The impact of pre-ictal statin use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage

BACKGROUND

Pleiotropic effects of statins may be beneficial in alleviating cerebral vasospasm (VS) and improving outcome after aneurysmal subarachnoid hemorrhage (aSAH). Initiation of statin treatment at aSAH is not recommended; however, the effect of pre-ictal and continued statin use is not fully investigated.

METHODS

Retrospective study comparing aSAH patients admitted in 2012 to 2021 with pre-ictal statin use versus those not using statins. Patient entry variables, radiological/sonological VS, symptomatic VS, and radiologically documented delayed cerebral ischemia (DCI) were registered. Outcome was scored in terms of mortality, modified Rankin score, Glasgow outcome score extended, and levels of fatigue. Patients were compared on group level and in a case-control design.

RESULTS

We included 961 patients, with 204 (21.2%) statin users. Statin users were older and had more often hypertension. Severe radiological/sonological VS, symptomatic VS, and DCI were less frequent in statin users, and their length of stay was shorter. Mortality, functional outcome, and levels of fatigue were similar in both groups. When analyzing 89 pairs of statin users and non-statin users matched for age, aSAH severity, gender, and hypertension, we confirmed decreased radiological/sonological and symptomatic VS as well as shorter length of stay in statin users. They also had more often a favorable functional outcome and lower levels of fatigue.

CONCLUSIONS

Patients with pre-ictal and continued use of statins have a reduced occurrence of radiological/sonological and symptomatic VS, shorter length of stay, and more often favorable functional outcome, whereas mortality is similar to non-statin users. Even though larger multicenter studies with common, strict protocols for prevention, diagnosis, and treatment of vasospasm are needed to finally establish the value of statins in aSAH, continuation of pre-ictal statin use seems worthwhile.

Is neutrophil-lymphocyte ratio a useful tool for predicting outcome in subarachnoid hemorrhage? A systematic review

Ruptured intracranial aneurysms, as the leading cause of spontaneous subarachnoid hemorrhage (aSAH), represents an emergency with high morbi-mortality. The comprehension of the underlying pathology that involves inflammatory and immune responses, through the neutrophil-to-lymphocyte ratio (NLR), could help to predict complications such as delayed cerebral ischemia (DCI) or rebleeding and the functional outcome. Systematic review of English-based literature through PubMed and Biblioteca Vitural em Saúde (BVS) to find papers discussing the use of NLR in the aSAH setting. Area-under-curve (AUC) of receiver operating characteristics (ROC), cutoff value, sensitivity, and specificity were retrieved. From 53 articles included, 4 papers were evaluated after exclusion criteria. Rebleeding could be predicted with a NLR cutoff value of 9.88 (sensitivity 72.3%, specificity 63.3%). The mean cutoff value for DCI was 12.85, with sensitivity 66.3% and specificity 75.8%. Finally, a worse 3-month functional outcome could be predicted with a mean sensitivity of 73.3% and a mean specificity of 54%. NLR is a new issue in scientific community, especially neurosurgery. The current understanding points to a multifactorial process after aSAH that emerges as alterations on the NLR. As a measurement readily available and cost-effect after admission of the patient, its use signals that patients that need expedite surgical treatment or more aggressive treatment for vasospasm. As other medical subspecialties already use this ratio to predict outcomes, the literature reviewed by this paper constitute the earliest clues that higher NLR predicts re-bleeding, DCI, and functional outcome.

The correlation between gene polymorphisms of endothelial nitric oxide synthase and aneurismal subarachnoid hemorrhage

To discuss the association of the T786C and G894T polymorphisms of endothelial nitric oxide synthase (eNOS) with the occurrence and prognosis of aneurismal subarachnoid hemorrhage (aSAH). One hundred sixty-nine patients with aSAH were collected as the case group, which was divided into the good prognosis group and adverse prognosis group according to the condition 3 months after the treatment. One hundred fifty-six healthy volunteers were collected as the control group. The allele and genotype of T786C and G894T polymorphisms of eNOS were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The genotype and allele frequency of eNOS were compared between different groups. And then, the risk factors of aSAH occurrence and prognosis were analyzed by using the logistic regression model. Both the genotype and allele frequency distributions of T786C and G894T between the case group and control group were significantly different (P < 0.05). There were significant differences in the distribution of G894T and T786C allele frequency and G894T genotype between the good prognosis group and adverse prognosis group, and there was no difference in T786C genotype. The results of the logistic regression analysis indicated that T786C and G894T polymorphisms of eNOS were independent influencing factors on the occurrence of aSAH and the G894T polymorphism was also closely related to the prognosis. T786C and G894T polymorphisms of eNOS gene were correlated with the occurrence and prognosis of aSAH, and the G894T polymorphism might be an independent influencing factor.

Possible role of Eptifibatide drip in-patient with aneurysmal subarachnoid hemorrhage in vasospasm prevention

OBJECTIVE

Approximately 18,000 patients suffer from a subarachnoid hemorrhage (SAH) in the United States annually. SAH is a form of stroke and comprises 1%-5% of all strokes. Nearly 50% of all SAH cases end in fatality within 30 days of presentation; one of eight patients die before reaching a hospital. Those who survive often have neurological or cognitive impairment.

METHODS

This case report describes the course of two patients who presented to the emergency department with aneurismal subarachnoid hemorrhage and received external ventricular drainage and endovascular treatment of their aneurysm.

RESULTS

Both patients required treatment with Eptifibatide drip after endovascular approach and their SAH in the basal cisterns resolved by day 5. Neither patient developed signs of clinical or subclinical vasospasm.

COMMENTS

Eptifibatide drip facilitated resolution of the thick clot in the subarachnoid space early enough to eliminate the direct toxicity of oxyhemoglobin on the cerebral arteries and arachnoid granulations, thus preventing vasospasm and eliminating the necessity for a long-term shunt.

Cortisol dynamics are associated with electrocardiographic abnormalities following the aneurysmal subarachnoid hemorrhage

Context:

Electrocardiographic (ECG) abnormalities are common following subarachnoid hemorrhage (SAH). It probably represents cardiovascular stress after SAH.

Aims:

The purpose of this study was to assess cortisol dynamics in relation to the ECG abnormality and disease course of SAH.

Settings and Design:

The study follows a consecutive cohort of aneurysmal SAH patients, who underwent surgery within 72 hours of onset, and they were followed up for 10 days.

Materials and Methods:

Serum cortisols, cortisol-binding globulin (CGB), adenocorticotropic hormone were measured (between 08.00-09.00 hours) preoperatively and then on postoperative days (PODs) 2, 4, 7, and 10. Electrocardiographs (ECG) were recorded on initial assessment and after surgery on daily basis in ICU. ECG abnormalities will be followed up by measurement of cardiac troponin T to quantify the myocyte necrosis.

Statistical Analysis Used:

Logistic regression analysis using commercial available software STATA 9.

Results:

A total of 44 patients (20 M and 24 F) were eligible for the cohort analysis. Average patient age is 52.02 years (52.02 ± 11.23), and 86% (6/44) arrived with World Federation of Neurosurgical Society Scale grade 3 or better. The ECG abnormality was found in 10 cases (22.7%), but the abnormal TnT (>1 μg/l) were found in eight cases, and two cases contribute to the mortality. The ECG abnormalities are significantly associated with total cortisol on day 4 (P < 0.05) and free cortisol on day 2 (P = 0.0065).

Conclusions:

Elevated levels of morning cortisol within the first four days after surgery are associated with the ECG abnormality.

The association between cortisol dynamics and the course of aneurysmal subarachnoid hemorrhage

Context:

One of aneurysmal subarachnoid hemorrhage complication is delayed ischemic neurological deficits (DIND). It is postulated that cortisol dynamics might be associated with the severity of this complication.

Aims:

The goal of the study is to investigate whether the peak of morning serum cortisol levels are associated with the severity of its complication during the course of the disease.

Settings and Design:

This is a prospective cohort study conducted from January 2009 to June 2011, at our institution.

Materials and Methods:

The study follows a consecutive cohort of patients for 14 days after the aneurysmal subarachnoid hemorrhage. Serum cortisols, cortisol binding globulin, adenocorticotrophic hormone (ACTH) were measured pre operatively and then on post operative days (POD) 2, 4, 7, and 10. Blood was drawn to coincide with peak cortisol levels between 08.00-09.00 hours. Neurological examinations were conducted at least twice daily and patient outcome were graded according to modified Ranklin Scale. DIND was defined by a decrease in the Glasgow Coma Scale of two or more points compared to the status on POD 1.

Statistical Analysis:

All the results were analyzed using statistical software, Statistical Package for Social Sciences (SPSS v61; SPSS, Inc., Chicago, IL). Logistic regression analysis was used to compare the relationship between the variables.

Results:

Thirty six consecutive patients are collected, but only 28 patients (12 M and 16 F) were eligible for the cohort analysis. Average patient age is 50.75 years old (50.75±12.27), and more than 50% (15/28) arrived with World Federation of Neurologic Surgeons grade 3 or better. Elevated total cortisol levels of more than 24 mg/dl on day 2, 4, and 10 were associated with DIND, and the most significant being on day 4 (P=0.011). These patients also had a higher grade on the modified Ranklin scale of disability.

Conclusions:

This study shows that the elevated levels of morning total cortisol in the serum are associated with the onset of DIND during the disease course, and it's also associated with bad outcomes.