricular intraventricular hemorrhage. RESULTS One hundred thirty-three patients (45.7%) developed cerebral vasospasm. Hunt Hess grade greater than 2 (odds ratio [OR] 4.52, 95% confidence interval [CI] 2.74-7.46), adjacent cistern blood (OR 4.1, 95% CI 2.51-6.7), interhemispheric thick blood (OR 5.72, 95% CI 3.41-9.59), and biventricular intraventricular hemorrhage (OR 1.92, 95% CI 1.19-3.02) were significant risk factors. Application of our algorithm yielded a sensitivity of 29%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 54.5%, which was superior compared to metrics from current institutional practice criteria. Inter-rater agreement was substantial at mean kappa = 0.75. CONCLUSION Application of our novel clinical algorithm produced successful identification of aSAH patients who experience zero risk of clinical vasospasm. Our algorithm is simple to apply with high reliability and is superior to currently available clinical and radiographic metrics.
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Affiliation(s)
- Yifei Duan
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - James Wright
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christina Wright
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Berje Shammassian
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Curtis Tatsuoka
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Nicholas Bambakidis
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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12
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Neidert MC, Maldaner N, Stienen MN, Roethlisberger M, Zumofen DW, D’Alonzo D, Marbacher S, Maduri R, Hostettler IC, Schatlo B, Schneider MM, Seule MA, Schöni D, Goldberg J, Fung C, Arrighi M, Valsecchi D, Bijlenga P, Schaller K, Bozinov O, Regli L, Burkhardt JK, Fandino J, Marbacher S, D'Alonzo D, Coluccia D, Schmid N, Zumofen D, Roethlisberger M, Mariani L, Guzman R, Monsch AU, Bläsi S, Fung C, Bervini D, Beck J, Raabe A, Goldberg J, Schöni D, Gralla J, Zweifel-Zehnder A, Gutbrod K, Müri R, Maduri R, Thomas Daniel R, Starnoni D, Messerer M, Levivier M, Beaud V, Valsecchi D, Arrighi M, Venier A, Reinert M, Kuhlen DE, Robert T, Rossi S, Sacco L, Bijlenga P, Corniola M, Schaller K, Chicherio C, Seule MA, Ferrari A, Weyerbrock A, Hlavica M, Fournier JY, Früh S, Schatlo B, Burkhardt JK, Stienen MN, Keller E, Regli L, Bozinov O, Maldaner N, Finkenstädt S, Neidert MC, Brugger P, Mondadori C. The Barrow Neurological Institute Grading Scale as a Predictor for Delayed Cerebral Ischemia and Outcome After Aneurysmal Subarachnoid Hemorrhage: Data From a Nationwide Patient Registry (Swiss SOS). Neurosurgery 2018; 83:1286-1293. [DOI: 10.1093/neuros/nyx609] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/06/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marian Christoph Neidert
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Nikolaus Stienen
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Donato D’Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Rodolfo Maduri
- Department Clinical Neurosciences, Service Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | - Bawarjan Schatlo
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - Michel M Schneider
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Martin A Seule
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Daniel Schöni
- Department of Neurosurgery, Inselspital Bern, Bern, Switzerland
| | | | - Christian Fung
- Department of Neurosurgery, Inselspital Bern, Bern, Switzerland
| | - Marta Arrighi
- Department of Neurosurgery, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Daniele Valsecchi
- Department of Neurosurgery, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Philippe Bijlenga
- Department of Neurosurgery, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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13
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Darkwah Oppong M, Gembruch O, Herten A, Frantsev R, Chihi M, Dammann P, El Hindy N, Forsting M, Sure U, Jabbarli R. Intraventricular Hemorrhage Caused by Subarachnoid Hemorrhage: Does the Severity Matter? World Neurosurg 2018; 111:e693-e702. [PMID: 29305915 DOI: 10.1016/j.wneu.2017.12.148] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/21/2017] [Accepted: 12/23/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Aneurysm rupture might be accompanied by intraventricular hemorrhage (IVH), which is associated with poor outcome of subarachnoid hemorrhage (SAH). The aim of this study was to analyze risk factors and clinical impact of IVH severity. METHODS A total of 995 consecutive patients with SAH treated at our institution between January 2003 and June 2016 were eligible for this study. Clinical and radiologic findings were correlated with the presence and severity of IVH assessed with the original Graeb score. RESULTS A total of 487 patients with SAH (48.9%) presented with IVH (mean IVH severity, 5.48 points [±3.5]). IVH severity correlated with poorer initial clinical condition (World Federation of Neurosurgical Societies grade >3; P < 0.001), acute hydrocephalus (P = 0.001), and poor outcome at 6 months (modified Rankin Scale score >2; P < 0.001). The location of the ruptured aneurysm in the anterior cerebral artery independently predicted the occurrence (P = 0.007) and severity of IVH (P < 0.001). In turn, aneurysm size affected only the severity of IVH (P = 0.001) but not its occurrence (P = 0.153). Early complications of SAH occurring within 72 hours after the bleeding event (cerebral infarction [P = 0.043], early mortality [P = 0.001], and primary craniectomy [P = 0.043]) were independently associated with the severity of IVH. CONCLUSIONS Severity of aneurysmal IVH is a strong contributor to initial severity and early complications of SAH. Patients with larger aneurysms, especially located in the anterior cerebral artery, are at particular risk of severe IVH in cases of aneurysm rupture.
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Affiliation(s)
| | - Oliver Gembruch
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Annika Herten
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Roman Frantsev
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Nicolai El Hindy
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
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14
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Dengler NF, Sommerfeld J, Diesing D, Vajkoczy P, Wolf S. Prediction of cerebral infarction and patient outcome in aneurysmal subarachnoid hemorrhage: comparison of new and established radiographic, clinical and combined scores. Eur J Neurol 2017; 25:111-119. [DOI: 10.1111/ene.13471] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/06/2017] [Indexed: 12/22/2022]
Affiliation(s)
- N. F. Dengler
- Department of Neurosurgery; Charité Universitätsmedizin Berlin; Berlin
| | - J. Sommerfeld
- Department of Neurosurgery; Charité Universitätsmedizin Berlin; Berlin
| | - D. Diesing
- Department of Psychiatry; Charité Universitätsmedizin Berlin; Berlin Germany
| | - P. Vajkoczy
- Department of Neurosurgery; Charité Universitätsmedizin Berlin; Berlin
| | - S. Wolf
- Department of Neurosurgery; Charité Universitätsmedizin Berlin; Berlin
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15
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Eagles ME, Jaja BNR, Macdonald RL. Incorporating a Modified Graeb Score to the Modified Fisher Scale for Improved Risk Prediction of Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2017; 82:299-305. [DOI: 10.1093/neuros/nyx165] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 03/10/2017] [Indexed: 11/14/2022] Open
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16
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Dengler NF, Diesing D, Sarrafzadeh A, Wolf S, Vajkoczy P. The Barrow Neurological Institute Scale Revisited: Predictive Capabilities for Cerebral Infarction and Clinical Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2017; 81:341-349. [DOI: 10.1093/neuros/nyw141] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 12/28/2016] [Indexed: 11/14/2022] Open
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17
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Abstract
Subarachnoid haemorrhage is an uncommon and severe subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life. The rupture of an intracranial aneurysm is the underlining cause in 85% of cases. Survival from aneurysmal subarachnoid haemorrhage has increased by 17% in the past few decades, probably because of better diagnosis, early aneurysm repair, prescription of nimodipine, and advanced intensive care support. Nevertheless, survivors commonly have cognitive impairments, which in turn affect patients' daily functionality, working capacity, and quality of life. Additionally, those deficits are frequently accompanied by mood disorders, fatigue, and sleep disturbances. Management requires specialised neurological intensive care units and multidisciplinary clinical expertise, which is better provided in high-volume centres. Many clinical trials have been done, but only two interventions are shown to improve outcome. Challenges that remain relate to prevention of subarachnoid haemorrhage by improved screening and development of lower-risk methods to repair or stabilise aneurysms that have not yet ruptured. Multicentre cooperative efforts might increase the knowledge that can be gained from clinical trials, which is often limited by small studies with differing criteria and endpoints that are done in single centres. Outcome assessments that incorporate finer assessment of neurocognitive function and validated surrogate imaging or biomarkers for outcome could also help to advance the specialty.
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Tom A Schweizer
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
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18
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Woo PYM, Tse TPK, Chan RSK, Leung LNY, Liu SKK, Leung AYT, Wong HT, Chan KY. Computed tomography interobserver agreement in the assessment of aneurysmal subarachnoid hemorrhage and predictors for clinical outcome. J Neurointerv Surg 2016; 9:1118-1124. [DOI: 10.1136/neurintsurg-2016-012576] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/17/2016] [Accepted: 10/21/2016] [Indexed: 11/03/2022]
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19
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Kranthi S, Sahu BP, Aniruddh P. Factors affecting outcome in poor grade subarachnoid haemorrhage: An institutional study. Asian J Neurosurg 2016; 11:365-371. [PMID: 27695539 PMCID: PMC4974960 DOI: 10.4103/1793-5482.149991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Context: Poor grade subarachnoid hemorrhage (SAH) is usually associated with unfavorable outcomes and optimal management is deemed complicated. Most centres follow an expectant management strategy or a less aggressive approach till patients improve to good clinical grades. This approach has been associated with higher mortality and morbidity. However, not all patients with poor clinical condition fare badly. Identification and early aggressive management of this select group of patients may lead to favorable outcomes. Settings and Design: Prospective non-randomized study. Materials and Methods: We prospectively analyzed 19 cases presented in WFNS grade 4 and 5 and factors affecting their outcome at a tertiary care centre in south India. This study was aimed at identifying those few poor grade patients who are probable candidates for a good outcome. Statistical Analysis Used: All the variables were analyzed for possible correlations with the SPSS version 13 software. The Chi-square test with a P < 0.05 was taken as statistically significant. Results: Of 19 cases, 13 were operated and good outcome was seen in 53.8% of the patients who underwent surgery and aggressive management. All 7 patients who were managed conservatively died. 15.8% of the patients had low density changes (P = 0.625). Absence of such changes was associated with a good long term outcome (P = 0.004). 9 patients had intraventricular hemorrhage at presentation and 5 patients having hydrocephalus underwent extra-ventricular drainage. Statistically significant factors precluding good outcome were the presence of infarcts and thick SAH in the cisterns. Conclusions: Poor grade (WFNS 4 and 5) SAH patients with or without ICH, IVH, if operated within 3 days can give rise to favorable outcome in around 50%. However, presence of patchy infarcts associated with thick subarachnoid blood (Fisher grade 3) precludes long term survival or meaningful recovery. Hence, aggressive management is unlikely to alter the natural history of such patients.
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Affiliation(s)
- Sannepaneni Kranthi
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Barada P Sahu
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Purohit Aniruddh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India
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20
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Oh JH, Jwa SJ, Yang TK, Lee CS, Oh K, Kang JH. Intracranial Vasospasm without Intracranial Hemorrhage due to Acute Spontaneous Spinal Subdural Hematoma. Exp Neurobiol 2015; 24:366-70. [PMID: 26713084 PMCID: PMC4688336 DOI: 10.5607/en.2015.24.4.366] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/15/2015] [Accepted: 11/24/2015] [Indexed: 11/19/2022] Open
Abstract
Spontaneous spinal subdural hematoma (SDH) is very rare. Furthermore, intracranial vasospasm (ICVS) associated with spinal hemorrhage has been very rarely reported. We present an ICVS case without intracranial hemorrhage following SDH. A 41-year-old woman was admitted to our hospital with a complaint of severe headache. Multiple intracranial vasospasms were noted on a brain CT angiogram and transfemoral cerebral angiography. However, intracranial hemorrhage was not revealed by brain MRI or CT. On day 3 after admission, weakness of both legs and urinary incontinence developed. Spine MRI showed C7~T6 spinal cord compression due to hyperacute stage of SDH. After hematoma evacuation, her symptoms gradually improved. We suggest that spinal cord evaluation should be considered in patients with headache who have ICVS, although intracranial hemorrhage would not be visible in brain images.
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Affiliation(s)
- Jung-Hwan Oh
- Department of Neurology, Jeju National University Hospital, Jeju 63241, Korea
| | - Seung-Joo Jwa
- Department of Neurology, Jeju National University Hospital, Jeju 63241, Korea
| | - Tae Ki Yang
- Department of Neurosurgery, Jeju National University Hospital, Jeju 63241, Korea
| | - Chang Sub Lee
- Department of Neurosurgery, Jeju National University Hospital, Jeju 63241, Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University Medical Center, Seoul 02841, Korea
| | - Ji-Hoon Kang
- Department of Neurology, Jeju National University Hospital, Jeju 63241, Korea
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21
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Jaja BNR, Lingsma H, Steyerberg EW, Schweizer TA, Thorpe KE, Macdonald RL. Neuroimaging characteristics of ruptured aneurysm as predictors of outcome after aneurysmal subarachnoid hemorrhage: pooled analyses of the SAHIT cohort. J Neurosurg 2015; 124:1703-11. [PMID: 26495952 DOI: 10.3171/2015.4.jns142753] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Neuroimaging characteristics of ruptured aneurysms are important to guide treatment selection, and they have been studied for their value as outcome predictors following aneurysmal subarachnoid hemorrhage (SAH). Despite multiple studies, the prognostic value of aneurysm diameter, location, and extravasated SAH clot on computed tomography scan remains debatable. The authors aimed to more precisely ascertain the relation of these factors to outcome. METHODS The data sets of studies included in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository were analyzed including data on ruptured aneurysm location and diameter (7 studies, n = 9125) and on subarachnoid clot graded on the Fisher scale (8 studies; n = 9452) for the relation to outcome on the Glasgow Outcome Scale (GOS) at 3 months. Prognostic strength was quantified by fitting proportional odds logistic regression models. Univariable odds ratios (ORs) were pooled across studies using random effects models. Multivariable analyses were adjusted for fixed effect of study, age, neurological status on admission, other neuroimaging factors, and treatment modality. The neuroimaging predictors were assessed for their added incremental predictive value measured as partial R(2). RESULTS Spline plots indicated outcomes were worse at extremes of aneurysm size, i.e., less than 4 or greater than 9 mm. In between, aneurysm size had no effect on outcome (OR 1.03, 95% CI 0.98-1.09 for 9 mm vs 4 mm, i.e., 75th vs 25th percentile), except in those who were treated conservatively (OR 1.17, 95% CI 1.02-1.35). Compared with anterior cerebral artery aneurysms, posterior circulation aneurysms tended to result in slightly poorer outcome in patients who underwent endovascular coil embolization (OR 1.13, 95% CI 0.82-1.57) or surgical clipping (OR 1.32, 95% CI 1.10-1.57); the relation was statistically significant only in the latter. Fisher CT subarachnoid clot burden was related to outcome in a gradient manner. Each of the studied predictors accounted for less than 1% of the explained variance in outcome. CONCLUSIONS This study, which is based on the largest cohort of patients so far analyzed, has more precisely determined the prognostic value of the studied neuroimaging factors. Treatment choice has strong influence on the prognostic effect of aneurysm size and location. These findings should guide the development of reliable prognostic models and inform the design and analysis of future prospective studies, including clinical trials.
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Affiliation(s)
- Blessing N R Jaja
- Division of Neurosurgery and.,Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Institute of Medical Science
| | - Hester Lingsma
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, The Netherlands
| | - Tom A Schweizer
- Division of Neurosurgery and.,Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Institute of Medical Science
| | - Kevin E Thorpe
- Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; and
| | - R Loch Macdonald
- Division of Neurosurgery and.,Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Institute of Medical Science
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Przybycien-Szymanska MM, Ashley WW. Biomarker Discovery in Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:1453-64. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/06/2015] [Accepted: 03/08/2015] [Indexed: 12/19/2022] Open
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23
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Boers AM, Zijlstra IA, Gathier CS, van den Berg R, Slump CH, Marquering HA, Majoie CB. Automatic quantification of subarachnoid hemorrhage on noncontrast CT. AJNR Am J Neuroradiol 2014; 35:2279-86. [PMID: 25104292 DOI: 10.3174/ajnr.a4042] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Quantification of blood after SAH on initial NCCT is an important radiologic measure to predict patient outcome and guide treatment decisions. In current scales, hemorrhage volume and density are not accounted for. The purpose of this study was to develop and validate a fully automatic method for SAH volume and density quantification. MATERIALS AND METHODS The automatic method is based on a relative density increase due to the presence of blood from different brain structures in NCCT. The method incorporates density variation due to partial volume effect, beam-hardening, and patient-specific characteristics. For validation, automatic volume and density measurements were compared with manual delineation on NCCT images of 30 patients by 2 radiologists. The agreement with the manual reference was compared with interobserver agreement by using the intraclass correlation coefficient and Bland-Altman analysis for volume and density. RESULTS The automatic measurement successfully segmented the hemorrhage of all 30 patients and showed high correlation with the manual reference standard for hemorrhage volume (intraclass correlation coefficient = 0.98 [95% CI, 0.96-0.99]) and hemorrhage density (intraclass correlation coefficient = 0.80 [95% CI, 0.62-0.90]) compared with intraclass correlation coefficient = 0.97 (95% CI, 0.77-0.99) and 0.98 (95% CI, 0.89-0.99) for manual interobserver agreement. Mean SAH volume and density were, respectively, 39.3 ± 31.5 mL and 62.2 ± 5.9 Hounsfield units for automatic measurement versus 39.7 ± 32.8 mL and 61.4 ± 7.3 Hounsfield units for manual measurement. The accuracy of the automatic method was excellent, with limits of agreement of -12.9-12.1 mL and -7.6-9.2 Hounsfield units. CONCLUSIONS The automatic volume and density quantification is very accurate compared with manual assessment. As such, it has the potential to provide important determinants in clinical practice and research.
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Affiliation(s)
- A M Boers
- From the Departments of Radiology (A.M.B., I.A.Z., R.v.d.B., H.A.M., C.B.M.) Biomedical Engineering and Physics (A.M.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands Institute of Technical Medicine (A.M.B.)
| | - I A Zijlstra
- From the Departments of Radiology (A.M.B., I.A.Z., R.v.d.B., H.A.M., C.B.M.)
| | - C S Gathier
- Department of Neurology (C.S.G.), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - R van den Berg
- From the Departments of Radiology (A.M.B., I.A.Z., R.v.d.B., H.A.M., C.B.M.)
| | - C H Slump
- MIRA Institute for Biomedical Technology and Technical Medicine (C.H.S.), University of Twente, Enschede, the Netherlands
| | - H A Marquering
- From the Departments of Radiology (A.M.B., I.A.Z., R.v.d.B., H.A.M., C.B.M.) Biomedical Engineering and Physics (A.M.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - C B Majoie
- From the Departments of Radiology (A.M.B., I.A.Z., R.v.d.B., H.A.M., C.B.M.)
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Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand? Neurol Res Int 2013; 2013:373458. [PMID: 24228177 PMCID: PMC3817677 DOI: 10.1155/2013/373458] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 09/02/2013] [Accepted: 09/04/2013] [Indexed: 11/21/2022] Open
Abstract
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.
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Cerebral Vasospasm with Ischemia following a Spontaneous Spinal Subarachnoid Hemorrhage. Case Rep Med 2013; 2013:934143. [PMID: 23476668 PMCID: PMC3586460 DOI: 10.1155/2013/934143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/13/2013] [Indexed: 12/04/2022] Open
Abstract
Cerebral vasospasm is a well-known consequence of aneurysmal subarachnoid hemorrhage (SAH) triggered by blood breakdown products. Here, we present the first case of cerebral vasospasm with ischemia following a spontaneous spinal SAH. A 67-year-old woman, who was on Coumadin for atrial fibrillation, presented with chest pain radiating to the back accompanied by headache and leg paresthesias. The international normalized ratio (INR) was 4.5. Ten hours after presentation, she developed loss of movement in both legs and lack of sensation below the umbilicus. Spine MRI showed intradural hemorrhage. Her coagulopathy was reversed, and she underwent T2 to T12 laminectomies. A large subarachnoid hematoma was evacuated. Given her complaint of headache preoperatively and the intraoperative finding of spinal SAH, a head CT was done postoperatively that displayed SAH in peripheral sulci. On postoperative day 5, she became obtunded. Brain MRI demonstrated focal restricted diffusion in the left frontoparietal area. Formal angiography revealed vasospasm in anterior cerebral arteries bilaterally and right middle cerebral artery. Vasospasm was treated, and she returned to baseline within 48 hours. Spontaneous spinal SAH can result in the same sequelae typically associated with aneurysmal SAH, and the clinician must have a degree of suspicion in such patients. The pathophysiological mechanisms underlying cerebral vasospasm may explain this unique case.
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Wilson DA, Nakaji P, Abla AA, Uschold TD, Fusco DJ, Oppenlander ME, Albuquerque FC, McDougall CG, Zabramski JM, Spetzler RF. A Simple and Quantitative Method to Predict Symptomatic Vasospasm After Subarachnoid Hemorrhage Based on Computed Tomography. Neurosurgery 2012; 71:869-75. [DOI: 10.1227/neu.0b013e318267360f] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Jiménez-Roldán L, Alén JF, Gómez PA, Lobato RD, Ramos A, Munarriz PM, Lagares A. Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales. J Neurosurg 2012; 118:84-93. [PMID: 22998059 DOI: 10.3171/2012.8.jns12100] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome. METHODS A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome. CONCLUSIONS The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.
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Affiliation(s)
- Luis Jiménez-Roldán
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain
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Abstract
OBJECTIVE Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many patients with SAH are seriously ill and require a prolonged intensive care unit stay. Cardiopulmonary complications are common. The management of patients with SAH focuses on the anticipation, prevention, and management of these secondary complications. DATA SOURCES Source data were obtained from a PubMed search of the medical literature. DATA SYNTHESIS AND CONCLUSION The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means. During the first 1-2 weeks after hemorrhage, patients are at risk of delayed ischemic deficits due to vasospasm, autoregulatory failure, and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty, and intra-arterial vasodilators. SAH is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
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Kramer AH, Hehir M, Nathan B, Gress D, Dumont AS, Kassell NF, Bleck TP. A comparison of 3 radiographic scales for the prediction of delayed ischemia and prognosis following subarachnoid hemorrhage. J Neurosurg 2008; 109:199-207. [PMID: 18671630 DOI: 10.3171/jns/2008/109/8/0199] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Delayed cerebral ischemia is a major cause of morbidity and death following aneurysmal subarachnoid hemorrhage and requires timely intervention for a successful outcome to be achieved. In this study the investigators compared the commonly used Fisher scale with 2 newer radiographic scales for the prediction of vasospasm, delayed infarction, and poor outcome. METHODS This was a single-center, retrospective cohort study involving 271 consecutive patients with a ruptured cerebral aneurysm. Without knowledge of subsequent events, admission CT scans were each assigned scores by using 3 different grading schemes: the Fisher, modified Fisher, and Claassen scales. For each of the scales, the relationship between an increasing score and the risk of later complications was assessed in univariate and multiple logistic regression analyses. RESULTS With the Fisher scale, the risk of complications was relatively high when the score was 3, but not for other scores. In contrast, using the other scales, there was a more linear relationship between a rising score and the frequency of complications. This was particularly true for the modified Fisher scale, in which each stepwise increase was associated with an escalating risk of vasospasm, delayed infarction, and poor prognosis. Kappa scores measuring interobserver variability among 4 CT readers were also slightly better with the newer scales. CONCLUSIONS Although the modified Fisher and Claassen scales have yet to be prospectively validated, the authors' findings suggest that the clinical performance of these systems is superior to that of the Fisher scale.
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Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Alberta, Canada.
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Avitsian R, Schubert A. Anesthetic considerations for intraoperative management of cerebrovascular disease in neurovascular surgical procedures. Anesthesiol Clin 2007; 25:441-63, viii. [PMID: 17884703 DOI: 10.1016/j.anclin.2007.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite new surgical methods and interventions a considerable number of patients who undergo neurovascular procedures emergently or electively have substantial mortality, morbidity, and disability. Sound knowledge of pathophysiology of cerebral hypoperfusion, reliable and timely information from monitoring devices, and appropriate choice of therapeutic intervention is essential for successful anesthetic management of these patients. The management of perioperative vasospasm and temporary ischemia during aneurysm clipping require an understanding of cerebral vascular pathophysiology and neuroprotective measures.
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Affiliation(s)
- Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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