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Park DS, Roh HG, Chun YI, Jeon YS. Efficacy of Coil Embolization in Small, Anterior Circulation Aneurysms in Patients Less Than 40 Years Old. J Clin Med 2024; 13:4764. [PMID: 39200905 PMCID: PMC11355188 DOI: 10.3390/jcm13164764] [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: 07/16/2024] [Revised: 08/10/2024] [Accepted: 08/12/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Ruptured and unruptured aneurysms are less common in younger individuals compared to older patients. Endovascular treatment has gained popularity over surgical options in the general population, but surgery remains the primary treatment for younger patients due to concerns about higher recurrence rates with endovascular procedures. Methods: This study compared the immediate and long-term outcomes of endovascular treatment in patients under 40 years with those aged 41-60. The study included 239 patients who underwent endovascular treatment for intracranial aneurysms, divided into two age groups: under 40 and 41-60 years. The rates of immediate radiologic outcomes, complications, and recurrence were assessed. Results: The results showed successful aneurysm obliteration rates of 70.1% in the younger group and 64.0% in the older group. The complication rates were 1.5% in the younger group and 3.5% in the older group, with the older group experiencing more procedure-related complications, though this difference was not statistically significant. Long-term follow-up revealed recurrence rates of 23.2% in the younger group and 18.2% in the older group, with no significant difference. Conclusions: The study suggests that endovascular treatment is as effective and safe for patients under 40 years. Therefore, it may be considered an acceptable first-line treatment for younger patients, aligning its use with that in older populations.
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Affiliation(s)
- Dong Sun Park
- Department of Neurosurgery, Hanyang University Changwon Hanmaeum Hospital, Changwon 51139, Republic of Korea
| | - Hong Gee Roh
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Republic of Korea;
| | - Young Il Chun
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea;
| | - Yoo Sung Jeon
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea;
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Nolta NF, Christensen MB, Tresco PA. Advanced age is not a barrier to chronic intracortical single-unit recording in rat cortex. Front Neurosci 2024; 18:1389556. [PMID: 38817909 PMCID: PMC11138162 DOI: 10.3389/fnins.2024.1389556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/02/2024] [Indexed: 06/01/2024] Open
Abstract
Introduction Available evidence suggests that as we age, our brain and immune system undergo changes that increase our susceptibility to injury, inflammation, and neurodegeneration. Since a significant portion of the potential patients treated with a microelectrode-based implant may be older, it is important to understand the recording performance of such devices in an aged population. Methods We studied the chronic recording performance and the foreign body response (FBR) to a clinically used microelectrode array implanted in the cortex of 18-month-old Sprague Dawley rats. Results and discussion To the best of our knowledge, this is the first preclinical study of its type in the older mammalian brain. Here, we show that single-unit recording performance was initially robust then gradually declined over a 12-week period, similar to what has been previously reported using younger adult rats and in clinical trials. In addition, we show that FBR biomarker distribution was similar to what has been previously described for younger adult rats implanted with multi-shank recording arrays in the motor cortex. Using a quantitative immunohistochemcal approach, we observed that the extent of astrogliosis and tissue loss near the recording zone was inversely related to recording performance. A comparison of recording performance with a younger cohort supports the notion that aging, in and of itself, is not a limiting factor for the clinical use of penetrating microelectrode recording arrays for the treatment of certain CNS disorders.
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Affiliation(s)
- Nicholas F. Nolta
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Michael B. Christensen
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
- Department of Otolaryngology – Head & Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Patrick A. Tresco
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
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Hofmann BB, Donaldson DM, Neyazi M, Abusabha Y, Beseoglu K, Hänggi D, Cornelius JF, Fischer I, Muhammad S. Clinical Outcome Prediction of Early Brain Injury in Aneurysmal Subarachnoid Hemorrhage: the SHELTER-Score. Neurocrit Care 2024; 40:438-447. [PMID: 38030877 PMCID: PMC10959788 DOI: 10.1007/s12028-023-01879-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Despite intensive research on preventing and treating vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH), mortality and morbidity rates remain high. Early brain injury (EBI) has emerged as possibly the major significant factor in aSAH pathophysiology, emphasizing the need to investigate EBI-associated clinical events for improved patient management and decision-making. This study aimed to identify early clinical and radiological events within 72 h after aSAH to develop a conclusive predictive EBI score for clinical practice. METHODS This retrospective analysis included 561 consecutive patients with aSAH admitted to our neurovascular center between 01/2014 and 09/2022. Fourteen potential predictors occurring within the initial 72 h after hemorrhage were analyzed. The modified Rankin Scale (mRS) score at 6 months, discretized to three levels (0-2, favorable; 3-5, poor; 6, dead), was used as the outcome variable. Univariate ordinal regression ranked predictors by significance, and forward selection with McFadden's pseudo-R2 determined the optimal set of predictors for multivariate proportional odds logistic regression. Collinear parameters were excluded, and fivefold cross-validation was used to avoid overfitting. RESULTS The analysis resulted in the Subarachnoid Hemorrhage Associated Early Brain Injury Outcome Prediction score (SHELTER-score), comprising seven clinical and radiological events: age (0-4 points), World Federation of Neurosurgical Societies (0-2.5 points), cardiopulmonary resuscitation (CPR) (2 points), mydriasis (1-2 points), midline shift (0.5-1 points), early deterioration (1 point), and early ischemic lesion (2 points). McFadden's pseudo-R2 = 0.339, area under the curve for death or disability 0.899 and 0.877 for death. A SHELTER-score below 5 indicated a favorable outcome (mRS 0-2), 5-6.5 predicted a poor outcome (mRS 3-5), and ≥ 7 correlated with death (mRS 6) at 6 months. CONCLUSIONS The novel SHELTER-score, incorporating seven clinical and radiological features of EBI, demonstrated strong predictive performance in determining clinical outcomes. This scoring system serves as a valuable tool for neurointensivists to identify patients with poor outcomes and guide treatment decisions, reflecting the great impact of EBI on the overall outcome of patients with aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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4
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Lee KS, Siow I, Yang LW, Foo AS, Zhang JJ, Mathews I, Goh CP, Teo C, Nagarjun B, Chen V, Lwin S, Teo K, Low SW, Sun IS, Pang BC, Yang EW, Yang C, Gopinathan A, Yeo TT, Nga VD. Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study. Neurosurg Rev 2024; 47:100. [PMID: 38427140 PMCID: PMC10907408 DOI: 10.1007/s10143-024-02325-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.
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Affiliation(s)
- Keng Siang Lee
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore.
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
| | - Isabel Siow
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Lily Wy Yang
- Ministry of Health Holdings, Singapore, Singapore
| | - Aaron Sc Foo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - John Jy Zhang
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Ian Mathews
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Colin Teo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Bolem Nagarjun
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Vanessa Chen
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Sein Lwin
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Kejia Teo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Shiong Wen Low
- Division of Neurosurgery, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Ira Sy Sun
- Division of Neurosurgery, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Boon Chuan Pang
- Department of Neurosurgery, Khoo Teck Puat Hospital, Alexandra Health Private Limited, National University Health System, Singapore, Singapore
| | - Eugene Wr Yang
- Department of Neurosurgery, Khoo Teck Puat Hospital, Alexandra Health Private Limited, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Vincent Dw Nga
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
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Zhou Y, Qian D, Zhou Z, Li B, Ma Y, Chai E. A nomogram for predicting the risk of cerebral vasospasm after neurosurgical clipping in patients with aneurysmal subarachnoid hemorrhage. Front Neurol 2024; 15:1300930. [PMID: 38434203 PMCID: PMC10908552 DOI: 10.3389/fneur.2024.1300930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/07/2024] [Indexed: 03/05/2024] Open
Abstract
Purpose Cerebral vasospasm (CVS) is a common complication that occurs after neurosurgical clipping of intracranial aneurysms in patients with aSAH. This complication can lead to clinical deterioration and a poor prognosis. The aim of this study is to explore the risk factors for CVS in aSAH patients who have undergone neurosurgical clipping, develop a nomogram for CVS, and evaluate its performance. Methods Patients with aSAH who underwent neurosurgical clipping in the Department of Neurosurgery from January 2018 to January 2023 were selected as the subjects of this research. The clinical data of these patients were retrospectively analyzed. Logistic multivariate regression analysis was employed to identify the independent risk factors of CVS. A clinical prediction model in the form of a nomogram for CVS was developed using the R programming language and subsequently evaluated for its performance and quality. Results A total of 156 patients with aSAH were included in the analysis, comprising 109 patients in the training set and 47 patients in the validation set. In the training cohort, 27 patients (24.77%) developed CVS after neurosurgical clipping, while in the validation cohort, 15 patients (31.91%) experienced CVS. Multivariate regression analysis revealed that age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade were independent risk factors for CVS. The nomogram exhibited excellent discriminative performance in both the training set (AUC = 0.885) and the validation set (AUC = 0.906). Conclusion CVS was a prevalent complication following neurosurgical clipping in patients with aSAH, with a highly intricate pathogenesis and pathophysiological course. Early prediction of CVS represented a significant challenge in clinical practice. In this study, age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade emerged as independent risk factors for CVS. The resulting nomogram demonstrated substantial predictive value.
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Affiliation(s)
- Yu Zhou
- First Clinical Medical College, Lanzhou University, Lanzhou, China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
| | - Dongliang Qian
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
| | - Zhou Zhou
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjing, China
- National Clinical Research Center for Chinese Medicine Acquisition and Moxibustion, Tianjin University of Traditional Chinese Medicine, Tianjing, China
| | - Bin Li
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
| | - Yong Ma
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
- Clinical Medicine College, Ningxia Medical University, Yinchuan, China
| | - Erqing Chai
- First Clinical Medical College, Lanzhou University, Lanzhou, China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
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Wójtowicz K, Przepiorka L, Kujawski S, Maj E, Marchel A, Kunert P. Retrospective Application of Risk Scores to Unruptured Anterior Communicating Artery Aneurysms. J Clin Med 2024; 13:789. [PMID: 38337482 PMCID: PMC10856240 DOI: 10.3390/jcm13030789] [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: 12/25/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Treatment decisions for unruptured intracranial aneurysms (UIAs) pose a challenge for neurosurgeons, prompting the development of clinical scales assessing hemorrhage risk to provide management guidance. This study compares recommendations from the PHASES and UIA treatment scores (UIATS) applied to anterior communicating artery (AComA) UIAs against real-world management. METHODS While UIATS recommends management, for PHASES, an aneurysm with score of 10 or more was considered "high-risk". Analysis involved assessing the concordance in each group alongside comparison to real-word management. RESULTS Among 129 patients, 46.5% were observed and 53.5% were treated. PHASES scores were significantly higher in the treatment group (p = 0.00002), and UIATS recommendations correlated with real-world decisions (p < 0.001). We observed no difference in the frequencies of UIATS recommendations between high- and low-risk groups. When comparing the UIATS and PHASES, 33% of high-risk aneurysms received a UIATS conservative management recommendation. In 39% of high-risk aneurysms, the UIATS recommendation was not definitive. Conversely, 27% of low-risk aneurysms obtained a UIATS UIA repair recommendation. Overall, concordance between PHASES and UIATS was 32%. CONCLUSIONS Significant discordance in therapeutic suggestions underscores the predominant influence of center experience and individual assessments. Future studies should refine and validate decision-making strategies, potentially exploring alternative applications or developing tailored scales.
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Affiliation(s)
- Katarzyna Wójtowicz
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| | - Lukasz Przepiorka
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-077 Bydgoszcz, Poland
| | - Edyta Maj
- Second Department of Clinical Radiology, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
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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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Lenkeit A, Oppong MD, Dinger TF, Gümüs M, Rodemerk J, Chihi M, Ahmadipour Y, Uerschels AK, Dammann P, Deuschl C, Wrede KH, Sure U, Jabbarli R. The role of previous medical history and secondary complications for the outcome of aneurysmal subarachnoid hemorrhage in elderly patients. Clin Neurol Neurosurg 2023; 235:108027. [PMID: 37949039 DOI: 10.1016/j.clineuro.2023.108027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/11/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) presents a devastating diagnosis for elderly individuals, resulting in high morbidity and mortality rates. The aim of the study was to analyze the impact of medical history and complications during SAH on the outcome of elderly patients. METHODS Consecutive SAH cases aged ≥ 65 years old treated in our hospital between 01/2003 and 06/2016 were included (n = 218). Data on comorbidities, previous medication, initial severity, secondary complications, and the outcome were collected. Study endpoints were occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months after SAH. RESULTS Cerebral infarcts were documented in 111 (51.2 % ) individuals. Multivariate analysis showed that angiographic vasospasm caused an increase (adjusted odds ratio [aOR] = 3.11, p = 0.022) in the risk of infarction, whereas aspirin treatment decreased (aOR = 0.25, p = 0.001) the risk of infarction. In turn, increasing age (aOR = 1.11, p = 0.002), intracranial hypertension (>20 mmHg, aOR = 3.32, p = 0.006) and acute kidney failure (aOR = 6.65, p = 0.035) during SAH were independently related to the risk of in-hospital mortality (n = 50; 22.9 % ). Finally, patients' age (aOR = 1.09, p = 0.022), high initial SAH burden (WFNS ≥ 4: aOR = 7.5, p < 0.0001; intraventricular hemorrhage: aOR = 4.38, p = 0.007), aneurysm clipping (aOR = 4.07, p = 0.018), and intracranial hypertension during SAH (aOR = 4.08, p = 0.006) were independent predictors of unfavorable outcome (n = 106/192; 55.5 % ). Previous medical history showed no negative impact on the severity, course and outcome of SAH. CONCLUSION About half of elderly SAH patients face poor outcomes after aneurysm securing. The initial severity of and complications during SAH are the major contributors to poor treatment results. Our findings might help to optimize the treatment strategies.
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Affiliation(s)
- Annika Lenkeit
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Jan Rodemerk
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | | | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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Zhou J, Chen Y, Xia N, Zhao B, Wei Y, Yang Y, Liu J. Predicting the formation of mixed pattern hemorrhages in ruptured middle cerebral artery aneurysms based on a decision tree model: A multicenter study. Clin Neurol Neurosurg 2023; 234:108016. [PMID: 37862728 DOI: 10.1016/j.clineuro.2023.108016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/13/2023] [Accepted: 10/15/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE Mixed-pattern hemorrhages (MPH) commonly occur in ruptured middle cerebral artery (MCA) aneurysms and are associated with poor clinical outcomes. This study aimed to predict the formation of MPH in a multicenter database of MCA aneurysms using a decision tree model. METHODS We retrospectively reviewed patients with ruptured MCA aneurysms between January 2009 and June 2020. The MPH was defined as subarachnoid hemorrhages with intracranial hematomas and/or intraventricular hemorrhages and/or subdural hematomas. Univariate and multivariate logistic regression analyses were used to explore the prediction factors of the formation of MPH. Based on these prediction factors, a decision tree model was developed to predict the formation of MPH. Additional independent datasets were used for external validation. RESULTS We enrolled 436 patients with ruptured MCA aneurysms detected by computed tomography angiography; 285 patients had MPH (65.4%). A multivariate logistic regression analysis showed that age, aneurysm size, multiple aneurysms, and the presence of a daughter dome were the independent prediction factors of the formation of MPH. The areas under receiver operating characteristic curves of the decision tree model in the training, internal, and external validation cohorts were 0.951, 0.927, and 0.901, respectively. CONCLUSION Age, aneurysm size, the presence of a daughter dome, and multiple aneurysms were the independent prediction factors of the formation of MPH. The decision tree model is a useful visual triage tool to predict the formation of MPH that could facilitate the management of unruptured aneurysms in routine clinical work.
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Affiliation(s)
- Jiafeng Zhou
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Yongchun Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Nengzhi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Bing Zhao
- Department of Neurosurgery, Renji Hospital Shanghai Jiaotong University School of Medicine Shanghai, 200127, China
| | - Yuguo Wei
- GE Healthcare, Precision Health Institution, Hangzhou, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jinjin Liu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
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11
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Qiu W, Li W, Xu K, Zhu G, Luo H, Deng Y, Qin Z, Zeng K, Wei Y, Lin X. Prognostic significance of fibrinogen and neutrophil/lymphocyte ratio score and D-dimer/Albumin ratio for prognosis in patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107338. [PMID: 37690163 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107338] [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: 04/10/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Recent research indicates that systemic inflammation significantly affects the overall prognosis of individuals with aneurysmal subarachnoid hemorrhage. To delve deeper into this issue, a retrospective study was undertaken. The study aimed to investigate the relationship between fibrinogen and neutrophil/lymphocyte ratio scores, D-dimer/Albumin ratios, and the Glasgow Outcome Scale at 6 months post-discharge for patients with aSAH. METHODS A retrospective analysis was conducted on 321 patients who experienced aneurysmal subarachnoid hemorrhage. These patients were monitored using the Glasgow Outcome Scale six months after being discharged from Huizhou Central People's Hospital. Patients with GOS scores between 1 and 3 were classified as having a poor prognosis, while those with scores ranging from 4 to 5 were considered to have a good prognosis. To create distinct sets, patients were randomly divided into both training and validation groups. The best cut-off value for the D-dimer/Albumin ratio was established through ROC curves, and the scores for fibrinogen and the neutrophil/lymphocyte ratio were calculated. Utilizing multivariate logistic regression analysis, independent risk factors linked to an unfavorable prognosis in aSAH patients were identified. A nomogram model was developed and validated based on these findings, providing an improved approach for evaluating the prognostic influence of risk factors. To gauge the model's predictive performance, several analytical tools such as ROC curves, calibration curves, and decision curve analysis were employed. This comprehensive approach ensured a thorough assessment of the prognostic prediction capabilities of the model. RESULTS Multivariate regression analysis revealed that Age (OR=3.87, 95%CI=1.54-9.73, p=0.004), Pneumonia (OR=3.54, 95%CI=1.41-8.86, p=0.007), WFNS (OR=3.24, 95%CI=1.23-8.54, p=0.017), DAR (OR=2.88, 95%CI=1.13-7.34, p=0.027), and F-NLR (OR=3.12, 95%CI=1.22-7.97, p=0.017) were identified as independent risk factors influencing the prognosis of patients with aSAH. Additionally, the area under the ROC curve was 0.866 (95%CI=0.805-0.927) for the training set and 0.924 (95%CI=0.849-0.999) for the validation set. The calibration curve analysis demonstrated a minor error of 0.02 for the training set and 0.051 for the validation set. Furthermore, both the training set and validation set displayed significant clinical benefits according to the DCA curves, underscoring the meaningful utility of the developed nomogram. CONCLUSIONS Fibrinogen and neutrophil/lymphocyte ratio scores, and the D-dimer/Albumin ratio emerged as significant independent risk factors for prognosticating the outcomes of patients with aSAH. Leveraging these factors, a robust nomogram model was meticulously developed, showcasing its impressive precision in prognostic predictions. These results underscore the promising clinical applicability of these biomarkers as effective prognostic indicators for individuals afflicted by aSAH.
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Affiliation(s)
- Wenjie Qiu
- Guangdong Medical University, Zhanjiang, China
| | - Wencai Li
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Ke Xu
- Guangdong Medical University, Zhanjiang, China
| | - Gang Zhu
- Guangdong Medical University, Zhanjiang, China; Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China.
| | - Honghai Luo
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Yifan Deng
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Zhongzong Qin
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
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12
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Andersen S, Western E, Sorteberg W, Sorteberg A. The impact of pre-ictal statin use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3325-3338. [PMID: 37792050 PMCID: PMC10624707 DOI: 10.1007/s00701-023-05812-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Pleiotropic effects of statins may be beneficial in alleviating cerebral vasospasm (VS) and improving outcome after aneurysmal subarachnoid hemorrhage (aSAH). Initiation of statin treatment at aSAH is not recommended; however, the effect of pre-ictal and continued statin use is not fully investigated. METHODS Retrospective study comparing aSAH patients admitted in 2012 to 2021 with pre-ictal statin use versus those not using statins. Patient entry variables, radiological/sonological VS, symptomatic VS, and radiologically documented delayed cerebral ischemia (DCI) were registered. Outcome was scored in terms of mortality, modified Rankin score, Glasgow outcome score extended, and levels of fatigue. Patients were compared on group level and in a case-control design. RESULTS We included 961 patients, with 204 (21.2%) statin users. Statin users were older and had more often hypertension. Severe radiological/sonological VS, symptomatic VS, and DCI were less frequent in statin users, and their length of stay was shorter. Mortality, functional outcome, and levels of fatigue were similar in both groups. When analyzing 89 pairs of statin users and non-statin users matched for age, aSAH severity, gender, and hypertension, we confirmed decreased radiological/sonological and symptomatic VS as well as shorter length of stay in statin users. They also had more often a favorable functional outcome and lower levels of fatigue. CONCLUSIONS Patients with pre-ictal and continued use of statins have a reduced occurrence of radiological/sonological and symptomatic VS, shorter length of stay, and more often favorable functional outcome, whereas mortality is similar to non-statin users. Even though larger multicenter studies with common, strict protocols for prevention, diagnosis, and treatment of vasospasm are needed to finally establish the value of statins in aSAH, continuation of pre-ictal statin use seems worthwhile.
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Affiliation(s)
- S Andersen
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway
| | - E Western
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Nydalen, P.B. 4950, 0424, Oslo, Norway
| | - W Sorteberg
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway
| | - A Sorteberg
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway.
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13
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Fortunato M, Lin F, Uddin A, Subah G, Patel R, Feldstein E, Lui A, Dominguez J, Merckling M, Xu P, McIntyre M, Gandhi C, Al-Mufti F. Frailty as a Predictor of Outcomes in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:1498. [PMID: 37891864 PMCID: PMC10605612 DOI: 10.3390/brainsci13101498] [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: 09/15/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.
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Affiliation(s)
- Michael Fortunato
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Fangyi Lin
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Anaz Uddin
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Galadu Subah
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Rohan Patel
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Eric Feldstein
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Aiden Lui
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Jose Dominguez
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Matthew Merckling
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Patricia Xu
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Matthew McIntyre
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Chirag Gandhi
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
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Murayama H, Kanemaru K, Yoshioka H, Fukamachi A, Shimizu T, Omata T, Fukasawa I, Nagasaka M, Nakano S, Asari Y, Kinouchi H. Chronological Change of the Clinical Features and Treatment Outcomes for Subarachnoid Hemorrhage in Japan: A Multicenter Retrospective Study. Neurol Med Chir (Tokyo) 2023; 63:464-472. [PMID: 37612120 PMCID: PMC10687669 DOI: 10.2176/jns-nmc.2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/08/2023] [Indexed: 08/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) treatment has progressed, and patients are rapidly aging in Japan. Consequently, dynamic changes must have emerged in the clinical practice of SAH. This study aimed to elucidate chronological changes of aneurysmal SAH and the prognostic factors in the previous quarter century in Japan. We conducted a retrospective survey regarding aneurysmal SAH in eight institutions in Japan. The study included 848, 863, and 781 patients in the first (1989-1993), second (1999-2003), and third (2009-2013) periods, respectively. The chronological changes of factors that influenced the poor outcomes and differences between the nonelderly (<75 years) and elderly patients were investigated. Mean age was significantly higher in patients in the third period (61.4 years) than in those in the other two periods (first, 57.8 years; second, 59.5 years). During these periods, the proportion of good outcomes did not change; however, the mortality rate significantly decreased from 19% in the first period to 11% and 9.2% in the second and third periods, respectively. The poor outcome was mainly caused by the significantly higher incidence of systemic complication and procedural complication in the first period and the significantly lower incidence of delayed ischemic neurological deficit in the third period. The elderly patients had significantly poorer clinical outcomes than the nonelderly ones. During the last 25 years, the age of patients with aneurysmal SAH has rapidly increased. The study results may contribute to the improvement of the treatment strategy of SAH in advanced countries with a rapidly aging population.
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Affiliation(s)
- Hiroaki Murayama
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Kazuya Kanemaru
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Akira Fukamachi
- Department of Neurosurgery and Radiology, Nasu Neurosurgical Center
| | - Tsuneo Shimizu
- Department of Neurosurgery, Kanto Neurosurgical Hospital
| | | | | | | | - Shin Nakano
- Department of Neurosurgery, Yamanashi Prefectural Central Hospital
| | | | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
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15
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Yamaguchi S, Izumo T, Sato I, Morofuji Y, Kaminogo M, Anda T, Horie N, Matsuo T. Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:2855-2864. [PMID: 37434015 DOI: 10.1007/s00701-023-05705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. METHODS The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms. RESULTS Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. CONCLUSIONS Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.
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Affiliation(s)
- Susumu Yamaguchi
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan.
| | - Izumi Sato
- Department of Clinical Epidemiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Makio Kaminogo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeo Anda
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
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Zhou Z, Lu W, Zhang C, Xiang L, Xiang L, Chen C, Wang B, Guo L, Shan Y, Li X, Zhao Z, Zou J, Dai X, Zhao Z. A visualized MAC nomogram online predicts the risk of three-month mortality in Chinese elderly aneurysmal subarachnoid hemorrhage patients undergoing endovascular coiling. Neurol Sci 2023; 44:3209-3220. [PMID: 37020068 PMCID: PMC10075504 DOI: 10.1007/s10072-023-06777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is an aggressive disease with higher mortality rate in the elderly population. Unfortunately, the previous models for predicting clinical prognosis are still not accurate enough. Therefore, we aimed to construct and validate a visualized nomogram model to predict online the 3-month mortality in elderly aSAH patients undergoing endovascular coiling. METHOD We conducted a retrospective analysis of 209 elderly aSAH patients at People's Hospital of Hunan Province, China. A nomogram was developed based on multivariate logistic regression and forward stepwise regression analysis, then validated using the bootstrap validation method (n = 1000). In addition, the performance of the nomogram was evaluated by various indicators to prove its clinical value. RESULT Morbid pupillary reflex, age, and using a breathing machine were independent predictors of 3-month mortality. The AUC of the nomogram was 0.901 (95% CI: 0.853-0.950), and the Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (p = 0.4328). Besides, the bootstrap validation method internally validated the nomogram with an area under the curve of the receiver operator characteristic (AUROC) of 0.896 (95% CI: 0.846-0.945). Decision curve analysis (DCA) and clinical impact curve (CIC) indicated the nomogram's excellent clinical utility and applicability. CONCLUSION An easily applied visualized nomogram model named MAC (morbid pupillary reflex-age-breathing machine) based on three accessible factors has been successfully developed. The MAC nomogram is an accurate and complementary tool to support individualized decision-making and emphasizes that patients with higher risk of mortality may require closer monitoring. Furthermore, a web-based online version of the risk calculator would greatly contribute to the spread of the model in this field.
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Affiliation(s)
- Zhou Zhou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wei Lu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Cheng Zhang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - BiJun Wang
- Clinical Research Institute, Hengyang Medical School, The Affiliated Nanhua Hospital, University of South China, Hengyang, China
| | - LeHeng Guo
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - YaJie Shan
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - XueMei Li
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Zheng Zhao
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - JianJun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China.
| | - XiaoMing Dai
- Department of Hepatobiliary Surgery, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, China.
| | - ZhiHong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China.
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17
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Sheehan TO, Davis NW, Guo Y, Kelly DL, Yoon SL, Horgas AL. Predictors of Time to Aneurysm Repair and Mortality in Aneurysmal Subarachnoid Hemorrhage. J Neurosci Nurs 2022; 54:182-189. [PMID: 35796309 DOI: 10.1097/jnn.0000000000000660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND : Prompt aneurysm repair is essential to prevent rebleeding after aneurysmal subarachnoid hemorrhage. To date, most studies on this topic have focused on 1 set of predictors (eg, hospital or patient characteristics) and on 1 outcome (either time to aneurysm repair or mortality). The purpose of this study was to test a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, controlling for disease severity and comorbidity, and considering time to aneurysm repair as a potential influence in these relationships. METHODS : A sample of aneurysmal subarachnoid hemorrhage patients with a principal procedure of clipping or coiling was selected (n = 387) from a statewide administrative database for cross-sectional retrospective analysis. The primary study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. RESULTS : Patients who underwent a coiling procedure were more likely to be treated within the first 24 hours of admission compared with those undergoing clipping (odds ratio, 0.54; 95% CI, 0.35-0.84; P = .01). Patients treated at a certified comprehensive stroke center (CSC) had a 72% reduction in odds of death compared with those treated at primary stroke centers (odds ratio, 0.28; 95% CI, 0.10-0.77; P = .01), after controlling for disease severity and comorbid conditions. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. CONCLUSION : Our results indicate that treatment at a CSC was associated with a lower risk of in-hospital mortality. Time to aneurysm repair did not influence mortality and did not explain the mortality benefit observed in CSCs. Research is needed to explore interdisciplinary hospital factors including nursing and nurse-sensitive interventions that may explain the relationship between CSCs and mortality outcomes.
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Park SW, Lee JY, Heo NH, Han JJ, Lee EC, Hong DY, Lee DH, Lee MR, Oh JS. Short- and long-term mortality of subarachnoid hemorrhage according to hospital volume and severity using a nationwide multicenter registry study. Front Neurol 2022; 13:952794. [PMID: 35989903 PMCID: PMC9389169 DOI: 10.3389/fneur.2022.952794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/11/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction Recent improvements in treatment for subarachnoid hemorrhage (SAH) have decreased the mortality rates; however, the outcomes of SAH management are dependent on many other factors. In this study, we used nationwide, large-scale, observational data to investigate short- and long-term mortality rates after SAH treatment and the influence of patient severity and hospital volume. Patients and methods We selected patients with SAH treated with clipping and coiling from the South Korean Acute Stroke Assessment Registry. High- and low-volume hospitals performed ≥20 clipping and coiling procedures and <20 clipping and coiling procedures per year, respectively. Short- and long-term mortality were tracked using data from the Health Insurance Review and Assessment Service. Results Among 2,634 patients treated using clipping and coiling, 1,544 (58.6%) and 1,090 (41.4%) were hospitalized in high- and low-volume hospitals, respectively, and 910 (34.5%) and 1,724 (65.5%) were treated with clipping and coiling, respectively. Mortality rates were 13.5, 14.4, 15.2, and 16.1% at 3 months, 1, 2, and 4 years, respectively. High-volume hospitals had a significantly lower 3-month mortality rate. Patients with mild clinical status had a significantly lower 3-month mortality rate in high-volume hospitals than in low-volume hospitals. Patients with severe clinical status had significantly lower 1- and 2-year mortality rates in high-volume hospitals than in low-volume hospitals. Conclusion Short- and long-term mortality in patients with SAH differed according to hospital volume. In the modern endovascular era, clipping and coiling can lead to better outcomes in facilities with high stroke-care capabilities.
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Affiliation(s)
- Sang-Won Park
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Ji Young Lee
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Nam Hun Heo
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - James Jisu Han
- Department of Molecular Biophysics and Biochemistry, Yale University, New Haven, CT, United States
| | - Eun Chae Lee
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Dong-Yong Hong
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Dong-Hun Lee
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Man Ryul Lee
- Soonchunhyang Institute of Medi-Bio Science (SIMS), Soonchunhyang University, Cheonan, South Korea
- *Correspondence: Man Ryul Lee
| | - Jae Sang Oh
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
- Jae Sang Oh
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Yamada SM, Tomita Y, Takeda R, Nakane M. What is the impact of vasospasm on traumatic subarachnoid hemorrhage: Two cases of report. Trauma Case Rep 2021; 36:100543. [PMID: 34712767 PMCID: PMC8529170 DOI: 10.1016/j.tcr.2021.100543] [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] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Abstract
It is difficult to predict that vasospasm would occur in traumatic subarachnoid hemorrhage (SAH) patients. Younger age, a lower score of Glasgow coma scale (GCS≦8) on admission, and greater cisternal blood volume are considered to correlate with post-traumatic vasospasm. We present two cases of traumatic SAH with post-traumatic vasospasm; one was a 74-year-old man and the other was a 72-year-old woman. They were alert without any neurological deficits on admission, although the SAH was focally thick as if caused by an aneurysmal rupture. The thick SAH was still identified on follow-up CT performed in a few days. The patients demonstrated cognitive dysfunction at the 4th and 5th day of admission, respectively, and imaging studies revealed vasospasm at the artery in the thick SAH. After treatments, the vasospasm resolved and both patients recovered from the disorientation completely in three weeks. The authors considered that focally thick traumatic SAH with poor clearance is the most influential factor to post-traumatic vasospasm independent of age or a GCS score. A low GCS score in head trauma patients might be mainly associated with existence of brain contusion, intracerebral hemorrhage, epidural, or subdural hemorrhages, which are frequently associated with traumatic SAH. If the traumatic SAH is focally thick with poor clearance, it might be better to initiate prompt treatments for vasospasm within 3 days after trauma. The delay in treatments for vasospasm contributes to poor outcomes.
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Affiliation(s)
- Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
| | - Ririko Takeda
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
| | - Makoto Nakane
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507, Japan
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20
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Caffes N, Wenger N, Cannarsa G, Oliver J, Onwukwe C, Gandhi D, Simard JM. Unruptured cerebral aneurysms in elderly patients: key challenges and management. Ann Med 2021; 53:1839-1849. [PMID: 34664535 PMCID: PMC8530485 DOI: 10.1080/07853890.2021.1990393] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/03/2021] [Indexed: 12/01/2022] Open
Abstract
Unruptured cerebral aneurysms are increasingly identified in elderly patients as the global life expectancy continues to rise and non-invasive vascular imaging becomes more prevalent. The optimal management of unruptured aneurysms in elderly patients remains controversial. Variability in life expectancy, comorbidities and rupture risk coupled with heterogenous endovascular and surgical treatments contribute to a paucity of clear guidelines, and current management is highly individualized. Elderly patients present unique considerations including frailty, cognitive dysfunction, vasculopathy, reduced life expectancy and overall worse prognosis in case of rupture which shape the risks and likelihood of success of endovascular and microsurgical treatment. In this review, we provide a comprehensive overview of unruptured cerebral aneurysms in the elderly, with a particular focus on the natural history, key challenges associated with advanced age, management and future innovations to further refine treatment.Key MessagesThe management of unruptured cerebral aneurysms in elderly patients remains controversial.Key challenges including frailty, cognitive dysfunction, reduced life expectancy, vasculopathy and poor prognosis with aneurysm rupture add complexity to endovascular and surgical decision making not encountered with younger demographics.A thorough understanding of available treatment options, likelihood of treatment success and associated risks weighed against the risk of aneurysm rupture informs patient discussion and management.
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Affiliation(s)
- Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicole Wenger
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chimdiya Onwukwe
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
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21
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Esmael A, Flifel ME, Elmarakby F, Belal T. Predictive value of the transcranial Doppler and mean arterial flow velocity for early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2021; 29:218-228. [PMID: 34777542 DOI: 10.1177/1742271x20976965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/27/2020] [Indexed: 01/15/2023]
Abstract
Objectives We aimed to predict cerebral vasospasm in acute aneurysmal subarachnoid hemorrhage and to determine the cut-off values of the mean flow velocity by the use of transcranial Doppler. Methods A total of 40 patients with acute aneurysmal subarachnoid hemorrhage were included in this study and classified into two groups. The first group was 26 patients (65%) with cerebral vasospasm and the second group was 14 patients (35%) without vasospasm. Initial evaluation using the Glasgow Coma Scale and the severity of aneurysmal subarachnoid hemorrhage was detected by using both the clinical Hunt and Hess and radiological Fisher grading scales. All patients underwent transcranial Doppler evaluations five times in 10 days measuring the mean flow velocities (MFV) of cerebral arteries. Results Patients with cerebral vasospasm were associated with significantly higher mean Glasgow Coma Scale score (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), with significantly higher mean diabetes mellitus (p = 0.03), significantly higher mean systolic blood pressure and diastolic blood pressure (p = 0.02 and p = 0.005 respectively) and significantly higher MFVs measured within the first 10 days. Logistic regression analysis demonstrated that MFV ≥81 cm/s in the middle cerebral artery is accompanied by an almost five-fold increased risk of vasospasm (OR 4.92, p < 0.01), while MFV ≥63 cm/s in the anterior cerebral artery is accompanied by a three-fold increased risk of vasospasm (OR 3.12, p < 0.01), and MFV ≥42 cm/s in the posterior cerebral artery is accompanied by a two-fold increased risk of vasospasm (OR 2.11, p < 0.05). Conclusion Transcranial Doppler is a useful tool for early detection, monitoring, and prediction of post subarachnoid vasospasm and valuable for early therapeutic intervention before irreversible ischemic neurological deficits take place.
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Affiliation(s)
- Ahmed Esmael
- Neurology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed E Flifel
- Neurology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Farid Elmarakby
- Neuropsychiatry Department, Mataria Teaching Hospital, Egypt
| | - Tamer Belal
- Neurology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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22
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Rehman S, Phan HT, Reeves MJ, Thrift AG, Cadilhac DA, Sturm J, Breslin M, Callisaya ML, Vemmos K, Parmar P, Krishnamurthi RV, Barker-Collo S, Feigin V, Chausson N, Olindo S, Cabral NL, Carolei A, Marini C, Degan D, Sacco S, Correia M, Appelros P, Kõrv J, Vibo R, Minelli C, Sposato L, Pandian JD, Kaur P, Azarpazhooh MR, Morovatdar N, Gall S. Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT). J Stroke Cerebrovasc Dis 2021; 31:106201. [PMID: 34794031 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106201] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types. METHODS We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints. RESULTS Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year. CONCLUSION Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia
| | - Hoang T Phan
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Jonathan Sturm
- Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia
| | - Michele L Callisaya
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia; Struttura Complessa di Neurologia, Ospedale Michele e Pietro Ferrero, Verduno (Cuneo), ASL CN2, Italy
| | | | - Priya Parmar
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Rita V Krishnamurthi
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | | | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Nicolas Chausson
- Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Stephane Olindo
- Stroke Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Norberto L Cabral
- Deceased. Formerly Clinica Neurológica de Joinville, Joinville Stroke Registry, University of Joinville Region-Univille, Joinville, Brazil
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy
| | - Carmine Marini
- Department of Life, Health, and Environmental Sciences, University of L'Aquila, Italy
| | - Diana Degan
- Struttura Complessa di Neurologia, Ospedale Michele e Pietro Ferrero, Verduno (Cuneo), ASL CN2, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy
| | - Manuel Correia
- Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal
| | - Peter Appelros
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Riina Vibo
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Cesar Minelli
- Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation, Matão, SP, Brazil
| | - Luciano Sposato
- Department of Neurology, Western University, London, Ontario, Canada
| | | | - Paramdeep Kaur
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada
| | - M Reza Azarpazhooh
- Department of Clinical Neurological Sciences, University of Western, London, Ontario, Canada
| | - Negar Morovatdar
- Clinical Research Development Unit, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seana Gall
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia; Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
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23
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Mehdi SMA, Devanand DP. Electroconvulsive Therapy in Elderly Patients With Cerebral Aneurysms: A Systematic Review With Clinical Recommendations. J Geriatr Psychiatry Neurol 2021; 34:504-512. [PMID: 34402339 DOI: 10.1177/08919887211039016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Electroconvulsive therapy (ECT) is commonly used in the elderly due to its proven efficacy and safety profile. However, presence of cardiovascular comorbidities such as cerebral aneurysms may complicate the course of treatment. Our knowledge about the possible risk factors and precautionary measures remains limited. METHODS We performed a systematic review of published case reports of elderly patients with cerebral aneurysms treated with ECT. RESULTS A total of 11 cases were included for the review. One patient died because of subarachnoid hemorrhage (SAH) secondary to ictal hypertensive surge during treatment with ECT. DISCUSSION Risk factors such as history of hypertension, age of the patient, extent of the ictal surge in blood pressure, efficacy of prophylactic treatment to control surge in blood pressure and characteristics of cerebral aneurysm each elevated the risk of complication in these cases. We reviewed safety measures based on the evidence from the current literature available. CONCLUSION ECT is safe in elderly patients with cerebral aneurysms provided appropriate safety measures are employed. Screening for cerebral aneurysms in high risk patients, effective prevention and management of blood pressure elevation acutely during ECT is the best practice to avoid adverse outcomes.
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Affiliation(s)
- Syed Muhammad Ahsan Mehdi
- Geriatric Psychiatry Clinical Fellowship Program, Columbia University Medical Center, New York, NY, USA
| | - D P Devanand
- Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Medical Center, New York, NY, USA
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24
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Catapano JS, Labib MA, Frisoli FA, Cadigan MS, Baranoski JF, Cole TS, Zhou JJ, Nguyen CL, Whiting AC, Ducruet AF, Albuquerque FC, Lawton MT. An evaluation of the SAFIRE grading scale as a predictor of long-term outcomes for patients in the Barrow Ruptured Aneurysm Trial. J Neurosurg 2021; 135:1067-1071. [PMID: 33450736 DOI: 10.3171/2020.7.jns193431] [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: 12/18/2019] [Accepted: 07/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The SAFIRE grading scale is a novel, computable scale that predicts the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients in acute follow-up. However, this scale also may have prognostic significance in long-term follow-up and help guide further management. METHODS The records of all patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) were retrospectively reviewed, and the patients were assigned SAFIRE grades. Outcomes at 1 year and 6 years post-aSAH were analyzed for each SAFIRE grade level, with a poor outcome defined as a modified Rankin Scale score > 2. Univariate analysis was performed for patients with a high SAFIRE grade (IV or V) for odds of poor outcome at the 1- and 6-year follow-ups. RESULTS A total of 405 patients with confirmed aSAH enrolled in the BRAT were analyzed; 357 patients had 1-year follow-up, and 333 patients had 6-year follow-up data available. Generally, as the SAFIRE grade increased, so did the proportion of patients with poor outcomes. At the 1-year follow-up, 18% (17/93) of grade I patients, 22% (20/92) of grade II patients, 32% (26/80) of grade III patients, 43% (38/88) of grade IV patients, and 75% (3/4) of grade V patients were found to have poor outcomes. At the 6-year follow-up, 29% (23/79) of grade I patients, 24% (21/89) of grade II patients, 38% (29/77) of grade III patients, 60% (50/84) of grade IV patients, and 100% (4/4) of grade V patients were found to have poor outcomes. Univariate analysis showed that a SAFIRE grade of IV or V was associated with a significantly increased risk of a poor outcome at both the 1-year (OR 2.5, 95% CI 1.5-4.2; p < 0.001) and 6-year (OR 3.7, 95% CI 2.2-6.2; p < 0.001) follow-ups. CONCLUSIONS High SAFIRE grades are associated with an increased risk of a poor recovery at late follow-up.
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25
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Yu F, Saand A, Xing C, Lee JW, Hsu L, Palmer OP, Jackson V, Tang L, Ning M, Du R, Kochanek PM, Lo EH, Chou SHY. CSF lipocalin-2 increases early in subarachnoid hemorrhage are associated with neuroinflammation and unfavorable outcome. J Cereb Blood Flow Metab 2021; 41:2524-2533. [PMID: 33951946 PMCID: PMC8504948 DOI: 10.1177/0271678x211012110] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Lipocalin-2 mediates neuro-inflammation and iron homeostasis in vascular injuries of the central nervous system (CNS) and is upregulated in extra-CNS systemic inflammation. We postulate that cerebrospinal fluid (CSF) and blood lipocalin-2 levels are associated with markers of inflammation and functional outcome in subarachnoid hemorrhage (SAH). We prospectively enrolled 67 SAH subjects, serially measured CSF and plasma lipocalin-2, matrix metallopeptidase 9 (MMP-9), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) on post-SAH days 1-5 and assessed outcome by modified Rankin Scale (mRS) every 3 months. Unfavorable outcome is defined as mRS > 2. Twenty non-SAH patients undergoing lumbar drain trial were enrolled as controls. Lipocalin-2 was detectable in the CSF and significantly higher in SAH compared to controls (p < 0.0001). Higher CSF LCN2 throughout post-SAH days 1-5 was associated with unfavorable outcome at 3 (p = 0.0031) and 6 months (p = 0.014). Specifically, higher CSF lipocalin-2 on post-SAH days 3 (p = 0.036) and 5 (p = 0.016) were associated with unfavorable 3-month outcome. CSF lipocalin-2 levels positively correlated with CSF IL-6, TNF-α and MMP-9 levels. Higher plasma lipocalin-2 levels over time were associated with worse 6-month outcome. Additional studies are required to understand the role of lipocalin-2 in SAH and to validate CSF lipocalin-2 as a potential biomarker for SAH outcome.
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Affiliation(s)
- Fang Yu
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aisha Saand
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Changhong Xing
- Department of Pathology, South Western Medical Center, University of Texas, Dallas, TX, USA.,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Liangge Hsu
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Octavia P Palmer
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vanessa Jackson
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - MingMing Ning
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Pediatrics and Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eng H Lo
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sherry H-Y Chou
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
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26
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Munarriz PM, Navarro-Main B, Alén JF, Jiménez-Roldán L, Castaño-Leon AM, Moreno-Gómez LM, Paredes I, García-Pérez D, Panero I, Eiriz C, Esteban-Sinovas O, Bárcena E, Gómez PA, Lagares A. The influence of aneurysm morphology on the volume of hemorrhage after rupture. J Neurosurg 2021; 136:1015-1023. [PMID: 34534958 DOI: 10.3171/2021.3.jns21293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors determining the risk of rupture of intracranial aneurysms have been extensively studied; however, little attention is paid to variables influencing the volume of bleeding after rupture. In this study the authors aimed to evaluate the impact of aneurysm morphological variables on the amount of hemorrhage. METHODS This was a retrospective cohort analysis of a prospectively collected data set of 116 patients presenting at a single center with subarachnoid hemorrhage due to aneurysmal rupture. A volumetric assessment of the total hemorrhage volume was performed from the initial noncontrast CT. Aneurysms were segmented and reproduced from the initial CT angiography study, and morphology indexes were calculated with a computer-assisted approach. Clinical and demographic characteristics of the patients were included in the study. Factors influencing the volume of hemorrhage were explored with univariate correlations, multiple linear regression analysis, and graphical probabilistic modeling. RESULTS The univariate analysis demonstrated that several of the morphological variables but only the patient's age from the clinical-demographic variables correlated (p < 0.05) with the volume of bleeding. Nine morphological variables correlated positively (absolute height, perpendicular height, maximum width, sac surface area, sac volume, size ratio, bottleneck factor, neck-to-vessel ratio, and width-to-vessel ratio) and two correlated negatively (parent vessel average diameter and the aneurysm angle). After multivariate analysis, only the aneurysm size ratio (p < 0.001) and the patient's age (p = 0.023) remained statistically significant. The graphical probabilistic model confirmed the size ratio and the patient's age as the variables most related to the total hemorrhage volume. CONCLUSIONS A greater aneurysm size ratio and an older patient age are likely to entail a greater volume of bleeding after subarachnoid hemorrhage.
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Affiliation(s)
- Pablo M Munarriz
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre.,2Universidad Complutense de Madrid
| | | | - Jose F Alén
- 2Universidad Complutense de Madrid.,3Department of Neurosurgery, Hospital Universitario La Princesa; and
| | | | | | | | - Igor Paredes
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | | | - Irene Panero
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | - Carla Eiriz
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | | | - Eduardo Bárcena
- 4Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pedro A Gómez
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | - Alfonso Lagares
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre.,2Universidad Complutense de Madrid
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Factors predicting complications following cranioplasty. J Craniomaxillofac Surg 2021; 50:134-139. [PMID: 34580005 DOI: 10.1016/j.jcms.2021.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 07/30/2021] [Accepted: 08/21/2021] [Indexed: 11/20/2022] Open
Abstract
This study aimed to identify factors that predict complications following cranioplasty, by conducting a retrospective cohort study at a large tertiary care center. Electronic databases were searched to identify all patients who underwent cranioplasty at our institution. Baseline demographics, perioperative variables, and outcomes were extracted. Logistic regression analyses were conducted to identify factors associated with cranioplasty complications. Of the 92 included patients, 15 (16.3%) experienced one or more complications, with 11 (73.3%) experiencing complication within 30 days of cranioplasty. Patients aged ≤60 had decreased odds of all-cause complication (OR 0.058; 95% CI 0.008-0.434) and cranioplasty graft removal (OR 0.035; 95% CI 0.004-0.321) on multivariate analysis. Titanium mesh cranioplasties were associated with increased odds of all-cause complication (OR 19.776; 95% CI 1.021-382.901), and cranioplasty removal (OR 29.780; 95% CI 1.330-666.878). A longer craniectomy-cranioplasty interval was associated with increased odds of cranioplasty removal (OR 1.005; 95% CI 1.000-1.010). An initial craniectomy indication of cerebral infarction was associated with decreased odds of all-cause complication (OR 0.042; 95% CI 0.002-0.876) and cranioplasty removal (OR 0.032; 95% CI 0.001-0.766). Elderly patients may require more aggressive follow-up and antibiotic prophylaxis in the postoperative period following cranioplasty. Additionally, avoiding the use of titanium mesh cranioplasties and prolonged craniectomy-cranioplasty intervals may further reduce complications.
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Dutta G, Jagetia A, Srivastava AK, Singh D, Singh H, Chawla R, Agarwal A, Iqbal M, Tandon M. Intra-operative cerebral blood flow assessment by indocyanine green video-angiography after temporary arterial occlusion in aneurysm surgery and its clinical implications: a prospective study. J Cerebrovasc Endovasc Neurosurg 2021; 23:210-220. [PMID: 34384018 PMCID: PMC8497725 DOI: 10.7461/jcen.2021.e2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/15/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Indocyanine green video angiography (ICG-VA) is a routine while performing vascular surgery to assess patency of perforators, completeness of clipping and/or to assess patency of anastomosis. Its usefulness in assessing cerebral blood flow and perfusion is not well studied. This study is aimed to assess the cerebral blood flow and perfusion after temporary clipping and to correlate with the risk of ischemia. Methods Prospective analysis of intra-operative ICG-VA performed during temporary arterial occlusion in 38 patients from January 2014 to December 2018 was conducted. Co-relation with post-operative MR diffusion weighted imaging (MR DWI) in terms of vascular territory of interest within 48 hours of surgery was performed. Clinical outcome was assessed using modified Rankin Scale (mRS) score 1-month post-surgery. Results 43 aneurysms in 38 patients clipped using ICG-VA were included in this study. No side effect of ICG dye was seen in any patients. The number of times temporary clips applied had a direct relationship to the delay in appearance of ICG in the surgical field which became statistically significant after application of 3rd temporary clip. Nine (23.7%) patients developed ischemia following the procedure confirmed by post-operative MR DWI and all the ischemic cases had visible decrease in ICG fluorescence post-temporary clipping. Conclusions No previous study had tried to assess the intraoperative cerebral blood flow and perfusion during temporary clipping of parent vessels during aneurysm surgery. The use of ICG-VA can be extended to assess perfusion in desired territory by merely assessing the degree of opacification.
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Affiliation(s)
- Gautam Dutta
- Department of Neuro-Surgery, Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
| | - Anita Jagetia
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Arvind K Srivastava
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Daljit Singh
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Hukum Singh
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Rajiv Chawla
- Department of Neuro-Anesthesia, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Atul Agarwal
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Mohd Iqbal
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Monica Tandon
- Department of Neuro-Anesthesia, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
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Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series. Can J Neurol Sci 2021; 49:62-69. [PMID: 33726874 DOI: 10.1017/cjn.2021.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre. METHODS We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months' follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression. RESULTS Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4-5) was seen from discharge to 6 months, but not from 6 to 12 months' follow-up, without difference between clipping and coiling. CONCLUSION These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.
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Interleukin 6 in cerebrospinal fluid is a biomarker for delayed cerebral ischemia (DCI) related infarctions after aneurysmal subarachnoid hemorrhage. Sci Rep 2021; 11:12. [PMID: 33420113 PMCID: PMC7794326 DOI: 10.1038/s41598-020-79586-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022] Open
Abstract
Interleukin 6 (IL-6) is a prominent proinflammatory cytokine and has been discussed as a potential biomarker for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage. In the present study we have analyzed the time course of serum and cerebrospinal fluid (CSF) IL-6 levels in 82 patients with severe aneurysmal subarachnoid hemorrhage (SAH) requiring external ventricular drains in correlation to angiographic vasospasm, delayed cerebral ischemia, secondary infarctions and other clinical parameters. We observed much higher daily mean IL-6 levels (but also large interindividual variations) in the CSF than the serum of the patients with a peak between days 4 and 14 including a maximum on day 5 after SAH. Individual CSF peak levels correlated significantly with DCI (mean day 4–14 peak, DCI: 26,291 ± 24,159 pg/ml vs. no DCI: 16,184 ± 13,163 pg/ml; P = 0.023). Importantly, CSF IL-6 levels differed significantly between cases with DCI and infarctions and patients with DCI and no infarction (mean day 4–14 peak, DCI with infarction: 37,209 ± 26,951 pg/ml vs. DCI, no infarction: 15,123 ± 11,239 pg/ml; P = 0.003), while findings in the latter patient group were similar to cases with no vasospasm (mean day 4–14 peak, DCI, no infarction: 15,123 ± 11,239 vs. no DCI: 15,840 ± 12,979; P = 0.873). Together, these data support a potential role for elevated CSF IL-6 levels as a biomarker for DCI with infarction rather than for DCI in general. This fits well with a growing body of evidence linking neuroinflammation to ischemia and infarction, but (together with the large interindividual variations observed) limits the diagnostic usefulness of CSF IL-6 levels in SAH patients.
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Kutty RK, Sivanandapanicker JL, Sreemathyamma SB, Prabhakar RB, Peethambaran A, Libu GK. The Outcome of Aneurysm Clipping in Septuagenarians - A Retrospective Analysis in a Basic Neurovascular Unit. Neurol India 2020; 68:101-107. [PMID: 32129256 DOI: 10.4103/0028-3886.279659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit. Materials and Methods A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3. Results There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes. Conclusion A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Rajmohan B Prabhakar
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Gnanaseelan K Libu
- Department of Community Medicine and Government Medical College, Thiruvananthapuram, Kerala, India
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Albanna W, Merkelbach L, Schubert GA, Stoppe C, Heussen N, Riabikin A, Wiesmann M, Blume C, Jablawi F, Schiefer J, Clusmann H, Neuloh G. Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents. J Neurol Sci 2020; 420:117219. [PMID: 33162063 DOI: 10.1016/j.jns.2020.117219] [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: 07/31/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Endovascular treatment of ruptured cerebral aneurysms frequently requires antiplatelet medication to prevent thromboembolism. This might raise concern regarding the risk of postprocedural hemorrhage (pH), e.g. from placement of intracranial probes. We explored the risk of PH associated with standard antiplatelet therapy (sAP: acetylsalicylic acid, and/or clopidogrel) in the context of aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed a total of 146 consecutive cases with cerebral aneurysms treated between 1/2011-12/2015, and distinguished between minor (0.5 cm3) - 4 cm3) or major (> 4 cm3) PH occurring within four weeks after intervention. A separate analysis included hemorrhages related to placement of intracranial probes and drainages in the subgroup of 99 cases with such surgical interventions (pPH). Clinical outcome was assessed via Glasgow Outcome Scale (GOS) twelve months after aSAH. RESULTS A total of 49 cases (33.6%) in the overall sample sustained PH, there were 19 cases of pPH. Multifactorial analyses yielded sAP as an independent predictor for minor, but not major PH (p < 0.001 vs. p = 0.829), with comparable results for pPH (p = 0.001 vs. p = 0.184). sAP did not influence the clinical outcome in either group. CONCLUSIONS sAP was associated with a higher rate of minor PH and, more specifically, of minor pPH. However, it was neither accompanied by the occurrence of major hemorrhages nor by unfavorable clinical outcome. Future prospective studies should confirm these observations and hemorrhage risks associated with extended anticoagulation regimes after complex interventions and intra-arterial vasospasm therapy should be explored in order to facilitate interdisciplinary decision-making in aSAH.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Germany.
| | | | | | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Germany
| | - Nicole Heussen
- Department of Medical Statistics, RWTH Aachen University, Germany; Medical School, Sigmund Freud Private University, Vienna, Austria
| | - Alexander Riabikin
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Germany
| | | | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Germany
| | - Georg Neuloh
- Department of Neurosurgery, RWTH Aachen University, Germany
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Taussky P, Agnoletto G, Grandhi R, Alexander MD, Wong KH, Albers GW, de Havenon A. Prediction of death after endovascular thrombectomy in the extended window: a secondary analysis of DEFUSE 3 ". J Neurointerv Surg 2020; 13:805-808. [PMID: 33077580 DOI: 10.1136/neurintsurg-2020-016548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE 3) clinical trial assessed the use of endovascular thrombectomy (EVT) during the period 6-16 hours after last normal in selected patients. This is a secondary cohort analysis of the DEFUSE 3 data assessing potential predictive variables for mortality in the EVT-treated patients. METHODS The primary outcome was death within 90 days. Patients who died and those who did not were compared statistically. We developed a predictive score using preprocedural variables that were statistically predictive of death in univariate regression analysis (P<0.1). RESULTS Of the 182 patients in the DEFUSE 3 study, 92 (mean age 69 years; 50% male) met our inclusion criteria, and 15.2% of these patients met the primary outcome. Patient age, baseline National Institutes of Health Stroke Scale (NIHSS) score, wake-up stroke, statin use, and history of diabetes were statistically associated with death. Statin use did not improve the prediction score so was excluded. Thus, our model included four predictors, with one point each given for age >75 years, NIHSS ≥20, wake-up stroke, and diabetes, yielding low (0-1), moderate (2), and high (3-4) risk of death. In the low-risk, moderate-risk, and high-risk categories, 2/52 (3.9%), 3/23 (13.0%), and 9/17 (52.9%) of patients died, respectively (P<0.001). CONCLUSIONS Despite selective inclusion criteria and overwhelming benefit for EVT, a substantial number of EVT patients in DEFUSE 3 died. The preprocedural variables age, NIHSS, wake-up stroke, and diabetes may predict this risk. Our predictive score provides a basis for future research to determine which factors influence lethal outcome after EVT.
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Affiliation(s)
- Philipp Taussky
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Guilherme Agnoletto
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Matthew D Alexander
- Radiology and Biomedical Imaging, University of Utah Health, Salt Lake City, Utah, USA
| | - Ka-Ho Wong
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University, Stanford, California, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
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Risk factors of chronic shunt dependent hydrocephalus following aneurysmal subarachnoid haemorrhage. Clin Neurol Neurosurg 2020; 198:106095. [PMID: 32763663 DOI: 10.1016/j.clineuro.2020.106095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute and delayed hydrocephalus are common sequelae following aneurysmal subarachnoid haemorrhage. AIMS To identify factors that may influence cerebrospinal fluid diversion either temporarily or permanently in order to guide clinical judgement. METHODS Patients treated in our unit between 01/2014 until 12/2017 with aneurysmal SAH were retrospectively analysed to identify significant factors predisposing to CSF diversion. RESULTS 242 patients were analysed (180F, 62M) with mean age 56 years over 36 months. 31 % patients had EVD inserted and 12 % received shunts. 19 patients had EVDs prior to their shunt. 11.8 % patients received serial lumbar puncture. Higher WFNS (P<0.05) and Fisher grade (P<0.05) were associated with increased rates of EVD insertion and shunting. Higher WFNS and Fisher scores were observed within posterior circulation aneurysms. Lower GCS and higher WFNS had significant correlation towards early shunting (P<0.05). EVD infection predisposes to higher rates of shunt conversion (P<0.05). Factors predisposing to post aneurysmal subarachnoid haemorrhage hydrocephalus and CSF drainage included aneurysm location in posterior circulation (P<0.05), increasing relative need of EVD insertion by 185 % and shunting by 240 %. Basilar tip aneurysms had even higher incidence of shunting (42 % of all posterior circulation aneurysms). Posterior circulation aneurysms had significantly higher risk of requiring EVD insertion, with 48 % of aneurysms in the posterior circulation compared to 25 % in the anterior circulation requiring EVDs (P<0.05). Incidence of posterior circulation aneurysms increases with age (>50(P<0.05)). CONCLUSION Our study demonstrated factors that may predict chronic post aneurysmal subarachnoid haemorrhage hydrocephalus (PASHH) in patients that will ultimately need timely intervention.
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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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Kanamaru H, Kawakita F, Asada R, Miura Y, Shiba M, Toma N, Suzuki H. Prognostic factors varying with age in patients with aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2020; 76:118-125. [PMID: 32299775 DOI: 10.1016/j.jocn.2020.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/04/2020] [Indexed: 11/27/2022]
Abstract
With the advent of an aging society, more elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) have been treated. We investigated if prognostic factors differ with age in aSAH patients. In a prospectively maintained aSAH database at multiple institutions from 2013 to 2016, 238 patients who underwent clipping or coiling for a ruptured aneurysm within 48 h of onset were divided into elderly (≥75 years; 57 patients) and non-elderly groups, or categorized into 4-age groups (<54, 55-64, 65-74, and ≥75 years). Prognostic factors and clinical characteristics were retrospectively analyzed. The elderly group had a higher incidence of pre-morbidities, co-morbidities, poor admission World Federation of Neurological Surgeons (WFNS) grades, modified Fisher grade 4, and resultantly 90-day poor outcomes (modified Rankin scale [mRS] 3-6). Multivariate logistic regression analyses revealed that independent determinants for poor outcomes were hypertension and modified Fisher grade 4 in the elderly group, and admission WFNS grades IV-V, systemic complications, non-procedural cerebral infarction and shunt-dependent chronic hydrocephalus in the non-elderly group. The 4-age group analyses showed that higher age group was more frequently associated with the prognostic factors. As higher age itself causes poor outcomes and more association of prognostic factors, prognostic factors in elderly patients may be rather limited.
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Affiliation(s)
- Hideki Kanamaru
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
| | - Fumihiro Kawakita
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Reona Asada
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Masato Shiba
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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- Members along with their affiliations listed in the Supplementary Material
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Hironaka K, Aso S, Suzuki M, Matano F, Matsui H, Fushimi K, Yasunaga H, Morita A. Outcomes in Elderly Japanese Patients Treated for Aneurysmal Subarachnoid Hemorrhage: A Retrospective Nationwide Study. J Stroke Cerebrovasc Dis 2020; 29:104795. [PMID: 32222416 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104795] [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: 12/06/2019] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE Japan has the largest elderly population in the world. As data on the clinical outcomes in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH), including those older than 80 years, are lacking, we analyzed the characteristics of 54,805 aSAH patients and recorded their treatments and clinical outcomes using a Japanese nationwide inpatient database. METHODS Using the Japanese Diagnostic Procedure Combination database, we identified aSAH patients aged 18 years or older who were hospitalized between July 1, 2010 and March 31, 2016. They were categorized as less than or equal to 60-, 61-70-, 71-80-, 81-90-, and greater than or equal to 91 years of age. The primary outcome was the modified Rankin Scale (mRS) score at discharge. Multivariable logistic regression analysis was performed to examine factors affecting the mRS score at discharge. RESULTS Of 54,805 patients, 37.5% were aged less than or equal to 60 years; 24.8% were 61-70-, 21.8% were 71-80-, 13.9% were 81-90-, and 2.0% were greater than or equal to 91 years old at the time of the insult. Among 46,107 patients younger than 81 years, 58.9% underwent surgical clipping (SC), 22.9% endovascular coiling (EC), and 18.2% were treated conservatively. There were 8,698 patients aged 81 years or older, 32.4% underwent SC, 23.2% EC, and 44.4% were treated conservatively. A poor mRS score (3-6) at discharge was recorded in 87.2% of patients older than 80 years. Multivariable logistic regression was used to compare their estimated odds ratio (OR) for a poor mRS score at discharge with that of patients aged less than or equal to 60 years. The OR increased by 87% in patients between 61 and 70 years of age (P < .001; OR, 1.87; 95% confidence interval (CI), 1.77-1.98), by 358% in patients aged from 71 to 80 years (P < .001; OR, 4.58; 95%CI, 4.29-4.89), by 1,035% in patients between 81 and 90 years (P < .001; OR, 11.35; 95%CI, 10.32-12.49), and by 1,710% in patients aged more than or equal to 91 years (P < .001; OR, 18.10; 95%CI, 13.96-23.46). CONCLUSIONS As the treatment outcomes in elderly aSAH patients, especially those 80 years old or older, were poor, the appropriate therapy decisions must be made on a case-by-case basis.
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Affiliation(s)
- Kohei Hironaka
- Department of Neurological Surgery, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan.
| | - Shotaro Aso
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Masanori Suzuki
- Department of Neurological Surgery, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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Fang YJ, Mei SH, Lu JN, Chen YK, Chai ZH, Dong X, Araujo C, Reis C, Zhang JM, Chen S. New risk score of the early period after spontaneous subarachnoid hemorrhage: For the prediction of delayed cerebral ischemia. CNS Neurosci Ther 2019; 25:1173-1181. [PMID: 31407513 PMCID: PMC6776741 DOI: 10.1111/cns.13202] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose The aim of this study is to identify the early predictors for delayed cerebral ischemia (DCI) and develop a risk stratification score by focusing on the early change after aneurysmal subarachnoid hemorrhage (aSAH). Methods The study retrospectively reviewed aSAH patients between 2014 and 2015. Risk factors within 72 hours after aSAH were included into univariable and multivariable logistic regression analysis to screen the independent predictors for DCI and to design a risk stratification score. Results We analyzed 702 aSAH patients; four predictors were retained from the final multivariable analysis: World Federation of Neurosurgical Societies scale (WFNS; OR = 4.057, P < .001), modified Fisher Scale (mFS; OR = 2.623, P < .001), Subarachnoid Hemorrhage Early Brain Edema Score (SEBES; OR = 1.539, P = .036), and intraventricular hemorrhage (IVH; OR = 1.932, P = .002). According to the regression coefficient, we created a risk stratification score ranging from 0 to 7 (WFNS = 3, mFS = 2, SEBES = 1, and IVH = 1). The new score showed a significantly higher area under curve (0.785) compared with other scores (P < .001). Conclusion The early DCI score provides a practical method at the early 72 hours after aSAH to predict DCI.
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Affiliation(s)
- Yuan-Jian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shu-Hao Mei
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia-Nan Lu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi-Ke Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhao-Hui Chai
- Department of Neurosurgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Dong
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Camila Araujo
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jian-Min Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Brain Research Institute, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution. J Stroke Cerebrovasc Dis 2019; 28:1943-1950. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/21/2019] [Accepted: 03/16/2019] [Indexed: 11/24/2022] Open
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Lublinsky S, Major S, Kola V, Horst V, Santos E, Platz J, Sakowitz O, Scheel M, Dohmen C, Graf R, Vatter H, Wolf S, Vajkoczy P, Shelef I, Woitzik J, Martus P, Dreier JP, Friedman A. Early blood-brain barrier dysfunction predicts neurological outcome following aneurysmal subarachnoid hemorrhage. EBioMedicine 2019; 43:460-472. [PMID: 31162113 PMCID: PMC6558266 DOI: 10.1016/j.ebiom.2019.04.054] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/28/2019] [Accepted: 04/28/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Disease progression and delayed neurological complications are common after aneurysmal subarachnoid hemorrhage (aSAH). We explored the potential of quantitative blood-brain barrier (BBB) imaging to predict disease progression and neurological outcome. METHODS Data were collected as part of the Co-Operative Studies of Brain Injury Depolarizations (COSBID). We analyzed retrospectively, blinded and semi-automatically magnetic resonance images from 124 aSAH patients scanned at 4 time points (24-48 h, 6-8 days, 12-15 days and 6-12 months) after the initial hemorrhage. Volume of brain with apparent pathology and/or BBB dysfunction (BBBD), subarachnoid space and lateral ventricles were measured. Neurological status on admission was assessed using the World Federation of Neurosurgical Societies and Rosen-Macdonald scores. Outcome at ≥6 months was assessed using the extended Glasgow outcome scale and disease course (progressive or non-progressive based on imaging-detected loss of normal brain tissue in consecutive scans). Logistic regression was used to define biomarkers that best predict outcomes. Receiver operating characteristic analysis was performed to assess accuracy of outcome prediction models. FINDINGS In the present cohort, 63% of patients had progressive and 37% non-progressive disease course. Progressive course was associated with worse outcome at ≥6 months (sensitivity of 98% and specificity of 97%). Brain volume with BBBD was significantly larger in patients with progressive course already 24-48 h after admission (2.23 (1.23-3.17) folds, median with 95%CI), and persisted at all time points. The highest probability of a BBB-disrupted voxel to become pathological was found at a distance of ≤1 cm from the brain with apparent pathology (0·284 (0·122-0·594), p < 0·001, median with 95%CI). A multivariate logistic regression model revealed power for BBBD in combination with RMS at 24-48 h in predicting outcome (ROC area under the curve = 0·829, p < 0·001). INTERPRETATION We suggest that early identification of BBBD may serve as a key predictive biomarker for neurological outcome in aSAH. FUND: Dr. Dreier was supported by grants from the Deutsche Forschungsgemeinschaft (DFG) (DFG DR 323/5-1 and DFG DR 323/10-1), the Bundesministerium für Bildung und Forschung (BMBF) Center for Stroke Research Berlin 01 EO 0801 and FP7 no 602150 CENTER-TBI. Dr. Friedman was supported by grants from Israel Science Foundation and Canada Institute for Health Research (CIHR). Dr. Friedman was supported by grants from European Union's Seventh Framework Program (FP7/2007-2013; grant #602102).
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Affiliation(s)
- Svetlana Lublinsky
- Departments of Brain & Cognitive Sciences, Physiology & Cell Biology, Faculty of Health Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vasilis Kola
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Viktor Horst
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Germany
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Oliver Sakowitz
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Germany; Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Rudolf Graf
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ilan Shelef
- Departments of Brain & Cognitive Sciences, Physiology & Cell Biology, Faculty of Health Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Diagnostic Imaging, Soroka University Medical Center, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Alon Friedman
- Departments of Brain & Cognitive Sciences, Physiology & Cell Biology, Faculty of Health Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Medical Neuroscience and Brain Repair Center, Dalhousie University, Halifax, Nova Scotia, Canada.
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Machine Learning Analysis of Matricellular Proteins and Clinical Variables for Early Prediction of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Mol Neurobiol 2019; 56:7128-7135. [PMID: 30989629 DOI: 10.1007/s12035-019-1601-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/03/2019] [Indexed: 12/17/2022]
Abstract
Although delayed cerebral ischemia (DCI) is a well-known complication after subarachnoid hemorrhage (SAH), there are no reliable biomarkers to predict DCI development. Matricellular proteins (MCPs) have been reported relevant to DCI and expected to become biomarkers. As machine learning (ML) enables the classification of various input data and the result prediction, the aim of this study was to construct early prediction models of DCI development with clinical variables and MCPs using ML analyses. Early-stage clinical data of 95 SAH patients in a prospective cohort were analyzed and applied to a ML algorithm, random forest, to construct three prediction models: (1) a model with only clinical variables on admission, (2) a model with only plasma levels of MCP (periostin, osteopontin, and galectin-3) at post-onset days 1-3, and (3) a model with both clinical variables on admission and MCP values at days 1-3. The prediction accuracy of the development of DCI, angiographic vasospasm, or cerebral infarction and the importance of each feature were computed. The prediction accuracy of DCI development was 93.9% in model 1, 87.2% in model 2, and 95.1% in model 3, but that of angiographic vasospasm or cerebral infarction was lower. The three most important features in model 3 for DCI were periostin, osteopontin, and galectin-3, followed by aneurysm location. All of the early-stage prediction models of DCI development constructed by ML worked with high accuracy and sensitivity. One-time early-stage measurement of plasma MCPs served for reliable prediction of DCI development, suggesting their potential utility as biomarkers.
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Malhotra A, Wu X, Forman HP, Matouk CC, Hughes DR, Gandhi D, Sanelli P. Management of Unruptured Intracranial Aneurysms in Older Adults: A Cost-effectiveness Analysis. Radiology 2019; 291:411-417. [PMID: 30888931 DOI: 10.1148/radiol.2019182353] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Unruptured intracranial aneurysms (UIAs) are relatively common and are being increasingly diagnosed, with a significant proportion in older patients (˃ 65 years old). Serial imaging is often performed to assess change in size or morphology of UIAs since growing aneurysms are known to be at high risk for rupture. However, the frequency and duration of surveillance imaging have not been established. Purpose To evaluate the cost-effectiveness of routine treatment (aneurysm coil placement) versus four different strategies for imaging surveillance of UIAs in adults older than 65 years. Materials and Methods A Markov decision-analytic model was constructed from a societal perspective. Age-dependent input parameters were obtained from published literature. Analysis included adults older than 65 years, with incidental detection of UIA and no prior history of subarachnoid hemorrhage. Five different management strategies for UIAs in older adults were evaluated: (a) annual MR angiography, (b) biennial MR angiography, (c) MR angiography every 5 years, (d) coil placement and follow-up, and (e) limited MR angiography follow-up for the first 2 years after detection only. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Probabilistic, one-way, and two-way sensitivity analyses were performed. Results Imaging follow-up for the first 2 years after detection is the most cost-effective strategy (cost = $24 572, effectiveness = 13.73 QALYs), showing the lowest cost and highest effectiveness. The conclusion remains robust in probabilistic and one-way sensitivity analyses. Time-limited imaging follow-up remains the optimal strategy when the annual growth rate and rupture risk of growing aneurysms are varied. If annual rupture risk of nongrowing aneurysms is greater than 7.1%, coil placement should be performed directly. Conclusion Routine preventive treatment or periodic, indefinite imaging follow-up is not a cost-effective strategy in all adults older than 65 years with unruptured intracranial aneurysms. More aggressive management strategies should be reserved for patients with high risk of rupture, such as those with aneurysms larger than 7 mm and those with aneurysms in the posterior circulation. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Cloft in this issue.
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Affiliation(s)
- Ajay Malhotra
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Xiao Wu
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Howard P Forman
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Charles C Matouk
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Danny R Hughes
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Dheeraj Gandhi
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Pina Sanelli
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
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Tam CW, Shum HP, Yan WW. Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Indian J Crit Care Med 2019; 23:562-567. [PMID: 31988546 PMCID: PMC6970205 DOI: 10.5005/jp-journals-10071-23292] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background Electrolyte disturbance is one of the complications of subarachnoid hemorrhage (SAH) and its prognostic value is not fully understood. The focus of this study is to evaluate the impact of dysnatremia and dyskalemia on functional outcomes in patients with aneurysmal SAH. Materials and methods Patients with spontaneous aneurysmal SAH who were admitted to our intensive care unit (ICU) between 1st January 2011 and 31st December 2016 were included. Demographic data, biochemical parameters from days 1 to day 11 of ICU admission, disease severity, and clinical outcome were recorded. The prognosis was estimated using the Glasgow outcome scale (GOS) at 3 months after the initial insult. Results A total of 244 patients were included in this study. There were 139 patients (57.0%) with hyponatremia (Na < 135 mmol/L) while 82 patients (33.6%) had hypernatremia (Na >146 mmol/L). Hyponatremia, hypernatremia, and sodium fluctuation >12 mmol/L were more commonly found in those patients with poor outcome. However, both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient's prognosis. Logistic regression analysis identified the following independent predictors of poor outcome (GOS 1–3 at 3 months): age >55 years old, acute physiology and chronic health evaluation IV (APACHE IV) score >50, World Federation of Neurosurgical Societies (WFNS) grade >3, Fisher grade >2, presence of intracranial hemorrhage (ICH)/intraventricular hemorrhage (IVH), use of mannitol, use of loop diuretic aneurysms, involving posterior circulation, and hypernatremia >146 mmol/L. Conclusion Hypernatremia, but not hyponatremia, in patients with aneurysmal SAH is associated with poor outcome. Both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient's prognosis. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes. Clinical significance Dysnatremia and dyskalemia are common in patients with aneurysmal SAH, but only hypernatremia is associated with poor outcome. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes. How to cite this article Tam CWY, Shum HP, Yan WW. Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Indian J Crit Care Med 2019;23(12):562–567.
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Affiliation(s)
- Catherine Wy Tam
- Department of Radiology, North District Hospital, Sheung Shui, Hong Kong SAR, China
| | - H P Shum
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
| | - W W Yan
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
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Goldberg J, Schoeni D, Mordasini P, Z’Graggen W, Gralla J, Raabe A, Beck J, Fung C. Survival and Outcome After Poor-Grade Aneurysmal Subarachnoid Hemorrhage in Elderly Patients. Stroke 2018; 49:2883-2889. [DOI: 10.1161/strokeaha.118.022869] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Johannes Goldberg
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Daniel Schoeni
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology (P.M., J. Gralla), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Werner Z’Graggen
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology (P.M., J. Gralla), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andreas Raabe
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jürgen Beck
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Christian Fung
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
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Eom TO, Park ES, Park JB, Kwon SC, Sim HB, Lyo IU, Kim MS. Does Neurosurgical Clipping or Endovascular Coiling Lead to More Cases of Delayed Hydrocephalus in Patients with Subarachnoid Hemorrhage? J Cerebrovasc Endovasc Neurosurg 2018; 20:87-95. [PMID: 30370242 PMCID: PMC6196142 DOI: 10.7461/jcen.2018.20.2.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/11/2018] [Accepted: 05/20/2018] [Indexed: 11/24/2022] Open
Abstract
Objective We investigated whether clipping or endovascular treatment (EVT) can reduce the incidence of delayed hydrocephalus. We also investigated whether additional procedures, namely lumbar drainage and extra-ventricular drainage (EVD), decrease the incidence of delayed hydrocephalus in patients with subarachnoid hemorrhage (SAH). Materials and Methods One-hundred and fifty-two patients who had undergone an operation for SAH were enrolled in this study. Clinical data, radiological data, and procedural data were investigated. Procedural data included the operating technique (clipping vs. EVT) and the use of additional procedures (no procedure, lumbar drainage, or EVD). Delayed hydrocephalus was defined as a condition in which the Evan's index was 0.3 or higher, as assessed using brain computed tomography more than 2 weeks after surgery, requiring shunt placement due to neurological deterioration. Results Of the 152 patients, 45 (29.6%) underwent surgical clipping and 107 (70.4%) underwent EVT. Twenty-five (16.4%) patients developed delayed hydrocephalus. Age (p = 0.019), procedure duration (p = 0.004), and acute hydrocephalus (p = 0.030) were significantly correlated with the incidence of delayed hydrocephalus. However, the operation technique (p = 0.593) and use of an additional procedure (p = 0.378) were not significantly correlated with delayed hydrocephalus incidence. Conclusion No significant difference in the incidence of delayed hydrocephalus was associated with operation technique or use of an additional procedure in patients with SAH. However, delayed hydrocephalus was significantly correlated with old age, long procedural duration, and acute hydrocephalus. Therefore, we recommend that additional procedures should be discontinued as soon as possible.
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Affiliation(s)
- Tae Oong Eom
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jun Bum Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soon Chan Kwon
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hong Bo Sim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - In Uk Lyo
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Min Soo Kim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Nie Y, Song R, Chen W, Qin Z, Zhang J, Tang J. Effects of stellate ganglion block on cerebrovascular vasodilation in elderly patients and patients with subarachnoid haemorrhage. Br J Anaesth 2018; 117:131-2. [PMID: 27317713 DOI: 10.1093/bja/aew157] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Y Nie
- Guangzhou, Guangdong, China
| | - R Song
- Guangzhou, Guangdong, China
| | - W Chen
- Guangzhou, Guangdong, China
| | - Z Qin
- Guangzhou, Guangdong, China
| | | | - J Tang
- Guangzhou, Guangdong, China
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Predicting factors for shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2018; 160:1407-1413. [PMID: 29766339 DOI: 10.1007/s00701-018-3560-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 05/03/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) is a major complication that leads to a medical burden and poor clinical outcomes. The aim of this study was to evaluate the predictive factors of shunt-dependent hydrocephalus focusing on postoperative fever and infection. METHOD A total of 418 patients were included in this study and the patient demographic features, radiologic findings, days of fever burden, and infection were compared between the shunt (n = 72) and no shunt group (n = 346). Days of fever burden was defined as the total number of days with the highest body temperature ≥ 38.0 °C each day from day 1 to day 14. Pneumonia, urinary tract infection (UTI), meningitis, and bacteremia were recorded in all patients. RESULTS The independent predictive factors for shunt-dependent hydrocephalus were older age ≥ 65, microsurgical clipping, placement of extraventricular drainage (EVD), days of fever burden, and infection. The incidence of shunt dependency was 2.4% in the no fever burden patients (n = 123), 14.9% in the 1-3 days of fever burden patients (n = 161), 27.0% in the 4-6 days of fever burden patients (n = 74), and 41.7% in the ≥ 7 days of fever burden patients with statistical significance among groups (p < 0.001). CONCLUSION The rate of shunt dependency increased proportionally as the days of fever burden increased. Older age (≥ 65), microsurgical clipping, placement of EVD, days of fever burden, and infection were independent predictive factors for shunt dependency. Proper postoperative care for maintaining normal body temperature and preventing infectious disease can help reduce the rate of shunt dependency and improve clinical outcomes.
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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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Nemoto M, Masuda H, Sakaeyama Y, Okonogi S, Node Y, Ueda K, Ando S, Kondo K, Harada N, Sugo N. Clinical Characteristics of Subarachnoid Hemorrhage with an Intracerebral Hematoma and Prognostic Factors. J Stroke Cerebrovasc Dis 2018; 27:1160-1166. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/13/2017] [Accepted: 11/23/2017] [Indexed: 11/26/2022] Open
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Trends of Platelet Volume Index Predicts Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. World Neurosurg 2018; 111:e624-e631. [DOI: 10.1016/j.wneu.2017.12.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/19/2017] [Accepted: 12/20/2017] [Indexed: 12/21/2022]
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