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Sawarkar DP, Singh PK, Nandish HS, Sharma R, Kedia S, Meena R, Kumar R. Incidence of Rebleed Following Cerebrospinal Fluid (CSF) Drainage in Poor Grade Subarachnoid Hemorrhage: An Institutional Experience. Neurol India 2024; 72:572-577. [PMID: 39041975 DOI: 10.4103/ni.ni_622_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/18/2022] [Indexed: 07/24/2024]
Abstract
BACKGROUND The outcome of poor grade subarachnoid hemorrhage (SAH) is dismal. Some of these patients need cerebrospinal fluid (CSF) drainage procedure for the hydrocephalus and intraventricular hemorrhage (IVH) which may precipitate rebleeding. However, aneurysmal rebleed following CSF drainage procedure is controversial. OBJECTIVE Our study aimed at analyzing the effect of CSF drainage procedure on aneurysmal rebleeding. MATERIAL AND METHODS We retrospectively analyzed the records of all the consecutive patients diagnosed with poor grade aneurysmal SAH over three year period. Patients initially requiring either external ventricular drainage (EVD) or lumbar drain (LD) were included in the study group, and the rest (not requiring drainage) were included in the control group. Rebleeding was confirmed on computed tomography. The factors affecting rebleeding were analyzed. RESULTS Overall 194 patients with poor grade SAH were enrolled in the study (91 males: 103 females; mean age: 50.6 years). The study group had 91 patients (83 EVD and 8 LD) while 103 patients were in the control group. Posterior circulation aneurysms, poor grade SAH, hydrocephalus, and IVH were more common in the study group P < 0.001. The rebleeding rate was 7.6% in the study group and 8.7% in the control group. On univariate analysis size >1 cm, multiplicity, multilobularity, vasospasm, and CSF drainage were significant risk factors for rebleeding (P < 0.001). On multivariate analysis aneurysm size >1 cm, CSF overdrainage >250 ml/day were significantly associated with risk of rebleeding. CONCLUSION Ventricular drainage is essential to relieve acute hydrocephalus and drain IVH in SAH and we found no significant association between CSF drainage and rebleeding. However, rapid overdrainage of CSF can lead to aneurysm rupture, hence controlled controlled CSF drainage should be undertaken.
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Affiliation(s)
- Dattaraj P Sawarkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Almeida Xavier S, Rodrigues A, Meira T, Mota Dória H, Figueira C, Amorim J, Pestana R, Nobrega J, Franco J, Carneiro Â. Fly and treat: Endovascular treatment of ruptured aneurysms at an insular tertiary center. J Stroke Cerebrovasc Dis 2023; 32:107390. [PMID: 37866295 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107390] [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: 02/23/2023] [Revised: 09/15/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023] Open
Abstract
(Objectives) Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition associated with poor outcomes. Early intervention is critical, particularly in low-volume hospitals, which are advised to transfer aSAH patients to high-volume centers. This study examines a novel protocol implemented in 2016 at Região Autónoma da Madeira, a Portuguese island. It involves the mobilization of experienced neurointerventionalists from high-volume hospitals to provide aSAH treatment. (Methods) We conducted a retrospective analysis on 30 aSAH patients who underwent endovascular treatment at the island center between November 2016 and April 2022. Additionally, we included a comparison group of 74 aSAH patients, treated with the endovascular approach at Hospital de Braga (high volume center at Portugal mainland). (Results) There was no statistical difference in patients' clinical severity between both hospitals (median WFNS score of 1). Although 90 % of patients in the novel protocol group received treatment within 3 days, we observed a significant delay compared to Hospital de Braga. Rates of aneurysm occlusion and intra-procedure complications between the two groups were similar. At the 3-months follow-up, there were no statistically significant differences between groups regarding patients that achieved a modified Rankin score of 2 or less. However, the island center exhibited a significantly higher mortality rate. (Conclusions) Overall, our results suggest that making the neurointerventionalist fly to an insular center is feasible and allows most patients to be treated within the first 72 h, as recommended. We highlight some potential recommendations for implementing this model and discuss possible causes that might justify the high mortality rate.
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Affiliation(s)
- Sofia Almeida Xavier
- Neuroradiology department, Hospital de Braga, Portugal, 4710-243 Braga, Portugal.
| | - Alexandra Rodrigues
- Neuroradiology Unit, Hospital Central do Funchal - SESARAM, Funchal, Portugal; Neuroradiology department, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Torcato Meira
- Neuroradiology department, Hospital de Braga, Portugal, 4710-243 Braga, Portugal; School of Medicine, University of Minho, Braga, Portugal
| | - Hugo Mota Dória
- Neuroradiology Unit, Hospital Central do Funchal - SESARAM, Funchal, Portugal
| | - Carolina Figueira
- Neuroradiology Unit, Hospital Central do Funchal - SESARAM, Funchal, Portugal
| | - José Amorim
- Neuroradiology department, Hospital de Braga, Portugal, 4710-243 Braga, Portugal
| | - Ricardo Pestana
- Neurosurgery department, Hospital Central do Funchal- SESARAM, Funchal, Portugal
| | - Júlio Nobrega
- Intensive care medicine department, Hospital Central do Funchal - SESARAM. Funchal, Portugal
| | - José Franco
- Neuroradiology Unit, Hospital Central do Funchal - SESARAM, Funchal, Portugal
| | - Ângelo Carneiro
- Neuroradiology department, Hospital de Braga, Portugal, 4710-243 Braga, Portugal
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Uchikawa H, Kin T, Koizumi S, Sato K, Uchida T, Takeda Y, Koike T, Kiyofuji S, Yamashiro S, Mukasa A, Saito N. Aneurysmal Inflow Rate Coefficient Predicts Ultra-early Rebleeding in Ruptured Intracranial Aneurysms: Preliminary Report of a Computational Fluid Dynamics Study. Neurol Med Chir (Tokyo) 2023; 63:450-456. [PMID: 37612121 PMCID: PMC10687667 DOI: 10.2176/jns-nmc.2023-0003] [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: 01/21/2023] [Accepted: 05/25/2023] [Indexed: 08/25/2023] Open
Abstract
Rebleeding from a ruptured intracranial aneurysm has poor outcomes. Although numerous factors are associated with rebleeding, studies on computational fluid dynamics (CFD) on hemodynamic parameters associated with early rebleeding are scarce. In particular, no report of rebleeding in ultra-early phase exists. We aimed to elucidate the specific hemodynamic parameters associated with ultra-early rebleeding using CFD. In this study, the rebleeding group included patients with aneurysmal subarachnoid hemorrhage (aSAH) that rebled within 6 h from the onset. The control group included patients without rebleeding, observed for >10 h following the initial rupture. Clinical images after initial rupture and before rebleeding were used to build 3D vessel models for hemodynamic analysis focusing on the following parameters: time-averaged wall shear stress (WSS), normalized WSS, low shear area, oscillatory shear index, relative residence time, pressure loss coefficient, and aneurysmal inflow rate coefficient (AIRC). Five and 15 patients in the rebleeding and control groups, respectively, met the inclusion criteria. The World Federation of Neurosurgical Surgeons grade was significantly higher in the rebleeding group (p = 0.0088). Hemodynamic analysis showed significantly higher AIRC in the rebleeding group (p = 0.042). The other parameters were not significantly different between groups. There were no significant differences or correlations between SAH severity and AIRC. AIRC was identified as a hemodynamic parameter associated with ultra-early rebleeding of ruptured intracranial aneurysms. Thus, AIRC calculation may enable the prediction of ultra-early rebleeding.
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Affiliation(s)
- Hiroki Uchikawa
- Department of Neurosurgery, The University of Tokyo
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University
| | - Taichi Kin
- Department of Neurosurgery, The University of Tokyo
| | | | - Katsuya Sato
- Department of Neurosurgery, The University of Tokyo
| | | | | | | | | | | | - Akitake Mukasa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University
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Yamaguchi S, Izumo T, Sato I, Morofuji Y, Kaminogo M, Anda T, Horie N, Matsuo T. Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:2855-2864. [PMID: 37434015 DOI: 10.1007/s00701-023-05705-4] [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: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. METHODS The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms. RESULTS Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. CONCLUSIONS Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.
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Affiliation(s)
- Susumu Yamaguchi
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan.
| | - Izumi Sato
- Department of Clinical Epidemiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Makio Kaminogo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeo Anda
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
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Chen C, Wang C, Zhang C, Zhou H, Lu Z, Feng Y. Prognostic Risk Factors of One-stage Surgical Clipping in aSAH Elderly Patients with MIAs. J Craniofac Surg 2023; 34:2071-2076. [PMID: 37394694 DOI: 10.1097/scs.0000000000009387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 07/04/2023] Open
Abstract
OBJECTIVE To discuss the prognostic factors affecting the prognosis of 1-stage surgical clipping in aneurysmal subarachnoid hemorrhage (aSAH) elderly patients with multiple intracranial aneurysms (MIAs). MATERIALS AND METHODS A total of 84 elderly patients with aSAH who had MIAs and underwent 1-stage surgical clipping were retrospectively analyzed. Follow-up was conducted with patients 30 days after discharge using the Glasgow Outcome Scale (GOS). A GOS score of 1 to 3 was defined as a poor outcome, and a GOS score of 4 to 5 was defined as a good outcome. General information (gender, age, size of aneurysm, location of rupture of the responsible aneurysm, H-H grade, CT characteristics of aSAH, number of subarachnoid hemorrhages, operation opportunity, postoperative complications, and intraoperative rupture) and complications(cerebral infarction, hydrocephalus, electrolyte disturbance, and encephaledema)were recorded. Univariate analysis and multivariate regression analysis were used to analyze factors that may affect outcomes. RESULTS Univariate analysis showed that the number of SAH events ( P =0.005), intraoperative rupture ( P =0.048) and postoperative complications ( P =0.002) were associated with the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. Multivariate analysis showed that the number of SAH events (odds ratio [OR] 4.740, 95% confidence interval [CI] 1.056 to 21.282, P =0.042) and postoperative complications (OR 4.531, 95% CI 1.266 to 16.220, P =0.020) were independently associated with the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. CONCLUSIONS The number of SAH events and postoperative complications are independent risk factors for the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. These factors contribute to the timely treatment of potentially related patients.
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Affiliation(s)
- Cheng Chen
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao City China
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Doherty RJ, Henry J, Brennan D, Javadpour M. Predictive factors for pre-intervention rebleeding in aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:24. [PMID: 36562905 DOI: 10.1007/s10143-022-01930-0] [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: 08/18/2022] [Revised: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
Rebleeding before intervention is a devastating complication of aneurysmal subarachnoid haemorrhage (aSAH). It often occurs early and is associated with poor outcomes. We present a systematic review and meta-analysis to identify potential predictors of rebleeding in aSAH. A database search identified studies detailing the occurrence of pre-intervention rebleeding in aSAH, and 809 studies were screened. The association between rebleeding and a variety of demographic, clinical, and radiological factors was examined using random effects meta-analyses. Fifty-six studies totalling 33,268 patients were included. Rebleeding occurred in 3,223/33,268 patients (11.1%, 95%CI 9.4-13), with risk decreasing by approximately 0.2% per year since 1981. Systolic blood pressure (SBP) during admission was higher in patients who rebled compared with those who did not (MD 7.4 mmHg, 95%CI 2.2 - 12.7), with increased risk in cohorts with SBP > 160 mmHg (RR 2.12, 95%CI 1.35-3.34), but not SBP > 140 mmHg. WFNS Grades IV-V (RR 2.05, 95%CI 1.13-3.74) and Hunt-Hess grades III-V (RR 2.12, 95%CI 1.38-3.28) were strongly associated with rebleeding. Fisher grades IV (RR 2.24, 95%CI 1.45-3.49) and III-IV (RR 2.05, 95%CI 1.17-3.6) were also associated with an increased risk. Awareness of potential risk factors for rebleeding is important when assessing patients with aSAH to ensure timely management in high-risk cases. Increased SBP during admission, especially > 160 mmHg, poorer clinical grades, and higher radiological grades are associated with an increased risk. These results may also aid in designing future studies assessing interventions aimed at reducing the risk of rebleeding.
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Affiliation(s)
- Ronan J Doherty
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - Jack Henry
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - David Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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Gathier CS, Zijlstra IJAJ, Rinkel GJE, Groenhof TKJ, Verbaan D, Coert BA, Müller MCA, van den Bergh WM, Slooter AJC, Eijkemans MJC. Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2022; 72:154124. [PMID: 36208555 DOI: 10.1016/j.jcrc.2022.154124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/04/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVE Blood pressure is presumably related to rebleeding and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (aSAH) and could serve as a target to improve outcome. We assessed the associations between blood pressure and rebleeding or DCI in aSAH-patients. MATERIALS AND METHODS In this observational study in 1167 aSAH-patients admitted to the intensive care unit (ICU), adjusted hazard ratio's (aHR) were calculated for the time-dependent association of blood pressure and rebleeding or DCI. The aHRs were presented graphically, relative to a reference mean arterial pressure (MAP) of 100 mmHg and systolic blood pressure (sBP) of 150 mmHg. RESULTS A MAP below 100 mmHg in the 6, 3 and 1 h before each moment in time was associated with a decreased risk of rebleeding (e.g. within 6 h preceding rebleeding: MAP = 80 mmHg: aHR 0.30 (95% confidence interval (CI) 0.11-0.80)). A MAP below 60 mmHg in the 24 h before each moment in time was associated with an increased risk of DCI (e.g. MAP = 50 mmHg: aHR 2.59 (95% CI 1.12-5.96)). CONCLUSIONS Our results suggest that a MAP below 100 mmHg is associated with decreased risk of rebleeding, and a MAP below 60 mmHg with increased risk of DCI.
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Affiliation(s)
- Celine S Gathier
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - IJsbrand A J Zijlstra
- Department of Radiology, Amsterdam University Medical Center, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - T Katrien J Groenhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Donnelly P, McMillen J, Raman V, Jiwrajka M. Intracranial aneurysms: The era of endovascular intervention in Australia. J Clin Neurosci 2022; 97:127-135. [DOI: 10.1016/j.jocn.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/11/2021] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
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ABO blood group in aneurysmal subarachnoid haemorrhage-a pilot study. Acta Neurochir (Wien) 2022; 164:507-515. [PMID: 35039955 DOI: 10.1007/s00701-021-05079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To evaluate the distribution and impact of ABO blood group on the baseline characteristics and clinical outcomes of patients presenting with aneurysmal subarachnoid haemorrhage (aSAH). METHODS Retrospective, single-centre study of patients admitted to a neurosurgical department in the UK, with a diagnosis of spontaneous subarachnoid haemorrhage between May 2014 and January 2020. Patients were categorised by ABO blood type and by Rhesus status. Clinical outcomes such as initial bleeding, rebleeding, delayed cerebral ischaemia (DIND) and venous thromboembolism were analysed in relation to the size of their association with ABO blood type. Hospital mortality rate, Glasgow Outcome Score (GOS) - at discharge and 3 months post-ictus, requirement for ventriculoperitoneal shunt insertion, discharge destination and inpatient length of stay were also considered. RESULTS Four-hundred twelve adult patients admitted with aSAH were included in our analysis. The distribution of ABO group or Rhesus status in our cohort did not differ significantly from the general population in the UK. Blood group A patients had a significantly increased risk of developing DIND, compared with non-blood group A patients (OR, 1.88 [95% CI: 1.10-3.21]). CONCLUSIONS ABO blood type appears to influence aSAH sequelae. Blood group A patients are at highest risk of DIND following aSAH.
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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Browne D, Simms H. Radiological investigations in non-aneurysmal subarachnoid haemorrhage: A 5-year review. BRAIN AND SPINE 2022; 2:100913. [PMID: 36248176 PMCID: PMC9560667 DOI: 10.1016/j.bas.2022.100913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
Abstract
All patients with a Fisher grade 2 bleed and a negative CT angiogram had catheter angiography negative for any abnormality. Neuroradiologists identified vascular abnormalities not reported by district general hospitals. Follow-up MRI may be a useful adjunct in subarachnoid haemorrhage.
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Maagaard M, Karlsson WK, Ovesen C, Gluud C, Jakobsen JC. Interventions for altering blood pressure in people with acute subarachnoid haemorrhage. Cochrane Database Syst Rev 2021; 11:CD013096. [PMID: 34787310 PMCID: PMC8596376 DOI: 10.1002/14651858.cd013096.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Subarachnoid haemorrhage has an incidence of up to nine per 100,000 person-years. It carries a mortality of 30% to 45% and leaves 20% dependent in activities of daily living. The major causes of death or disability after the haemorrhage are delayed cerebral ischaemia and rebleeding. Interventions aimed at lowering blood pressure may reduce the risk of rebleeding, while the induction of hypertension may reduce the risk of delayed cerebral ischaemia. Despite the fact that medical alteration of blood pressure has been clinical practice for more than three decades, no previous systematic reviews have assessed the beneficial and harmful effects of altering blood pressure (induced hypertension or lowered blood pressure) in people with acute subarachnoid haemorrhage. OBJECTIVES To assess the beneficial and harmful effects of altering arterial blood pressure (induced hypertension or lowered blood pressure) in people with acute subarachnoid haemorrhage. SEARCH METHODS We searched the following from inception to 8 September 2020 (Chinese databases to 27 January 2019): Cochrane Stroke Group Trials register; CENTRAL; MEDLINE; Embase; five other databases, and five trial registries. We screened reference lists of review articles and relevant randomised clinical trials. SELECTION CRITERIA Randomised clinical trials assessing the effects of inducing hypertension or lowering blood pressure in people with acute subarachnoid haemorrhage. We included trials irrespective of publication type, status, date, and language. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We assessed the risk of bias of all included trials to control for the risk of systematic errors. We performed trial sequential analysis to control for the risks of random errors. We also applied GRADE. Our primary outcomes were death from all causes and death or dependency. Our secondary outcomes were serious adverse events, quality of life, rebleeding, delayed cerebral ischaemia, and hydrocephalus. We assessed all outcomes closest to three months' follow-up (primary point of interest) and maximum follow-up. MAIN RESULTS We included three trials: two trials randomising 61 participants to induced hypertension versus no intervention, and one trial randomising 224 participants to lowered blood pressure versus placebo. All trials were at high risk of bias. The certainty of the evidence was very low for all outcomes. Induced hypertension versus control Two trials randomised participants to induced hypertension versus no intervention. Meta-analysis showed no evidence of a difference between induced hypertension versus no intervention on death from all causes (risk ratio (RR) 1.60, 95% confidence interval (CI) 0.57 to 4.42; P = 0.38; I2 = 0%; 2 trials, 61 participants; very low-certainty evidence). Trial sequential analyses showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. Meta-analysis showed no evidence of a difference between induced hypertension versus no intervention on death or dependency (RR 1.29, 95% CI 0.78 to 2.13; P = 0.33; I2 = 0%; 2 trials, 61 participants; very low-certainty evidence). Trial sequential analyses showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. Meta-analysis showed no evidence of a difference between induced hypertension and control on serious adverse events (RR 2.24, 95% CI 1.01 to 4.99; P = 0.05; I2 = 0%; 2 trials, 61 participants; very low-certainty evidence). Trial sequential analysis showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. One trial (41 participants) reported quality of life using the Stroke Specific Quality of Life Scale. The induced hypertension group had a median of 47 points (interquartile range 35 to 55) and the no-intervention group had a median of 49 points (interquartile range 35 to 55). The certainty of evidence was very low. One trial (41 participants) reported rebleeding. Fisher's exact test (P = 1.0) showed no evidence of a difference between induced hypertension and no intervention on rebleeding. The certainty of evidence was very low. Trial sequential analysis showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. One trial (20 participants) reported delayed cerebral ischaemia. Fisher's exact test (P = 1.0) showed no evidence of a difference between induced hypertension and no intervention on delayed cerebral ischaemia. The certainty of the evidence was very low. Trial sequential analysis showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. None of the trials randomising participants to induced hypertension versus no intervention reported on hydrocephalus. No subgroup analyses could be conducted for trials randomising participants to induced hypertension versus no intervention. Lowered blood pressure versus control One trial randomised 224 participants to lowered blood pressure versus placebo. The trial only reported on death from all causes. Fisher's exact test (P = 0.058) showed no evidence of a difference between lowered blood pressure versus placebo on death from all causes. The certainty of evidence was very low. AUTHORS' CONCLUSIONS Based on the current evidence, there is a lack of information needed to confirm or reject minimally important intervention effects on patient-important outcomes for both induced hypertension and lowered blood pressure. There is an urgent need for trials assessing the effects of altering blood pressure in people with acute subarachnoid haemorrhage. Such trials should use the SPIRIT statement for their design and the CONSORT statement for their reporting. Moreover, such trials should use methods allowing for blinded altering of blood pressure and report on patient-important outcomes such as mortality, rebleeding, delayed cerebral ischaemia, quality of life, hydrocephalus, and serious adverse events.
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Affiliation(s)
- Mathias Maagaard
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - William K Karlsson
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen NV, Denmark
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus C Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Kim D, Pyen J, Whang K, Cho S, Jang Y, Kim J, Koo Y, Choi J. Factors associated with rebleeding after coil embolization in patients with aneurysmal subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2021; 24:36-43. [PMID: 34695883 PMCID: PMC8984641 DOI: 10.7461/jcen.2021.e2021.05.006] [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: 05/06/2021] [Accepted: 08/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate, and hemorrhage amounts and perioperative rebleeding importantly determines prognosis. However, despite adequate treatment, prognosis is poor in many ruptured aneurysm cases. In this study, we identified and evaluated factors related to perioperative rebleeding in patients with aSAH. Methods The medical and surgical records of 166 patients that underwent endovascular embolization for a ruptured cerebral aneurysm at a single institution from 2014 to 2016 were retrospectively analyzed to identify risk factors of rebleeding. All patients were examined for risk factors and evaluated for increased hemorrhage by brain computed tomography at 3 days after surgery. Results This series included 54 men (32.5%) and 112 women (67.5%) of mean age 58.3±14.3 years. After procedures, 26 patients (15.7%) experienced rebleeding, and 1 of these (0.6%) experienced an intraoperative aneurysmal rupture. External ventricular drainage (EVD) (odds ratio [OR] 5.389, [95% confidence interval (CI) 1.171- 24.801]) and modified Fisher grade (OR 2.037, [95% CI 1.077-3.853]) were found to be independent risk factors of rebleeding, and perioperative rebleeding was strongly associated with patient outcomes (p<0.001). Conclusions We concluded the rebleeding risk after aSAH is greater in patients with large hemorrhage amounts and a high pre-operative modified Fisher grade, and thus, we caution neurosurgeons should take care in such cases.
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Affiliation(s)
- Donghee Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jinsu Pyen
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sungmin Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeongyu Jang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Younmoo Koo
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106075. [PMID: 34481320 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.
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15
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Hvas CL, Hvas AM. Hemostasis and Fibrinolysis following Aneurysmal Subarachnoid Hemorrhage: A Systematic Review on Additional Knowledge from Dynamic Assays and Potential Treatment Targets. Semin Thromb Hemost 2021; 48:356-381. [PMID: 34261149 DOI: 10.1055/s-0041-1730346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mortality after aneurysmal subarachnoid hemorrhage (aSAH) is augmented by rebleeding and delayed cerebral ischemia (DCI). A range of assays evaluating the dynamic process of blood coagulation, from activation of clotting factors to fibrinolysis, has emerged and a comprehensive review of hemostasis and fibrinolysis following aSAH may reveal targets of treatment. We conducted a systematic review of existing literature assessing coagulation and fibrinolysis following aSAH, but prior to treatment. PubMed, Embase, and Web of Science were searched on November 18, 2020, without time boundaries. In total, 45 original studies were eventually incorporated into this systematic review, divided into studies presenting data only from conventional or quantitative assays (n = 22) and studies employing dynamic assays (n = 23). Data from conventional or quantitative assays indicated increased platelet activation, whereas dynamic assays detected platelet dysfunction possibly related to an increased risk of rebleeding. Secondary hemostasis was activated in conventional, quantitative, and dynamic assays and this was related to poor neurological outcome and mortality. Studies systematically investigating fibrinolysis were sparse. Measurements from conventional or quantitative assays, as well as dynamic fibrinolysis assays, revealed conflicting results with normal or increased lysis and changes were not associated with outcome. In conclusion, dynamic assays were able to detect reduced platelet function, not revealed by conventional or quantitative assays. Activation of secondary hemostasis was found in both dynamic and nondynamic assays, while changes in fibrinolysis were not convincingly demonstrable in either dynamic or conventional or quantitative assays. Hence, from a mechanistic point of view, desmopressin to prevent rebleeding and heparin to prevent DCI may hold potential as therapeutic options. As changes in fibrinolysis were not convincingly demonstrated and not related to outcome, the use of tranexamic acid prior to aneurysm closure is not supported by this review.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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16
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Mahta A, Murray K, Reznik ME, Thompson BB, Wendell LC, Furie KL. Early Neurological Changes and Interpretation of Clinical Grades in Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105939. [PMID: 34171650 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Hunt and Hess (HH) and World Federation of Neurological Surgeons (WFNS) grades are commonly used to report clinical severity of aneurysmal subarachnoid hemorrhage (aSAH). We sought to determine the impact of early neurological changes and the timing of clinical grade assignment on the prognostication accuracy. METHODS We retrospectively reviewed a cohort of consecutive patients with aSAH who were admitted to an academic center. Patients with confirmed aneurysmal cause were included. Relevant clinical data including daily clinical grades, imaging data and functional outcome were analyzed. Favorable outcome was defined as mRS 0 to 3. Early neurological improvement (ENI) and early neurological deterioration (END) were respectively defined as any improvement or deterioration of HH grades from hospital day 1 to the earliest time from hospital day 2 to 5. RESULTS Of 310 patients, 24% experienced early neurological changes from hospital day 1 to 3. For each point increase in HH grades from day 1 to day 3, the odds ratio for worse outcome was 2.57 (95% CI [1.74-3.79]) and for each point decrease in HH grades from day 1 to day 3, the odds ratio for worse outcome was 0.28 (95% CI [0.17-0.47]). Receiver Operating Characteristic curve analysis revealed that clinical grades on day 3 had higher accuracy in predicting worse outcome than clinical grades on day 1. CONCLUSION Early changes in neurological status can alter trajectory of hospital course and functional outcome. The prognostic accuracy of the clinical grades from hospital day 3 is significantly greater than those on admission.
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Affiliation(s)
- Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Kayleigh Murray
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael E Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Bradford B Thompson
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Linda C Wendell
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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17
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Ultra-Early Induction of General Anesthesia for Reducing Rebleeding Rates in Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105926. [PMID: 34171637 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/16/2021] [Accepted: 05/24/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Rebleeding of aneurysmal subarachnoid hemorrhage (aSAH) is one of the significant risk factors for poor clinical outcome. The rebleeding risk is the highest during the acute phase with an approximate rebleeding rate of 9-17% within the first 24 h. Theoretically, general anesthesia can stabilize a patient's vital signs; however, its effectiveness as initial management for preventing post-aSAH rebleeding remains unclear. The purpose of this study was to determine the feasibility and safety of ultra-early general anesthesia induction for reducing the rebleeding rates among patients with aSAH. MATERIALS AND METHODS We retrospectively evaluated patients with aSAH who were admitted to our department between January 2013 and December 2019. All the patients underwent ultra-early general anesthesia induction as initial management regardless of their severity. We evaluated the rebleeding rate before definitive treatment, factors influencing rebleeding, and general anesthesia complications. RESULTS We included 191 patients with two-third of them having a poor clinical grade (World Federation of Neurological Society [WFNS] grade IV or V). The median duration from admission to general anesthesia induction was 22 min. Rebleeding before definitive treatment occurred in nine patients (4.7%). There were significant differences in the Glasgow Coma Scale score (p = 0.047), WFNS grade (p = 0.02), and dissecting aneurysm (p <0.001) between the rebleeding and non-rebleeding patients. There were no cases of unsuccessful tracheal intubation or rebleeding during general anesthesia induction. CONCLUSION Ultra-early general anesthesia induction could be performed safely in patients with aSAH, regardless of the WFNS grade; moreover, it resulted in lower rebleeding rate than that reported in previous epidemiological reports.
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18
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de Winkel J, van der Jagt M, Lingsma HF, Roozenbeek B, Calvillo E, Chou SHY, Dziedzic PH, Etminan N, Huang J, Ko NU, Loch MacDonald R, Martin RL, Potu NR, Venkatasubba Rao CP, Vergouwen MDI, Suarez JI. International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2021; 10:jcm10040762. [PMID: 33672807 PMCID: PMC7917699 DOI: 10.3390/jcm10040762] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 12/18/2022] Open
Abstract
Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24–48 h, and eight percent within 48–72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other p < 0.001, and EU vs. other p < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other p < 0.001, EU vs. other p < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, p < 0.05) and other centers (81%, p < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, p < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
| | - Eusebia Calvillo
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Sherry H-Y. Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Peter H. Dziedzic
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Nima Etminan
- Department of Neurosurgery, University of Heidelberg School of Medicine, 69117 Mannheim, Germany;
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Nerissa U. Ko
- Department of Neurology, UCSF Weill Institute for Neurosciences, UCSF School of Medicine, San Francisco, CA 94143, USA;
| | - Robert Loch MacDonald
- UCSF Fresno Department of Neurosurgery, UCSF School of Medicine, University Neuroscience Institute, Fresno, CA 93701, USA;
| | - Renee L. Martin
- Department of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Niteesh R. Potu
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Chethan P. Venkatasubba Rao
- Departments of Neurology, Neurosurgery, and Center for Space medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Mervyn D. I. Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands;
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence:
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19
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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20
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Horie N, Sato S, Kaminogo M, Morofuji Y, Izumo T, Anda T, Matsuo T. Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage. J Neurosurg 2020; 133:1401-1410. [PMID: 31518984 DOI: 10.3171/2019.6.jns19704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysm rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding might help to identify patients who will benefit from acute management. This study was performed to investigate the predictors of aneurysm rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods. METHODS The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. The authors performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and outcome after SAH. RESULTS Preoperative rebleeding occurred in 7.2% of patients. Patient age (p = 0.01), multiple aneurysms (p < 0.01), aneurysm size (p < 0.0001), and heart disease (p = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery [ACoA]), family history (p = 0.02), preoperative rebleeding (p < 0.01), and clipping/coiling (p < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR 4.00; 95% CI 1.82-8.80; p < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (p < 0.0001) and intraoperative rebleeding (p < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH. CONCLUSIONS Aneurysm rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.
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Affiliation(s)
| | - Shuntaro Sato
- 2Clinical Research Center, Nagasaki University School of Medicine, Nagasaki, Japan
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21
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Does Transport by a Doctor Helicopter Affect Blood Pressure in Stroke Patients? Air Med J 2020; 39:360-363. [PMID: 33012472 DOI: 10.1016/j.amj.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/01/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Herein we investigate whether transportation by doctor helicopter (DH) affects blood pressure (BP) in stroke patients. METHODS A total of 119 stroke patients treated by the DH between April 2015 and March 2019 were analyzed. The average BP before and after admission to the DH was compared for all stroke patients. The average BP before and after in the infarct group (cerebral infarction/transient ischemic attack) and the bleeding group (cerebral hemorrhage/subarachnoid hemorrhage) was compared. The average BP before and after in Glasgow Coma Scale (GCS) mild, moderate, and severe groups was also compared. Statistical analysis was performed using a paired t-test. RESULTS The average BP of stroke patients increased after admission to the DH (before = 156.8 mm Hg and after = 165.0 mm Hg, P < .01). Both the infarct group and the bleeding group had elevated BP after admission (infarct group: before = 151.2 mm Hg and after = 157.8 mm Hg, P = .02; bleeding group: before = 167.5 mm Hg and after = 178.5 mm Hg, P = .04). The BP after admission was elevated only in the mild GCS group. CONCLUSION When transporting conscious stroke patients by the DH, it is necessary to keep in mind that BP may elevate.
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22
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Howard BM, Hu R, Barrow JW, Barrow DL. Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage. Neurosurg Focus 2020; 47:E20. [PMID: 31786554 DOI: 10.3171/2019.9.focus19653] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/20/2019] [Indexed: 11/06/2022]
Abstract
Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.
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Affiliation(s)
- Brian M Howard
- 1Department of Neurosurgery, and.,2Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta; and
| | - Ranliang Hu
- 2Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta; and
| | - Jack W Barrow
- 3Mercer University School of Medicine, Savannah, Georgia
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Tasiou A, Brotis AG, Paschalis T, Tzerefos C, Kapsalaki EZ, Giannis T, Tzannis A, Fountas KN. Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience. Int J Neurosci 2020; 132:38-50. [PMID: 32746674 DOI: 10.1080/00207454.2020.1801676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Thanasis Paschalis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Eftychia Z Kapsalaki
- Department of Neuroradiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Theofanis Giannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alkiviadis Tzannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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Post R, Germans MR, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. Update of the ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage (ULTRA) trial: statistical analysis plan. Trials 2020; 21:199. [PMID: 32070395 PMCID: PMC7029526 DOI: 10.1186/s13063-020-4118-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recurrent bleeding from an intracranial aneurysm after subarachnoid hemorrhage (SAH) is associated with unfavorable outcome. Recurrent bleeding before aneurysm occlusion can be performed occurs in up to one in five patients and most often happens within the first 6 h after the primary hemorrhage. Reducing the rate of recurrent bleeding could be a major factor in improving clinical outcome after SAH. Tranexamic acid (TXA) reduces the risk of recurrent bleeding but has thus far not been shown to improve functional outcome, probably because of a higher risk of delayed cerebral ischemia (DCI). To reduce the risk of ultraearly recurrent bleeding, TXA should be administered as soon as possible after diagnosis and before transportation to a tertiary care center. If TXA is administered for a short duration (i.e., < 24 h), it may not increase the risk of DCI. The aim of this paper is to present in detail the statistical analysis plan (SAP) of the ULTRA trial (ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage), which is currently enrolling patients and investigating whether ultraearly and short-term TXA treatment in patients with aneurysmal SAH improves clinical outcome at 6 months. METHODS/DESIGN The ULTRA trial is a multicenter, prospective, randomized, open, blinded endpoint, parallel-group trial currently ongoing at 8 tertiary care centers and 16 of their referral centers in the Netherlands. Participants are randomized to standard care or to receive TXA at a loading dose of 1 g, immediately followed by 1 g every 8 h for a maximum of 24 h, in addition to standard care, as soon as SAH is diagnosed. In the TXA group, TXA administration is stopped immediately prior to treatment (coil or clip) of the causative aneurysm. Primary outcome is the modified Rankin Scale (mRS) score at 6 months after SAH, dichotomized into good (mRS 0-3) and poor (mRS 4-6) outcomes, assessed blind to treatment allocation. Secondary outcomes include case fatalities at 30 days and at 6 months and causes of poor clinical outcome. Safety outcomes are recurrent bleeding, DCI, hydrocephalus, per-procedural complications, and other complications such as infections occurring during hospitalization. Data analyses will be according to this prespecified SAP. TRIAL REGISTRATION Netherlands Trial Register, NTR3272. Registered on 25 January 2012. ClinicalTrials.gov, NCT02684812. Registered on 17 February 2016.
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Affiliation(s)
- René Post
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, PO Box 85060, Utrecht, 3508 AB, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands.
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Darkwah Oppong M, Gümüs M, Pierscianek D, Herten A, Kneist A, Wrede K, Barthel L, Forsting M, Sure U, Jabbarli R. Aneurysm rebleeding before therapy: a predictable disaster? J Neurosurg 2019; 131:1473-1480. [PMID: 30544356 DOI: 10.3171/2018.7.jns181119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk. METHODS All patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors. RESULTS Data from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction. CONCLUSIONS Certain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Michael Forsting
- 2Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
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An H, Park J, Kang DH, Son W, Lee YS, Kwak Y, Ohk B. Should Cerebral Angiography Be Avoided within Three Hours after Subarachnoid Hemorrhage? J Korean Neurosurg Soc 2019; 62:526-535. [PMID: 31484228 PMCID: PMC6732357 DOI: 10.3340/jkns.2018.0238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 05/09/2019] [Indexed: 11/27/2022] Open
Abstract
Objective While the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH.
Methods Patients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans.
Results In-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p =0.032). Cerebral angiography after SAH was performed on 88 patients ≤3 hours, 74 patients between 3–6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ≤3 hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography.
Conclusion Despite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.
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Affiliation(s)
- Hong An
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Wonsoo Son
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young-Sup Lee
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Youngseok Kwak
- Department of Neurosurgery, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Boram Ohk
- Clinical Trial Center, Kyungpook National University Hospital, Daegu, Korea
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Subarachnoid Hemorrhage in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Post R, Germans MR, Boogaarts HD, Ferreira Dias Xavier B, Van den Berg R, Coert BA, Vandertop WP, Verbaan D. Short-term tranexamic acid treatment reduces in-hospital mortality in aneurysmal sub-arachnoid hemorrhage: A multicenter comparison study. PLoS One 2019; 14:e0211868. [PMID: 30730957 PMCID: PMC6366882 DOI: 10.1371/journal.pone.0211868] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Recurrent bleeding is one of the major causes of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Antifibrinolytic therapy is known to reduce recurrent bleeding, however, its beneficial effect on outcome remains unclear. The effect of treatment with tranexamic acid (TXA) until aneurysm treatment on clinical outcome is evaluated. Methods Patients with an aSAH from two high-volume tertiary referral treatment centers in the Netherlands, Academic Medical Center (AMC) and Radboud University Medical Center (RUMC), between January 2012 and December 2015 were included. Patients were classified into one of two groups; standard treatment or TXA treatment. Demographic and clinical characteristics, in-hospital complications and clinical outcome were compared between the two groups. Multivariate logistic regression was used to adjust for the influence of treatment center and baseline differences. Results Standard treatment was given in 509 patients, and 119 patients received additional TXA therapy before aneurysm occlusion. Patients treated with TXA did not experience less recurrent bleeding adjusted or unadjusted for treatment center (adjusted odds ratio [aOR] 0.80, 95% confidence interval [95% CI]: 0.37–1.73). In-hospital mortality, was significantly lower in the TXA group than the standard care group (adjusted OR [aOR] 0.42, 95% CI: 0.20–0.85). Poor outcome (mRS 4–6) assessed after six months was not different between treatment groups (aOR 1.05, 95% CI: 0.64–1.74). Conclusions Pooled data from two high-volume treatment centers did not show improved clinical outcome after additional TXA treatment in aSAH patients. However, TXA treatment was associated with a decrease in mortality.
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Affiliation(s)
- R. Post
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - M. R. Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zürich, Zürich, Switzerland
| | - H. D. Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - R. Van den Berg
- Department of Radiology, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - B. A. Coert
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - W. P. Vandertop
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - D. Verbaan
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
- * E-mail:
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Francoeur CL, Roh D, Schmidt JM, Mayer SA, Falo MC, Agarwal S, Connolly ES, Claassen J, Elkind MS, Park S. Desmopressin administration and rebleeding in subarachnoid hemorrhage: analysis of an observational prospective database. J Neurosurg 2019; 130:502-508. [PMID: 29393750 PMCID: PMC6688966 DOI: 10.3171/2017.7.jns17990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/14/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Rebleeding remains a frequent and catastrophic event leading to poor outcome after subarachnoid hemorrhage (SAH). Reduced platelet function after the initial bleed is associated with higher risk of early rebleeding. Desmopressin (DDAVP) is a well-known hemostatic agent, and recent guidelines already suggest its use in individuals exposed to antiplatelet drugs. The authors hypothesized that DDAVP administration in patients with SAH at admission would be associated with lower risks of rebleeding. METHODS The authors performed an observational cohort study of patients enrolled in the Columbia University SAH Outcome Project between August 1996 and July 2015. The authors compared the rate of rebleeding between patients who were and those who were not treated with DDAVP. After adjustment for known predictors, logistic regression was used to measure the association between treatment with DDAVP and risks of rebleeding. RESULTS Among 1639 patients with SAH, 12% were treated with DDAVP. The main indication for treatment was suspected exposure to an antiplatelet agent. The overall incidence of rebleeding was 9% (1% among patients treated with DDAVP compared with 8% among those not treated). After adjustment for antiplatelet use and known predictors, treatment with DDAVP was associated with a 45% reduction in the risks of rebleeding (adjusted OR 0.55, 95% CI 0.27-0.97). DDAVP was associated with a higher incidence of hyponatremia but not with thrombotic events or delayed cerebral ischemia. CONCLUSIONS Treatment with DDAVP was associated with a lower risk of rebleeding among patients with SAH. These findings support further study of DDAVP as first-line therapy for medical hemostasis in patients with SAH.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada; Department of Critical Care, CHU de Québec—Université Laval, 1401 18e rue Québec, Québec G1J 1Z4, Canada
| | - David Roh
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - J. Michael Schmidt
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Stephan A. Mayer
- Department of Neurology, Neuroscience Institute, Henry Ford Health System, 2799 W. Grand Blvd, Detroit MI 48202
| | - M. Cristina Falo
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Sachin Agarwal
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - E. Sander Connolly
- Department of Neurosurgery, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States, United States
| | - Jan Claassen
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Mitchell S Elkind
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Soojin Park
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
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Sudden intracerebral aneurysm rupture during endovascular coiling. Acta Neurochir (Wien) 2018; 160:2409-2410. [PMID: 30367251 DOI: 10.1007/s00701-018-3703-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
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Ezhar Y, D'Aragon F, Echave P. Hemodynamic responses to tracheal intubation with Bonfils compared to C-MAC videolaryngoscope: a randomized trial. BMC Anesthesiol 2018; 18:124. [PMID: 30193574 PMCID: PMC6129002 DOI: 10.1186/s12871-018-0592-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 08/28/2018] [Indexed: 11/10/2022] Open
Abstract
Background Direct laryngoscopy (DL) produce tachycardia and hypertension that could be fatal in a patient with a brain injury. Bonfils fiberscope and C-MAC videolaryngoscope are associated with little hemodynamic instability compared to DL. Scientific evidence comparing these two alternatives does not exist. We conducted this study to determine the hemodynamic effects of Bonfils compared to C-MAC in patients undergoing elective surgery. Methods Fifty (50) patients listed for elective surgery were randomly assigned to endotracheal intubation with Bonfils or C-MAC. After a standardized induction, intubation was done via the retromolar approach (Bonfils group) or via videolaryngoscopy (C-MAC group). A research assistant, who was not blinded to the intervention, recorded heart rate (HR) and arterial blood pressure (systolic, diastolic and mean arterial blood pressure [MAP]) at induction and at every minute during the 5 min post intubation. The primary outcome was the hemodynamic response to intubation, as verified every minute for the first 5 min compared to baseline value. Results After randomization, the two groups were comparable except for ASA I/II ratio which was slightly higher in the C-MAC group (p = 0.046). Heart rate (p = 0.40) and MAP (p = 0.30) were comparable between the two groups within 5 min post intubation. Intubation time was shorter with C-MAC than with Bonfils (30 ± 2 s vs 38 ± 2 s; p = 0.02). Conclusion Hemodynamic responses to tracheal intubation using the Bonfils fiberscope is comparable to the C-MAC videolaryngoscope among patients scheduled for an elective surgery. In light of these findings, using either technique appears to be a reasonable course of action. Trial registration ISRCTN #34923, retrospectively registered, 26/03/2018. Electronic supplementary material The online version of this article (10.1186/s12871-018-0592-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Youssef Ezhar
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Universite de Sherbrooke, 3001 12th Avenue N., Sherbrooke, Quebec, J1H 5N4, Canada
| | - Frederick D'Aragon
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Universite de Sherbrooke, 3001 12th Avenue N., Sherbrooke, Quebec, J1H 5N4, Canada. .,Research Centre, Centre Hospitalier Universitaire de Sherbrooke and Faculty of Medicine and Health Sciences, Universite de Sherbrooke, Sherbrooke, Quebec, J1H 5N4, Canada.
| | - Pablo Echave
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Universite de Sherbrooke, 3001 12th Avenue N., Sherbrooke, Quebec, J1H 5N4, Canada
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Maagaard M, Karlsson WK, Ovesen C, Gluud C, Jakobsen JC. Interventions for altering blood pressure in people with acute subarachnoid haemorrhage. Hippokratia 2018. [DOI: 10.1002/14651858.cd013096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Mathias Maagaard
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - William K Karlsson
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Christian Ovesen
- Bispebjerg Hospital, University of Copenhagen; Department of Neurology; Bispebjerg Bakke 23 Copenhagen NV Denmark 2400
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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van Lieshout JH, Pumplün I, Fischer I, Kamp MA, Cornelius JF, Steiger HJ, Boogaarts HD, Petridis AK, Beseoglu K. Volume of cerebrospinal fluid drainage as a predictor for pretreatment aneurysmal rebleeding. J Neurosurg 2018; 128:1778-1784. [DOI: 10.3171/2017.2.jns162748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEInitiation of external CSF drainage has been associated with a significant increase in rebleeding probability after aneurysmal subarachnoid hemorrhage (aSAH). However, the implications for acute management are uncertain. The purpose of this study was to evaluate the role of the amount of drained CSF on aneurysmal rebleeding.METHODSConsecutive patients with aSAH were analyzed retrospectively. Radiologically confirmed cases of aneurysmal in-hospital rebleeding were identified and predictor variables for rebleeding were retrieved from hospital records. Clinical predictors were identified through multivariate analysis, and logistic regression analysis was performed to ascertain the cutoff value for the rebleeding probability.RESULTSThe study included 194 patients. Eighteen cases (9.3%) of in-hospital rebleeding could be identified. Using multivariate analysis, in-hospital rebleeding was significantly associated with initiation of CSF drainage (p = 0.001) and CSF drainage volume (63 ml [interquartile range (IQR) 55–69 ml] vs 25 ml [IQR 10–35 ml], p < 0.001). Logistic regression showed that 58 ml of CSF drainage within 6 hours results in a 50% rebleeding probability. The relative risk (RR) for rebleeding after drainage of more than 60 ml in 6 hours was 5.4 times greater compared with patients with less CSF drainage (RR 5.403, 95% CI 2.481–11.767; p < 0.001, number needed to harm = 1.687).CONCLUSIONSVolume of CSF drainage was highly correlated with the probability of in-hospital aneurysmal rebleeding. These findings suggest that the rebleeding probability can be affected in acute management should the placement of an external ventricular catheter be necessary. This finding necessitates meticulous control of the amount of drained CSF and the development of a definitive treatment protocol for this group of patients.
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Affiliation(s)
- Jasper H. van Lieshout
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Ina Pumplün
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Igor Fischer
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Marcel A. Kamp
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Jan F. Cornelius
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Hans J. Steiger
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | | | - Athanasios K. Petridis
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Kerim Beseoglu
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
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Nemoto M, Masuda H, Sakaeyama Y, Okonogi S, Node Y, Ueda K, Ando S, Kondo K, Harada N, Sugo N. Clinical Characteristics of Subarachnoid Hemorrhage with an Intracerebral Hematoma and Prognostic Factors. J Stroke Cerebrovasc Dis 2018; 27:1160-1166. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/13/2017] [Accepted: 11/23/2017] [Indexed: 11/26/2022] Open
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Post R, Zijlstra IJA, Berg RVD, Coert BA, Verbaan D, Vandertop WP. High-Dose Nadroparin Following Endovascular Aneurysm Treatment Benefits Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2017; 83:281-287. [DOI: 10.1093/neuros/nyx381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/13/2017] [Indexed: 12/21/2022] Open
Abstract
Abstract
BACKGROUND
Delayed cerebral ischemia (DCI) is one of the major causes of delayed morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH).
OBJECTIVE
To evaluate the effect of high-dose nadroparin treatment following endovascular aneurysm treatment on the occurrence of DCI and clinical outcome.
METHODS
Medical records of 158 adult patients with an aSAH were retrospectively analyzed. Those patients treated endovascularly for their ruptured aneurysm were included in this study. They received either high-dose (twice daily 5700 AxaIE) or low-dose (once daily 2850 AxaIE) nadroparin treatment after occlusion of the aneurysm. Medical charts were reviewed and imaging was scored by 2 independent neuroradiologists. Data with respect to in-hospital complications, peri-procedural complications, discharge location, and mortality were collected.
RESULTS
Ninety-three patients had received high-dose nadroparin, and 65 patients prophylactic low-dose nadroparin. There was no significant difference in clinical DCI occurrence between patients treated with high-dose (34%) and low-dose (31%) nadroparin. More patients were discharged to home in patients who received high-dose nadroparin (40%) compared to low-dose (17%; odds ratio [OR] 3.13, 95% confidence interval [95% CI]: 1.36-7.24). Furthermore, mortality was lower in the high-dose group (5%) compared to the low-dose group (23%; OR 0.19, 95% CI: 0.07-0.55), also after adjusting for neurological status on admission (OR 0.21, 95% CI: 0.07-0.63).
CONCLUSION
Patients who were treated with high-dose nadroparin after endovascular treatment for aneurysmal SAH were more often discharged to home and showed lower mortality. High-dose nadroparin did not, however, show a decrease in the occurrence of clinical DCI after aSAH. A randomized controlled trial seems warranted.
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Affiliation(s)
- Rene Post
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
| | | | - Rene van den Berg
- Department of Neurora-diology, Academic Medical Center Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
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Aneurysm rebleeding after placement of external ventricular drainage: a systematic review and meta-analysis. Acta Neurochir (Wien) 2017; 159:695-704. [PMID: 28243810 DOI: 10.1007/s00701-017-3124-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The association between external ventricular drainage (EVD) and aneurysm rerupture is still a controversial issue. We performed a systematic review and meta-analysis of published series reporting data of EVD placement in aneurysmal subarachnoid hemorrhage (SAH) with the aim to evaluate the relationship between ventricular drainage and aneurysm rebleeding. METHOD PRISMA/MOOSE guidelines were followed. The Newcastle-Ottawa Scale was used to assess the quality of the studies. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on series reporting patients with EVD placement and aneurysmal SAH. The reported studies were analyzed with a primary aim to calculate the strength of the association (odds ratio) between rebleeding and EVD placement in patients with SAH. RESULTS Our systematic review included 16 articles with a total of 6804 patients with SAH of which 595 (8.7%) had aneurysmal rebleeding. Ventricular drainage was inserted in 19% of patients. Rebleeding occurred in 18.8% (95% CI = 16.4-20.6%) of patients requiring EVD and in 6.4% (95% CI = 5.8-7.1%) of patients who did not require EVD (OR = 3.92, p < 0.0001). The mean time between EVD placement and rebleeding was 1 h (range, 0-8 h). The maximal aneurysm diameter of patients with rerupture was larger when compared with patients without rerupture (9.9 mm vs. 7.5 mm; p < 0.04). High Fisher grades (III-IV) were present in 75% of patients with rerupture and in 60% of patients without aneurysmal rerupture (p < 0.0001). CONCLUSIONS Our study conclusively defined an association between EVD and rebleeding. However, the effective role of EVD in aneurysm rebleeding is insufficiently investigated in the literature. Other significant factors of rebleeding are usually observed in patients requiring ventricular drainage. According to our findings, a causal relationship between EVD and aneurysm rebleeding could be a plausible hypothesis, at least in certain cases.
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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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Weyhenmeyer J, Guandique CF, Leibold A, Lehnert S, Parish J, Han W, Tuchek C, Pandya J, Leipzig T, Payner T, DeNardo A, Scott J, Cohen-Gadol AA. Effects of distance and transport method on intervention and mortality in aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 128:490-498. [PMID: 28186453 DOI: 10.3171/2016.9.jns16668] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Most patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) initially present to a hospital that lacks a neurosurgical unit. These patients require interhospital transfer (IHT) to tertiary facilities capable of multidisciplinary neurosurgical intervention. Yet, little is known about the effects of IHT on the outcomes of patients suffering from aSAH. In this study, the authors examined the effects of IHT and transport method on the timing of treatment, rebleed rates, and overall outcomes of patients who have experienced aSAH. METHODS A retrospective review of medical records identified all consecutive patients who presented with aSAH at an outside hospital and subsequently underwent IHT to a tertiary aneurysm care center and patients who initially presented directly to a tertiary aneurysm care facility between 2008 and 2015. Demographic, operative, radiological, hospital of initial evaluation, transfer method, and outcome data were retrospectively collected. RESULTS The authors identified 763 consecutive patients who were evaluated for aSAH at a tertiary aneurysm care facility either directly or following IHT. For patients who underwent IHT and after accounting for these patients' clinical variability and dichotomizing the patients into groups transferred less than 20 miles and more than 20 miles, the authors noted a significant increase in mortality rates: 7% (< 20 miles) and 18.8% (> 20 miles) (p = 0.004). The increased mortality rate was partially explained by an increased rate of initial presentation to an accredited stroke center in patients undergoing IHT of less than 20 miles (p = 0.000). The method of transport (ground or air ambulance) was found to have significant effect on the patients' outcomes as measured by the Glasgow Outcome Scale score (p = 0.021); patients who underwent ground transport demonstrated a higher likelihood of discharge to home (p = 0.004). The increased severity of presentation in the patient cohort undergoing IHT by air as defined by the Glasgow Coma Scale score, a need for an external ventricular drain, Hunt and Hess grade, and intubation status at presentation did not result in increased mortality when compared with the ground cohort (p = 0.074). In addition, there was an 8-hour increase in duration of time from admission to treatment for the air cohort as compared with the ground cohort (p = 0.054), indicating a potential for further improvement in the overall outcome of this patient group. CONCLUSIONS Aneurysmal SAH remains a challenging neurosurgical disease process requiring highly coordinated care in tertiary referral centers. In this study, the overall distance traveled and the transport method affected patient outcomes. The time from admission to treatment should continue to improve. Further analysis of IHT with a focus on patient monitoring and treatment during transport is warranted.
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Affiliation(s)
- Jonathan Weyhenmeyer
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | | | - Adam Leibold
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Stephen Lehnert
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jonathan Parish
- 3Carolina's Medical Center Department of Neurosurgery, Charlotte, North Carolina
| | - Woody Han
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Chad Tuchek
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Janit Pandya
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Thomas Leipzig
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Troy Payner
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Andrew DeNardo
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - John Scott
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Aaron A Cohen-Gadol
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Ishikawa K, Omori K, Takeuchi I, Jitsuiki K, Yoshizawa T, Ohsaka H, Nakao Y, Yamamoto T, Yanagawa Y. A comparison between evacuation from the scene and interhospital transportation using a helicopter for subarachnoid hemorrhage. Am J Emerg Med 2016; 35:543-547. [PMID: 27979421 DOI: 10.1016/j.ajem.2016.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/25/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE We investigated the changes in the vital signs and the final outcomes subarachnoid hemorrhage (SAH) patients who were evacuated from the scene using the doctor-helicopter (Dr. Heli) service and those who only underwent interhospital transportation using the doctor-helicopter Dr. Heli service to investigate safety of this system. METHODS We retrospectively investigated all of the patients with non-traumatic SAH who were transported by a Dr. Heli between January 2010 and March 2016. The subjects were divided into two groups: the Scene group included subjects who were evacuated from the scene by a Dr. Heli, while the Interhospital group included subjects who were transported by a ground ambulance to a nearby medical facility and then transported by a Dr. Heli to a single tertiary center. RESULTS The systolic blood pressure, ratio of cardiac arrest, and Fisher classification values of the patients in the Scene group were significantly greater than those in the Interhospital group. The Glasgow Coma Scale in the Scene group was significantly lower than that in the Interhospital group. After excluding the patients with cardiac arrest, the Glasgow Coma Scale scores of the patients in the two groups did not differ to a statistically significant extent during, before or after transportation. There were no significant differences in Glasgow Outcome Scores or the survival ratio of the two groups, even when cardiac arrest patients were included. CONCLUSION The present study indirectly suggests the safety of using a Dr. Heli to evacuate SAH patients from the scene.
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Affiliation(s)
- Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Toshihiko Yoshizawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Yasuaki Nakao
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Takuji Yamamoto
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan.
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Foreman PM, Chua M, Harrigan MR, Fisher WS, Vyas NA, Lipsky RH, Walters BC, Tubbs RS, Shoja MM, Griessenauer CJ. Association of nosocomial infections with delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neurosurg 2016; 125:1383-1389. [DOI: 10.3171/2015.10.jns151959] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE
Delayed cerebral ischemia (DCI) is a recognized complication of aneurysmal subarachnoid hemorrhage (aSAH) that contributes to poor outcome. This study seeks to determine the effect of nosocomial infection on the incidence of DCI and patient outcome.
METHODS
An exploratory analysis was performed on 156 patients with aSAH enrolled in the Cerebral Aneurysm Renin Angiotensin System study. Clinical and radiographic data were analyzed with univariate analysis to detect risk factors for the development of DCI and poor outcome. Multivariate logistic regression was performed to identify independent predictors of DCI.
RESULTS
One hundred fifty-three patients with aSAH were included. DCI was identified in 32 patients (20.9%). Nosocomial infection (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.09–11.2, p = 0.04), ventriculitis (OR 25.3, 95% CI 1.39–458.7, p = 0.03), aneurysm re-rupture (OR 7.55, 95% CI 1.02–55.7, p = 0.05), and clinical vasospasm (OR 43.4, 95% CI 13.1–143.4, p < 0.01) were independently associated with the development of DCI. Diagnosis of nosocomial infection preceded the diagnosis of DCI in 15 (71.4%) of 21 patients. Patients diagnosed with nosocomial infection experienced significantly worse outcomes as measured by the modified Rankin Scale score at discharge and 1 year (p < 0.01 and p = 0.03, respectively).
CONCLUSIONS
Nosocomial infection is independently associated with DCI. This association is hypothesized to be partly causative through the exacerbation of systemic inflammation leading to thrombosis and subsequent ischemia.
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Affiliation(s)
- Paul M. Foreman
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Michelle Chua
- 2Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mark R. Harrigan
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Winfield S. Fisher
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Nilesh A. Vyas
- 3Department of Neurosciences, INOVA Health System, Fairfax, Virginia
| | - Robert H. Lipsky
- 3Department of Neurosciences, INOVA Health System, Fairfax, Virginia
| | - Beverly C. Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 3Department of Neurosciences, INOVA Health System, Fairfax, Virginia
| | | | | | - Christoph J. Griessenauer
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 5Beth Israel Deaconess Medical Center, Division of Neurosurgery, Harvard University, Boston, Massachusetts
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Solanki C, Pandey P, Rao KVLN. Predictors of aneurysmal rebleed before definitive surgical or endovascular management. Acta Neurochir (Wien) 2016; 158:1037-44. [PMID: 27068042 DOI: 10.1007/s00701-016-2784-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/21/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers. METHOD A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis. RESULTS Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002). CONCLUSIONS Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.
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Affiliation(s)
- Chirag Solanki
- Department of Neurosurgery, NIMHANS (National Institute of Mental Health and Neuroscinences), Bengaluru, Karnataka, 560029, India
| | - Paritosh Pandey
- Consultant Neurosurgeon, Manipal Hospital, Bengaluru, Karnataka, India
| | - K V L N Rao
- Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, 560029, India.
- Department of Neurosurgery, Faculty Block, Neurosurgery office, NIMHANS campus, Bengaluru, Karnataka, 560029, India.
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Chen J, Zhu J, He J, Wang Y, Chen L, Zhang C, Zhou J, Yang L. Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma. Oncol Lett 2016; 11:3173-3178. [PMID: 27123084 DOI: 10.3892/ol.2016.4327] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 01/28/2016] [Indexed: 11/05/2022] Open
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is the most common cerebrovascular disease. The conventional treatment for SAH is usually associated with high mortality. The present study aims to assess the prognosis of microsurgical treatment for patients with poor-grade aneurysm (Hunt and Hess grades IV-V) associated with intracerebral hematoma. A total of 18 consecutive patients who were diagnosed with poor-grade aneurysm accompanied with intracerebral hematoma were retrospectively recruited. All patients underwent microsurgical treatment between April 2010 and June 2013 at The 101st Hospital of Chinese People's Liberation Army (Wuxi, China). Among them, 15 cases underwent microsurgery within 24 h of SAH, and 3 cases underwent microsurgery 24 h following SAH. All 18 cases were examined by computed tomography angiography (CTA). The outcome was assessed during a follow-up time of 6-36 months. According to the Glasgow Outcome Scale, 4 patients experienced a good recovery, 6 were dissatisfied with the outcome, 4 were in vegetative state and 4 succumbed to disease. Poor outcome occurred in patients with an aneurysm diameter >10 mm, exhibited >50 ml volume of intracerebral hematoma or presented cerebral hernia prior to the surgical operation. The outcome of ultra-early surgery (within 24 h of SAH) was improved, compared with that of surgery following 24 h of SAH (P=0.005). Among 7 patients who accepted extraventricular drainage, good outcomes were achieved in 4 of them, whereas dissatisfaction and mortality occurred in 2 and 1 patients, respectively. Therefore, ultra-early microsurgery (within 24 h of SAH) combined with extraventricular drainage may improve the prognosis of patients with poor-grade aneurysm.
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Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jun Zhu
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jianqing He
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Yuhai Wang
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Lei Chen
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Chunlei Zhang
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jingxu Zhou
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Likun Yang
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
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Predictors of good functional outcomes and mortality in patients with severe rebleeding after aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2016; 144:28-32. [PMID: 26963087 DOI: 10.1016/j.clineuro.2016.02.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/28/2016] [Accepted: 02/29/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Aneurysmal rebleeding is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH); however, limited data on severity of rebleeding and outcomes after severe rebleeding are available. We aimed to determine predictors of good outcome and mortality after severe rebleeding. MATERIALS AND METHODS In a multicenter poor-grade aneurysm study, 60 patients with severe rebleeding, defined as new hemorrhage with poor clinical condition caused by rebleeding, were identified. Good functional outcome was defined as a modified Rankin scale (mRS) of ≤2, and mortality was defined as a mRS of 6. Multivariate logistic analyses were used to determine predictors of good outcome and mortality. RESULTS Of the 58 patients included in this report, 24 (41.3%) patients experienced rebleeding within 24h after ictus. 42 (72.4%) patients had died at 12 months. The rate of good outcome increased from 5.2% at discharge to 13.8% at 6 months and 19.0% at 12 months. In multivariate analysis, World Federation of Neurosurgical Societies (WFNS) grade IV after rebleeding (P=0.007) and aggressive treatment (P=0.039) were independently associated with good outcome. A higher modified Fisher grade before rebledding (P=0.040), larger aneurysms (P=0.005), and lower Glasgow coma score after rebleeding (P=0.003) were independently associated with increased mortality. CONCLUSIONS A better clinical condition after rebleeding were independently associated with good outcome and inversely associated with morality after severe rebleeding. Despite high mortality of rebleeding, patients with WFNS grade IV treated with aggressive treatment were more likely to have good outcomes regardless of their condition before rebleeding.
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Lin QS, Ping-Chen, Lin YX, Lin ZY, Yu LH, Dai LS, Kang DZ. Systolic Blood Pressure Variability is a Novel Risk Factor for Rebleeding in Acute Subarachnoid Hemorrhage: A Case-Control Study. Medicine (Baltimore) 2016; 95:e3028. [PMID: 26986118 PMCID: PMC4839899 DOI: 10.1097/md.0000000000003028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
UNLABELLED Rebleeding of an aneurysm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Whereas numerous studies have demonstrated predictors of rebleeding and effect of systolic blood pressure variability (SBPV) on stroke, few data on the association between SBPV and rebleeding. Here, we sought to identify the effect of SBPV on rebleeding in acute aneurysmal SAH. Case-control study. From January 2010 to June 2015, 612 patients with aneurysmal SAH were enrolled in our tertiary care medical center. MAIN OUTCOME MEASURES Consecutive patients with acute (<3 days from ictus) aneurismal rebleeding or repair or death were retrospectively included. Antihypertensive therapy based on a predefined standardized protocol was prescribed to lower and maintain SBP between 120 and 160 mm Hg. SBP was measured hourly until a censoring event occurred. SBPV was determined as standard deviation (SD) and successive variation (SV). Binary logistic regression was used to assess the association between SBPV and rebleeding. Rebleeding occurred in 61 (10.0%) of the 612 patients. We identified 47 acute rebleeding as cases and 382 early repair or early death as controls. On binary logistic regression analysis, rebleeding was associated with the SD of SBP (odds ratio [OR], 1.254; 95% confidence interval [CI], 1.131-1.391; P < 0.001) and the SV of SBP (OR, 1.131; 95% CI, 1.039-1.231; P = 0.004). No significant difference was seen between rebleeding and mean systolic blood pressure (MSBP). SBPV is associated with increased rates of acute aneurysmal rebleeding. Further prospective research is warranted to confirm that SBP stability prevents acute aneurysm rebleeding.
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Affiliation(s)
- Qing-Song Lin
- From the Department of Neurosurgery (Q-SL, Y-XL, Z-YL, L-HY, L-SD); and Department of Anesthesiology, the First Affiliated Hospital of Fujian Medical University (P-C), Fuzhou, Fujian, People's Republic of China
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Aneurismi arteriosi intracranici. Neurologia 2016. [DOI: 10.1016/s1634-7072(15)76145-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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de Oliveira Manoel AL, Goffi A, Marotta TR, Schweizer TA, Abrahamson S, Macdonald RL. The critical care management of poor-grade subarachnoid haemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:21. [PMID: 26801901 PMCID: PMC4724088 DOI: 10.1186/s13054-016-1193-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50% to 35% in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada. .,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Alberto Goffi
- Toronto Western Hospital MSNICU, 2nd Floor McLaughlin Room 411-H, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Tom R Marotta
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Simon Abrahamson
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - R Loch Macdonald
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
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Lee SH, Song KJ, Shin SD, Ro YS, Kim MJ, Holmes JF. The Relationship between Clinical Outcome in Subarachnoidal Hemorrhage Patients with Emergency Medical Service Usage and Interhospital Transfer. J Korean Med Sci 2015; 30:1889-95. [PMID: 26713067 PMCID: PMC4689836 DOI: 10.3346/jkms.2015.30.12.1889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/29/2015] [Indexed: 12/05/2022] Open
Abstract
Prompt diagnosis and appropriate transport of patients with subarachnoid hemorrhage (SAH) is critical. We aimed to study differences in clinical outcomes by emergency medical services (EMS) usage and interhospital transfer in patients with SAH. We analyzed the CAVAS (CArdioVAscular disease Surveillance) database which is an emergency department-based, national cohort of cardiovascular disease in Korea. Eligible patients were adults with non-traumatic SAH diagnosed between January 2007 and December 2012. We excluded those whose EMS use and intershopital transfer data was unknown. The primary and secondary outcomes were mortality and neurologic status at discharge respectively. We compared the outcomes between each group using multivariable logistic regressions, adjusting for sex, age, underlying disease, visit time and social history. Of 5,461 patients with SAH, a total of 2,645 were enrolled. Among those, 258 used EMS and were transferred from another hospital, 686 used EMS only, 1,244 were transferred only, and 457 did not use EMS nor were transferred. In the regression analysis, mortality was higher in patients who used EMS and were transferred (OR 1.40, 95% CI 1.02-1.92), but neurologic disability was not meaningfully different by EMS usage and interhospital transfer. In Korea, SAH patients' mortality is higher in the case of EMS use or receiving interhospital transfer.
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Affiliation(s)
- Sang Hwa Lee
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Min Jung Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - James F. Holmes
- Department of Emergency Medicine, UC Davis Medical Center(JFH), Davis, CA, USA
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Current Management of Aneurysmal Subarachnoid Hemorrhage Guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci 2015. [DOI: 10.1017/s0317167100021521] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT:Published medical evidence pertaining to the management of aneurysmal subarachnoid hemorrhage (SAH) was critically reviewed in order to prepare practice guidelines for this condition. SAH should be considered as a possible cause of all sudden and/or unusual headaches, and every attempt should be made to recognize mild SAHs, as they are still frequently misdiagnosed. The first test for SAH is computed tomography (CT), followed by lumbar puncture when the CT is negative for intracranial bleeding (the case in only several per cent of patients within 24 hours of aneurysm bleeding). Urgent cerebral angiography is necessary to detect the underlying cerebral aneurysm. The advantage of rapid diagnosis of SAH followed by early aneurysm repair is minimizing the risk of catastrophic aneurysm rebleeding. Early surgery for aneurysm repair is often possible and is recommended, unless the aneurysm location or size renders it technically difficult to expose in clot-laden subarachnoid cisterns beneath an acutely swollen brain. Aneurysm ablation is optimally accomplished with open microsurgery and clipping of the aneurysm neck, although other options include proximal parent artery occlusion, “trapping” of the aneurysmal segment of the artery, and embolization of thrombogenic materials (e.g., platinum “microcoils”) directly into the aneurysm dome using endovascular techniques. Neurological outcome following SAH is also optimized through the prevention of secondary SAH complications, and further management specific for ruptured cerebral aneurysms can include anticonvulsants, neuroprotectants, and various agents and techniques to prevent or reverse delayed-onset cerebral vasospasm. All patients with aneurysmal SAH should be treated with the calcium antagonist nimodipine, and in certain circumstances patients should receive anticonvulsants. Induced arterial hypertension, hypervolemia and in some instances percutaneous balloon angioplasty are recommended to reverse vasospasm causing symptomatic cerebral ischemia prior to cerebral infarction.
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