Study on prognosis of acutely ruptured intracranial aneurysms (SPARTA): a protocol for a multicentre prospective cohort study

BACKGROUND

Ruptured intracranial aneurysms resulting in subarachnoid haemorrhage can be treated by open surgical or endovascular treatment. Despite multiple previous studies, uncertainties on the optimal treatment practice still exists. The resulting treatment variation may result in a variable, potentially worse, patient outcome. To better inform future treatment strategies, this study aims to identify the effectiveness of different treatment strategies in patients with ruptured intracranial aneurysms by investigating long-term functional outcome, complications and cost-effectiveness. An explorative analysis of the diagnostic and prognostic value of radiological imaging will also be performed.

METHODS

This multi-centre observational prospective cohort study will have a follow-up of 10 years. A total of 880 adult patients with a subarachnoid haemorrhage caused by a ruptured intracranial aneurysm will be included. Calculation of sample size (N = 880) was performed to show non-inferiority of clip-reconstruction compared to endovascular treatment on 1 year outcome, assessed by using the ordinal modified Rankin Scale. The primary endpoint is the modified Rankin Scale score and mortality at 1 year after the initial subarachnoid haemorrhage. Patients will receive 'non-experimental' regular care during their hospital stay. For this study, health questionnaires and functional outcome will be assessed at baseline, before discharge and at follow-up visits.

DISCUSSION

Despite the major healthcare and societal burden, the optimal treatment strategy for patients with subarachnoid haemorrhage caused by ruptured intracranial aneurysms is yet to be determined. Findings of this comparative effectiveness study, in which in-between centre variation in practice and patient outcome are investigated, will provide evidence on the effectiveness of treatment strategies, hopefully contributing to future high value treatment standardisation.

TRIAL REGISTRATION NUMBER

NCT05851989 DATE OF REGISTRATION: May 10th, 2023.

Validity of the modified Rankin Scale in patients with aneurysmal subarachnoid hemorrhage: a randomized study

PURPOSE

The modified Rankin Scale (mRS), a clinician-reported outcome measure of global disability, has never been validated in patients with aneurysmal subarachnoid hemorrhage (aSAH). The aims of this study are to assess: (1) convergent validity of the mRS; (2) responsiveness of the mRS; and (3) the distribution of mRS scores across patient-reported outcome measures (PROMs).

METHODS

This is a prospective randomized multicenter study. The mRS was scored by a physician for all patients, and subsequently by structured interview for half of the patients and by self-assessment for the other half. All patients completed EuroQoL 5D-5L, RAND-36, Stroke Specific Quality of Life scale (SS-QoL) and Global Perceived Effect (GPE) questionnaires. Convergent validity and responsiveness were assessed by testing hypotheses.

RESULTS

In total, 149 patients with aSAH were included for analysis. The correlation of the mRS with EQ-5D-5L was r = - 0.546, while with RAND-36 physical and mental component scores the correlation was r = - 0.439and r = - 0.574 respectively, and with SS-QoL it was r = - 0.671. Three out of four hypotheses for convergent validity were met. The mRS assessed through structured interviews was more highly correlated with the mental component score than with the physical component score of RAND-36. Improvement in terms of GPE was indicated by 83% of patients; the mean change score of these patients on the mRS was - 0.08 (SD 0.915). None of the hypotheses for responsiveness were met.

CONCLUSION

The results show that the mRS generally correlates with other instruments, as expected, but it lacks responsiveness. A structured interview of the mRS is best for detecting disabling neuropsychological complaints.

REGISTRATION

URL: https://trialsearch.who.int ; Unique identifier: NL7859, Date of first administration: 08-07-2019.

Management of patients with a neurovascular conflict involving the optic nerve and a non-diseased intracranial artery: Three cases

Introduction

Determining whether a neurovascular conflict (NVC) involving the anterior visual pathway (AVP) and a non-diseased intracranial artery is amenable for microvascular decompression is challenging. Moreover, it is unclear whether microvascular decompression of the optic nerve is an effective therapy.

Research question

What are the outcomes of different treatment strategies for NVCs involving the AVP and a non-diseased intracranial artery?

Material and methods

Data on patients with symptomatic NVCs involving the AVP and a non-diseased intracranial artery was collected and included treatment and outcome parameters. The case series was drafted in accordance with the CARE guidelines.

Results

Three patients aged 53,53 and 55 visited our out-patient clinic with a suspected symptomatic NVC between the optic nerve and a non-diseased intracranial artery. A conservative treatment was opted for in the first patient aimed at treating her glaucoma, with temporary improvement of symptoms. Microvascular decompression of the optic nerve was performed in two patients. One operated patient developed post-operative complications resulting in posterior circulation perfusion decline, while the other experienced a worse tunnel vision with a decrease in visual acuity.

Discussion and conclusion

The diagnosis of a symptomatic NVC between the AVP and a non-diseased intracranial artery should be considered with caution, i.e. after exclusion of all other causes. Microvascular decompression can be performed but does not necessarily improve symptoms. A better understanding of the pathophysiological mechanisms underlying these NVCs is warranted to determine the benefit of microvascular decompression of the optic nerve.

Inter-method reliability of the modified Rankin Scale in patients with subarachnoid hemorrhage

Background and objectives

The modified Rankin Scale (mRS) is one of the most frequently used outcome measures in trials in patients with an aneurysmal subarachnoid hemorrhage (aSAH). The assessment method of the mRS is often not clearly described in trials, while the method used might influence the mRS score. The aim of this study is to evaluate the inter-method reliability of different assessment methods of the mRS.

Methods

This is a prospective, randomized, multicenter study with follow-up at 6 weeks and 6 months. Patients aged ≥ 18 years with aSAH were randomized to either a structured interview or a self-assessment of the mRS. Patients were seen by a physician who assigned an mRS score, followed by either the structured interview or the self-assessment. Inter-method reliability was assessed with the quadratic weighted kappa score and percentage of agreement. Assessment of feasibility of the self-assessment was done by a feasibility questionnaire.

Results

The quadratic weighted kappa was 0.60 between the assessment of the physician and structured interview and 0.56 between assessment of the physician and self-assessment. Percentage agreement was, respectively, 50.8 and 19.6%. The assessment of the mRS through a structured interview and by self-assessment resulted in systematically higher mRS scores than the mRS scored by the physician. Self-assessment of the mRS was proven feasible.

Discussion

The mRS scores obtained with different assessment methods differ significantly. The agreement between the scores is low, although the reliability between the assessment methods is good. This should be considered when using the mRS in clinical trials.

Trial registration

www.trialregister.nl; Unique identifier: NL7859.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10880-4.

The Role of the Glycocalyx in the Pathophysiology of Subarachnoid Hemorrhage-Induced Delayed Cerebral Ischemia

The glycocalyx is an important constituent of blood vessels located between the bloodstream and the endothelium. It plays a pivotal role in intercellular interactions in neuroinflammation, reduction of vascular oxidative stress, and provides a barrier regulating vascular permeability. In the brain, the glycocalyx is closely related to functions of the blood-brain barrier and neurovascular unit, both responsible for adequate neurovascular responses to potential threats to cerebral homeostasis. An aneurysmal subarachnoid hemorrhage (aSAH) occurs following rupture of an intracranial aneurysm and leads to immediate brain damage (early brain injury). In some cases, this can result in secondary brain damage, also known as delayed cerebral ischemia (DCI). DCI is a life-threatening condition that affects up to 30% of all aSAH patients. As such, it is associated with substantial societal and healthcare-related costs. Causes of DCI are multifactorial and thought to involve neuroinflammation, oxidative stress, neuroinflammation, thrombosis, and neurovascular uncoupling. To date, prediction of DCI is limited, and preventive and effective treatment strategies of DCI are scarce. There is increasing evidence that the glycocalyx is disrupted following an aSAH, and that glycocalyx disruption could precipitate or aggravate DCI. This review explores the potential role of the glycocalyx in the pathophysiological mechanisms contributing to DCI following aSAH. Understanding the role of the glycocalyx in DCI could advance the development of improved methods to predict DCI or identify patients at risk for DCI. This knowledge may also alter the methods and timing of preventive and treatment strategies of DCI. To this end, we review the potential and limitations of methods currently used to evaluate the glycocalyx, and strategies to restore or prevent glycocalyx shedding.

Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort

OBJECTIVE

Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania.

METHODS

A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model.

RESULTS

In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model.

CONCLUSIONS

The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.

The risk factors of 9-year follow-up on hypertension in middle-aged people in Tujia-Nationality settlement of China

The aim of this study was to investigate the risk factors of hypertension in middle-aged people within the Tujia-Nationality settlement in China. Demographics questionnaires and fitness tests were performed to identify the risk factors of hypertension in middle-aged people in the years 2005, 2010 and 2014 in the area of southwest Hubei of China. Of the 2428 participants, 568 were classified as hypertensive, giving an overall occurrence of hypertension at 23.4%, and the prevalence of hypertension was the highest in the year 2014 (34.9%). Furthermore, Tujia minority had a significantly higher risk for having hypertension (odds ratio=1.055 with 95% confidence interval (CI): 1.039-1.072; P=0.001) than Han people. Individuals with the lowest level of cardiorespiratory fitness (CRF) had a 2.483-fold risk for hypertension (95% CI, 1.530-4.031; P=0.001). Obesity and overweight individuals increased the risk by 3.470-fold and 2.124-fold, respectively, for having hypertension compared to normal weight people. Finally, white-collar workers had a 58.1 and 31.8% higher risk for hypertension than blue-collar workers in rural and urban areas, respectively. These results demonstrated that the prevalence of hypertension was higher between 2011 and 2014 in the area. The main risk factors for developing hypertension were found to be sex (as woman), Tujia minority, white-collar workers, overweight-obese, those with a middle school education, and those with the lowest CRF.

Critical slowing down near the multiferroic phase transition in MnWO4

By using broadband dielectric spectroscopy in the radio frequency and microwave range, we studied the magnetoelectric dynamics in the multiferroic chiral antiferromagnet MnWO_{4}. Above the multiferroic phase transition at T_{N2}≈12.6  K we observe a critical slowing of the corresponding magnetoelectric fluctuations resembling the soft-mode behavior in canonical ferroelectrics. This electric-field-driven excitation carries much less spectral weight than ordinary phonon modes. Also, the critical slowing down of this mode scales with an exponent larger than 1, which is expected for magnetic second-order phase transition scenarios. Therefore, the investigated dynamics have to be interpreted as the softening of an electrically active magnetic excitation, an electromagnon.

Vector chiral phases in the frustrated 2D XY model and quantum spin chains

The phase diagram of the frustrated 2D classical and 1D quantum XY models is calculated analytically. Four transitions are found: the vortex unbinding transitions triggered by strong fluctuations occur above and below the chiral transition temperature. Vortex interaction is short range on small and logarithmic on large scales. The chiral transition, though belonging to the Ising universality class by symmetry, has different critical exponents due to nonlocal interaction. In a narrow region close to the Lifshitz point a reentrant phase transition between paramagnetic and quasiferromagnetic phase appears. Applications to antiferromagnetic quantum spin chains and multiferroics are discussed.

The increase of plasma homocysteine concentrations with age is partly due to the deterioration of renal function as determined by plasma cystatin C

One of the main determinants of plasma homocysteine in healthy subjects is serum creatinine. In the present study, we therefore investigated the relation between plasma homocysteine concentration, serum creatinine and a new marker for glomerular filtration rate, plasma cystatin C concentration. Cystatin C reflects the glomerular filtration better than serum creatinine and is not related to the muscle mass and formation of creatinine. The study group consisted of 255 healthy subjects from a well-defined area in the southern part of Sweden. The concentration of plasma homocysteine was increased in men compared to women. This difference disappeared when men and women were stratified by serum creatinine values. Statistically significant correlations were noted between plasma homocysteine and age, plasma cystatin C and serum creatinine. It is shown that plasma homocysteine is not only correlated to serum creatinine as a result of renal function but also as a result of the relationship between homocysteine production and creatine-creatinine synthesis. Using linear regression we were able to show that plasma cystatin C had a higher explanatory value than age. Serum creatinine showed a lower explanatory power than age. The findings in the present study might suggest that the increase of plasma homocysteine concentration with age could be partly due to the deterioration of renal function.

Malassezia furfur: a cause of occlusion of percutaneous central venous catheters in infants in the intensive care nursery

Growth of Malassezia furfur in the intravascular catheter used for administration of lipid emulsion resulted in occlusion of deep intravascular Silastic catheters in 12 infants in 2 intensive care nurseries. At the time of occlusion visible growth was noted in the clear catheter which was connected to the Silastic intravascular line. Five infants showed clinical signs suggestive of sepsis. The yield of M. furfur from blood cultures and catheter tips was low even when oil enrichment was used. The highest yield of M. furfur was found in the connecting catheter (11 of 11). The source from and the route by which M. furfur entered the catheter remain unclear. The potential portals of entry include the proximal and distal ends of the connecting catheter as well as the colonized skin of the infants and caretakers.