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Snow R, Shamshad A, Helliwell A, Wendell LC, Thompson BB, Furie KL, Reznik ME, Mahta A. Predictors of hospital length of stay and long-term care facility placement in aneurysmal subarachnoid hemorrhage. World Neurosurg X 2024; 22:100320. [PMID: 38440380 PMCID: PMC10911846 DOI: 10.1016/j.wnsx.2024.100320] [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: 05/16/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is frequently associated with complications, extended hospital length of stay (LOS) and high health care related costs. We sought to determine predictors for hospital LOS and discharge disposition to a long-term care facility (LTCF) in aSAH patients. Methods We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed to identify predictors for hospital LOS. We then created a 10-point scoring system to predict discharge disposition to a LTCF. Results In a cohort of 318 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. Hospital LOS was longer for survivors (median 19 days, IQR 14-25) than for non-survivors (median 5 days, IQR 2-8; p < 0.001). Main predictors for longer LOS for this cohort were ventriculoperitoneal shunt (VPS) requirement (p < 0.001), delayed cerebral ischemia (p = 0.026), and pneumonia (p = 0.014). The strongest predictor for LTCF disposition was age older than 60 years (OR 1.14, 95% CI 1.07-1.21; p < 0.001). LTCF score had high accuracy in predicting discharge disposition to a LTCF (area under the curve [AUC] 0.83; 95% CI 0.75-0.91). Forty-one percent of patients who were discharged to a LTCF had significant functional recovery at 3 months post-discharge. Conclusions VPS requirement and aSAH related complications were associated with longer hospital LOS compared to other factors. LTCF score has high accuracy in predicting discharge disposition to a LTCF.
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Affiliation(s)
- Ryan Snow
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alizeh Shamshad
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alexandra Helliwell
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Linda C. Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, MA, USA
| | | | - Karen L. Furie
- 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
| | - 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
- Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Wang X, Zhao Y, Zhao J, Deng L. Neutrophil-lymphocyte ratio on first and third postoperative days: associated with severe pneumonia in aneurysmal subarachnoid hemorrhage patients undergoing surgeries. Neurosurg Rev 2024; 47:70. [PMID: 38277044 DOI: 10.1007/s10143-024-02295-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/04/2024] [Accepted: 01/14/2024] [Indexed: 01/27/2024]
Abstract
Severe postoperative pneumonia can increase the risk of poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to explore the associations of preoperative or postoperative inflammatory markers calculated from blood cell counts with severe pneumonia. This retrospective study was conducted at the First Affiliated Hospital of Yangtze University from January 2019 to June 2023. The associations of neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), and systemic inflammation response index (SIRI) with severe pneumonia were analyzed. There were 159 patients with pneumonia and 21 patients without pneumonia. There were 41 patients with severe pneumonia and 118 patients with non-severe pneumonia. The multivariate logistic regression analysis showed that NLR on the first postoperative (OR = 2.574, 95%CI: 1.035-6.403, p = 0.042) and third postoperative days (OR = 4.296, 95%CI: 1.699-10.860, p = 0.002) were associated with severe pneumonia in aSAH patients. Among patients ≥ 60 years, SIRI on the preoperative day (OR = 7.430, 95%CI: 1.443-38.251, p = 0.016) and NLR on the third postoperative day (OR = 4.748, 95%CI: 1.286-17.801, p = 0.020) were associated with severe pneumonia. Among patients < 60 years, NLR on the first postoperative day (OR = 24.149, 95%CI: 3.476-167.747, p = 0.001) was associated with severe pneumonia. The NLR on the first and third postoperative days were possibly associated with severe pneumonia in aneurysmal subarachnoid hemorrhage patients undergoing clipping or embolization surgeries. Dynamic detection of NLR during early perioperative period may help clinicians to predict the development of severe pneumonia.
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Affiliation(s)
- Xian Wang
- Department of Pharmacy, The First Affiliated Hospital of Yangtze University, Jingzhou, 434000, China
| | - Yongfeng Zhao
- Department of Hematology, The First Affiliated Hospital of Yangtze University, Jingzhou, 434000, China
| | - Jian Zhao
- Department of Neurosurgery, The Neurointensive Care Unit, The First Affiliated Hospital of Yangtze University, Jingzhou, 434000, China
| | - Li Deng
- Medical Department, The First Affiliated Hospital of Yangtze University, Jingzhou, 434000, China.
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Sato A, Kitazawa K, Nishikawa A, Murata T, Wada N, Seguchi T, Hanaoka Y, Kobayashi S, Abe D, Yamamoto Y, Sasaki T, Murase H, Hongo K, Horiuchi T. Proposed imaging assessment score for aneurysmal subarachnoid hemorrhage correlated with prognosis: Shinshu Aneurysmal subarachnoid hemorrhage score. J Clin Neurosci 2024; 119:30-37. [PMID: 37976912 DOI: 10.1016/j.jocn.2023.11.012] [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: 09/02/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) imaging has been shown to correlate with prognosis. However, no numerical index of bleeding severity has been established. This study aimed to propose a new simple scoring system for computed tomography imaging of aSAH and to confirm its effectiveness in retrospective and prospective studies. METHODS We devised an image evaluation system as an objective index. This system was established by scoring six items, with a maximum total of 19 points. Using this score, named the Shinshu Aneurysmal Subarachnoid Hemorrhage Score (S-score), we performed a retrospective study of 210 patients with aSAH at a single institution to confirm its efficacy. Age and World Federation of Neurosurgical Societies grades were adopted as other verification items, and the modified Rankin Scale was used for prognostic evaluation. A multicenter prospective study was then conducted to examine the function of the score by examining 214 patients with aSAH. RESULTS In the retrospective study, the threshold of the S-score between good and poor prognoses was 9/19 points. The area under the curve by receiver operating characteristic analysis of the S-score was 0.819, suggesting efficacy, with an odds ratio (OR) of 1.291 (1.077-1.547). In the prospective study, the judgment capability of the S-score was evaluated with a sensitivity of 0.674, specificity of 0.881, positive predictive value of 0.789, negative predictive value of 0.804, false-positive ratio of 0.119, false-negative ratio of 0.325, positive likelihood ratio of 6.072, and negative likelihood ratio of 1.369. S-score showed a significant difference in prognosis. The OR was 1.183 (1.009-1.388). CONCLUSIONS The scoring system could contribute to patient prognosis assessment. S-score and its prognostic formulas may serve as an objective source of information in the development of clinical medicine.
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Affiliation(s)
- Atsushi Sato
- Division of Neurosurgery, Ina Central Hospital, Ina, Nagano, Japan.
| | - Kazuo Kitazawa
- Division of Neurosurgery, Aizawa Hospital, Matsumoto, Nagano, Japan
| | | | - Takahiro Murata
- Division of Neurosurgery, Shinonoi General Hospital, Nagano, Japan
| | - Naomichi Wada
- Division of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | | | - Yoshiki Hanaoka
- Department of Neurosurgery, Shinshu University Hospital, Matsumoto, Nagano, Japan
| | | | - Daishiro Abe
- Division of Neurosurgery, Iida Hospital, Iida, Japan
| | | | - Tetsuo Sasaki
- Division of Neurosurgery, Ina Central Hospital, Ina, Nagano, Japan
| | - Hiromu Murase
- Division of Neurosurgery, Ina Central Hospital, Ina, Nagano, Japan
| | - Kazuhiro Hongo
- Division of Neurosurgery, Ina Central Hospital, Ina, Nagano, Japan
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University Hospital, Matsumoto, Nagano, Japan
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Henry J, Dablouk MO, Kapoor D, Koustais S, Corr P, Nolan D, Coffey D, Thornton J, O'Hare A, Power S, Rawluk D, Javadpour M. Outcomes following poor-grade aneurysmal subarachnoid haemorrhage: a prospective observational study. Acta Neurochir (Wien) 2023; 165:3651-3664. [PMID: 37968366 DOI: 10.1007/s00701-023-05884-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Up to 35% of aneurysmal subarachnoid haemorrhage (aSAH) cases may present as poor grade, defined as World Federation of Neurosurgical Societies (WFNS) grades IV and V. In this study, we evaluate functional outcomes and prognostic factors. METHODS This prospective study included all patients referred to a national, centralized neurosurgical service with a diagnosis of poor-grade aSAH between 01/01/2016 and 31/12/2019. Multivariable logistic regression models were used to estimate probability of poor functional outcomes, defined as a Glasgow Outcome Scale (GOS) of 1-3 at 3 months. RESULTS Two hundred fifty-seven patients were referred, of whom 116/257 (45.1%) underwent treatment of an aneurysm, with 97/116 (84%) treated within 48 h of referral. Median age was 62 years (IQR 51-69) with a female predominance (167/257, 65%). Untreated patients tended to be older; 123/141 (87%) had WFNS V, 60/141 (45%) unreactive pupils and 21/141 (16%) circulatory arrest. Of all referred patients, poor outcome occurred in 169/230 (73.5%). Unreactive pupils or circulatory arrest conferred a universally poor prognosis, with mortality in 55/56 (98%) and 19/19 (100%), respectively. The risk of a poor outcome was 14.1% (95% CI 4.5-23.6) higher in WFNS V compared with WFNS IV. Age was important in patients without circulatory arrest or unreactive pupils, with risk of a poor outcome increasing by 1.8% per year (95% CI 1-2.7). In patients undergoing aneurysm securement, 48/101 (47.5%) had a poor outcome, with age, rebleeding, vasospasm and cerebrospinal fluid (CSF) diversion being important prognosticators. The addition of serum markers did not add significant discrimination beyond the clinical presentation. CONCLUSIONS The overall outcomes of WFNS IV and V aSAH remain poor, mainly due to the devastating effects of the original haemorrhage. However, in patients selected for aneurysm securement, good outcomes can be achieved in more than half of patients. Age, pre-intervention rebleeding, vasospasm, and CSF diversion are important prognostic factors.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Mohammed O Dablouk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dhruv Kapoor
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Stavros Koustais
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paula Corr
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Nolan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Coffey
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Daniel Rawluk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland.
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [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: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - 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, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Yuwapattanawong K, Chanthima P, Thamjamrassri T, Keen J, Qiu Q, Fong C, Robinson EF, Dhulipala VB, Walters AM, Athiraman U, Kim LJ, Vavilala MS, Levitt MR, Lele AV. The Association Between Illness Severity Scores and In-hospital Mortality After Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2023; 35:299-306. [PMID: 35297396 DOI: 10.1097/ana.0000000000000840] [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: 10/27/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the association with in-hospital mortality of 8 illness severity scores in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, we investigated the association with in-hospital mortality of admission Hunt and Hess (HH) score, Fisher grade, severity of illness and risk of mortality scores, and serial Glasgow coma scale (GCS) score in patients with aSAH. We also explored the changes in GCS between admission and discharge using a multivariate model adjusting for age, clinical vasospasm, and external ventricular drain status. RESULTS Data from 480 patients with aSAH, of which 383 (79.8%) aneurysms were in the anterior circulation, were included in analysis. Patients were female (n=340, 70.8%) with a median age of 56 (interquartile range: 48 to 66) years. The majority (n=332, 69.2%) had admission HH score 3 to 5, Fisher grade 3 to 4 (n=437, 91%), median severity of illness 3 (range: 1 to 4), median risk of mortality 3 (range: 1 to 4), and median admission GCS of 13 (interquartile range: 7 to 15). Overall, 406 (84.6%) patients received an external ventricular drain, 469 (97.7%) underwent aneurysm repair, and 60 died (12.5%). Compared with admission HH score, GCS 24 hours after admission (area under the curve: 0.84, 95% confidence interval [CI]: 0.79-0.88) and 24 hours after aneurysm repair (area under the curve: 0.87, 95% CI: 0.82-0.90) were more likely to be associated with in-hospital mortality. Among those who died, the greatest decline in GCS was noted between 24 hours after aneurysm repair and discharge (-3.38 points, 95% CI: -4.17, -2.58). CONCLUSIONS Compared with admission HH score, GCS 24 hours after admission (or 24 h after aneurysm repair) is more likely to be associated with in-hospital mortality after aSAH.
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Affiliation(s)
| | | | | | | | - Qian Qiu
- Harborview Injury Prevention and Research Center
| | - Christine Fong
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | | | | | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | - Abhijit V Lele
- Harborview Injury Prevention and Research Center
- Departments of Neurological Surgery
- Anesthesiology and Pain Medicine, Harborview Medical Center
- Neurocritical Service, Harborview Medical Center, Seattle, WA
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Zhou Z, Liu Z, Yang H, Zhang C, Zhang C, Chen J, Wang Y. A nomogram for predicting the risk of poor prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage following microsurgical clipping. Front Neurol 2023; 14:1146106. [PMID: 37034089 PMCID: PMC10073426 DOI: 10.3389/fneur.2023.1146106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Objective Aneurysmal subarachnoid hemorrhage (aSAH) is a common and potentially fatal cerebrovascular disease. Poor-grade aSAH (Hunt-Hess grades IV and V) accounts for 20-30% of patients with aSAH, with most patients having a poor prognosis. This study aimed to develop a stable nomogram model for predicting adverse outcomes at 6 months in patients with aSAH, and thus, aid in improving the prognosis. Method The clinical data and imaging findings of 150 patients with poor-grade aSAH treated with microsurgical clipping of intracranial aneurysms on admission from December 2015 to October 2021 were retrospectively analyzed. Least absolute shrinkage and selection operator (LASSO), logistic regression analyses, and a nomogram were used to develop the prognostic models. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow tests were used to assess discrimination and calibration. The bootstrap method (1,000 repetitions) was used for internal validation. Decision curve analysis (DCA) was performed to evaluate the clinical validity of the nomogram model. Result LASSO regression analysis showed that age, Hunt-Hess grade, Glasgow Coma Scale (GCS), aneurysm size, and refractory hyperpyrexia were potential predictors for poor-grade aSAH. Logistic regression analyses revealed that age (OR: 1.107, 95% CI: 1.056-1.116, P < 0.001), Hunt-Hess grade (OR: 8.832, 95% CI: 2.312-33.736, P = 0.001), aneurysm size (OR: 6.871, 95% CI: 1.907-24.754, P = 0.003) and refractory fever (OR: 3.610, 95% CI: 1.301-10.018, P < 0.001) were independent predictors of poor outcome. The area under the ROC curve (AUC) was 0.909. The calibration curve and Hosmer-Lemeshow tests showed that the nomogram had good calibration ability. Furthermore, the DCA curve showed better clinical utilization of the nomogram. Conclusion This study provides a reliable and valuable nomogram that can accurately predict the risk of poor prognosis in patients with poor-grade aSAH after microsurgical clipping. This tool is easy to use and can help physicians make appropriate clinical decisions to significantly improve patient prognosis.
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Wen L, Zhou L, Wu Q, Zhou X, Zhang X. Feasibility of FDCT Early Brain Parenchymal Blood Volume Maps in Predicting Short-Term Prognosis in Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 13:888369. [PMID: 35911895 PMCID: PMC9329812 DOI: 10.3389/fneur.2022.888369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Aneurysmal subarachnoid hemorrhage (SAH) is accompanied by cerebral perfusion changes. We aimed to measure the parenchymal blood volume (PBV) maps acquired by C-arm flat-panel detector CT (FDCT) to assess the cerebral blood volume at an early stage in aneurysmal SAH and to explore the correlation with the outcomes at discharge. Methods Data of 66 patients with aneurysmal SAH who underwent FDCT PBV examination were retrospectively analyzed. The PBV of regions of interest, including the cortices of the bilateral frontal lobe, the parietal lobe, the occipital lobe, and the cerebral hemisphere, as well as the basal ganglia, were measured and quantitatively analyzed. The clinical and imaging data of the patients were also collected, and logistic regression analysis was performed to explore the correlation between the perfusion parameters and outcomes at discharge. Results The favorable and poor outcomes at discharge were found in 37 (56.06%) and 29 (43.94%) patients, respectively. The whole-brain PBV was significantly correlated with the Hunt-Hess grades (p < 0.005) and the WFNSS grades (p < 0.005). The whole-brain PBV of the poor prognosis was significantly higher than that of the favorable prognosis (35.17 ± 7.66 vs. 29.78 ± 5.54, p < 0.005). The logistic regression analysis showed that the PBV of the parietal lobe at the bleeding side (OR = 1.10, 95%CI: 1.00-1.20, p = 0.04) was an independent risk factor predicting the short-term prognosis. Conclusions Parenchymal blood volume (PBV) maps could reflect the cerebral blood volume throughout the brain to characterize its perfusion status at an early stage in aneurysmal SAH. It enables a one-stop imaging evaluation and treatment in the same angio-suite and may serve as a reliable technique in clinical assessment of aneurysmal SAH.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Medical Imaging Center, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Variations of perforating arteries of anterior communicating artery in cases with anterior communicating artery aneurysms: a cadaveric anatomical study. Acta Neurochir (Wien) 2022; 164:2127-2139. [PMID: 35614324 DOI: 10.1007/s00701-022-05253-3] [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: 01/31/2022] [Accepted: 05/13/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE In terms of postoperative morbidity and mortality, preservation of the perforating arteries branching from the anterior communicating artery (ACoA) during clipping is particularly imperative in patients with ACoA aneurysm. In the present study, we aimed to investigate whether perforating arteries originated from ACoA were pushed away in a different location in patients with ACoA aneurysm. Furthermore, if they did so, we aimed to identify the direction in which they were dislocated and how the perforating arteries could be preserved during clipping. METHODS Herein, we categorized 40 brains obtained from cadavers into two groups. The first (n = 26) and second (n = 14) groups included cases without and with ACoA aneurysms, respectively. After completing the preparation procedure, the brains were dissected using surgical microscope and the relevant anatomical region was examined and photographed. Finally, statistical analyses were performed on the data and the results were documented. RESULTS In the aneurysms with posterior and superior projections, the perforators appeared to be pushed away inferiorly and were frequently noted at the anteroinferior part of the aneurysm neck. Most of the cases, where one of the A1s was larger at one side, the perforating arteries arose from the larger A1 side. CONCLUSION The mortality and morbidity associated with damage to the perforators can be reduced by approaching the patient from the dominant A1 side and pursuing the perforators primarily at the anteroinferior part of the aneurysm neck in the aneurysms with superior and posterior projections.
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11
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Raabe A, Beck J, Goldberg J, Z Graggen WJ, Branca M, Marbacher S, D'Alonzo D, Fandino J, Stienen MN, Neidert MC, Burkhardt JK, Regli L, Hlavica M, Seule M, Roethlisberger M, Guzman R, Zumofen DW, Maduri R, Daniel RT, El Rahal A, Corniola MV, Bijlenga P, Schaller K, Rölz R, Scheiwe C, Shah M, Heiland DH, Schnell O, Fung C. Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Stroke 2022; 53:2346-2351. [PMID: 35317612 DOI: 10.1161/strokeaha.121.036699] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort. METHODS We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version-the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4-6). RESULTS Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, P<0.001) whereas the sensitivity decreased from 0.88 to 0.37 (P<0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, P<0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, P<0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, P<0.001). CONCLUSIONS The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification-presence of brain stem signs is required for grade V-should be added to the WFNS classification. REGISTRATION URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.
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Affiliation(s)
- Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland (A.R., J.G., W.J.Z.)
| | - Jürgen Beck
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland (A.R., J.G., W.J.Z.)
| | - Werner J Z Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland (A.R., J.G., W.J.Z.)
| | | | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., D.D., J.F.)
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., D.D., J.F.)
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., D.D., J.F.)
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zürich Switzerland (M.N.S., M.C.N., L.R.)
| | - Marian C Neidert
- Department of Neurosurgery, University Hospital Zürich Switzerland (M.N.S., M.C.N., L.R.)
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zürich Switzerland, Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia (J.-K.B.)
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zürich Switzerland (M.N.S., M.C.N., L.R.)
| | - Martin Hlavica
- Department of Neurosurgery, Kantonsspital St. Gallen Switzerland (M.H., M.S.)
| | - Martin Seule
- Department of Neurosurgery, Kantonsspital St. Gallen Switzerland (M.H., M.S.)
| | | | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel Switzerland (M.R., R.G.)
| | - Daniel Walter Zumofen
- Department of Surgery, Neurology, and Radiology, Maimonides Medical Center, SUNY Downstate University, Brooklyn, NY (D.W.Z.)
| | - Rodolfo Maduri
- Avaton Surgical Group, Swiss Medical Network, Clinique de Genolier, Switzerland (R.M.)
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital Lausanne Switzerland (R.T.D.)
| | - Amir El Rahal
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Marco V Corniola
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Philippe Bijlenga
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Karl Schaller
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Roland Rölz
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Christian Scheiwe
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Mukesch Shah
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Oliver Schnell
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Christian Fung
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
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Hanalioglu S, Sahin B, Sayyahmelli S, Ozaydin B, Erginoglu U, Aycan A, Baskaya MK. The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era. Acta Neurochir (Wien) 2022; 164:781-793. [PMID: 35133482 DOI: 10.1007/s00701-022-05112-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity regardless of treatment. Herein, we re-evaluate the safety and efficacy of microsurgical treatment for managing PGASAH patients in the current endovascular era. METHODS We retrospectively reviewed 141 consecutive patient records in a single institution who underwent microsurgical (n = 80) or endovascular (n = 61) treatment for PGASAH. RESULTS Baseline characteristics were similar, except for more intracerebral hematomas (46.3% vs 24.6%, p = 0.009), fewer intraventricular hemorrhages (26.3% vs 59%, p < 0.001), and fewer posterior circulation aneurysms (5.1% vs 44.3%, p < 0.001) in the microsurgery group. Decompressive craniectomy (58.5% vs 24.6%, p < 0.001) and shunt-dependent hydrocephalus (63.7% vs 41%, p = 0.01) were more common for microsurgery, while procedural ischemic complications were less common (5% vs 24.6%, p = 0.001). Both early (12.5% vs 32.8%, p = 0.006) and late mortality rates (22.5% vs 39.3%, p = 0.041) were lower for microsurgery, and favorable 12-month outcomes (modified Rankin scale = 0-2) were better (62.5% vs 42.6%, p = 0.026). Multivariate analysis revealed that advanced age, neurological grade, modified Fisher grade, larger aneurysm size, rebleeding, and cerebral infarctions were independent predictors of poor outcome. Microsurgery fared marginally better than endovascular treatment (OR: 2.630, 95% CI: [0.991-6.981], p = 0.052). CONCLUSIONS Timely and efficient treatment, either via open microsurgery or endovascular surgery, provided favorable outcomes for over half of PGASAH patients in this series. Therefore, early treatment should be offered to all PGASAH patients regardless of clinical and/or radiological factors. Microsurgery remains an effective treatment modality for selected PGASAH patients in the endovascular era.
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13
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Predictive effects of admission white blood cell counts and hounsfield unit values on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 212:107087. [PMID: 34929583 DOI: 10.1016/j.clineuro.2021.107087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/23/2021] [Accepted: 12/04/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Neuroinflammatory response is deemed the primary pathogenesis of delayed cerebral ischemia (DCI) caused by aneurysmal subarachnoid hemorrhage (aSAH). Both white blood cell (WBC) count and Hounsfield Unit (HU) are gradually considered can reflect inflammation in DCI. This study aims to identify the relationship between WBC count and HU value and investigate the effects of both indicators in predicting DCI after aSAH. METHODS We enrolled 109 patients with aSAH admitted within 24 h of onset in our study. A multivariate logistic regression analysis was used to evaluate the admission WBC count, HU value, and combined WBC-HU associated with DCI. The receiver operating characteristic curve and area under the curve (AUC) were used to determine thresholds and detect the predictive ability of these predictors. These indicators were also compared with the established inflammation markers. RESULTS Thirty-six (33%) patients developed DCI. Both WBC count and HU value were strongly associated with the admission glucose level (ρ = .303, p = .001; ρ = .273, p = .004), World Federation of Neurosurgical Societies grade (ρ = .452, p < .001; ρ = .578; p < .001), Hunt-Hess grade (ρ = .450, p < .001; ρ = .510, p < .001), and modified Fisher scale score (ρ = .357, p < .001; ρ = .330, p < .001). After controlling these public variables, WBC count (ρ = .300, p = .002) positively correlated with HU value. An early elevated WBC (odds ratio [OR] 1.449, 95% confidence interval [CI]: 1.183-1.774, p < .001) count and HU value (OR 1.304, 95%CI: 1.149-1.479, p < .001) could independently predict the occurrence of DCI. However, only these patients with both WBC count and HU value exceeding the cut-off points (OR 36.89, 95%CI: 5.606-242.78, p < .001) were strongly correlated with DCI. Compared with a single WBC count (AUC 0.811, 95%CI: 0.729-0.892, p < .001) or HU value (AUC 0.869, 95%CI: 0.803-0.936, p < .001), the combined WBC-HU (AUC 0.898, 95%CI: 0.839-0.957, p < .001) demonstrated a better ability to predict the occurrence of DCI. Inspiringly, the prediction performance of these indicators outperformed the established inflammatory markers. CONCLUSION An early elevated WBC count and HU value could independently predict DCI occurrence between 4 and 30 days after aSAH. Furthermore, WBC count was positively correlated with HU value, and the combined WBC-HU demonstrated a superior prediction ability for DCI development compared with the individual indicator.
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14
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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15
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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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16
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Martini ML, Neifert SN, Shuman WH, Chapman EK, Schüpper AJ, Oermann EK, Mocco J, Todd M, Torner JC, Molyneux A, Mayer S, Roux PL, Vergouwen MDI, Rinkel GJE, Wong GKC, Kirkpatrick P, Quinn A, Hänggi D, Etminan N, van den Bergh WM, Jaja BNR, Cusimano M, Schweizer TA, Suarez JI, Fukuda H, Yamagata S, Lo B, Leonardo de Oliveira Manoel A, Boogaarts HD, Macdonald RL. Rescue therapy for vasospasm following aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis with machine learning. J Neurosurg 2021; 136:134-147. [PMID: 34214980 DOI: 10.3171/2020.12.jns203778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy. METHODS Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. RESULTS The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17). CONCLUSIONS Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.
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Affiliation(s)
- Michael L Martini
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Sean N Neifert
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - William H Shuman
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Emily K Chapman
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | | | - Eric K Oermann
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - J Mocco
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Michael Todd
- 2Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota
| | - James C Torner
- 3Departments of Epidemiology, Surgery, and Neurosurgery, College of Public Health and Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Andrew Molyneux
- 4Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom
| | - Stephan Mayer
- 5Wayne State University School of Medicine, Detroit, Michigan
| | | | - Mervyn D I Vergouwen
- 7Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- 7Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - George K C Wong
- 8Division of Neurosurgery, Prince of Wales Hospital and the Chinese University of Hong Kong, China
| | - Peter Kirkpatrick
- 9University of Cambridge, Nuffield Health Cambridge Hospital, Cambridge, United Kingdom
| | - Audrey Quinn
- 10Department of Anaesthesia, Cheriton House, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Daniel Hänggi
- 11Department of Neurosurgery, Düsseldorf University Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nima Etminan
- 12Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Walter M van den Bergh
- 13Department of Critical Care, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Blessing N R Jaja
- Divisions of14Neurosurgery and.,15Neurology, St. Michael's Hospital, Toronto, Ontario.,16Neuroscience Research Program, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario
| | - Michael Cusimano
- 17Education and Public Health, St. Michael's Hospital, University of Toronto, Keenan Research Centre and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Tom A Schweizer
- 16Neuroscience Research Program, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario
| | - Jose I Suarez
- 18Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hitoshi Fukuda
- 19Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Sen Yamagata
- 19Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Benjamin Lo
- 20Department of Neurosurgery, Lenox Hill Hospital, New York, New York
| | | | - Hieronymus D Boogaarts
- 22Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - R Loch Macdonald
- 23University of California San Francisco, Fresno Campus, University Neurosciences Institutes, Fresno, California
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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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Gouvêa Bogossian E, Diaferia D, Minini A, Ndieugnou Djangang N, Menozzi M, Peluso L, Annoni F, Creteur J, Schuind S, Dewitte O, Taccone FS. Time course of outcome in poor grade subarachnoid hemorrhage patients: a longitudinal retrospective study. BMC Neurol 2021; 21:196. [PMID: 33985460 PMCID: PMC8117582 DOI: 10.1186/s12883-021-02229-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Background Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients’ characteristics, the presence of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors. Methods We performed a single center retrospective cohort study from 2004 to 2018. All non-traumatic SAH patients with poor grade on admission (WFNS score of 4 or 5) who remained at least 24 h in the hospital were included. Time course was analyzed into four groups according to the years of admission (2004–2007; 2008–2011; 2012–2015 and 2016–2018). Results A total of 353 patients were included in this study: 202 patients died (57 %) and 260 (74 %) had unfavorable neurological outcome (UO) at 3 months. Mortality tended to decrease in in 2008–2011 and 2016–2018 periods (HR 0.55 [0.34–0.89] and HR 0.33 [0.20–0.53], respectively, when compared to 2004–2007). The proportion of patients with UO remained high and did not vary significantly over time. Patients with WFNS 5 had higher mortality (68 % vs. 34 %, p = 0.001) and more frequent UO (83 % vs. 54 %, p = 0.001) than those with WFNS 4. In the multivariable analysis, WFNS 5 was independently associated with mortality (HR 2.12 [1.43–3.14]) and UO (OR 3.23 [1.67–6.25]). The presence of hydrocephalus was associated with a lower risk of mortality (HR 0.60 [0.43–0.84]). Conclusions Both hospital mortality and UO remained high in poor grade SAH patients. Patients with WFNS 5 on admission had worse prognosis than others; this should be taken into consideration for future clinical studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02229-1.
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Affiliation(s)
- Elisa Gouvêa Bogossian
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Daniela Diaferia
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Narcisse Ndieugnou Djangang
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Menozzi
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Olivier Dewitte
- Department of Neurosurgery Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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19
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Application of Near-Infrared Spectroscopy for the Detection of Delayed Cerebral Ischemia in Poor-Grade Subarachnoid Hemorrhage. Neurocrit Care 2021; 35:767-774. [PMID: 33963480 PMCID: PMC8104035 DOI: 10.1007/s12028-021-01223-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 02/23/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND The objective of this study was to investigate the clinical feasibility of near-infrared spectroscopy (NIRS) for the detection of delayed cerebral ischemia (DCI) in patients with poor-grade subarachnoid hemorrhage (SAH) treated with coil embolization. METHODS Cerebral regional oxygen saturation (rSO2) was continuously monitored via two-channel NIRS for 14 days following SAH. The rSO2 levels according to DCI were analyzed by using the Mann-Whitney U-test. A receiver operating characteristic curve was generated on the basis of changes in rSO2 by using the rSO2 level on day 1 as a reference value to determine the optimal cutoff value for identifying DCI. RESULTS Twenty-four patients with poor-grade SAH were included (DCI, n = 8 [33.3%]; non-DCI, n = 16 [66.7%]). The rSO2 levels of patients with DCI were significantly lowered from 6 to 9 days compared with those in without DCI. The rSO2 level was 62.55% (58.30-63.40%) on day 6 in patients with DCI versus 65.40% (60.90-68.70%) in those without DCI. By day 7, it was 60.40% (58.10-61.90%) in patients with DCI versus 64.25% (62.50-67.10%) those without DCI. By day 8, it was 58.90% (56.50-63.10%) in patients with DCI versus 66.05% (59.90-69.20%) in those without DCI, and by day 9, it was 60.85% (58.40-65.20%) in patients with DCI versus 65.80% (62.70-68.30%) in those without DCI. A decline of greater than 14.5% in the rSO2 rate yielded a sensitivity of 92.86% (95% confidence interval: 66.1-99.8%) and a specificity of 88.24% (95% confidence interval: 72.5-96.7%) for identifying DCI. A decrease by more than 14.7% of the rSO2 level indicates a sensitivity of 85.7% and a specificity of 85.7% for identifying DCI. CONCLUSIONS Near-infrared spectroscopy shows some promising results for the detection of DCI in patients with poor-grade SAH. Further studies involving a large cohort of the SAH population are required to confirm our results.
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20
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Kurogi R, Kada A, Ogasawara K, Kitazono T, Sakai N, Hashimoto Y, Shiokawa Y, Miyachi S, Matsumaru Y, Iwama T, Tominaga T, Onozuka D, Nishimura A, Arimura K, Kurogi A, Ren N, Hagihara A, Nakaoku Y, Arai H, Miyamoto S, Nishimura K, Iihara K. Effects of case volume and comprehensive stroke center capabilities on patient outcomes of clipping and coiling for subarachnoid hemorrhage. J Neurosurg 2021; 134:929-939. [PMID: 32168489 DOI: 10.3171/2019.12.jns192584] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Improved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH. METHODS The authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1-25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH. RESULTS Overall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55-0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53-0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59-0.96 vs Q4 OR 0.65, 95% CI 0.51-0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54-0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes. CONCLUSIONS The effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.
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Affiliation(s)
- Ryota Kurogi
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Akiko Kada
- 2Department of Clinical Trials and Research, National Hospital Organization, Nagoya Medical Center, Nagoya
| | | | - Takanari Kitazono
- 4Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Nobuyuki Sakai
- 5Department of Neurosurgery, Kobe City Medical Centre General Hospital, Kobe
| | | | - Yoshiaki Shiokawa
- 7Department of Neurosurgery, Kyorin University School of Medicine, Mitaka
| | - Shigeru Miyachi
- 8Department of Neurosurgery, Aichi Medical University, Nagakute
| | - Yuji Matsumaru
- 9Department of Neurosurgery, University of Tsukuba, Tsukuba
| | - Toru Iwama
- 10Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu
| | - Teiji Tominaga
- 11Department of Neurosurgery, Tohoku University School of Medicine, Sendai
| | - Daisuke Onozuka
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Ataru Nishimura
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Koichi Arimura
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Ai Kurogi
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Nice Ren
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Akihito Hagihara
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Yuriko Nakaoku
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Hajime Arai
- 13Department of Neurosurgery, Juntendo University School of Medicine, Tokyo; and
| | - Susumu Miyamoto
- 14Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kunihiro Nishimura
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Koji Iihara
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
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21
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Liu J, Xiong Y, Zhong M, Yang Y, Guo X, Tan X, Zhao B. Predicting Long-Term Outcomes After Poor-Grade Aneurysmal Subarachnoid Hemorrhage Using Decision Tree Modeling. Neurosurgery 2021; 87:523-529. [PMID: 32171016 DOI: 10.1093/neuros/nyaa052] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 01/12/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite advances in the treatment of poor-grade aneurysmal subarachnoid hemorrhage (aSAH), predicting the long-term outcome of aSAH remains challenging, although essential. OBJECTIVE To predict long-term outcomes after poor-grade aSAH using decision tree modeling. METHODS This was a retrospective analysis of a prospective multicenter observational registry of patients with poor-grade aSAH with a World Federation of Neurosurgical Societies (WFNS) grade IV or V. Outcome was assessed by the modified Rankin Scale (mRS) at 12 mo, and an unfavorable outcome was defined as an mRS of 4 or 5 or death. Long-term prognostic models were developed using multivariate logistic regression and decision tree algorithms. An additional independent testing dataset was collected for external validation. Overall accuracy, sensitivity, specificity, and area under receiver operating characteristic curves (AUC) were used to assess model performance. RESULTS Of the 266 patients, 139 (52.3%) had an unfavorable outcome. Older age, absence of pupillary reactivity, lower Glasgow coma score (GCS), and higher modified Fisher grade were independent predictors of unfavorable outcome. Modified Fisher grade, pupillary reactivity, GCS, and age were used in the decision tree model, which achieved an overall accuracy of 0.833, sensitivity of 0.821, specificity of 0.846, and AUC of 0.88 in the internal test. There was similar predictive performance between the logistic regression and decision tree models. Both models achieved a high overall accuracy of 0.895 in the external test. CONCLUSION Decision tree model is a simple tool for predicting long-term outcomes after poor-grade aSAH and may be considered for treatment decision-making.
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Affiliation(s)
- Jinjin Liu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianzhong Guo
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianxi Tan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Zhao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine Shanghai, China
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22
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Silva MA, Lai PMR, Du R, Aziz-Sultan MA, Patel NJ. The Ruptured Arteriovenous Malformation Grading Scale (RAGS): An Extension of the Hunt and Hess Scale to Predict Clinical Outcome for Patients With Ruptured Brain Arteriovenous Malformations. Neurosurgery 2021; 87:193-199. [PMID: 31586199 DOI: 10.1093/neuros/nyz404] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/26/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Arteriovenous malformation (AVM) rupture is highly morbid. Outcomes after AVM rupture differ from other types of brain hemorrhage. There are no specific widely used grading systems designed to predict clinical outcome after AVM rupture. OBJECTIVE To develop an all-comers scoring system to grade patients with AVM rupture and predict clinical outcome more accurately than grading systems currently in use. METHODS We retrospectively reviewed patients who presented to our institution with a ruptured AVM. Using change in modified Rankin Score (mRS) as our response variable, we generated an ordinal logistic regression model to test for significant predictor variables. The full model was sequentially condensed until the simplest model with the highest area under the receiver operating curve (AUROC) was achieved. RESULTS A total of 115 patients who presented with ruptured AVMs were included in the study, with a mean follow-up time of 4 yr. The Ruptured AVM Grading Scale (RAGS) consists of the Hunt and Hess (HH) score (1-5), patient age (<35 = 0, 35-70 = 1, and >70 = 2), deep venous drainage (1), and eloquence (1). The RAGS score outperformed other neurosurgical grading scales in predicting change in mRS, with an AUROC greater than 0.80 across all follow-up periods. CONCLUSION The RAGS score is a simple extension of the HH scale that predicts clinical outcome after AVM rupture more accurately than other grading systems.
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Affiliation(s)
- Michael A Silva
- Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts.,Department of Neurosurgery, Jackson Memorial Hospital, Miller School of Medicine, University of Miami, Miami, Florida
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
| | - Mohammad A Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
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23
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Xia N, Chen J, Zhan C, Jia X, Xiang Y, Chen Y, Duan Y, Lan L, Lin B, Chen C, Zhao B, Chen X, Yang Y, Liu J. Prediction of Clinical Outcome at Discharge After Rupture of Anterior Communicating Artery Aneurysm Using the Random Forest Technique. Front Neurol 2020; 11:538052. [PMID: 33192969 PMCID: PMC7658443 DOI: 10.3389/fneur.2020.538052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 09/23/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease. Anterior communicating artery (ACoA) aneurysm is the most frequent location of intracranial aneurysms. The purpose of this study is to predict the clinical outcome at discharge after rupture of ACoA aneurysms using the random forest machine learning technique. Methods: A total of 607 patients with ruptured ACoA aneurysms were included in this study between December 2007 and January 2016. In addition to basic clinical variables, 12 aneurysm morphologic parameters were evaluated. A multivariate logistic regression analysis was performed to determine the independent predictors of poor outcome. Of the 607 patients, 485 patients were randomly selected for training and the remaining for internal testing. The random forest model was developed using the training data set. An additional 202 patients from February 2016 to December 2017 were collected for externally validating the model. The prediction performance of the random forest model was compared with two radiologists. Results: Patients' age (odds ratio [OR] = 1.04), ventilated breathing status (OR = 4.23), World Federation of Neurosurgical Societies (WFNS) grade (OR = 2.13), and Fisher grade (OR = 1.50) are significantly associated with poor outcome. None of the investigated morphological parameters of ACoA aneurysm is an independent predictor of poor outcome. The developed random forest model achieves sensitivities of 78.3% for internal test and 73.8% for external test. The areas under receiver operating characteristic (ROC) curve of the random forest model were 0.90 for the internal test and 0.84 for the external test. Both sensitivities and areas under ROC curves of our model are superior to those of two raters in both internal and external tests. Conclusions: The random forest model presents good performance in predicting the outcome after rupture of ACoA aneurysms, which may aid in clinical decision making.
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Affiliation(s)
- Nengzhi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jie Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chenyi Zhan
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiufen Jia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yilan Xiang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yongchun Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yuxia Duan
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Li Lan
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Boli Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chao Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Zhao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoyu Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jinjin Liu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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24
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Hardigan T, Kellner C, Oermann EK. Commentary. Neurosurgery 2020; 87:E291-E292. [DOI: 10.1093/neuros/nyaa073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
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25
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Ariyada K, Ohida T, Shibahashi K, Hoda H, Hanakawa K, Murao M. Long-term Functional Outcomes for World Federation of Neurosurgical Societies Grade V Aneurysmal Subarachnoid Hemorrhage after Active Treatment. Neurol Med Chir (Tokyo) 2020; 60:390-396. [PMID: 32669527 PMCID: PMC7431870 DOI: 10.2176/nmc.oa.2020-0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This study investigated the long-term outcomes of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (SAH) who underwent early aneurysm repair. We evaluated consecutive patients with WFNS grade V aneurysmal SAH from April 2010 to March 2015 who underwent aneurysm repair within 72 h after onset. We assessed the functional outcomes at discharge and 3 years after onset using the modified Rankin Scale (mRS). The primary outcome was defined as a favorable functional outcome (mRS ≤2). We identified 145 patients with grade V SAH during the study period. Of these, 44 patients (19 males and 25 females; median age, 64 years; range, 24–79 years) met the inclusion criteria. For aneurysm repair, surgical clipping and coiling were performed in 40 (90.9%) and 4 (9.1%) patients, respectively. Although no patient had a favorable functional outcome at discharge, 11 (25.0%) patients had a favorable functional outcome at the end of follow-up. The number of patients with a favorable outcome significantly increased during the first year (P = 0.012) and during the follow-up period (P <0.001). Patients who underwent active rehabilitation had significant improvement. Our study showed that one-fourth of the patients who underwent early aneurysm repair with WFNS grade V SAH achieved a mRS score of ≤2 over a 3-year period. It might be important to consider age and rehabilitation for better clinical outcomes. Larger studies are required to adequately assess the long-term functional outcomes and other multi-faceted prognoses.
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Affiliation(s)
- Kenichi Ariyada
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Tomoya Ohida
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Masahiko Murao
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
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26
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Mader MM, Piffko A, Dengler NF, Ricklefs FL, Dührsen L, Schmidt NO, Regelsberger J, Westphal M, Wolf S, Czorlich P. Initial pupil status is a strong predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage. Sci Rep 2020; 10:4764. [PMID: 32179801 PMCID: PMC7076009 DOI: 10.1038/s41598-020-61513-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/27/2020] [Indexed: 11/30/2022] Open
Abstract
Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Anonymized data of 477 aSAH patients admitted to our medical center from November 2010 to August 2018 were retrospectively analyzed. Identification of variables independently predicting in-hospital mortality was performed by multivariable logistic regression analysis. Final regression models included Hunt & Hess scale (H&H), pupil status and age or in a simplified variation only H&H and pupil status, leading to the design of novel H&H-Pupil-Age score (HHPA) and simplified H&H-Pupil score (sHHP), respectively. In an external validation cohort of 402 patients, areas under the receiver operating characteristic curves (AUROC) of HHPA (0.841) and sHHP (0.821) were significantly higher than areas of H&H (0.794; p < 0.001) or World Federation of Neurosurgical Societies (WFNS) scale (0.775; p < 0.01). Accordingly, including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. HHPA and sHHP allow simple, early and detailed prognosis assessment while predictive performance remained strong in an external validation cohort suggesting adequate generalizability and low interrater variability.
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Affiliation(s)
- Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA, 94305, USA.
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nora F Dengler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nils O Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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27
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Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5. Acta Neurochir (Wien) 2020; 162:533-544. [PMID: 31980948 DOI: 10.1007/s00701-019-04190-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results. METHODS Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months. RESULTS We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors. CONCLUSIONS Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.
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van Donkelaar CE, Bakker NA, Birks J, Veeger NJGM, Metzemaekers JDM, Molyneux AJ, Groen RJM, van Dijk JMC. Prediction of Outcome After Aneurysmal Subarachnoid Hemorrhage. Stroke 2020; 50:837-844. [PMID: 30869562 DOI: 10.1161/strokeaha.118.023902] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Early prediction of clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH) is still lacking accuracy. In this observational cohort study, we aimed to develop and validate an accurate bedside prediction model for clinical outcome after aSAH, to aid decision-making at an early stage. Methods- For the development of the prediction model, a prospectively kept single-center cohort of 1215 aSAH patients, admitted between 1998 and 2014, was used. For temporal validation, a prospective cohort of 224 consecutive aSAH patients from the same center, admitted between 2015 and 2017, was used. External validation was performed using the ISAT (International Subarachnoid Aneurysm Trial) database (2143 patients). Primary outcome measure was poor functional outcome 2 months after aSAH, defined as modified Rankin Scale score 4-6. The model was constructed using multivariate regression analyses. Performance of the model was examined in terms of discrimination and calibration. Results- The final model included 4 predictors independently associated with poor outcome after 2 months: age, World Federation of Neurosurgical Societies grade after resuscitation, aneurysm size, and Fisher grade. Temporal validation showed high discrimination (area under the receiver operating characteristic curve, 0.90; 95% CI, 0.85-0.94), external validation showed fair to good discrimination (area under the receiver operating characteristic curve, 0.73; 95% CI, 0.70-0.76). The model showed satisfactory calibration in both validation cohorts. The SAFIRE grading scale was derived from the final model: size of the aneurysm, age, Fisher grade, world federation of neurosurgical societies after resuscitation. Conclusions- The SAFIRE grading scale is an accurate, generalizable, and easily applicable model for early prediction of clinical outcome after aSAH.
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Affiliation(s)
- Carlina E van Donkelaar
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Nicolaas A Bakker
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Jaqueline Birks
- Center for Statistics in Medicine, Oxford, United Kingdom (J.B.)
| | - Nic J G M Veeger
- Department of Epidemiology (N.J.G.M.V.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Jan D M Metzemaekers
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Andrew J Molyneux
- Neurovascular Research Unit, Nuffield Department of Surgery, University of Oxford and Oxford Radcliff Hospitals NHS Trust, United Kingdom (A.J.M.)
| | - Rob J M Groen
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - J Marc C van Dijk
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.D.M.M., R.J.M.G., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
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Perry JJ, Sivilotti MLA, Émond M, Hohl CM, Khan M, Lesiuk H, Abdulaziz K, Wells GA, Stiell IG. Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule. Stroke 2019; 51:424-430. [PMID: 31805846 DOI: 10.1161/strokeaha.119.026969] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background and Purpose- The Ottawa subarachnoid hemorrhage (SAH) rule identifies patients with headache requiring no testing for SAH, while the 6-hour computed tomography (CT) rule guides when to forgo a lumbar puncture. Our objectives were to: (1) estimate the clinical impact of the Ottawa SAH rule and the 6-hour-CT rule on testing rates (ie, CT, lumbar puncture, CT angiography); (2) validate the 6-hour-CT rule for SAH when applied prospectively in a new cohort of patients. Methods- We conducted a multicenter prospective before/after implementation study from 2011 to 2016 with 6 months follow-up at 6 tertiary-care Canadian Academic Emergency Departments. Consecutive alert, neurologically intact adults with headache were included. For intervention period, physicians were given a 1-hour lecture, pocket cards, posters were installed, and physicians indicated Ottawa SAH rule criteria when ordering CTs. SAH was defined by blood on CT, xanthochromia in cerebrospinal fluid, or >1×106/L red blood cells in cerebrospinal fluid with aneurysm. Results- We enrolled 3672 patients, 1743 before and 1929 after implementation, including 188 with SAH. Proportions undergoing CT was unchanged (88.0% versus 87.5%; P=0.643). Lumbar puncture use decreased (38.9% versus 25.9%; P<0.0001). Additional testing following CT (ie, lumbar puncture or CT angiography) decreased (51.3% versus 42.2%; P<0.0001). Admissions declined (9.8% versus 7.4%; P=0.011). Mean emergency department stay was unchanged (6.3±4.0 versus 6.4±4.2 hours; P=0.685). The Ottawa SAH rule was 100% (95% CI, 98.1%-100%) sensitive, and the 6-hour-CT rule was 95.5% (95% CI, 89.8-98.5) sensitive for SAH. The 6-hour-CT rule missed 5 SAHs: 1 radiology misread, 2 incidental aneurysms, 1 nonaneurysmal cause, and 1 profoundly anemic patient. Conclusions- The Ottawa SAH rule and the 6-hour-CT rule are highly sensitive and can be used routinely when SAH is considered in patients with headache. Implementing both rules was associated with a meaningful decrease in testing and admissions to hospital.
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Affiliation(s)
- Jeffrey J Perry
- From the Departments of Emergency Medicine (I.G.S., J.J.P.), University of Ottawa, Canada.,School of Epidemiology, Public Health and Preventative Medicine (I.G.S., J.J.P., G.A.W.), University of Ottawa, Canada.,the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
| | - Marco L A Sivilotti
- the Departments of Emergency Medicine and of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada (M.L.A.S.)
| | - Marcel Émond
- the Division of Emergency Medicine, Université Laval, Quebec City, Canada (M.E.)
| | - Corinne M Hohl
- the Department of Emergency Medicine, University of British Columbia, Vancouver, Canada (C.M.H.)
| | - Maryam Khan
- the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
| | - Howard Lesiuk
- the Division of Neurosurgery (H.L.), University of Ottawa, Canada
| | - Kasim Abdulaziz
- the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
| | - George A Wells
- School of Epidemiology, Public Health and Preventative Medicine (I.G.S., J.J.P., G.A.W.), University of Ottawa, Canada
| | - Ian G Stiell
- From the Departments of Emergency Medicine (I.G.S., J.J.P.), University of Ottawa, Canada.,School of Epidemiology, Public Health and Preventative Medicine (I.G.S., J.J.P., G.A.W.), University of Ottawa, Canada.,the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
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Dundar TT, Abdallah A, Yurtsever I, Guler EM, Ozer OF, Uysal O. Serum SUR1 and TRPM4 in patients with subarachnoid hemorrhage. Neurosurg Rev 2019; 43:1595-1603. [PMID: 31707576 DOI: 10.1007/s10143-019-01200-6] [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: 08/25/2019] [Revised: 10/18/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
Neuroinflammation plays an important role in neuronal injury after aneurysmal subarachnoid hemorrhage (aSAH). Sulfonylurea receptor 1 (SUR1) and transient receptor potential cation channel subfamily M member 4 (TRPM4) receptors play an important role in the pathogenesis of several neural injuries, such as neural edema, spinal cord damage, stroke, and neuronal damage in aSAH. This study aimed to investigate the relationship of serum SUR1 and TRPM4 levels with the neurological status within the first 15 days after aSAH. In this prospective study, blood samples were collected from 44 consecutive patients on the 1st, 4th, and 14th days after aSAH. Serum SUR1 and TRPM4 levels were measured using an enzyme-linked immunosorbent assay kit. Glasgow coma scale and World Federation of Neurosurgical Societies (WFNS) scores upon presentation and Glasgow outcome scale (GOS) score on the 14th day were recorded. Serum SUR1 and TRPM4 levels on the 1st, 4th, and 14th days were significantly higher in patients with aSAH than in normal individuals. This increase in the levels varied among the 1st, 4th, and 14th days. On the first day, a correlation was observed between serum SUR1, but not TRPM4, levels and the WFNS score. Moreover, on the 14th day, an association of serum SUR1 and TRPM4 levels with the GOS score was noted. Serum SUR1 and TRPM4 levels were significantly upregulated in the peripheral blood samples. Further study is warranted to establish the utility of SUR1 and TRPM4 as biomarkers in patients with aSAH.
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Affiliation(s)
- Tolga Turan Dundar
- Department of Neurosurgery, Bezmialem Vakif University, Adnan Menderes Bulvari, Vatan Street, 34093, Fatih, Istanbul, Turkey.
| | - Anas Abdallah
- Department of Neurosurgery, Bezmialem Vakif University, Adnan Menderes Bulvari, Vatan Street, 34093, Fatih, Istanbul, Turkey
| | - Ismail Yurtsever
- Department of Radiology, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - Eray Metin Guler
- Department of Biochemistry, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - Omer Faruk Ozer
- Department of Biochemistry, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - Omer Uysal
- Department of Biostatistics, Bezmialem Vakif University, 34093, Istanbul, Turkey
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Catapano JS, Zabramski JM, Baranoski JF, Brigeman S, Morgan CD, Hendricks BK, Mooney MA, Albuquerque FC, Nakaji P, Spetzler RF. The Prognostic Significance of a Cast Fourth Ventricle in Ruptured Aneurysm Patients With Intraventricular Hemorrhage in the Barrow Ruptured Aneurysm Trial (BRAT). Neurosurgery 2019; 85:E275-E283. [PMID: 30476225 DOI: 10.1093/neuros/nyy493] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 10/29/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Ruptured aneurysms causing intraventricular hemorrhage (IVH) are associated with high morbidity. The presence of blood that completely fills the fourth ventricle (cast fourth ventricle, CFV) is thought to be particularly ominous, but studies documenting the outcome of such cases are lacking. OBJECTIVE To investigate the outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and CFV. METHODS We reviewed 406 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT, NCT01593267, clinicaltrials.gov); 238 patients with aSAH and IVH were identified, and imaging was reviewed for the presence of CFV. Outcome was evaluated at the 1-yr follow-up. A poor outcome was defined as modified Rankin Scale score >2. RESULTS CFV was identified in 25 patients. Admission Glasgow Coma Score was lower in CFV patients, 7.8 versus 11.5 (P < .001). At discharge and the 1-yr follow-up, patients with CFV had a greater risk of a poor outcome (P < .001 and P = .002, respectively). In a subgroup analysis of 79 patients with IVH and initial Glasgow Coma Score ≤ 8, almost 50% of the patients with IVH but without CFV had made a good recovery versus 7% of patients with CFV (odds ratio [OR] 15, P = .002). On multivariate analysis, CFV was a greater predictor of a poor prognosis at 1 yr post-aSAH than Hunt and Hess grade >3 (6.4 OR vs 2.9 OR [P < .001], respectively). CONCLUSION The presence of CFV is a predictor of poor outcome in patients with aSAH. When compared to other patients with IVH and aSAH, CFV is a stronger predictor of a poor outcome than a poor Hunt and Hess Grade.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Scott Brigeman
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Clinton D Morgan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Benjamin K Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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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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Anqi X, Ruiqi C, Yanming R, Chao Y. Elevated hemoglobin is associated with poor prognosis in Tibetans with poor-grade aneurysmal subarachnoid hemorrhage after clipping: A Retrospective Case-Control Study. Neurochirurgie 2019; 65:365-369. [PMID: 31301387 DOI: 10.1016/j.neuchi.2019.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/19/2019] [Accepted: 06/10/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES High hemoglobin (HGB) concentration is frequently seen in Tibetans in clinical practice; however, the impact on postsurgical prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is not precisely known. Thus, we sought to understand the association between high HGB level and postoperative outcome in Tibetans with poor-grade aSAH. PATIENTS AND METHODS Results of clipping in consecutive Tibetan patients with poor-grade aSAH were analyzed retrospectively for the period January 2012 to January 2017. Based on the upper limit (160g/L) of normal hemoglobin levels, patients were divided to a high (HHC) and a normal (NHC) HGB-level cohort according to the first routine blood result on admission. Propensity score matching was used for baseline matching in the 2 cohorts. Postoperative complications in the 2 groups were compared. Prognosis after ictus, including 6-month neurological functional status and mortality at 30 days and 6 months were also assessed. RESULTS Risk of ischemia, pulmonary embolism and lower-limb deep venous thrombosis (DVT) was higher in HHC than NHC (62.88% vs. 21.64%; P<0.001; 10.30% vs. 1.31%, P<0.005; 24.74% vs. 7.21%, P<0.001, respectively). Hospital stay also differed significantly (15.82±3.86 vs. 10.37±4.80 days; P<0.001). Out of the 194 patients, 150 survived at 6 months. At 6-month neurological functional follow-up, 8 NHC patients had favorable modified Rankin scale (mRS) scores ≤2 at discharge, versus only 1 HHC patient, showing better outcome in NHC than HHC (8.25% vs. 1.03%; P=0.035). In-hospital mortality was significantly greater in HHC than NHC (17.52% vs. 7.22%; P=0.029). 30-day post-ictus mortality was 30.93% in HHC versus 14.43% in NHC (P<0.006). There was also a significant difference in mortality at 6 months post-ictus (47.42% vs. 18.56%; P<0.001). CONCLUSION High HGB level was associated with increased risk of postsurgical cerebral ischemia, pulmonary embolism and lower-limb DVT and poor prognosis in poor-grade aSAH patients. Preoperative hemodilution therapy might be beneficial in reducing operative complications, reducing hospital stay and improving short-term prognosis for neurological functional recovery in aSAH patients with high HGB concentration, but further detailed research is needed.
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Affiliation(s)
- X Anqi
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
| | - C Ruiqi
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
| | - R Yanming
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
| | - Y Chao
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
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Matano F, Fujiki Y, Mizunari T, Koketsu K, Tamaki T, Murai Y, Yokota H, Morita A. Serum Glucose and Potassium Ratio as Risk Factors for Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:1951-1957. [PMID: 31060790 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/14/2019] [Accepted: 03/16/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Cerebral vasospasm is associated with poor prognosis in patients with aneurysmal subarachnoid hemorrhage (SAH), and biomarkers for predicting poor prognosis have not yet been established. We attempted to clarify the relationship between serum glucose/potassium ratio and cerebral vasospasm in patients with aneurysmal SAH. METHODS We studied 333 of 535 aneurysmal SAH patients treated between 2006 and 2016 (123 males, 210 females; mean age 59.7 years; range 24-93). We retrospectively analyzed the relationship between cerebral vasospasm grade and clinical risk factors, including serum glucose/potassium ratio. RESULTS Postoperative angiography revealed cerebral vasospasm in 112 patients (33.6%). Significant correlations existed between the ischemic complication due to cerebral vasospasm and glucose/potassium ratio (P < .0001), glucose (P = .016), and potassium (P = .0017). Serum glucose/potassium ratio was elevated in the cerebral vasospasm grade dependent manner (Spearman's r = 0.1207, P = .0279). According to the Glasgow Outcome Scale (GOS) score at discharge, 185 patients (55.5%) had a poor outcome (GOS scores 1-3). Serum glucose/potassium ratio was significantly correlated between poor outcome (GOS scores 1-3) and age (P < .0001), serum glucose/potassium ratio (P < .0001), glucose (P < .0001), potassium (P = .0004), white blood cell count (P = .0012), and cerebral infarction due to cerebral vasospasm (P < .0001). Multivariate logistic regression analyzes showed significant correlations between cerebral infarction due to cerebral vasospasm and serum glucose/potassium ratio (P = .018), glucose (P = .027), and potassium (P = .052). CONCLUSIONS Serum glucose/potassium ratio in cases of aneurysmal SAH was significantly associated with cerebral infarction due to cerebral vasospasm and GOS at discharge. Therefore, this factor was useful to predict prognosis in patients with cerebral vasospasm and aneurysmal SAH.
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Affiliation(s)
- Fumihiro Matano
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan.
| | - Yu Fujiki
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takayuki Mizunari
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Kenta Koketsu
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Tomonori Tamaki
- Department of Neurosurgery, Tama Nagayama Hospital, Tokyo, Japan
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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Zheng K, Zhong M, Zhao B, Chen SY, Tan XX, Li ZQ, Xiong Y, Duan CZ. Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Risk Factors Affecting Clinical Outcomes in Intracranial Aneurysm Patients in a Multi-Center Study. Front Neurol 2019; 10:123. [PMID: 30873104 PMCID: PMC6400833 DOI: 10.3389/fneur.2019.00123] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 01/30/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: Patients with poor-grade aneurysm subarachnoid hemorrhage (SAH) have commonly been considered to have a poor prognosis. The objective of this study was to investigate the independent risk factors affecting clinical outcomes in intracranial aneurysm patients with poor-grade aneurysm subarachnoid hemorrhage (aSAH) underwent different intervention therapies. Methods: A multicenter observational registry of 324 poor-grade aSAH patients treated at tertiary referral centers from October 2010 to March 2012 were enrolled in this study. The clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. Clinical outcomes were assessed via a modified Rankin Scale at 12 months. Multivariate logistic regression models were used to develop prognostic models. The area under the receiver operator characteristic curves (AUC) and Hosmer-Lemeshow tests were used to assess discrimination and calibration. WAP score was developed to predict risk of poor outcome. Results: Older age, female gender, ventilated breathing status, non-reactive pupil response, pupil dilation, lower GCS score, a WFNS grade of V, intraventricular hemorrhage, a higher Fisher grade, a higher modified Fisher grade, and conservative treatment were calculated to be associated with a relatively poor outcome. Multivariate analyses revealed that older age, lower Glasgow coma scale score (GCS), the absence of pupillary reactivity, higher modified Fisher grade, and conservative treatment were independent predictors of poor outcome, showed good discrimination and calibration. Patients with WFNS grade V, older age and non-reactive pupillary reactivity were predicted to have a poor outcome by WAP risk score. Conclusions: A simple WAP risk score had good discrimination and calibration in the prediction of outcome. The risk score can be easily measured and may complement treatment decision-making.
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Affiliation(s)
- Kuang Zheng
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, The National Key Clinic Specialty, The Neurosurgery Institute of Guangdong Province, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Zhong
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Zhao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Si-Yan Chen
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xian-Xi Tan
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ze-Qun Li
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chuan-Zhi Duan
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, The National Key Clinic Specialty, The Neurosurgery Institute of Guangdong Province, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Wang X, Han C, Xing D, Wang C, Ding X. Early management of poor-grade aneurysmal subarachnoid hemorrhage: A prognostic analysis of 104 patients. Clin Neurol Neurosurg 2019; 179:4-8. [PMID: 30776564 DOI: 10.1016/j.clineuro.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/30/2019] [Accepted: 02/03/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to investigate the efficacy of early management for poor-grade aneurysmal subarachnoid hemorrhage (aSAH; WFNS grade IV and V), and analyze the prognostic factors. PATIENTS AND METHODS A total of 104 consecutive patients with poor-grade aSAH from the Department of Neurosurgery, the Second Hospital of Shandong University were enrolled between January 2010 and December 2017. All these patients underwent early microsurgical clipping or endovascular coiling within three days after onset. Microsurgical clipping or endovascular coiling was selected according to aneurysm patterns, patient clinical status, interdisciplinary consultation, and the decision-making of the family. The individual prognosis was evaluated using the modified Rankin scale (mRS), while the prognostic factors were analyzed using multivariate logistic regression analysis. RESULTS There were 58 patients with grade IV aSAH and 46 patients with grade V aSAH. Microsurgical clipping was performed in 71 cases, while endovascular coiling was performed in 33 cases. According to the statistical results, microsurgical clipping was preferred by patients with CT Fisher grade III-IV, WFNS grade V, cerebral hernia, intracranial hematoma and preoperative rebleeding. At six months after onset, the overall rate of favorable outcome (mRS ≤ 2) was 36.5%. Furthermore, the favorable outcome rate was 56.9% in grade IV patients and 11.1% in grade V patients. Moreover, the univariate and multivariate logistic regression analyses revealed that CT Fisher grade I-II, WFNS grade IV and endovascular coiling were associated with a favorable prognosis, while the CT low-density area was slightly correlated to a poor prognosis. CONCLUSION The treatment of aSAH at the early stage by microsurgical clipping or endovascular coiling should be highlighted, especially for patients with WFNS grade IV. CT Fisher grade I-II, WFNS grade IV and endovascular coiling may predict a favorable prognosis, and the CT low-density area appeared to be a possible risk factor for poor prognosis.
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Affiliation(s)
- Xiaofei Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Chao Han
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Deguang Xing
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Chengwei Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Xuan Ding
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China.
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Shibata A, Matano F, Fujiki Y, Mizunari T, Murai Y, Yokota H, Morita A. Efficacy of Thyrotropin-Releasing Hormone Analog for Protracted Disturbance of Consciousness due to Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:988-993. [PMID: 30660483 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 12/07/2018] [Accepted: 12/16/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The efficacy of thyrotropin-releasing hormone tartrate (TRH-T) for treating prolonged disturbance of consciousness due to aneurysmal subarachnoid hemorrhage (SAH) remains unclear. The purpose of the present study was to determine whether TRH-T was really effective, and what was the recovery factor when it was valid. This was a retrospective study of a single facility. METHODS We treated 208 patients with aneurysmal SAH at our hospital between 2011 and 2017. Among them, we investigated 97 cases in which TRH-T was administered to prolonged disturbance of consciousness. Thirty one patients with Hasegawa dementia rating scale-revised (HDS-R) score less than 20 were included. Patients' HDS-R scores were evaluated 7 days after clipping the aneurysm and 2 days after completing a course of TRH-T treatment. HDS-R score increases of greater than or over equal to 8 and less than 8 were defined as good and poor outcomes, respectively. Outcomes were compared to 11 patients who did not receive TRH-T treatment. RESULTS Average initial and post-treatment HDS-R scores were 9 ± 6.6 and 19 ± 9.5, respectively. The good outcome group included 19 patients. Statistically significant differences in HDS-R score changes were observed between the group with initial HDS-R scores of 0-4 and the other groups. Poor outcomes were significantly correlated with age of greater than 60 years and initial HDS-R scores less than oroverequal to 4 points. The improvement in HDS-R score was significantly greater in the TRH-T administration group than the control group. CONCLUSIONS TRH-T was effective for treating prolonged disturbance of consciousness due to aneurysmal SAH, especially in young patients with HDS-R scores between 5 and 20.
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Affiliation(s)
- Ami Shibata
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan; Department of Neurosurgery, Chiba Hokusoh Hospital, Inzai, Chiba, Japan.
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Yu Fujiki
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takayuki Mizunari
- Department of Neurosurgery, Chiba Hokusoh Hospital, Inzai, Chiba, Japan
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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Haug Nordenmark T, Karic T, Sorteberg W, Sorteberg A. Predictors of cognitive function in the acute phase after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2019; 161:177-184. [PMID: 30535853 DOI: 10.1007/s00701-018-3760-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cognitive dysfunction is the most common form of neurological impairment after aneurysmal subarachnoid hemorrhage (aSAH) in the chronic phase. Cognitive deficits in the acute phase after aSAH, however, remain scarcely investigated. The aim of the present study was to test cognitive function and to identify medical predictors of cognitive deficits in the acute phase of aSAH. METHODS Prospective study including 51 patients treated for aSAH. Patients were treated in accordance with a standardized institutional protocol and subjected to neuropsychological evaluation around discharge from neurosurgical care. The neuropsychological test results were transformed into a global cognitive impairment index where an index value of 0.00 is considered normal and 1.00 is considered maximally pathological. Patients with an index score of less than 0.75 were considered having good global cognitive function while those with an index score equal to or above 0.75 were considered having poor global cognitive function. Univariate and multiple regression analysis were used to identify medical predictors of cognitive function. RESULTS Fifty-seven percent of the patients had poor cognitive function. They showed severe cognitive deficits, with most tests falling well below two standard deviations from the expected normal mean. Poor cognitive function was not reflected in a poor modified Rankin score in almost half of the cases. Patients with good cognitive function showed only mild cognitive deficits with most tests falling only slightly below the normal mean. Delayed memory was the most affected function in both groups. Univariate analysis identified acute hydrocephalus and aSAH-acquired cerebral infarction to be predictors of poor cognitive function. Cerebrospinal fluid drainage in excess of 2000 ml six-folded the risk of poor cognitive function, whereas a new cerebral infarction 11-folded the respective risk of poor cognitive function. CONCLUSION More than half of aSAH patients have severe cognitive deficits in the acute phase. The modified Rankin Score should be combined with neuropsychological screening in the acute phase after aSAH to get a more accurate description of the patients' disabilities. Acute hydrocephalus and aSAH-acquired cerebral infarction are the strongest predictors of poor cognitive function in the acute phase.
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Abstract
Abstract:Object:Our experience in Calgary was reviewed to determine the safety and clinical effectiveness of coiling in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).Methods:Patients with Hunt-Hess grades IV and V aneurysmal subarachnoid hemorrhage who underwent endovascular coiling between January 1999 and April 2009 at Foothills Medical Centre, Calgary, Alberta, Canada were reviewed. The primary outcome measure was the Modified Rankin Score after at least six months. Secondary outcome measures included extent of aneurysm occlusion and peri-procedural complications. In patients with favourable functional outcomes, Barthel's Index (BI), Re-integration to normal living index (RINL), and Zung depression scale (ZDS) were determined.Results:Thirty-three patients were identified (median age of 57 years; 73% female) and 69% were Hunt-Hess grade IV subarachnoid hemorrhage and 22 % were grade V Endovascular coiling resulted in absence of residual flow into the aneurysm fundus in 91%. Only seven procedure-related complications occurred with no deaths attributed to the procedure. Vasospasm, hydrocephalus, and pneumonia were the most common non-procedural complications. Average follow-up was 27 +/- 17 months. Overall mortality was 32%, but 53% of patients had good functional outcome (mRS<3). Nine patients completed the BI, RINL, and ZDS with average BI 99 +/- 2, RINL 89 +/- 14, ZDS 33 +/-11, suggesting minimal deficits in function and mood.Conclusions:Endovascular coiling in patients with high-grade subarachnoid hemorrhage is safe. While the morbidity and mortality from high-grade aneurysmal subarachnoid hemorrhage remains significant, favourable radiologic and functional outcomes can be achieved in a significant proportion of these critically ill patients.
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Doerfler S, Faerber J, McKhann GM, Elliott JP, Winn HR, Kumar M, Levine J, Le Roux PD. The Incidence and Impact of Secondary Cerebral Insults on Outcome After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 114:e483-e494. [DOI: 10.1016/j.wneu.2018.02.195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/25/2018] [Accepted: 02/28/2018] [Indexed: 02/04/2023]
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Comparison of Aggressive Surgical Treatment and Palliative Treatment in Elderly Patients with Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5818937. [PMID: 29998135 PMCID: PMC5994574 DOI: 10.1155/2018/5818937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
Objective To compare the current treatment approach in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) and identify the independent predictors of the outcome after aggressive surgical treatment. Method This prospective, multicenter cohort study included 104 poor-grade aneurysmal SAH elderly patients, 60 years or older, treated in our institution from October 2010 to March 2013. Patients were grouped according to three treatment arms. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at baseline and at a 12-month follow-up. Univariate and multivariate analysis were performed using the following factors: sex, age, smoking history, breathing ability, alcohol consumption, cerebral hernia, aneurysm location, aneurysm diameter, WFNS grade, CT Fisher grade, treatment approach, and the timing of the aneurysm surgery. Results At the 12-month follow-up, patients in the coiling group and clipping group had better prognosis than patients in the palliative treatment group. Univariate analysis confirmed that the treatment approach, WFNS grade, CT Fisher grade, and age are critical factors for neurological outcomes in poor-grade SAH. Multivariate analysis indicated that WFNS grade V, CT Fisher grades 3-5, and palliative treatment were independent predictors of poor prognoses. Conclusion Aggressive surgical treatment improves the prognoses in poor-grade aneurysm elderly patients with SAH. Elderly Patients of WFNS grade IV and CT Fisher grades 1-2 are more likely to have a better outcome.
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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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Abulhasan YB, Alabdulraheem N, Simoneau G, Angle MR, Teitelbaum J. Mortality after Spontaneous Subarachnoid Hemorrhage: Causality and Validation of a Prediction Model. World Neurosurg 2018; 112:e799-e811. [PMID: 29410174 DOI: 10.1016/j.wneu.2018.01.160] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/19/2018] [Accepted: 01/20/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate primary causes of death after spontaneous subarachnoid hemorrhage (SAH) and externally validate the HAIR score, a prognostication tool, in a single academic institution. METHODS We reviewed all patients with SAH admitted to our neuro-intensive care unit between 2010 and 2016. Univariate and multivariate logistic regressions were performed to identify predictors of in-hospital mortality. The HAIR score predictors were Hunt and Hess grade at treatment decision, age, intraventricular hemorrhage, and rebleeding within 24 hours. Validation of the HAIR score was characterized with the receiver operating curve, the area under the curve, and a calibration plot. RESULTS Among 434 patients with SAH, in-hospital mortality was 14.1%. Of the 61 mortalities, 54 (88.5%) had a neurologic cause of death or withdrawal of care and 7 (11.5%) had cardiac death. Median time from SAH to death was 6 days. The main causes of death were effect of the initial hemorrhage (26.2%), rebleeding (23%) and refractory cerebral edema (19.7%). Factors significantly associated with in-hospital mortality in the multivariate analysis were age, Hunt and Hess grade, and intracerebral hemorrhage. Maximum lumen size was also a significant risk factor after aneurysmal SAH. The HAIR score had a satisfactory discriminative ability, with an area under the curve of 0.89. CONCLUSIONS The in-hospital mortality is lower than in previous reports, attesting to the continuing improvement of our institutional SAH care. The major causes are the same as in previous reports. Despite a different therapeutic protocol, the HAIR score showed good discrimination and could be a useful tool for predicting mortality.
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Affiliation(s)
- Yasser B Abulhasan
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada; Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait.
| | - Najayeb Alabdulraheem
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Gabrielle Simoneau
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Mark R Angle
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeanne Teitelbaum
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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Fujiki Y, Matano F, Mizunari T, Murai Y, Tateyama K, Koketsu K, Kubota A, Kobayashi S, Yokota H, Morita A. Serum glucose/potassium ratio as a clinical risk factor for aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 129:870-875. [PMID: 29148905 DOI: 10.3171/2017.5.jns162799] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (SAH) can result in poor outcomes, and biomarkers for predicting poor prognosis have not yet been established. The aim of this study was to clarify the significance of the serum glucose/potassium ratio for predicting the prognosis of aneurysmal SAH. METHODS The authors retrospectively reviewed the records of 565 patients with aneurysmal SAH between 2006 and 2016. The patient group comprised 208 men and 357 women (mean age 61.5 years, range 10-95 years). A statistical analysis was conducted of the clinical and laboratory risk factors of poor outcome, including the serum glucose/potassium ratio. RESULTS On estimation of the initial assessment using Hunt and Kosnik (H-K) grading, 233 patients (41.2%) were classified as the severe SAH group (H-K Grade IV or V). There were significant correlations between the severe SAH group and serum glucose/potassium ratio (p < 0.0001). Serum glucose/potassium ratio was elevated in an H-K grade-dependent manner (Spearman's r = 0.5374, p < 0.0001). With the estimation of the Glasgow Outcome Scale (GOS) score at discharge, 355 patients (62.8%) were classified as poor outcome (GOS score 1-3). The serum glucose/potassium ratio was elevated in a GOS score at discharge-dependent manner (Spearman's r = 0.4006, p < 0.0001), and was significantly elevated in the poor outcome group compared with the good outcome group (GOS score 4 or 5; p = 0.0245). There were significant correlations between poor outcome and serum glucose/potassium ratio (p < 0.0001), age (p < 0.0001), brain natriuretic peptide levels (p = 0.011), cerebral infarction due to vasospasm (p < 0.0001), and H-K grade (p < 0.0001). Multivariate logistic regression analyses showed significant correlations between poor outcome and serum glucose/potassium ratio (p = 0.009). CONCLUSIONS In this study, the serum glucose/potassium ratio of patients with aneurysmal SAH at admission was significantly correlated with H-K grade and GOS score at discharge. Therefore, this ratio was useful for predicting prognosis of aneurysmal SAH, especially in severe cases.
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Affiliation(s)
- Yu Fujiki
- Departments of1Emergency and Critical Care Medicine and
| | - Fumihiro Matano
- 2Department of Neurosurgery, Chiba Hokusoh Hospital, Tokyo, Japan
| | | | - Yasuo Murai
- 3Neurological Surgery, Nippon Medical School; and
| | | | | | - Asami Kubota
- 2Department of Neurosurgery, Chiba Hokusoh Hospital, Tokyo, Japan
| | - Shiro Kobayashi
- 2Department of Neurosurgery, Chiba Hokusoh Hospital, Tokyo, Japan
| | | | - Akio Morita
- 3Neurological Surgery, Nippon Medical School; and
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de Oliveira Manoel AL, Mansur A, Silva GS, Germans MR, Jaja BNR, Kouzmina E, Marotta TR, Abrahamson S, Schweizer TA, Spears J, Macdonald RL. Functional Outcome After Poor-Grade Subarachnoid Hemorrhage: A Single-Center Study and Systematic Literature Review. Neurocrit Care 2017; 25:338-350. [PMID: 27651379 DOI: 10.1007/s12028-016-0305-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population. METHODS Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment. RESULTS The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter. CONCLUSION Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada. .,Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Ann Mansur
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil.,Instituto Israelita de Pesquisa Albert Einstein, Neurology Program, São Paulo, Brazil
| | - Menno R Germans
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Blessing N R Jaja
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada
| | - Ekaterina Kouzmina
- Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Thomas R Marotta
- Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada
| | - Simon Abrahamson
- Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Anesthesiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Tom A Schweizer
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada
| | - Julian Spears
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - R Loch Macdonald
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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The Prognosis Factors for Endovascular Coiling of Aneurysm in Patients With Ruptured Intracranial Aneurysm. J Craniofac Surg 2017; 28:e535-e539. [DOI: 10.1097/scs.0000000000003818] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cai K, Zhang Y, Shen L, Ji Q, Xu T, Cao M. Characteristics of Blood Pressure Profiles After Endovascular Coiling as Predictors of Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 104:459-466. [DOI: 10.1016/j.wneu.2017.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
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Das KK, Singh S, Sharma P, Mehrotra A, Bhaisora K, Sardhara J, Srivastava AK, Jaiswal AK, Behari S, Kumar R. Results of Proactive Surgical Clipping in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Pattern of Recovery and Predictors of Outcome. World Neurosurg 2017; 102:561-570. [DOI: 10.1016/j.wneu.2017.03.090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/27/2022]
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Kurogi R, Kada A, Nishimura K, Kamitani S, Nishimura A, Sayama T, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Yoshimura S, Okuchi K, Suzuki A, Nakamura F, Onozuka D, Hagihara A, Iihara K. Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study). J Neurosurg 2017; 128:1318-1326. [PMID: 28548595 DOI: 10.3171/2016.12.jns161039] [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] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although heterogeneity in patient outcomes following subarachnoid hemorrhage (SAH) has been observed across different centers, the relative merits of clipping and coiling for SAH remain unknown. The authors sought to compare the patient outcomes between these therapeutic modalities using a large nationwide discharge database encompassing hospitals with different comprehensive stroke center (CSC) capabilities. METHODS They analyzed data from 5214 patients with SAH (clipping 3624, coiling 1590) who had been urgently hospitalized at 393 institutions in Japan in the period from April 2012 to March 2013. In-hospital mortality, modified Rankin Scale (mRS) score, cerebral infarction, complications, hospital length of stay, and medical costs were compared between the clipping and coiling groups after adjustment for patient-level and hospital-level characteristics by using mixed-model analysis. RESULTS Patients who had undergone coiling had significantly higher in-hospital mortality (12.4% vs 8.7%, OR 1.3) and a shorter median hospital stay (32.0 vs 37.0 days, p < 0.001) than those who had undergone clipping. The respective proportions of patients discharged with mRS scores of 3-6 (46.4% and 42.9%) and median medical costs (thousands US$, 35.7 and 36.7) were not significantly different between the groups. These results remained robust after further adjustment for CSC capabilities as a hospital-related covariate. CONCLUSIONS Despite the increasing use of coiling, clipping remains the mainstay treatment for SAH. Regardless of CSC capabilities, clipping was associated with reduced in-hospital mortality, similar unfavorable functional outcomes and medical costs, and a longer hospital stay as compared with coiling in 2012 in Japan. Further study is required to determine the influence of unmeasured confounders.
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Affiliation(s)
- Ryota Kurogi
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Akiko Kada
- 2Department of Clinical Trials and Research, National Hospital Organization Nagoya Medical Centre, Nagoya
| | - Kunihiro Nishimura
- 3Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita
| | - Satoru Kamitani
- 4Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo
| | - Ataru Nishimura
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Tetsuro Sayama
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | | | - Kazunori Toyoda
- 6Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita
| | | | - Junichi Ono
- 8Department of Neurosurgery, Chiba Cerebral and Cardiovascular Centre, Chiba
| | | | - Toru Aruga
- 10Department of Emergency and Critical Care Medicine, Showa University Hospital, Shinagawa
| | - Shigeru Miyachi
- 11Department of Neurosurgery, Osaka Medical College, Takatsuki
| | - Izumi Nagata
- 12Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu
| | - Shinya Matsuda
- 13Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu
| | | | - Kazuo Okuchi
- 15Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara
| | - Akifumi Suzuki
- 16Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-Akita; and
| | - Fumiaki Nakamura
- 4Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo
| | - Daisuke Onozuka
- 17Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihito Hagihara
- 17Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
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Abstract
Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.
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