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Martino F, Trainel M, Guillaume J, Schaffar A, Escalard S, Pons A, Engrand N. Outcome of Aneurysmal Subarachnoid Hemorrhage Not Altered With Transatlantic Airplane Transfer: A Bicentric Matched Case-control Study. J Neurosurg Anesthesiol 2024:00008506-990000000-00121. [PMID: 39051941 DOI: 10.1097/ana.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/17/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE It is recommended that ruptured cerebral aneurysms are treated in a high-volume center within 72 hours of ictus. We assessed the impact of long-distance aeromedical evacuation in patients presenting aSAH. METHODS This case-control study compared patients with aneurysmal subarachnoid hemorrhage (aSAH) who had a 6750 km air transfer from Guadeloupe (a Caribbean island) to Paris, France, for neurointerventional management in a tertiary center with a matched cohort from Paris region treated in the same center over a 10-year period (2010 to 2019). The 2 populations were matched on age, sex, World Federation of Neurological Surgeons score, and Fisher score. The primary outcome was a 1-year modified Rankin Scale score ≤3. Secondary outcomes included time from diagnosis to securing aneurysm, 1-year mortality, and a cost analysis. RESULTS Among 128 consecutive aSAH transferred from Guadeloupe, 93 were matched with 93 patients from the Paris area. The proportion of patients with 1-year modified Rankin Scale ≤3 (75% vs 82%, respectively; P= 0.5) and 1-year mortality (18% vs 14%, respectively; P= 0.2) was similar in the Guadeloupe and Paris groups. The median (interquartile range: Q1, Q3) time from diagnosis to securing the aneurysm was higher in the patients from Guadeloupe than those from Paris (48 [30, 63] h vs 23 [12, 24] h, respectively; P< 0.001). Guadeloupean patients received mechanical ventilation (58% vs 38%; P< 0.001) and external ventricular drainage (55% vs 39%; P= 0.005) more often than those from Paris. The additional cost of treating a Guadeloupe patient in Paris was estimated at 7580 Euros or 17% of the estimated cost in Guadeloupe. CONCLUSIONS Long-distance aeromedical evacuation of patients with aSAH from Guadeloupe to Paris resulted in a 25-hour increase in time to aneurysm coiling embolization time but did not impact 1-year functional outcomes or mortality.
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Affiliation(s)
- Frédéric Martino
- Intensive Care Unit, CHU de Guadeloupe, Chemin Chauvel, Les Abymes, Guadeloupe
- Université Paris Cité and Université des Antilles INSERM, BIGR, Paris
| | - Milan Trainel
- Neuro-Intensive Care Unit, Rothschild Foundation Hospital
| | | | | | - Simon Escalard
- Department of Interventional Neuro-Radiology, Rothschild Foundation Hospital, Paris Cedex, France
| | - Adrien Pons
- Intensive Care Unit, CHU de Guadeloupe, Chemin Chauvel, Les Abymes, Guadeloupe
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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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3
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Llompart-Pou JA, Pérez-Bárcena J, Lagares A, Godoy DA. Twelve controversial questions in aneurysmal subarachnoid hemorrhage. Med Intensiva 2024; 48:92-102. [PMID: 37951804 DOI: 10.1016/j.medine.2023.09.003] [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: 07/06/2023] [Accepted: 09/28/2023] [Indexed: 11/14/2023]
Abstract
Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients.
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Affiliation(s)
- Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain.
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Alfonso Lagares
- Servicio de Neurocirugía. Hospital Universitario 12 de Octubre. Madrid. Spain
| | - Daniel Agustín Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina
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Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery 2023; 93:636-645. [PMID: 37010298 DOI: 10.1227/neu.0000000000002467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine Fondazione Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A, Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology Spedali Civili University Hospital, Brescia, Italy
| | | | - Giordano Nardin
- Department of Critical Care, SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care, Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | | | | | - Pietro Mortini
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Neurocritical Care San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Wu B, Huang Z, Liu H, He J, Ju Y, Chen Z, Zhang T, Yi F. Ultra-early endovascular treatment improves prognosis in High grade aneurysmal subarachnoid hemorrhage: A single-center retrospective study. Front Neurol 2022; 13:963624. [PMID: 36034293 PMCID: PMC9413045 DOI: 10.3389/fneur.2022.963624] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The long-term survival prognosis of patients with high-grade (Hunt-Hess grade IV–V or World Federation of Neurosurgical Societies grade IV–V) aneurysmal subarachnoid hemorrhage (aSAH) is generally poor, and the association between endovascular treatment timing and the prognosis of high-grade aSAH has not been explored in depth. This retrospective cohort study aimed to determine whether endovascular treatment within 24 h of high-grade aSAH is associated with a better prognosis. Methods We retrospectively analyzed the clinical data of patients with high-grade aSAH who were admitted to our institution between January 2018 and January 2021. The Modified Rankin Scale score was used to assess the 6-month prognosis of patients. Univariate and multivariate logistic regression analyses were used to identify the factors associated with prognosis. The area under the receiver operating characteristic (ROC) curve was used to assess the model's discriminatory ability. Results Eighty-six patients were included in the study. In the multivariate analysis, the timing of endovascular treatment (odds ratio = 7.003 [1.800–27.242], P = 0.005) was an independent risk factor for prognosis. The ROC curve showed that the predictive power of the timing of endovascular treatment was 0.744, the best cut-off value was 12.5 h, and the corresponding sensitivity and specificity were 71.4 and 70.5%, respectively. Hydrocephalus (P = 0.005) and pulmonary infection (P = 0.029) were also associated with prognosis. In addition, cerebrospinal fluid drainage immediately after endovascular treatment had a significant effect on reducing hydrocephalus formation. Conclusions Endovascular therapy within 24 h is feasible and improves the prognosis of patients with high-grade aSAH.
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Affiliation(s)
- Botao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Zhe Huang
- Department of Radiology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Huan Liu
- Department of General Surgery, Zhongshan Hospital of Traditional Chinese Medicine, Guangzhou University of Traditional Chinese Medicine, Zhongshan, China
| | - Jiayao He
- Department of Orthopedics, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Yan Ju
- Department of Endocrinology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Ziwei Chen
- Department of Neurosurgery, The Third Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Taiwei Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Fuxin Yi
- Department of Neurosurgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
- *Correspondence: Fuxin Yi
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Long B, Gottlieb M. Tranexamic acid for aneurysmal subarachnoid hemorrhage. Acad Emerg Med 2022; 29:798-800. [PMID: 35266599 DOI: 10.1111/acem.14482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston Texas USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush University Medical Center Chicago Illinois USA
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Donnelly P, McMillen J, Raman V, Jiwrajka M. Intracranial aneurysms: The era of endovascular intervention in Australia. J Clin Neurosci 2022; 97:127-135. [DOI: 10.1016/j.jocn.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/11/2021] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
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8
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Hanalioglu S, Sahin B, Sayyahmelli S, Ozaydin B, Erginoglu U, Aycan A, Baskaya MK. The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era. Acta Neurochir (Wien) 2022; 164:781-793. [PMID: 35133482 DOI: 10.1007/s00701-022-05112-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity regardless of treatment. Herein, we re-evaluate the safety and efficacy of microsurgical treatment for managing PGASAH patients in the current endovascular era. METHODS We retrospectively reviewed 141 consecutive patient records in a single institution who underwent microsurgical (n = 80) or endovascular (n = 61) treatment for PGASAH. RESULTS Baseline characteristics were similar, except for more intracerebral hematomas (46.3% vs 24.6%, p = 0.009), fewer intraventricular hemorrhages (26.3% vs 59%, p < 0.001), and fewer posterior circulation aneurysms (5.1% vs 44.3%, p < 0.001) in the microsurgery group. Decompressive craniectomy (58.5% vs 24.6%, p < 0.001) and shunt-dependent hydrocephalus (63.7% vs 41%, p = 0.01) were more common for microsurgery, while procedural ischemic complications were less common (5% vs 24.6%, p = 0.001). Both early (12.5% vs 32.8%, p = 0.006) and late mortality rates (22.5% vs 39.3%, p = 0.041) were lower for microsurgery, and favorable 12-month outcomes (modified Rankin scale = 0-2) were better (62.5% vs 42.6%, p = 0.026). Multivariate analysis revealed that advanced age, neurological grade, modified Fisher grade, larger aneurysm size, rebleeding, and cerebral infarctions were independent predictors of poor outcome. Microsurgery fared marginally better than endovascular treatment (OR: 2.630, 95% CI: [0.991-6.981], p = 0.052). CONCLUSIONS Timely and efficient treatment, either via open microsurgery or endovascular surgery, provided favorable outcomes for over half of PGASAH patients in this series. Therefore, early treatment should be offered to all PGASAH patients regardless of clinical and/or radiological factors. Microsurgery remains an effective treatment modality for selected PGASAH patients in the endovascular era.
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Shi M, Yang C, Chen ZH, Xiao LF, Zhao WY. Efficacy and Safety of Tranexamic Acid in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Surg 2022; 8:790149. [PMID: 35083272 PMCID: PMC8784421 DOI: 10.3389/fsurg.2021.790149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Tranexamic acid has been shown to reduce rebleeding after aneurysmal subarachnoid hemorrhage; however, whether it can reduce mortality and improve clinical outcomes is controversial. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of the tranexamic acid in aneurysmal subarachnoid hemorrhage. We conducted a comprehensive literature search of PubMed, Embase, Web of Science, and Cochrane Library from inception to March 2021 for randomized controlled trials (RCTs) comparing tranexamic acid and placebo in adults with aneurysmal subarachnoid hemorrhage. The risk of bias was evaluated using the Cochrane Handbook, and the quality of evidence was evaluated using the GRADE approach. This meta-analysis included 13 RCTs, involving 2,888 patients. In patients with aneurysmal subarachnoid hemorrhage tranexamic acid had no significant effect on all-cause mortality (RR = 0.96; 95% CI = 0.84–1.10, p = 0.55, I2 = 44%) or poor functional outcome (RR = 1.04; 95% CI = 0.95–1.15, p = 0.41) compared with the control group. However, risk of rebleeding was significantly lower (RR = 0.59; 95% CI = 0.43–0.80, p = 0.0007, I2 = 53%). There were no significant differences in other adverse events between tranexamic acid and control treatments, including cerebral ischemia (RR = 1.17; 95% CI = 0.95–1.46, p = 0.15, I2 = 53%). At present, routine use of tranexamic acid after subarachnoid hemorrhage cannot be recommended. For a patient with subarachnoid hemorrhage, it is essential to obliterate the aneurysm as early as possible. Additional higher-quality studies are needed to further assess the effect of tranexamic acid on patients with subarachnoid hemorrhage.
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Affiliation(s)
- Min Shi
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao Yang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zu-han Chen
- Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ling-fei Xiao
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen-yuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Wen-yuan Zhao
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Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106075. [PMID: 34481320 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.
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Aneurysmal Subarachnoid Hemorrhage: Review of the Pathophysiology and Management Strategies. Curr Neurol Neurosci Rep 2021; 21:50. [PMID: 34308493 DOI: 10.1007/s11910-021-01136-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Aneurysmal subarachnoid hemorrhage remains a devastating disease process despite medical advances made over the past 3 decades. Much of the focus was on prevention and treatment of vasospasm to reduce delayed cerebral ischemia and improve outcome. In recent years, there has been a shift of focus onto early brain injury as the precursor to delayed cerebral ischemia. This review will focus on the most recent data surrounding the pathophysiology of aneurysmal subarachnoid hemorrhage and current management strategies. RECENT FINDINGS There is a paucity of successful trials in the management of subarachnoid hemorrhage likely related to the targeting of vasospasm. Pathophysiological changes occurring at the time of aneurysmal rupture lead to early brain injury including cerebral edema, inflammation, and spreading depolarization. These events result in microvascular collapse, vasospasm, and ultimately delayed cerebral ischemia. Management of aneurysmal subarachnoid hemorrhage has remained the same over the past few decades. No recent trials have resulted in new treatments. However, our understanding of the pathophysiology is rapidly expanding and will advise future therapeutic targets.
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de Winkel J, van der Jagt M, Lingsma HF, Roozenbeek B, Calvillo E, Chou SHY, Dziedzic PH, Etminan N, Huang J, Ko NU, Loch MacDonald R, Martin RL, Potu NR, Venkatasubba Rao CP, Vergouwen MDI, Suarez JI. International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2021; 10:jcm10040762. [PMID: 33672807 PMCID: PMC7917699 DOI: 10.3390/jcm10040762] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 12/18/2022] Open
Abstract
Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24–48 h, and eight percent within 48–72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other p < 0.001, and EU vs. other p < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other p < 0.001, EU vs. other p < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, p < 0.05) and other centers (81%, p < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, p < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
| | - Eusebia Calvillo
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Sherry H-Y. Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Peter H. Dziedzic
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Nima Etminan
- Department of Neurosurgery, University of Heidelberg School of Medicine, 69117 Mannheim, Germany;
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Nerissa U. Ko
- Department of Neurology, UCSF Weill Institute for Neurosciences, UCSF School of Medicine, San Francisco, CA 94143, USA;
| | - Robert Loch MacDonald
- UCSF Fresno Department of Neurosurgery, UCSF School of Medicine, University Neuroscience Institute, Fresno, CA 93701, USA;
| | - Renee L. Martin
- Department of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Niteesh R. Potu
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Chethan P. Venkatasubba Rao
- Departments of Neurology, Neurosurgery, and Center for Space medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Mervyn D. I. Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands;
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence:
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13
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Lam J, Ravina K, Rennert RC, Russin JJ. Cerebrovascular bypass for ruptured aneurysms: A case series. J Clin Neurosci 2021; 85:106-114. [PMID: 33581780 DOI: 10.1016/j.jocn.2020.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/07/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.
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Affiliation(s)
- Jordan Lam
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA
| | - Kristine Ravina
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA
| | - Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Jonathan J Russin
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA.
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14
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Chen Y, Lian BQ, Peng L, Ding CY, Lin YX, Yu LH, Wang DL, Kang DZ. Neutrophil to lymphocyte ratio is a prognosis factor for post-operative pneumonia in aneurysmal subarachnoid hemorrhage patients. Chin Med J (Engl) 2020; 134:682-689. [PMID: 33394700 PMCID: PMC7989986 DOI: 10.1097/cm9.0000000000001304] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Although a variety of risk factors of pneumonia after clipping or coiling of the aneurysm (post-operative pneumonia [POP]) in patients with aneurysmal subarachnoid hemorrhage (aSAH) have been studied, the predictive model of POP after aSAH has still not been well established. Thus, the aim of this study was to assess the feasibility of using admission neutrophil to lymphocyte ratio (NLR) to predict the occurrence of POP in aSAH patients. Methods: We evaluated 711 aSAH patients who were enrolled in a prospective observational study and collected admission blood cell counts data. We analyzed available demographics and baseline variables for these patients and analyzed the correlation of these factors with POP using Cox regression. After screening out the prognosis-related factors, the predictive value of these factors for POP was further assessed. Results: POP occurred in 219 patients (30.4%) in this cohort. Patients with POP had significantly higher NLR than those without (14.11 ± 8.90 vs. 8.80 ± 5.82, P < 0.001). Multivariate analysis revealed that NLR remained a significant factor independently associated with POP following aSAH after adjusting for possible confounding factors, including the age, World Federation of Neurosurgical Societies (WFNS) grade, endovascular treatment, and ventilator use. And the predictive value of NLR was significantly increased after WFNS grade was combined with NLR (NLR vs. WFNS grade × NLR, P = 0.011). Conclusions: Regardless of good or poor WNFS grade, patients having NLR >10 had significantly worse POP survival rate than patients having NLR ≤10. NLR at admission might be helpful as a predictor of POP in aSAH patients.
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Affiliation(s)
- Yue Chen
- The Graduate School of Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Bao-Qiang Lian
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Lei Peng
- Department of Neurosurgery, The People's Hospital of China Three Gorges University, The First People's Hospital of Yichang, Yichang, Hubei 443000, China
| | - Chen-Yu Ding
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Liang-Hong Yu
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Deng-Liang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350001, China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350001, China
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15
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Lu VM, Graffeo CS, Perry A, Carlstrom LP, Casabella AM, Wijdicks EFM, Lanzino G, Rabinstein AA. Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study. J Clin Neurosci 2020; 81:180-185. [PMID: 33222913 DOI: 10.1016/j.jocn.2020.09.064] [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: 07/04/2020] [Revised: 09/09/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood. METHODS A retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores. RESULTS Of 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3-5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3-5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome. CONCLUSIONS Early rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.
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Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States; Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States.
| | | | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanda M Casabella
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
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16
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Tasiou A, Brotis AG, Paschalis T, Tzerefos C, Kapsalaki EZ, Giannis T, Tzannis A, Fountas KN. Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience. Int J Neurosci 2020; 132:38-50. [PMID: 32746674 DOI: 10.1080/00207454.2020.1801676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Thanasis Paschalis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Eftychia Z Kapsalaki
- Department of Neuroradiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Theofanis Giannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alkiviadis Tzannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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17
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Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5. Acta Neurochir (Wien) 2020; 162:533-544. [PMID: 31980948 DOI: 10.1007/s00701-019-04190-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results. METHODS Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months. RESULTS We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors. CONCLUSIONS Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.
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18
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The accuracy of aneurysm size in predicting rebleeding after subarachnoid hemorrhage: a meta-analysis. Neurol Sci 2020; 41:1843-1850. [DOI: 10.1007/s10072-020-04297-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/13/2020] [Indexed: 10/25/2022]
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19
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Post R, Germans MR, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. Update of the ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage (ULTRA) trial: statistical analysis plan. Trials 2020; 21:199. [PMID: 32070395 PMCID: PMC7029526 DOI: 10.1186/s13063-020-4118-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recurrent bleeding from an intracranial aneurysm after subarachnoid hemorrhage (SAH) is associated with unfavorable outcome. Recurrent bleeding before aneurysm occlusion can be performed occurs in up to one in five patients and most often happens within the first 6 h after the primary hemorrhage. Reducing the rate of recurrent bleeding could be a major factor in improving clinical outcome after SAH. Tranexamic acid (TXA) reduces the risk of recurrent bleeding but has thus far not been shown to improve functional outcome, probably because of a higher risk of delayed cerebral ischemia (DCI). To reduce the risk of ultraearly recurrent bleeding, TXA should be administered as soon as possible after diagnosis and before transportation to a tertiary care center. If TXA is administered for a short duration (i.e., < 24 h), it may not increase the risk of DCI. The aim of this paper is to present in detail the statistical analysis plan (SAP) of the ULTRA trial (ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage), which is currently enrolling patients and investigating whether ultraearly and short-term TXA treatment in patients with aneurysmal SAH improves clinical outcome at 6 months. METHODS/DESIGN The ULTRA trial is a multicenter, prospective, randomized, open, blinded endpoint, parallel-group trial currently ongoing at 8 tertiary care centers and 16 of their referral centers in the Netherlands. Participants are randomized to standard care or to receive TXA at a loading dose of 1 g, immediately followed by 1 g every 8 h for a maximum of 24 h, in addition to standard care, as soon as SAH is diagnosed. In the TXA group, TXA administration is stopped immediately prior to treatment (coil or clip) of the causative aneurysm. Primary outcome is the modified Rankin Scale (mRS) score at 6 months after SAH, dichotomized into good (mRS 0-3) and poor (mRS 4-6) outcomes, assessed blind to treatment allocation. Secondary outcomes include case fatalities at 30 days and at 6 months and causes of poor clinical outcome. Safety outcomes are recurrent bleeding, DCI, hydrocephalus, per-procedural complications, and other complications such as infections occurring during hospitalization. Data analyses will be according to this prespecified SAP. TRIAL REGISTRATION Netherlands Trial Register, NTR3272. Registered on 25 January 2012. ClinicalTrials.gov, NCT02684812. Registered on 17 February 2016.
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Affiliation(s)
- René Post
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, PO Box 85060, Utrecht, 3508 AB, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands.
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20
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Kaneko J, Tagami T, Unemoto K, Tanaka C, Kuwamoto K, Sato S, Tani S, Shibata A, Kudo S, Kitahashi A, Yokota H. Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage. J NIPPON MED SCH 2019; 86:81-90. [PMID: 31130569 DOI: 10.1272/jnms.jnms.2019_86-203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus. METHODS We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes. RESULTS A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8). CONCLUSIONS Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.
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Affiliation(s)
- Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital.,Health Services and Systems Research, Duke-NUS Medical School.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Chie Tanaka
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | | | - Shin Sato
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Shosei Tani
- Department of Neurosurgery, Tominaga Hospital
| | - Ami Shibata
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Saori Kudo
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Akiko Kitahashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School
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21
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Sonig A, Shallwani H, Natarajan SK, Shakir HJ, Hopkins LN, Snyder KV, Siddiqui AH, Levy EI. Better Outcomes and Reduced Hospitalization Cost are Associated with Ultra-Early Treatment of Ruptured Intracranial Aneurysms: A US Nationwide Data Sample Study. Neurosurgery 2019; 82:497-505. [PMID: 28541411 DOI: 10.1093/neuros/nyx241] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The benefit of surgical treatment of ruptured aneurysms is well established. OBJECTIVE To determine whether ultra-early ruptured aneurysm treatment leads to not only improved outcomes but also reduced hospitalization cost. METHODS Using 2008-2011 Nationwide Inpatient Sample data, we analyzed demographic, clinical, and hospital factors for nontraumatic subarachnoid hemorrhage (SAH) patients who were "directly" admitted to the treating hospital where they underwent intervention (clipping/coiling). Patients treated on the day of admission (day 0) formed the ultra-early cohort; others formed the deferred treatment cohort. All Patient Refined Diagnosis-Related Groups were also included in regression analyses. RESULTS A total of 17 412 patients were directly admitted to a hospital following nontraumatic SAH where they underwent intervention (clipping/coiling). Mean patient age was 53.87 yr (median 53.00, standard deviation 14.247); 68.3% were women (n = 11 893). A total of 6338 (36.4%) patients underwent treatment on the day of admission (ultra-early). Patients who underwent treatment on day 0 had significantly more routine discharge dispositions than those treated >admission day 0 (P < .0001). In regression analysis, treatment on day 0 was protective against other than routine discharge disposition outcome (P < .0001; odds ratio 0.657; 95% confidence interval 0.614-0.838). Total cost incurred by hospitals was $4.36 billion. Mean cost of hospital charges in the ultra-early cohort was $239 126.05, which was significantly lower than that for the cohort treated >day 0 ($272 989.56, P < .001), Mann-Whitney U-test). Performance of an intervention on admission day 0 was protective against higher hospitalization cost (P < .0001; odds ratio 0.811; 95% confidence interval 0.732-0.899). CONCLUSION Ultra-early treatment of ruptured aneurysms is significantly associated with better discharge disposition and decreased hospitalization cost.
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Affiliation(s)
- Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Hussain Shallwani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Sabareesh K Natarajan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Hakeem J Shakir
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - L Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buf-falo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York.,Jacobs Institute, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buf-falo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York.,Jacobs Institute, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buf-falo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
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22
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Subarachnoid Hemorrhage in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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23
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Tack RW, Vergouwen MDI, van der Schaaf I, van der Zwan A, Rinkel GJ, Lindgren AE. Preventable poor outcome from rebleeding by emergency aneurysm occlusion in patients with aneurysmal subarachnoid haemorrhage. Eur Stroke J 2019; 4:240-246. [PMID: 31984231 DOI: 10.1177/2396987319828160] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/11/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction The risk of rebleeding is highest during the initial hours after aneurysmal subarachnoid haemorrhage (aSAH), but the aneurysm is not occluded in all patients immediately after admission.Our aim was to determine the proportion of aSAH patients with poor outcome from early in-hospital rebleeding that can be prevented by three emergency aneurysm occlusion regimes. Patients and methods From our prospectively collected database, we retrieved from all aSAH patients admitted between July 2007 and July 2017 data on clinical condition on admission, time of rebleeding, and outcome at 3 months. Results Of 1391 consecutive aSAH patients, 923 were in good clinical condition and had an aneurysm on initial imaging that was amenable for treatment. Poor outcome from rebleeding could have been avoided by treatment <4 h during day time shifts in 4 (0.4% [95% CI: 0.2-1.1]) patients (number needed to treat [NNT]: 250), by treatment and <1 h during daytime shift in 9 (1.0% [95% CI: 0.5-1.8]; NNT: 111), and treatment <1 h at 24/7 basis in 16 (1.7% [95% CI: 1.1-2.8%]; NNT: 59). Discussion Emergency aneurysm occlusion can reduce poor outcome due to rebleeding, but only in small proportions of patients. Whether such strategies lead to improved outcome for all patients and are cost-effective is highly uncertain. Conclusion We do not recommend instalment of a treatment regimen where occlusion of ruptured aneurysm is performed within 1 h on a 24/7 basis.
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Affiliation(s)
- Reinier Wp Tack
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mervyn DI Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Albert van der Zwan
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel Je Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Antti E Lindgren
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
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Comparison of Aggressive Surgical Treatment and Palliative Treatment in Elderly Patients with Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5818937. [PMID: 29998135 PMCID: PMC5994574 DOI: 10.1155/2018/5818937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
Objective To compare the current treatment approach in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) and identify the independent predictors of the outcome after aggressive surgical treatment. Method This prospective, multicenter cohort study included 104 poor-grade aneurysmal SAH elderly patients, 60 years or older, treated in our institution from October 2010 to March 2013. Patients were grouped according to three treatment arms. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at baseline and at a 12-month follow-up. Univariate and multivariate analysis were performed using the following factors: sex, age, smoking history, breathing ability, alcohol consumption, cerebral hernia, aneurysm location, aneurysm diameter, WFNS grade, CT Fisher grade, treatment approach, and the timing of the aneurysm surgery. Results At the 12-month follow-up, patients in the coiling group and clipping group had better prognosis than patients in the palliative treatment group. Univariate analysis confirmed that the treatment approach, WFNS grade, CT Fisher grade, and age are critical factors for neurological outcomes in poor-grade SAH. Multivariate analysis indicated that WFNS grade V, CT Fisher grades 3-5, and palliative treatment were independent predictors of poor prognoses. Conclusion Aggressive surgical treatment improves the prognoses in poor-grade aneurysm elderly patients with SAH. Elderly Patients of WFNS grade IV and CT Fisher grades 1-2 are more likely to have a better outcome.
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Galea JP, Dulhanty L, Patel HC. Predictors of Outcome in Aneurysmal Subarachnoid Hemorrhage Patients. Stroke 2017; 48:2958-2963. [DOI: 10.1161/strokeaha.117.017777] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/24/2017] [Accepted: 08/28/2017] [Indexed: 11/16/2022]
Affiliation(s)
- James P. Galea
- From the Vascular and Stroke Center, Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Center, University of Manchester, United Kingdom (J.P.G., H.C.P.); Greater Manchester Neurosciences Center, Salford Royal Foundation NHS Trust, United Kingdom (L.D., H.C.P.); and Ninewells Hospital and Medical School, Ninewells, Dundee, United Kingdom (J.P.G.)
| | - Louise Dulhanty
- From the Vascular and Stroke Center, Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Center, University of Manchester, United Kingdom (J.P.G., H.C.P.); Greater Manchester Neurosciences Center, Salford Royal Foundation NHS Trust, United Kingdom (L.D., H.C.P.); and Ninewells Hospital and Medical School, Ninewells, Dundee, United Kingdom (J.P.G.)
| | - Hiren C. Patel
- From the Vascular and Stroke Center, Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Center, University of Manchester, United Kingdom (J.P.G., H.C.P.); Greater Manchester Neurosciences Center, Salford Royal Foundation NHS Trust, United Kingdom (L.D., H.C.P.); and Ninewells Hospital and Medical School, Ninewells, Dundee, United Kingdom (J.P.G.)
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Tykocki T, Czyż M, Machaj M, Szydlarska D, Kostkiewicz B. Comparison of the timing of intervention and treatment modality of poor-grade aneurysmal subarachnoid hemorrhage. Br J Neurosurg 2017; 31:430-433. [PMID: 28436243 DOI: 10.1080/02688697.2017.1319906] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The timing and modality of intervention in the treatment of poor-grade aneurysmal subarachnoid haemorrhage (aSAH) has not been defined. The purpose of the study is to analyse whether early treatment and type of intervention influence the clinical outcomes of poor-grade aSAH patients. MATERIAL AND METHODS Patients with poor-grade aSAH were retrieved. Demographics, Fisher grade, radiological characteristics and clinical outcomes were recorded. Outcomes were compared using the modified Rankin Scale (mRS), for groups treated early within 24 hours of aSAH or later and by clipping or endovascular therapy. Multivariate multiple regression model and logistic regression were used to assess factors affecting outcomes at discharge in mRS and length of stay. RESULTS The study was conducted on 79 patients. 47 (59%) were treated by clipping, 38 (48%) received intervention within 24 hours of aSAH. Patients treated <24h had significantly lower mortality (n = 5; 13% vs. n = 14; 37%; p < .023), higher rate of 0-3 mRS (n = 22;58% vs. n = 9; 22%; p < .039) and were younger (49.5 ± 6.1 vs. 65.8 ± 7.4 years; p < .038). There were no significant differences in mRS between clipping and endovascular therapy. Predictors of length of stay were ICH, MLS, endovascular therapy, location in posterior circulation, Fisher grade and time to intervention <24h. Early intervention, <24h significantly influenced the favourable results in mRS (0-3); (OR 4,14; Cl95% 3.82-4.35). Posterior circulation aneurysms, midline shift and intracerebral hematoma were correlated with poor outcomes. CONCLUSIONS Early treatment, within 24 h, of poor-grade aSAH confirmed better clinical outcome compared to later aneurysm securement. There was no significant difference between clipping and endovascular treatment.
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Affiliation(s)
- Tomasz Tykocki
- a Department of Neurosurgery , Institute of Psychiatry and Neurology in Warsaw , Warsaw , Poland
| | - Marcin Czyż
- b The Centre for Spinal Studies and Surgery , Queens Medical Centre , Nottingham , UK
| | - Małgorzata Machaj
- c Department of Human Resource , Central Clinical Hospital of the Ministry of the Interior in Warsaw , Warsaw , Poland
| | - Dorota Szydlarska
- d Family Medicine Outpatient Clinic with Vaccination Centre , Central Clinical Hospital of the Ministry of the Interior in Warsaw , Warsaw , Poland
| | - Bogusław Kostkiewicz
- e Department of Neurosurgery , Central Clinical Hospital of the Ministry of the Interior in Warsaw , Warsaw , Poland
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Yao PS, Chen GR, Zheng SF, Kang DZ. Predictors of Postoperative Cerebral Ischemia in Patients with Ruptured Anterior Communicating Artery Aneurysms. World Neurosurg 2017; 103:241-247. [PMID: 28408258 DOI: 10.1016/j.wneu.2017.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/31/2017] [Accepted: 04/01/2017] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Cerebral ischemia is a major contributor to poor outcome after ruptured anterior communicating artery aneurysms (ACoAs), and is not well classified. In this article, we develop a classification and identify risk factors of cerebral ischemia after ruptured ACoAs. METHODS Three hundred sixty patients with ruptured ACoAs undergoing microsurgical clipping were collected. Sex, age, smoking status, Hunt-Hess grade, Fisher grade, hospital stay, surgical timing, hypertension, diabetes, postoperative cerebral ischemia, and postoperative modified Rankin Scale score were collected. Postoperative ischemic changes are classified according to a novel grade (ischemic grade I-IV). RESULTS Predictive factors of postoperative ischemia (grade I-IV) included sex (odds ratio [OR], 1.956; 95% confidence interval [CI], 1.262-3.032; P = 0.003) and Fisher grade (OR, 1.813; 95% CI, 1.144-2.871; P = 0.011). Male sex had a tendency to develop postoperative cerebral ischemia (61.3% in the ischemia group vs. 45.7% in the nonischemia group), while surgical timing did not. However, in patients with postoperative ischemia, early surgery within 3 days (OR, 3.334; 95% CI, 1.411-7.879; P = 0.006) and advanced age greater than 55 years (OR, 2.783; 95% CI, 1.214-6.382; P = 0.016) were risk factors for postoperative neurologic deficits (grade III-IV). CONCLUSIONS Male sex and higher Fisher grade predict postoperative ischemia (grade I-IV), whereas surgical timing does not. However, in patients with postoperative cerebral ischemia, early surgery within 3 days and age greater than 55 years can increase the frequency of postoperative neurological deficits (grade III-IV). Older male patients undergoing early microsurgery had a tendency to develop neurologic deficits.
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Affiliation(s)
- Pei-Sen Yao
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guo-Rong Chen
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shu-Fa Zheng
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
| | - De-Zhi Kang
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
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Weyhenmeyer J, Guandique CF, Leibold A, Lehnert S, Parish J, Han W, Tuchek C, Pandya J, Leipzig T, Payner T, DeNardo A, Scott J, Cohen-Gadol AA. Effects of distance and transport method on intervention and mortality in aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 128:490-498. [PMID: 28186453 DOI: 10.3171/2016.9.jns16668] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Most patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) initially present to a hospital that lacks a neurosurgical unit. These patients require interhospital transfer (IHT) to tertiary facilities capable of multidisciplinary neurosurgical intervention. Yet, little is known about the effects of IHT on the outcomes of patients suffering from aSAH. In this study, the authors examined the effects of IHT and transport method on the timing of treatment, rebleed rates, and overall outcomes of patients who have experienced aSAH. METHODS A retrospective review of medical records identified all consecutive patients who presented with aSAH at an outside hospital and subsequently underwent IHT to a tertiary aneurysm care center and patients who initially presented directly to a tertiary aneurysm care facility between 2008 and 2015. Demographic, operative, radiological, hospital of initial evaluation, transfer method, and outcome data were retrospectively collected. RESULTS The authors identified 763 consecutive patients who were evaluated for aSAH at a tertiary aneurysm care facility either directly or following IHT. For patients who underwent IHT and after accounting for these patients' clinical variability and dichotomizing the patients into groups transferred less than 20 miles and more than 20 miles, the authors noted a significant increase in mortality rates: 7% (< 20 miles) and 18.8% (> 20 miles) (p = 0.004). The increased mortality rate was partially explained by an increased rate of initial presentation to an accredited stroke center in patients undergoing IHT of less than 20 miles (p = 0.000). The method of transport (ground or air ambulance) was found to have significant effect on the patients' outcomes as measured by the Glasgow Outcome Scale score (p = 0.021); patients who underwent ground transport demonstrated a higher likelihood of discharge to home (p = 0.004). The increased severity of presentation in the patient cohort undergoing IHT by air as defined by the Glasgow Coma Scale score, a need for an external ventricular drain, Hunt and Hess grade, and intubation status at presentation did not result in increased mortality when compared with the ground cohort (p = 0.074). In addition, there was an 8-hour increase in duration of time from admission to treatment for the air cohort as compared with the ground cohort (p = 0.054), indicating a potential for further improvement in the overall outcome of this patient group. CONCLUSIONS Aneurysmal SAH remains a challenging neurosurgical disease process requiring highly coordinated care in tertiary referral centers. In this study, the overall distance traveled and the transport method affected patient outcomes. The time from admission to treatment should continue to improve. Further analysis of IHT with a focus on patient monitoring and treatment during transport is warranted.
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Affiliation(s)
- Jonathan Weyhenmeyer
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | | | - Adam Leibold
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Stephen Lehnert
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jonathan Parish
- 3Carolina's Medical Center Department of Neurosurgery, Charlotte, North Carolina
| | - Woody Han
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Chad Tuchek
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Janit Pandya
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Thomas Leipzig
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Troy Payner
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Andrew DeNardo
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - John Scott
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Aaron A Cohen-Gadol
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
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Clinical and Neuropsychological Outcome After Microsurgical and Endovascular Treatment of Ruptured and Unruptured Anterior Communicating Artery Aneurysms: A Single-Enter Experience. ACTA NEUROCHIRURGICA SUPPLEMENT 2017; 124:173-177. [DOI: 10.1007/978-3-319-39546-3_27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Aneurysm Surgery with Preoperative Three-Dimensional Planning in a Virtual Reality Environment: Technique and Outcome Analysis. World Neurosurg 2016; 96:489-499. [DOI: 10.1016/j.wneu.2016.08.124] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 08/27/2016] [Accepted: 08/30/2016] [Indexed: 11/22/2022]
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Hoogmoed J, van den Berg R, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. A strategy to expeditious invasive treatment improves clinical outcome in comatose patients with aneurysmal subarachnoid haemorrhage. Eur J Neurol 2016; 24:82-89. [PMID: 27670264 DOI: 10.1111/ene.13134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with poor clinical condition after aneurysmal subarachnoid haemorrhage (aSAH), treatment is often deferred until patients show signs of improvement. Early external ventricular drainage and aneurysm occlusion may improve prognosis also in poor grade patients. The clinical outcome of an expeditious approach was compared with that of a conservative approach. METHODS In all, 285 consecutive World Federation of Neurological Surgeons (WFNS) grade V aSAH patients admitted to three university hospitals between January 2000 and June 2007 were included. Two hospitals followed an expeditious approach, one a more conservative approach. Groups were compared with respect to demographic and clinical characteristics and outcome. Univariable and multivariable analyses were performed to determine the associations with good outcome (Glasgow Outcome Scale scores 4-5), using logistic regression models. RESULTS Good outcome was seen more often in expeditiously treated patients [22% vs. 11%; odds ratio (OR) 2.24, 95% confidence interval (CI) 1.17-4.27]. Expeditiously treated patients more often underwent aneurysm occlusion than conservatively treated patients (64% vs. 27%; OR 4.86, 95% CI 2.93-8.05) and placement of an external ventricular catheter (82% vs. 31%; OR 10.05, CI 5.72-10.66). There was no significant difference in rebleeding between patient groups. Occlusion of the aneurysm was the only variable that remained significant in the multivariable model with an OR of 43.73 (95% CI 10.34-184.97). CONCLUSIONS An expeditious invasive treatment strategy in WFNS grade V aSAH patients can lead to a better outcome. Hesitance in the early stages seems a self-fulfilling prophecy for a poor outcome.
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Affiliation(s)
- J Hoogmoed
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - R van den Berg
- Department of Neuroradiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B A Coert
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G J E Rinkel
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - W P Vandertop
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - D Verbaan
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
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Zhao B, Tan X, Zhao Y, Cao Y, Wu J, Zhong M, Wang S. Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:224-31. [PMID: 26421588 DOI: 10.1227/neu.0000000000001038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage. OBJECTIVE To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups. METHODS Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months. RESULTS Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome. CONCLUSION Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.
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Affiliation(s)
- Bing Zhao
- *Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; ‡Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; §Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Zhao B, Yang H, Zheng K, Li Z, Xiong Y, Tan X, Zhong M. Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage. J Neurosurg 2016; 126:1764-1771. [PMID: 27367238 DOI: 10.3171/2016.4.jns152587] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE An increasing number of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have received endovascular treatment. Endovascular treatment of poor-grade aSAH, however, is based on single-center retrospective studies, and predictors of long-term outcome have not been well defined. Using results from a multicenter prospective registry, the authors aimed to develop preoperative and postoperative prognostic models to predict poor outcome after endovascular treatment of poor-grade aSAH. METHODS A Multicenter Poor-grade Aneurysm Study (AMPAS) was a prospective and observational registry of consecutive patients with poor-grade aSAH. From October 2010 to March 2012, 366 patients were enrolled in the registry, and 136 patients receiving endovascular treatment were included in this study. Outcome was assessed by modified Rankin Scale (mRS) score at 12 months, and poor outcome was defined as an mRS score of 4, 5, or 6. Prognostic models were developed in multivariate logistic regression models. The area under receiver operating characteristic curves (AUC) was used to assess the model's discriminatory ability, and Hosmer-Lemeshow goodness-of-fit tests were used to assess the calibration. RESULTS At 12 months, 64 patients (47.0%) had a poor outcome: 9 (6.6%) had an mRS score of 4, 6 (4.4%) had an mRS score of 5, and 49 (36.0%) had died. Univariate analyses showed that older age (p = 0.001), female sex (p = 0.044), lower Glasgow Coma Scale score (p < 0.001), a World Federation of Neurosurgical Societies (WFNS) grade of V (p < 0.001), higher Fisher grade (p < 0.001), modified Fisher grade (p < 0.001), and wider neck aneurysm (p = 0.026) were associated with a poor outcome. There was a trend toward a worse outcome in patients with anterior communicating artery aneurysms (p = 0.080) and in those with incompletely occluded aneurysms (p = 0.063). After endovascular treatment, the presence of cerebral infarction (p = 0.039), symptomatic vasospasm (p = 0.039), and pneumonia (p = 0.006) were associated with a poor outcome. Multivariate analyses showed that the preoperative prognostic model including age, a WFNS grade of V, modified Fisher grade, and aneurysm neck size had excellent discrimination with an AUC of 0.86 (95% CI 0.80-0.92, p < 0.001), and a postoperative model that included these predictors as well as postoperative pneumonia had excellent discrimination (AUC = 0.87, 95% CI 0.81-0.93, p < 0.001). Both models had good calibration (p = 0.941 and p = 0.653, respectively). CONCLUSIONS Older age, WFNS Grade V, higher modified Fisher grade, wider neck aneurysm, and postoperative pneumonia were independent predictors of poor outcome after endovascular treatment of poor-grade aSAH. The preoperative model had almost the same discrimination as the postoperative model. Endovascular treatment should be carefully considered in patients with poor-grade aSAH with ruptured wide-neck aneurysms. ▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class I.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Kuang Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zequn Li
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianxi Tan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Ibrahim Ali AM, Ashmawy GAHO, Eassa AYE, Mansour OY. Hyperacute versus Subacute Coiling of Aneurysmal Subarachnoid Hemorrhage a Short-term Outcome and Single-Center Experience, Pilot Study. Front Neurol 2016; 7:79. [PMID: 27379005 PMCID: PMC4909731 DOI: 10.3389/fneur.2016.00079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 05/02/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND After the initial subarachnoid hemorrhage (SAH), rebleeding is the major cause of morbidity and poor outcome, which is maximal in the first 24 h. We supposed that the coiling of ruptured intracranial aneurysms within 24 h of SAH is related to the improved clinical outcome compared with coiling 24 h after aneurysmal SAH. OBJECTIVE We examined whether coiling ruptured aneurysms within 24 h of aneurysmal SAH is associated with better early 24 h and late 30 days outcome. METHOD This prospective study was carried on 30 patients with aneurysmal SAH presenting to the Alexandria University Hospital and Insurance Main Hospital during the period from February 2013 to May 2014. They were divided into two groups: Group I (10 patients treated within 24 h of presentation) and Group II (20 patients treated after 24 h of presentation). Time interval from presentation to treatment were 78.60 and 10.60 h for subacute and hyperacute group, respectively. All patients were treated with endovascular coiling. Change between admission and immediate postoperative World Federation of Neurosurgeons classification Scale was measured for early outcome, while remote outcome was measured by modified Rankin Scale at 30 days follow-up. RESULTS There was a clinical improvement regarding early 24 h outcome (weighted by postoperative WFNS grade) and on late 30 days outcome (weighted by Modified Rankin Scale Score) in the group managed within 24 h versus who were treated after 24 h (P = 0.049 and P = 0.024, respectively). There was a significant decrease in the incidence of clinical rebleeding detected by postoperative computed tomography (CT) of the brain in patients undergoing aneurysm treatment within 24 h (P = 0.029). CONCLUSION The study affirms evidence that the management of ruptured intracranial aneurysms within 24 h of SAH is associated with better immediate and short-term clinical outcome.
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Affiliation(s)
| | | | | | - Osama Yassin Mansour
- Department of Neurology and Psychiatry, Faculty of Medicine, University of Alexandria, Alexandria, Egypt; Stroke Center, Alexandria University Hospital, Alexandria, Egypt
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Zhao B, Lin F, Wu J, Zheng K, Tan X, Cao Y, Zhao Y, Wang S, Zhong M. A Multicenter Analysis of Computed Tomography Angiography Alone Versus Digital Subtraction Angiography for the Surgical Treatment of Poor-Grade Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2016; 91:106-11. [PMID: 27060510 DOI: 10.1016/j.wneu.2016.03.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased intracranial pressure, and these patients are unstable with a high risk of rebleeding. Computed tomography angiography (CTA) has been proposed as an examination tool for the rapid detection of ruptured aneurysms. We aimed to determine the safety and efficacy of CTA alone for surgical treatment of poor-grade aSAH compared with digital subtraction angiography (DSA). METHODS We conducted a multicenter retrospective analysis of 144 patients with poor-grade aSAH who underwent surgical treatment for 2 different cohorts. Patients were grouped into CTA alone and DSA groups. Baseline characteristics, postoperative complications, and clinical outcomes at discharge and at last follow-up were compared between the 2 groups. Multivariate logistic regression models were used to assess the association between CTA alone and clinical outcomes after we adjusted for potential confounders. RESULTS Of the 116 patients included, 42 (36.2%) patents received CTA alone and 74 patients (63.7%), including 12 patients with CTA and DSA and 62 patients with DSA alone, received DSA before surgical treatment. Patients with larger ruptured aneurysms (P = 0.006), aneurysm sizes of larger than 5 mm (P = 0.025), presence of single aneurysms (P = 0.018), and presence of intraventricular hemorrhage (P = 0.019) more often received CTA alone. All ruptured aneurysms were clipped successfully during surgery. There were no statistically significant differences in postoperative complications and clinical outcomes between the 2 groups. CONCLUSIONS Although CTA alone can be safely and effectively used in most patients requiring surgical treatment, additional DSA may be considered in patients with smaller ruptured aneurysms or in those with multiple aneurysms.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fuxin Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kuang Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianxi Tan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
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Chen J, Zhu J, He J, Wang Y, Chen L, Zhang C, Zhou J, Yang L. Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma. Oncol Lett 2016; 11:3173-3178. [PMID: 27123084 DOI: 10.3892/ol.2016.4327] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 01/28/2016] [Indexed: 11/05/2022] Open
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is the most common cerebrovascular disease. The conventional treatment for SAH is usually associated with high mortality. The present study aims to assess the prognosis of microsurgical treatment for patients with poor-grade aneurysm (Hunt and Hess grades IV-V) associated with intracerebral hematoma. A total of 18 consecutive patients who were diagnosed with poor-grade aneurysm accompanied with intracerebral hematoma were retrospectively recruited. All patients underwent microsurgical treatment between April 2010 and June 2013 at The 101st Hospital of Chinese People's Liberation Army (Wuxi, China). Among them, 15 cases underwent microsurgery within 24 h of SAH, and 3 cases underwent microsurgery 24 h following SAH. All 18 cases were examined by computed tomography angiography (CTA). The outcome was assessed during a follow-up time of 6-36 months. According to the Glasgow Outcome Scale, 4 patients experienced a good recovery, 6 were dissatisfied with the outcome, 4 were in vegetative state and 4 succumbed to disease. Poor outcome occurred in patients with an aneurysm diameter >10 mm, exhibited >50 ml volume of intracerebral hematoma or presented cerebral hernia prior to the surgical operation. The outcome of ultra-early surgery (within 24 h of SAH) was improved, compared with that of surgery following 24 h of SAH (P=0.005). Among 7 patients who accepted extraventricular drainage, good outcomes were achieved in 4 of them, whereas dissatisfaction and mortality occurred in 2 and 1 patients, respectively. Therefore, ultra-early microsurgery (within 24 h of SAH) combined with extraventricular drainage may improve the prognosis of patients with poor-grade aneurysm.
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Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jun Zhu
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jianqing He
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Yuhai Wang
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Lei Chen
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Chunlei Zhang
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jingxu Zhou
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Likun Yang
- Department of Neurosurgery, Wuxi Clinical Medical School, Anhui Medical University, The 101st Hospital of Chinese People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
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Zhao B, Tan X, Yang H, Zheng K, Li Z, Xiong Y, Zhong M. Stent-assisted coiling versus coiling alone of poor-grade ruptured intracranial aneurysms: a multicenter study. J Neurointerv Surg 2016; 9:165-168. [DOI: 10.1136/neurintsurg-2016-012259] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 11/04/2022]
Abstract
IntroductionEndovascular coiling is a valid treatment option for poor-grade ruptured aneurysms. However, little is known about stent-assisted coiling of poor-grade aneurysms.ObjectiveTo compare the safety and efficacy of stent-assisted coiling with coiling alone for poor-grade aneurysms.MethodsUsing multicenter data on poor-grade aneurysms, we performed a retrospective analysis of 131 consecutive patients treated with endovascular coiling within 14 days after ictus. Patients were split into two groups: stent-assisted coiling and coiling alone. Baseline characteristics, immediate angiographic results, perioperative complications, and clinical outcomes were compared between the two groups.ResultsTwenty-three (17.6%) patients were treated with stent-assisted coiling and 108 (82.4%) with coiling alone. There were no statistically significant differences in patient age, sex, clinical grade, Fisher grade, modified Fisher grade, aneurysm location, and size between the stent-assisted coiling and coiling alone groups. Intraprocedural aneurysm rupture, procedure-related ischemic complication, external ventricular drainage-related hemorrhagic complication, and symptomatic vasospasm did not differ between the two groups. Immediate angiographic results and clinical outcomes at discharge and at 6 and 12 months did not differ between the groups. Aneurysm rebleeding occurred in 4 (17.4%) patients after stent-assisted coiling compared with 2 (1.9%) patients after coiling alone (p<0.007). Multivariate analysis showed that incomplete aneurysm occlusion was independently associated with aneurysm rebleeding (p=0.016), and there was a trend toward aneurysm rebleeding after stent-assisted coiling (p=0.051).ConclusionsStent-assisted coiling of poor-grade aneurysms is feasible and safe compared with coiling alone. However, the hemorrhagic complication and aneurysm rebleeding may not be negligible.
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Aneurismi arteriosi intracranici. Neurologia 2016. [DOI: 10.1016/s1634-7072(15)76145-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Zhao B, Cao Y, Tan X, Zhao Y, Wu J, Zhong M, Wang S. Complications and outcomes after early surgical treatment for poor-grade ruptured intracranial aneurysms: A multicenter retrospective cohort. Int J Surg 2015; 23:57-61. [PMID: 26365431 DOI: 10.1016/j.ijsu.2015.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 08/10/2015] [Accepted: 09/06/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Early surgical treatment has been proposed to improve outcomes of selected patients with poor-grade ruptured intracranial aneurysms. We performed a multicenter retrospective analysis to identify complications and outcomes after early surgery. METHODS We analyzed data from the two cohorts of patients with poor-grade ruptured aneurysms. Poor-grade aneurysm was defined as a World Federation of Neurosurgical Society (WFNS) grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 h after poor-grade condition. RESULTS Of the 144 patients who underwent surgical treatment for poor-grade aneurysm, 80 underwent early surgery and were included in this report. Forty-one (51%) patients presented with a WFNS grade of IV and 39 (49%) presented with a WFNS grade of V. Cerebral infarction occurred in 17 (21%) patients and was the most common complication except for pneumonia. No patients had a good outcome after postoperative aneurysm rebleeding. At follow-up (mean 12.6 months), 37 (46%) patients had a good outcome after early surgery. Multivariate analysis showed that a WFNS grade of V, presence of intraventricular hemorrhage, brain herniation were independent predictors of poor outcome after early surgery. Patients with WFNS grade V more often had a poor outcome after postoperative cerebral infarction, rebleeding or symptomatic vasospasm. CONCLUSIONS Patients with a WFNS grade of V, intraventricular hemorrhage, brain herniation were more likely to have a poor outcome after early surgery. Postoperative complications, including rebleeding and cerebral infraction, should be prevented and treated aggressively to maximize the chance of good outcome in poor-grade patients.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China; Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, China; Department of Neurosurgery, Mayo Clinic, USA
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Xianxi Tan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China.
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Davies BM, Chung KC, Dulhanty L, Galea J, Patel HC. Pre-protection re-haemorrhage following aneurysmal subarachnoid haemorrhage: Where are we now? Clin Neurol Neurosurg 2015; 135:22-6. [DOI: 10.1016/j.clineuro.2015.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 04/09/2015] [Accepted: 04/25/2015] [Indexed: 11/28/2022]
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Ahmed O, Kalakoti P, Hefner M, Cuellar H, Guthikonda B. Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature. J Cerebrovasc Endovasc Neurosurg 2015; 17:113-9. [PMID: 26157691 PMCID: PMC4495085 DOI: 10.7461/jcen.2015.17.2.113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 10/17/2014] [Accepted: 03/19/2015] [Indexed: 11/23/2022] Open
Abstract
Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.
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Affiliation(s)
- Osama Ahmed
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Matthew Hefner
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Koźba-Gosztyła M, Czapiga B, Jarmundowicz W. Aneurismal subarachnoid hemorrhage: who remains for surgical treatment in the post-ISAT era? Arch Med Sci 2015; 11:536-43. [PMID: 26170846 PMCID: PMC4495139 DOI: 10.5114/aoms.2013.37333] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 07/30/2013] [Accepted: 08/04/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Although there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service. MATERIAL AND METHODS The study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed. RESULTS The annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%). CONCLUSIONS Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.
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Affiliation(s)
| | - Bogdan Czapiga
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
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Zhao B, Zhao Y, Tan X, Cao Y, Wu J, Zhong M, Wang S. Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis. BMJ Open 2015; 5:e007410. [PMID: 25877280 PMCID: PMC4401840 DOI: 10.1136/bmjopen-2014-007410] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To determine factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage (aSAH). DESIGN A multicentre retrospective analysis, observational study. SETTING High-volume teaching hospitals (more than 150 aSAH cases per year). PARTICIPANTS 118 patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V underwent surgical treatment. Ultra-early surgery was defined as surgery performed within 24 h of aSAH, and delayed surgery as surgery performed after 24 h. Outcome was assessed by modified Rankin Scale (mRS). The mean time of follow-up was 12.5±3.4 months (range 6-28 months). RESULTS 47 (40%) patients underwent ultra-early surgery, and 71 (60%) patients underwent delayed surgery. Patients with WFNS grade V (p=0.011) and brain herniation (p=0.004) more often underwent ultra-early surgery. Postoperative complications were similar in ultra-early and delayed surgery groups. Adjusted multivariate analysis showed the outcomes were similar between the two groups. Multivariate analysis of predictors of poor outcome, ultraearly surgery was not an independent predictor of poor outcome, while advanced age, postresuscitation WFNS V grade, intraventricular haemorrhage, brain herniation and non-middle cerebral artery (MCA) aneurysms were associated with poor outcome. CONCLUSIONS Although patients with WFNS grade V and brain herniation more often undergo ultra-early surgery, postoperative complications and outcomes in selected patients were similar in the two groups. Patients of younger age, WFNS grade IV, absence of intraventricular haemorrhage, absence of brain herniation and MCA aneurysms are more likely to have a good outcome. Ultra-early surgery could improve outcomes in carefully selected patients with poor-grade aSAH.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Xianxi Tan
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Ming Zhong
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
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Park J, Woo H, Kang DH, Kim YS, Kim MY, Shin IH, Kwak SG. Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes. J Neurosurg 2014; 122:383-91. [PMID: 25403841 DOI: 10.3171/2014.9.jns131784] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT While the incidence of a recurrent hemorrhage is highest within 24 hours of subarachnoid hemorrhage (SAH) and increases with the severity of the clinical grade, a recurrent hemorrhage can occur anytime after the initial SAH in patients with both good and poor clinical grades. Therefore, the authors adopted a 24-hour-a-day, formal protocol, emergency treatment strategy for patients with ruptured aneurysms to secure the aneurysms as early as possible. The incidences of in-hospital rebleeding and clinical outcomes were investigated and compared with those from previous years when broadly defined early treatment was used (<3 days of SAH). METHODS During an 11-year period, a total of 1224 patients with a ruptured aneurysm were managed using a strategy of broadly defined early treatment between 2001 and 2004 (Period B, n=423), a mixture of early or emergency treatment between 2005 and 2007, and a formal emergency treatment protocol between 2008 and 2011 (Period A, n=442). Propensity score matching was used to adjust the differences in age, sex, modified Fisher grade, World Federation of Neurosurgical Societies (WFNS) clinical grade at admission, size and location of a ruptured aneurysm, treatment modality (clip placement vs coil embolization), and time interval from SAH to admission between the two time periods. The matched cases were allotted to Group A (n=280) in Period A and Group B (n=296) in Period B and then compared. RESULTS During Period A under the formal emergency treatment protocol strategy, the catheter angiogram, endovascular coiling, and surgical clip placement were started at a median time from admission of 2.0 hours, 2.9 hours, and 3.1 hours, respectively. After propensity score matching, Group A showed a significantly reduced incidence of in-hospital rebleeding (2.1% vs 7.4%, p=0.003) and a higher proportion of patients with a favorable clinical outcome (modified Rankin Scale score 0-3) at 1 month (87.9% vs 79.7%, respectively; p=0.008). In particular, the patients with good WFNS grades in Group A experienced significantly less in-hospital rebleeding (1.7% vs 5.7%, respectively; p=0.018) and better clinical outcomes (1-month mRS score of 0-3: 93.8% vs 87.7%, respectively; p=0.021) than the patients with good WFNS grades in Group B. CONCLUSIONS Patients with ruptured aneurysms may benefit from a strategy of emergency application of surgical clip placement or endovascular coiling due to the reduced incidence of recurrent bleeding and improved clinical outcomes.
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Luo YC, Shen CS, Mao JL, Liang CY, Zhang Q, He ZJ. Ultra-early versus delayed coil treatment for ruptured poor-grade aneurysm. Neuroradiology 2014; 57:205-10. [DOI: 10.1007/s00234-014-1454-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/06/2014] [Indexed: 11/30/2022]
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Time intervals from subarachnoid hemorrhage to rebleed. J Neurol 2014; 261:1425-31. [PMID: 24807086 DOI: 10.1007/s00415-014-7365-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/25/2014] [Accepted: 04/26/2014] [Indexed: 12/17/2022]
Abstract
The most threatening early complication and predictor of poor outcome after an aneurysmal subarachnoid hemorrhage (aSAH) is a rebleed. To evaluate what proportion of rebleeds might be prevented by early treatment, we assessed the time interval from the initial hemorrhage to rebleed, and the location of the patient at the time of rebleed. Patient characteristics, World Federation of Neurological Surgeons grade on admission and modified Rankin Scale outcome scores, referring hospitals and time intervals from initial hemorrhage to treatment of 293 patients treated between 2008 and 2011 were evaluated. Time intervals to rebleeds and location of the patients at the time of rebleed were retrieved. Rebleeds were confirmed by CT in 12% of patients, and an additional 4% of patients was diagnosed as having a possible rebleed. Sixty percent of rebleeds occurred after admission to the treatment center. Almost all rebleeds occurred within 24 h, with a median time interval between initial hemorrhage and rebleed of 180 min. A significantly shorter time to treatment and a higher mortality were seen in the group of patients with a rebleed. Approximately, one in six patients with an aSAH had a rebleed, of which a majority might have been preventable because they occurred after admission to the treatment center. A reduction in the rebleed rate seems feasible by securing the aneurysm as soon as possible by improving in-hospital logistics for early aneurysm treatment. Alternative options, such as immediate administration of antifibrinolytics, are being explored in a multicenter trial.
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Robbert M, Germans MR, Hoogmoed J, van Straaten HAS, Coert BA, Peter Vandertop W, Verbaan D. Time intervals from aneurysmal subarachnoid hemorrhage to treatment and factors contributing to delay. J Neurol 2013; 261:473-9. [PMID: 24366653 DOI: 10.1007/s00415-013-7218-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 12/11/2013] [Indexed: 11/30/2022]
Abstract
In the management of aneurysmal subarachnoid hemorrhage (aSAH), aneurysm treatment as early as feasible is mandatory to minimize the risk of a rebleed and may thus improve outcome. We assessed the different time intervals from the first symptoms of aSAH to start of aneurysm treatment in an effort to identify which factors contribute mostly to a delay in time to treatment. In 278 aSAH patients, time intervals between the different steps from initial hemorrhage to aneurysm treatment were retrospectively reviewed, and delaying factors were determined. Half of the patients presented to a hospital within 115 min (IQR 60-431). The median (IQR) interval from hemorrhage to diagnosis was 169 min (96-513), and from diagnosis to treatment 1,057 min (416-1,428), or 17.6 h. Aneurysm treatment started within 24 h in 76 % of treated patients. Independent factors predicting delay to treatment were primary presentation at a referring hospital and admission to the treatment center later in the day. Delay in treatment was not independently related to poor outcome. The interval to aneurysm treatment might be improved upon by immediate and direct transport to the treatment center combined with optimization of in-hospital logistics, following the 'time-is-brain' concept so successfully adopted in the treatment of ischemic stroke.
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Affiliation(s)
- Menno Robbert
- Academic Medical Center, Amsterdam, The Netherlands,
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49
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Vascular smooth muscle cells in cerebral aneurysm pathogenesis. Transl Stroke Res 2013; 5:338-46. [PMID: 24323713 DOI: 10.1007/s12975-013-0290-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 09/25/2013] [Indexed: 10/26/2022]
Abstract
Vascular smooth muscle cells (SMC) maintain significant plasticity. Following environmental stimulation, SMC can alter their phenotype from one primarily concerned with contraction to a pro-inflammatory and matrix remodeling phenotype. This is a critical process behind peripheral vascular disease and atherosclerosis, a key element of cerebral aneurysm pathology. Evolving evidence demonstrates that SMCs and phenotypic modulation play a significant role in cerebral aneurysm formation and rupture. Pharmacological alteration of smooth muscle cell function and phenotypic modulation could provide a promising medical therapy to inhibit cerebral aneurysm progression. This study reviews vascular SMC function and its contribution to cerebral aneurysm pathophysiology.
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Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage. J Clin Neurosci 2013; 20:1213-8. [PMID: 23830590 DOI: 10.1016/j.jocn.2012.11.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 11/08/2012] [Indexed: 11/23/2022]
Abstract
Poor-grade (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V) subarachnoid hemorrhage (SAH) is associated with significant morbidity and mortality. However, the correlation between the timing, modality of intervention (clipping or coiling) and the clinical outcome is not clear. This study aims to examine this correlation. Patients presenting with WFNS grades IV and V aneurysmal SAH between 1997 and 2008 to a single centre were studied. An aggressive policy of early intervention was followed, and the selection of endovascular versus microsurgical intervention was made according to angiographic rather than clinical features. Clinical outcomes were graded using the modified Rankin scale (mRS) at 6 month follow-up. One hundred and forty-three poor-grade patients (23.9% of all 598 aneurysmal SAH patients) were studied. Treatment was microsurgical in 83 (58.0%) and endovascular in 60 (42%) patients. Twenty patients (14.0%) were lost to follow-up. Good outcome (mRS 0-2) at 6 months was found in 45 microsurgical patients (63.3%) and 24 endovascular patients (46.1%). This trend towards better clinical outcomes in the microsurgical group was not statistically significant. With an aggressive early treatment policy more than half of the poor-grade SAH patients demonstrated a good clinical outcome. Microsurgery and endovascular treatment, when selected primarily according to angiographic features, were equally likely to achieve good outcome.
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