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Koopman I, Tack RW, Rinkel GJ, Vergouwen MD. Abstract 96: CompLement C5 Antibodies For Decreasing Brain Injury After Aneurysmal Subarachnoid Hemorrhage (CLASH): A Randomized Controlled Phase II Clinical Trial. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The inflammatory response after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with early brain injury, delayed cerebral ischemia, and poor functional outcome. In experimental SAH studies, complement C5 antibodies administered shortly after SAH reduced brain injury with approximately 40%. We investigated the pharmacodynamic efficacy and safety of eculizumab (a complement C5 antibody) in aSAH patients.
Methods:
We conducted a randomized, controlled, open-label, phase II clinical trial with blinded outcome assessment in the Netherlands. Patients were randomized (1:1) to receive eculizumab plus standard care or to standard care alone. Eculizumab (1200 mg) was administered intravenously < 12 h, on day 3 and on day 7 after ictus. Patients in the intervention group received prophylactic antibiotics for 4 weeks and prophylactic antifungal therapy if the patient had a central line or an external ventricular shunt and a positive fungal or yeast culture. The primary outcome was C5a concentration in the cerebrospinal fluid (CSF) on day 3 after ictus. Secondary outcomes included the occurrence of adverse events, eculizumab concentration and inflammatory parameters in the blood and CSF, cerebral infarction on magnetic resonance imaging, and clinical and cognitive outcomes. We aimed to evaluate 26 patients with CSF assessments, 13 in the intervention group and 13 in the comparator group.
Results:
A total of 31 patients have been included, of which 26 with CSF samples.
Conclusions:
Final results will be presented at the conference.
Trial registration:
Netherlands Trial Register: NTR6752. European Clinical Trials Database (EudraCT): 2017-004307-51.
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Affiliation(s)
- Inez Koopman
- Neurology and Neurosurgery, Univ Med Cntr Utrecht, Utrecht, Netherlands
| | - Reinier W Tack
- Neurology and Neurosurgery, Univ Med Cntr Utrecht, Utrecht, Netherlands
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Neifert S, Oermann E, Mocco JD, Todd MM, Torner J, Molyneux A, Mayer SA, Leroux P, Vergouwen MD, Rinkel GJ, Wong GK, Kirkpatrick P, Quinn A, HÄNGGI D, Etminan N, van den Bergh W, Jaja B, Cusimano M, Schweizer T, Suarez JI, Fukuda H, Yamagata S, Lo B, Manoel ALD, Boogaarts H, MacDonald RL. Abstract P40: Declining Morbidity From Subarachnoid Hemorrhage in the Last 4 Decades: A Pooled Analysis of 13,343 Patients. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Subarachnoid hemorrhage (SAH) mortality is decreasing, but data on functional outcomes over time is lacking.
Methods:
We created trends of good (Glasgow Outcomes Scale [GOS] of 4 or 5) and optimal (GOS of 5) functional outcomes and mortality (GOS of 1) using linear regression in 15 SAH trials and registries from 1982 to 2014. Models adjusted for age, sex, history of hypertension, World Federation of Neurological Surgeons grade, Fisher grade, aneurysm size, location, and repair modality, and whether data was from a clinical trial or registry. Analyses were repeated separately for the clinical trials and registries. Missing data were handled with multiple imputation.
Results:
Overall, 13,343 SAH patients were included. 9,524 (71%) patients had good functional outcome, while 1,608 (12%) died. There was a 0.6% adjusted improvement (95% confidence interval [CI]: 0.5% to 0.7%; p<0.001) per year in good functional outcome and a 0.1% adjusted reduction (95% CI: -0.2% to -0.08%; p<0.001) per year in mortality. For patients enrolled in clinical trials, there was no change good functional outcomes (0%; 95% CI: -0.2% to 0.1%; p=0.923) or mortality (0.0% change per year; 95% CI: -0.09% to 0.1%; p=0.676). Clinical registry patients experienced a 1.2% improvement (95% CI: 1.0% to 1.4%; p<0.001) in good functional outcome and a 0.3% reduction (95% CI: -0.4% to -0.1%; p<0.001) in mortality.
Conclusions:
SAH morbidity and mortality decreased from the 1980s to 2010s. This data can be helpful for researchers planning trials, clinicians discussing expected outcomes with patients and family members, and healthcare administrators planning resource utilization.
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Affiliation(s)
| | | | | | | | | | | | | | - Peter Leroux
- Main Line Health and Thomas Jefferson Univ, Wynnewood, PA
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Lindgren AE, Bragan Turner E, Sillekens T, Meretoja A, Lee JM, Hemmen TM, Koivisto T, Alberts M, Lemmens R, Jääskeläinen JE, Vergouwen MD, Rinkel GJ. Abstract WMP25: Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Haemorrhage in Clinical Practice in Europe, USA and Australia. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wmp25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
RCTs have demonstrated better outcomes for coiling compared to clipping in patients with aneurysmal subarachnoid haemorrhage (aSAH). After these trials, the proportion of patients with coiled aneurysms has steadily increased, as have the numbers of physicians and hospitals providing the treatment. We studied whether coiling is also associated with a better outcome than clipping after aSAH in daily clinical practice.
Methods:
In Dr Foster Global Comparators, an administrative dataset from 22 tertiary care hospitals from Europe, the USA, and Australia, we retrieved data from 7658 aSAH patients discharged in 2007-2013 in whom the aneurysm had been occluded by clipping (n=3510) or coiling (n=4148). We calculated crude case-fatality rates with 95% confidence intervals (CI) at 14 days, and used multiple logistic regression to adjust for age, sex and differences in comorbidity/disease severity. Because the results from the administrative dataset contradicted those of the RCTs, we further explored our findings in a large clinical dataset (n=1501) consisting of prospectively collected consecutive aSAH patients treated 2006-2015 with clipping or coiling in two large European centres allowing additional adjustment for clinical condition on admission, aneurysm size and location.
Results:
In the administrative dataset the overall crude case-fatality rate at 14 days was 6·4% (95%CI 5·6
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7·2%) after clipping and 8·2% (95%CI 7·4-9·1%) after coiling. After adjustment for age, sex and comorbidity/severity, the odds ratio (OR) for case-fatality within 14 days after coiling compared to clipping was 1·32 (95%CI 1·10-1·58). In the clinical dataset crude 14-day fatality rate was 5·7% (95%CI 4·2-7·8%) for clipping and 9·0% (95%CI 7·3-11·2%) for coiling. In multivariable logistic regression analysis the OR for case-fatality within 14 days for coiling compared to clipping was 1·7 (95%CI 1·1-2·7), for case-fatality within 90 days 1·28 (95%CI 0·91-1·82) and for poor functional outcome at 90 days 0·78 (95%CI 0·6-1·01).
Conclusion:
In current clinical practice, outside the setting of a clinical trial, coiling after aSAH is associated with higher 14-day case-fatality and not with the substantial benefit on functional outcome as observed within the trials.
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Affiliation(s)
| | | | - Tomas Sillekens
- Neurology and Neurosurgery, UMC Utrecht, Utrecht, Netherlands
| | | | - Jin-Moo Lee
- Dept of Neurology and the Hope Cntr for Neurological disorders, Washington Univ Sch of Medicine, St. Louis, MO
| | | | | | | | - Robin Lemmens
- Dept of Neurosciences, Experimental Neurology, Institute for Neuroscience and Disease (LIND), KU Leuven - Univ of Leuven, VIB Cntr for Brain & Disease research, and Univ Hosps Leuven, Leuven, Belgium
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Bogdanovskaya M, Talbott J, Aslop R, Barclay L, Lee JM, Shaw L, Alberts MJ, Rinkel GJ, Hemmen TM. Abstract WP301: Does Stroke Conference Attendance Affect Patient Outcomes? Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Reduced hospital staffing out of hours and at weekends has been associated with adverse patient outcomes. Following recent study showing reduced adjusted mortality after acute heart disease during large cardiology conferences, we explored acute ischemic stroke (AIS) outcomes and practice patterns during stroke conferences.
Method:
We compared 7-day in-hospital mortality, all in-hospital mortality, and number of stroke admissions per day, baseline demographics, and length of stay (LOS) for patients admitted on stroke conferences days (SCD) and matched non-conference days (NCD) in the three weeks before and after. The
table
shows which countries’ data were used for each of the three conferences. Conferences were chosen if a large portion of stroke providers attended from each country under study. We used the Global Comparators data set that represents predominantly academic teaching hospitals from across Europe, Australia and the US. Outcomes were adjusted for country, age, sex, and comorbidity score, whether a patient was transferred into the hospital or had an emergency admission to the hospital in the previous 30 days.
Results:
We identified 6684 patients (SCD 940, NCD 5744), and found no difference in raw and adjusted outcomes between groups. The frequency of stroke admissions and LOS were similar. Mortality was 7.77% during SDC, 8.2% on NDC and 7-day in-hospital mortality was 4.04% during SDC and 4.65% on NDC. Using regression analysis, admission on a conference day was not a predictor for in-hospital mortality or 7-day in-hospital mortality.
Discussion:
We found no differences in practice pattern and outcomes for patients admitted with AIS during stroke conferences in this international dataset. Future monitoring of outcomes during large medical conferences using larger samples should focus on exact staffing ratio changes during conference times to assure robust patient care at all times.
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Bottle A, Bogdanovskaya M, Rinkel GJ, Shaw L, Lee JM, Hemmen TM. Abstract WP327: Nihss Proxy Using Administrative Data From the Us and Uk. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Comparing outcomes between hospitals for quality improvement needs risk adjustment for the severity of the stroke. The NIHSS is the standard instrument for this but has difficulties in collection and integration into administrative and other electronic databases. A proxy derived from existing data items would be useful.
Methods:
We derived a proxy using the 2014 national hospital administrative data for England and the 2012 US Nationwide Inpatient Sample. Diagnosis codes and procedures (performed on admission day) with a prevalence in ischaemic stroke admissions of at least 1% were tabulated and their potential for inclusion into a proxy independently assessed by members of a physician panel. Classification and regression trees helped inform the development of a logistic regression model that was used to finalise and evaluate the performance of the proxy when predicting in-hospital mortality. The proxy was also compared against the actual NIHSS in a sample of 282 US administrative records and 265 English records linked to those patients’ NIHSS from a separate study.
Results:
For England, there were 69,125 admissions and 9,130 in-hospital deaths; for the NIS there were 86,478 admissions and 3,795 in-hospital deaths. The physician panel agreed on 19 candidate variables, which included intubation, aspiration pneumonitis, dysphasia and aphasia, coma, and others. The models in England and the US retained most variables. The relative importance of each variable was similar in each database, with intubation, aspiration pneumonitis, and coma the most important. The c statistic for discrimination was 0.82 for the NIS and 0.69 for England; adding age, sex and admission source gave 0.84 for NIS and 0.78 for England. The adjusted odds ratio per unit increase in the proxy in the NIS was 1.16 (p<0.001). The correlation between our proxy and the actual NIHSS in our separate sample was 0.52 in England and 0.47 in the US.
Conclusions:
An NIHSS proxy can be derived using administrative data with either ICD9 or ICD10 and has reasonable prediction for in-hospital mortality.
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Affiliation(s)
| | | | | | - Louise Shaw
- Royal United Hosps Bath, Bath, United Kingdom
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Ackermark PY, Schepers VP, Post MW, Rinkel GJ, Passier PE, Visser-Meily JM. Longitudinal course of depressive symptoms and anxiety after aneurysmal subarachnoid hemorrhage. Eur J Phys Rehabil Med 2016; 53:98-104. [PMID: 27412071 DOI: 10.23736/s1973-9087.16.04202-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Symptoms of anxiety and depression are present in almost half of the patients who survive an aneurysmal subarachnoid hemorrhage (aSAH), but the long-term course is unknown. AIM To study the longitudinal course and predictors of symptoms of anxiety and depression after aSAH. DESIGN Prospective longitudinal study with test occasions at 3 months (baseline), 1 year (T2) and 2-5 years (T3) post-aSAH. SETTING SAH outpatient clinic. POPULATION One hundred forty-three patients visiting the outpatient clinic. METHODS Patients visiting our outpatient clinic 3 months after aSAH and living independently in the community completed the Beck Depression Inventory-II-NL and the State-Trait Anxiety Inventory at 3 months (T1), one year (T2) and 2-5 years (T3). Potential predictors were collected at T1. RESULTS Complete datasets from 93 patients were analyzed. Depressive symptoms were present in 39% (T1), 41% (T2) and 54% (T3) of patients, symptoms of anxiety in 52% (T1), 48% (T2) and 53% (T3). Of patients with depressive symptoms at T1, 72% still had symptoms at T3, compared to 67% for anxiety. Disability on the Glasgow Outcome Scale (GOS), passive coping (UCL-PR) and depressive symptoms at T1 were significantly independent variables explaining 52% of the variance of depressive symptoms at T2. GOS and UCL-PR at T1 were variables explaining 25% of the variance of depressive symptoms at T3. Depressive symptoms and anxiety at T1 were predictive variables for anxiety at T2 (explained variance 43%) and UCL-PR for anxiety at T3 (explained variance 21%). CONCLUSIONS The prevalence of symptoms of depression and anxiety remained high during the first 2-5 years after aSAH. Passive coping at 3 months after aSAH was the most consistent predictor of symptoms of anxiety and depression in the long term. CLINICAL REHABILITATION IMPACT Since many patients who are initially free of symptoms of depression and anxiety develop such symptoms over time, we advocate screening for these symptoms and coping strategies to identify these patients and apply targeted therapy.
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Affiliation(s)
- Pernilla Y Ackermark
- Brain Center Rudolf Magnus and Centre of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitation Center De Hoogstraat, Utrecht, The Netherlands.,Merem, Rehabilitation Centre De Trappenberg, Huizen, The Netherlands
| | - Vera P Schepers
- Brain Center Rudolf Magnus and Centre of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitation Center De Hoogstraat, Utrecht, The Netherlands
| | - Marcel W Post
- Brain Center Rudolf Magnus and Centre of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitation Center De Hoogstraat, Utrecht, The Netherlands
| | - Gabriel J Rinkel
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Patricia E Passier
- Brain Center Rudolf Magnus and Centre of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitation Center De Hoogstraat, Utrecht, The Netherlands
| | - Johanna M Visser-Meily
- Brain Center Rudolf Magnus and Centre of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitation Center De Hoogstraat, Utrecht, The Netherlands -
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Sokolov AA, Husain S, Sztajzel R, Croquelois A, Lobrinus JA, Thaler D, Städler C, Hungerbühler H, Caso V, Rinkel GJ, Michel P. Fatal subarachnoid hemorrhage following ischemia in vertebrobasilar dolichoectasia. Medicine (Baltimore) 2016; 95:e4020. [PMID: 27399083 PMCID: PMC5058812 DOI: 10.1097/md.0000000000004020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Vertebrobasilar dolichoectasia (VBD) is a chronic disorder with various cerebrovascular and compressive manifestations, involving subarachnoid hemorrhage (SAH). Occurrence of SAH shortly after worsening of clinical VBD symptoms has occasionally been reported. The goal of the study was to examine this association, in particular its pathophysiology, clinical precursor signs, time course, and outcome.To this end, in a retrospective multicenter study, we analyzed 20 patients with VBD and SAH in regard to preceding clinical symptoms, presence of vertebrobasilar thrombosis and ischemia, outcome and neuropathological correlates.Median age of the 7 female and 13 male patients was 70 years (interquartile range [IQR] 18.3 years). Fourteen patients (70%) presented with new or acutely worsening posterior fossa signs at a median of 3 days prior to SAH (IQR 2, range 0.5-14). A thrombus within the VBD was detected in 12 patients (60%). Thrombus formation was associated with clinical deterioration (χ = 4.38, P = 0.04) and ponto-cerebellar ischemia (χ = 8.09, P = 0.005). During follow-up after SAH, 13 patients (65%) died, after a median survival time of 24 hours (IQR 66.2, range 2-264 hours), with a significant association between proven ponto-cerebellar ischemia and case fatality (χ = 6.24, P = 0.01).The data establish an association between clinical deterioration in patients with VBD, vertebrobasilar ischemia, and subsequent SAH. Antithrombotic treatment after deterioration appears controversial and SAH outcome is frequently fatal. Our data also indicate a short window of 3 days that may allow for evaluating interventional treatment, preferably within randomized trials.
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Affiliation(s)
- Arseny A. Sokolov
- Stroke Center, Service de Neurologie, Département des Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Shakir Husain
- Department of Interventional Neurology and Stroke, Institute of Neurosciences, Saket City Hospital, New Delhi, India
| | - Roman Sztajzel
- Service de Neurologie, Département des Neurosciences Cliniques, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | | | - Johannes A. Lobrinus
- Service de Pathologie Clinique, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - David Thaler
- The Comprehensive Stroke Center, Tufts University Medical Center, Boston, MA
| | - Claudio Städler
- Servizio di Neurologia, Ospedale Regionale di Lugano, Lugano
| | | | - Valeria Caso
- Stroke Unit and Division of Internal and Cardiovascular Medicine, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Gabriel J. Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patrik Michel
- Stroke Center, Service de Neurologie, Département des Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
- Correspondence: P. Michel, Stroke Center, Service de Neurologie, Département des Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon, Lausanne, Switzerland (e-mail: )
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Zijlstra IA, Gathier CS, Boers AM, Marquering HA, Slooter AJ, Velthuis BK, Coert BA, Verbaan D, van den Berg R, Rinkel GJ, Majoie CB. Association of Automatically Quantified Total Blood Volume after Aneurysmal Subarachnoid Hemorrhage with Delayed Cerebral Ischemia. AJNR Am J Neuroradiol 2016; 37:1588-93. [PMID: 27102313 DOI: 10.3174/ajnr.a4771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/07/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The total amount of extravasated blood after aneurysmal subarachnoid hemorrhage, assessed with semiquantitative methods such as the modified Fisher and Hijdra scales, is known to be a predictor of delayed cerebral ischemia. However, prediction rates of delayed cerebral ischemia are moderate, which may be caused by the rough and observer-dependent blood volume estimation used in the prediction models. We therefore assessed the association between automatically quantified total blood volume on NCCT and delayed cerebral ischemia. MATERIALS AND METHODS We retrospectively studied clinical and radiologic data of consecutive patients with aneurysmal SAH admitted to 2 academic hospitals between January 2009 and December 2011. Adjusted ORs with associated 95% confidence intervals were calculated for the association between automatically quantified total blood volume on NCCT and delayed cerebral ischemia (clinical, radiologic, and both). The calculations were also performed for the presence of an intraparenchymal hematoma and/or an intraventricular hematoma and clinical delayed cerebral ischemia. RESULTS We included 333 patients. The adjusted OR of total blood volume for delayed cerebral ischemia (clinical, radiologic, and both) was 1.02 (95% CI, 1.01-1.03) per milliliter of blood. The adjusted OR for the presence of an intraparenchymal hematoma for clinical delayed cerebral ischemia was 0.47 (95% CI, 0.24-0.95) and of the presence of an intraventricular hematoma, 2.66 (95% CI, 1.37-5.17). CONCLUSIONS A higher total blood volume measured with our automated quantification method is significantly associated with delayed cerebral ischemia. The results of this study encourage the use of rater-independent quantification methods in future multicenter studies on delayed cerebral ischemia prevention and prediction.
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Affiliation(s)
- I A Zijlstra
- From the Departments of Radiology (I.A.Z, A.M.B., H.A.M, R.v.d.B., C.B.M.)
| | - C S Gathier
- Neurology (C.S.G., G.J.R.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - A M Boers
- From the Departments of Radiology (I.A.Z, A.M.B., H.A.M, R.v.d.B., C.B.M.) Biomedical Engineering and Physics (A.M.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands Department of Robotics and Mechatronics (A.M.B.), University of Twente, Enschede, the Netherlands
| | - H A Marquering
- From the Departments of Radiology (I.A.Z, A.M.B., H.A.M, R.v.d.B., C.B.M.) Biomedical Engineering and Physics (A.M.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | | | | | | | | | - R van den Berg
- From the Departments of Radiology (I.A.Z, A.M.B., H.A.M, R.v.d.B., C.B.M.)
| | - G J Rinkel
- Neurology (C.S.G., G.J.R.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - C B Majoie
- From the Departments of Radiology (I.A.Z, A.M.B., H.A.M, R.v.d.B., C.B.M.)
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van der Bilt IA, Hasan D, van den Brink RB, Cramer MJ, van der Jagt M, van Kooten F, Regtien JG, van den Berg MP, Groen RJ, Cate FJT, Kamp O, Götte MJ, Horn J, Girbes AR, Vandertop WP, Algra A, Rinkel GJ, Wilde AA. Time Course and Risk Factors for Myocardial Dysfunction After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2015; 76:700-5; discussion 705-6. [DOI: 10.1227/neu.0000000000000699] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Welleweerd JC, Bots ML, Kappelle LJ, Rinkel GJ, Ruigrok YM, Baas AF, van der Worp HB, Vergouwen MD, Bleys RL, Hendrikse J, Lo TR, Moll FL, de Borst GJ. Rationale and design of the extracranial Carotid artery Aneurysm Registry (CAR). J Cardiovasc Surg (Torino) 2015; 59:692-698. [PMID: 25658976 DOI: 10.23736/s0021-9509.16.08637-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Aneurysms of the extracranial carotid artery (ECAA) are rare. Although most ECAA are identified in asymptomatic patients, serious neurological complications may occur. Current literature on treatment outcome contains mainly case reports and small case series with incomplete data and lack of long-term follow-up. There is clear lack on natural follow-up data, and there is no clear treatment algorithm. An international web-based registry to collect data on patients with ECAA is designed to provide clinical guidance on this scarce pathology. METHODS The Carotid Aneurysm Registry (CAR) is open for inclusion of all patients with a fusiform or saccular ECAA. Patients with primary or secondary ECAA can be enrolled in CAR independent of the type of treatment (conservative or invasive). CAR participation does not interfere with the local physician's treatment policy. Follow-up and imaging can also be scheduled according to local clinical practice. The primary endpoint of the CAR in conservative patients is occurrence of symptoms related to the aneurysm at 30 days, one, three, and five years. The primary endpoint in invasively treated patients is freedom from symptoms of the aneurysm at 30 days, one, three, and five years. RESULTS Analyses will relate outcome to etiology, imaging characteristics, ECAA growth patterns, and (if applicable) revascularization technique applied. The aim of the registry is to prospectively collect follow-up data on patients with an ECAA, being either treated conservatively or by invasive aneurysm exclusion strategies. The CAR database will be used to address diagnostic and therapeutic research questions. CONCLUSIONS Collecting and analyzing the data gained from the registry could be the first step towards development of treatment guidelines and expert consensus for the management of ECAA.
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Affiliation(s)
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, UMCU, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, UMCU, Utrecht, The Netherlands
| | - Gabriel J Rinkel
- Department of Neurology and Neurosurgery, UMCU, Utrecht, The Netherlands
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMCU, Utrecht, The Netherlands
| | - Annette F Baas
- Department of Medical Genetics, UMCU, Utrecht, The Netherlands
| | | | - Mervyn D Vergouwen
- Department of Neurology and Neurosurgery, UMCU, Utrecht, The Netherlands
| | | | | | - T Rob Lo
- Department of Radiology, UMCU, Utrecht, The Netherlands
| | - Frans L Moll
- Department of Vascular Surgery, UMCU, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, The Netherlands -
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Etminan N, Brown RD, Beseoglu K, Juvela S, Morita A, Torner JC, Raymond J, Derdeyn CP, Raabe A, Mocco J, Abdulazim A, Korja M, Connolly ES, Steinmetz H, Lanzino G, Pasqualin A, Rüfenacht D, LeRoux P, Vajkoczy P, McDougall C, Hänggi D, Rinkel GJ, Macdonald RL. Abstract 106: Validation Of The Unruptured Intracranial Aneurysm Treatment Score (UIATS) to Guide Management of Unruptured Intracranial Aneurysms. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
We previously derived the Unruptured Intracranial Aneurysm Treatment Score (UIATS), designed using a multidisciplinary consensus approach among neurovascular specialists from diverse geographic and practice backgrounds. Here, we report on the development and validation of the final version of UIATS.
Method:
An international, multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 (39 panel members and 30 blinded external reviewers) specialists in the research and treatment of UIAs was convened. A web survey-based Delphi consensus process consisting of 7 rounds was utilized to rate numerous features of potential relevance in the assessment and treatment of UIAs and to develop the UIATS. Mean ratings were repeatedly used to determine statistical weight for each factor and then transformed into corresponding scores for every item to create the UIATS. For internal and blinded external validation, 30 representative cases of patients with UIAs were used to test the level of agreement (5 point Likert Scale) with treatment recommendations based on the UIATS.
Results:
The final UIATS system was designed in three domains (patient-, aneurysm - and treatment-related), comprising 13 different categories and 29 different features (Figure 1). Mean agreement based on Likert scores (5 indicating strong agreement and 1 indicating strong disagreement) was 4·2 for both reviewer cohorts, whereas mean agreement per case was 4·2 (panel members) and 4·5 (external reviewers) (p=0·017, Mann-Whitney-U Test).
Conclusion:
The final version of UIATS system was internally and externally validated by a large multidisciplinary group of neurovascular specialists, which suggests that the UIATS reflects contemporary decision-making regarding management of a patient with an UIA. The UIATS may aid clinicians in deciding on the appropriate management for an UIA.
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Affiliation(s)
- Nima Etminan
- Neurosurgery, Med Faculty, Heinrich Heine Univ, Düsseldorf, Germany
| | | | - Kerim Beseoglu
- Neurosurgery, Med Faculty, Heinrich Heine Univ, Düsseldorf, Germany
| | - Seppo Juvela
- Dept of Clinical Neurosciences, Univ of Helsinki, Helsinki, Finland, Helsinki, Finland
| | - Akio Morita
- Dept of Neurological Surgery, Nippon Med Sch,, Tokyo, Japan
| | - James C Torner
- Dept of Epidemiology, Univ of Iowa, Iowa City, IA, USA, Iowa, IA
| | - Jean Raymond
- Dept of Radiology - Interventional Neuroradiology, ?CHUM Rsch Cntr, Notre-Dame Hosp, Montreal, Canada
| | - Colin P Derdeyn
- Mallinckrodt Institute of Radiology, Washington Univ Sch of Medicine, St. Louis, MO
| | | | - J Mocco
- Neurosurgery, Vanderbilt Univ Med Cntr, Nashville, TN
| | - Amr Abdulazim
- Neurosurgery, Med Faculty, Heinrich Heine Univ, Düsseldorf, Germany
| | - Miikka Korja
- Neurosurgery, Helsinki Univ Central Hosp, Helsinki, Finland
| | - E. Sander Connolly
- Neurosurgery, Columbia Univ College of Physicians and Surgeons, New York, NY
| | | | | | | | | | - Peter LeRoux
- Brain and Spine Cntr, Lankenau Med Cntr, Wynnewood, PA
| | | | | | - Daniel Hänggi
- Neurosurgery, Med Faculty, Heinrich Heine Univ, Düsseldorf, Germany
| | - Gabriel J Rinkel
- Neurology and Neurosurgery, Univ Med Cntr Utrecht, Utrecht, Netherlands
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13
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Rinkel GJ, Visser-Meily JM, Speelman HJ. [More rapid transfer to an additional-care facility]. Ned Tijdschr Geneeskd 2004; 148:2426-8. [PMID: 15626305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Elderly patients admitted to a hospital ward often need additional care after discharge. Waiting for this additional care often leads to blocked beds. The administrative procedures for transferring patients to additional-care facilities require about 10 days. The main reason for this delay is the time needed by the regional indicating office (RIO) to do their assessment and to give approval. There are various possible ways to make the discharge procedure more efficient. Should the available capacity within the facilities be the only delaying factor, then this would constitute a task for the regional care office.
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Affiliation(s)
- G J Rinkel
- Universitair Medisch Centrum Utrecht, afd Neurologie, 3508 GA Utrecht
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14
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Rinkel GJ. [Improved risk counselling possible for patients with unruptured intracranial aneurysms]. Ned Tijdschr Geneeskd 2003; 147:1834-7. [PMID: 14533493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
The 'International Study of Unruptured Intracranial Aneurysms' (ISUIA) investigators have recently published the results of a large prospective, observational study on risks of rupture and risks of treatment in patients with unruptured intracranial aneurysms. In patients with aneurysms smaller than 7 mm no rupture of the carotid, middle cerebral and anterior communicating arteries occurred during follow up (mean 4.1 years) if there was no history of subarachnoid haemorrhage from a separate aneurysm. Risks were higher in aneurysms of the posterior circulation (2.5% in 5 years), and in patients with a previous episode of subarachnoid haemorrhage from another aneurysm (1.5 to 3.4% in 5 years for aneurysms < 7 mm). Size was the most important risk factor for rupture, and aneurysms of the posterior circulation > 25 mm had a 50% cumulative risk of rupture over 5 years. The absence of rupture in some subgroups, such as small aneurysms of the anterior communicating artery, is probably explained by the small numbers in these subgroups. Similarly, the lack of identification of risk factors other than size is probably explained by insufficient power of the study. The overall risk (defined as death or dependence) of surgical treatment was 13%, with patient age and size and site of the aneurysm as the most important risk factors. Endovascular treatment carried a 7 to 10% risk in most subgroups; only patients with aneurysms > 25 mm had increased risks. Age was not a risk factor for endovascular treatment. By making use of these results, patients can now be given sound advice regarding the benefits of preventive treatment in each individual case.
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Affiliation(s)
- G J Rinkel
- Universitair Medisch Centrum Utrecht, afd. Neurologie, Postbus 85.500, 3508 GA Utrecht.
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15
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Hop JW, Rinkel GJ, Algra A, van Gijn J. Changes in functional outcome and quality of life in patients and caregivers after aneurysmal subarachnoid hemorrhage. J Neurosurg 2001; 95:957-63. [PMID: 11765839 DOI: 10.3171/jns.2001.95.6.0957] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although the case-fatality rate after subarachnoid hemorrhage (SAH) does not change considerably after the first 4 weeks, functional outcome and the quality of life (QOL) may. To assess the extent of changes in functional outcome and QOL after SAH, the authors conducted a follow-up study at 18 months in patients and caregivers who had participated in a previous study of QOL 4 months after SAH. METHODS In a consecutive series of 98 patients admitted with SAH, 68 had survived until 4 months postbleed, at which time an initial outcome assessment had been performed in 64 of them. This series of 64 patients was contacted again at a median of 18 months after SAH. In all patients, functional outcome was assessed by means of the modified Rankin Scale (mRS). In 48 patients and 35 caregivers QOL was assessed using the SF-36, the Sickness Impact Profile (SIP), and a visual analog scale. The results were compared with the scores that had been obtained at 4 months after SAH. Thirty-two patients (50%) had improved at least one point on the mRS, in 23 patients functional outcome had remained unchanged, six patients had deteriorated one point on the mRS, and three had died. No major changes in the QOL of patients and caregivers could be found on the SIP, but on the SF-36 an improved QOL was detected in patients with better Rankin grades. On both instruments, the QOL at 18 months was still reduced compared with the reference population in all patients. CONCLUSIONS Functional outcome improves significantly between 4 months and 18 months post-SAH; studies on functional outcome after SAH can be compared only if outcome is assessed at the same time interval. The improved functional outcome seems to be accompanied by an improved QOL.
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Affiliation(s)
- J W Hop
- Department of Neurology, University of Utrecht, The Netherlands
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16
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Velthuis BK, van Leeuwen MS, Witkamp TD, Ramos LM, Berkelbach van der Sprenkel JW, Rinkel GJ. Surgical anatomy of the cerebral arteries in patients with subarachnoid hemorrhage: comparison of computerized tomography angiography and digital subtraction angiography. J Neurosurg 2001; 95:206-12. [PMID: 11780889 DOI: 10.3171/jns.2001.95.2.0206] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to compare computerized tomography (CT) angiography and digital subtraction (DS) angiography studies in patients with subarachnoid hemorrhage (SAH) to assess their vascular anatomy relevant to cerebral aneurysm surgery. METHODS From a prospective series of 100 patients with SAH, the authors selected 73 patients whose CT angiography studies were of adequate quality and in whom DS angiography of both carotid arteries had been performed. Eleven patients with no DS angiographic studies of the vertebrobasilar artery were only evaluated for the anterior half of the circle of Willis. Anterior communicating arteries (ACoAs), both precommunicating anterior cerebral arteries (A1 segments), both posterior communicating arteries (PCoAs), and both precommunicating posterior cerebral arteries (P1 segments) were assessed on CT angiography and DS angiography by two independent observers. CONCLUSIONS Computerized tomography angiography compares well with DS angiography for visualizing normal-sized arteries, and is superior for visualizing ACoAs and hypoplastic A1 and P, segments. Important preoperative aspects such as dominant A1 segments and PCoAs are equally well seen using either modality. Neither method enabled the authors to visualize more than 50% of PCoAs. Use of CT angiography can provide the required preoperative anatomical information for aneurysm surgery in most patients with SAH.
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Affiliation(s)
- B K Velthuis
- Department of Radiology, University Medical Center, Utrecht, The Netherlands.
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17
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Abstract
BACKGROUND AND PURPOSE Smoking, hypertension, alcohol consumption, autosomal dominant polycystic kidney disease (ADPKD), and positive family history for subarachnoid hemorrhage (SAH) are well-known risk factors for SAH. For effective prevention, knowledge about the contribution of these risk factors to the overall occurrence of SAH in the general population is pivotal. We therefore investigated the population attributable risks of the risk factors for SAH. METHODS We retrieved the relative risk and prevalence of established risk factors for SAH from the literature and calculated the population attributable risks of these risk factors. RESULTS Drinking alcohol 100 to 299 g/wk accounted for 11% of the cases of SAH, drinking alcohol >/=300 g/wk accounted for 21%, and smoking accounted for 20%. An additional 17% of the cases could be attributed to hypertension, 11% to a positive family history for SAH, and 0.3% to ADPKD. CONCLUSIONS Screening and preventive treatment of patients with familial preponderance of SAH alone will cause a modest reduction of the incidence of SAH in the general population. Further reduction can be achieved by reducing the prevalence of the modifiable risk factors alcohol consumption, smoking, and hypertension.
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Affiliation(s)
- Y M Ruigrok
- Department of Neurology, University Medical Center Utrecht (Netherlands).
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18
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Sluzewski M, Brilstra EH, van Rooij WJ, Wijnalda D, Tulleken CA, Rinkel GJ. Bilateral vertebral artery balloon occlusion for giant vertebrobasilar aneurysms. Neuroradiology 2001; 43:336-41. [PMID: 11338421 DOI: 10.1007/s002340000498] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We describe the clinical presentation, radiological and clinical results in six consecutive patients with a giant vertebrobasilar aneurysm treated by bilateral vertebral artery balloon occlusion. Five patients presented with headache and signs of brain-stem compression and one with subarachnoid haemorrhage. In all patients vertebral artery balloon occlusion was performed. In four, this followed successful test occlusion. In one patient, who did not tolerate the test occlusion, a bypass from the external carotid to the posterior cerebral artery preceded definitive vertebral artery occlusion. One patient underwent bypass surgery prior to test occlusion. At 6-22 months follow-up three patients had a good functional outcome and showed unchanged size or shrinkage of the aneurysm on MRI. Three other patients died; one from recurrent haemorrhage, and two probably from delayed brain-stem ischaemia. The presence of two large posterior communicating arteries predicted good functional outcome, which was also related to the clinical condition at presentation, and the degree of brain-stem compression and oedema on MRI. Bilateral vertebral artery balloon occlusion can be considered in patients with otherwise untreatable giant vertebrobasilar aneurysms. If test occlusion is not tolerated, a surgical bypass to the posterior circulation can be considered.
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Affiliation(s)
- M Sluzewski
- St. Elisabeth Ziekenhuis, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands.
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19
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20
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Abstract
The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.
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Affiliation(s)
- J van Gijn
- Department of Neurology, University Medical Centre, Utrecht, The Netherlands.
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21
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Abstract
OBJECTIVE To assess the time course of secondary ischemia and first rebleeding and the relation between the timing of operation and the time course of secondary ischemia in a consecutive series of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS Life table methods were used to assess the daily rates of ischemia and of rebleeding on day 0, day 1 to 3, day 4 to 10, day 11 to 14, and day 15 to 21. The authors compared the time course of secondary ischemia between patients operated within 4 days of SAH and those operated after 10 days. RESULTS Of 346 patients included, 220 were operated, 131 within 4 days and 74 after 10 days. The rebleed rate was highest on the day of the initial hemorrhage, then diminished, and increased slightly again during the second week. The rate of secondary ischemia was highest on day 4, diminished after day 10, but peaked again from day 14 to 18 for patients who were operated later than 10 days after aneurysmal rupture. The peak rate of ischemia was much higher after early than after late operation. Although patients with early operation were in a better clinical condition on admission, with a relatively low risk of secondary ischemia, the overall rate of secondary ischemia was as high as in patients with delayed operation. From day 11 to 21 the rebleed rate was higher than the rate of secondary ischemia. CONCLUSIONS These results indicate that operation is a risk factor for ischemia, especially when performed early. If operation is postponed, it should be planned soon after day 10, because of the relatively high rebleed rate from day 11 to 21.
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Affiliation(s)
- E H Brilstra
- University Department of Neurology, Utrecht, The Netherlands.
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22
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Abstract
BACKGROUND AND PURPOSE The method of choice for detecting or excluding a vertebrobasilar aneurysm still is a matter of debate in patients with a characteristically perimesencephalic pattern of subarachnoid hemorrhage (SAH) on CT. We used decision analysis to compare possible diagnostic strategies in these patients. METHODS A decision analytic model was developed to evaluate the effect of 4 different diagnostic strategies following a perimesencephalic pattern of SAH on CT: 1, no further investigation; 2, digital subtraction angiography (DSA) by catheter; 3, CT angiography as initial modality, not followed by DSA if negative; and 4, CT angiography as initial modality, followed by DSA. We used a 4% prevalence of a vertebrobasilar aneurysm given a perimesencephalic pattern of hemorrhage, a 97% sensitivity and specificity of CT angiography, and a 99.5% sensitivity and 100% specificity of DSA. In a prospectively collected series, the complication rate from DSA in patients with a perimesencephalic pattern of hemorrhage was 2.6%. We calculated the expected utility of each of the 4 diagnostic options and used sensitivity analyses to examine the influence of the plausible ranges of the various estimates used. RESULTS The expected utilities were 99.09 for CT angiography only, 98.96 for no further investigation, 98.22 for DSA, and 96.34 for CT angiography plus DSA. The results of the sensitivity analysis indicate that over a wide range of assumptions, CT angiography only is the most beneficial option. Only when the complication rate of catheter angiography is <0.2% is DSA the preferred strategy. CONCLUSIONS Our decision analysis shows that in patients with a perimesencephalic pattern of hemorrhage on CT, CT angiography only is the best diagnostic strategy. DSA can be omitted in patients with a perimesencephalic pattern of hemorrhage and a negative CT angiogram.
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Affiliation(s)
- Y M Ruigrok
- Department of Neurology, University Medical Center Utrecht, (Netherlands).
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van Rooij WJ, Sluzewski M, Metz NH, Nijssen PC, Wijnalda D, Rinkel GJ, Tulleken CA. Carotid balloon occlusion for large and giant aneurysms: evaluation of a new test occlusion protocol. Neurosurgery 2000; 47:116-21; discussion 122. [PMID: 10917354 DOI: 10.1097/00006123-200007000-00025] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Validation of a new angiographic test occlusion protocol before carotid balloon occlusion in patients with carotid aneurysms. METHODS Carotid occlusion was considered for 29 consecutive patients. From 1993 to 1995, test occlusion in four patients consisted of clinical observation for 30 minutes and during electroencephalographic registration. From 1996 onward, test occlusion in 25 patients consisted of clinical observation and angiography of collateral vessels. Permanent balloon occlusion was performed only when the cortical veins in both the occluded and the collateral vascular territories filled synchronously. RESULTS Two of the four patients with normal clinical and electroencephalographic findings during test occlusion developed delayed hypoperfusion infarction after permanent carotid occlusion. Seventeen of 25 patients (68%) demonstrated both clinical and angiographic tolerance, and no ischemic events occurred after permanent carotid occlusion. In one patient with clinical tolerance but angiographic nontolerance, permanent carotid occlusion had to be performed, which resulted in delayed hypoperfusion infarction. In two patients with angiographic nontolerance, venous filling became synchronous after bypass surgery. Long-term clinical follow-up showed an alleviation of the symptoms of mass effect in 14 of 21 patients (67%). Magnetic resonance imaging follow-up (range, 3-70 mo) revealed a reduction in the size of the aneurysm in 19 of 21 patients (90%). CONCLUSION Test occlusion with clinical and angiographic control is reliable, safe, and simple to perform.
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Affiliation(s)
- W J van Rooij
- Department of Radiology, St. Elisabeth Ziekenhuis, Tilburg, The Netherlands.
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24
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Abstract
The balance of risks of treatment for unruptured aneurysms might change if the prognosis after rupture depends on the size of the aneurysm. In a prospective series of patients with subarachnoid hemorrhage in whom aneurysmal size was measured by CT angiography performed on admission, poor outcome occurred more often in patients with large (> or =10 mm) aneurysms (63%) than in patients with small (<10 mm) aneurysms (41%; RR = 1.5; 95% CI 1.0 to 2.2). The relative risk remained essentially the same after adjustment for age, gender, location of the aneurysm, and amount of cisternal blood.
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Affiliation(s)
- E J Roos
- University Department of Neurology Utrecht, The Netherlands
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25
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van Dijk MA, Hogewind BL, Breuning MH, Rinkel GJ. [Intracranial aneurysms and autosomal dominant polycystic kidney disease]. Ned Tijdschr Geneeskd 2000; 144:1280-3. [PMID: 10908959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Three women aged 55, 47 and 40 years with polycystic kidney disease had several relatives with cystic kidneys, some of whom had died or been crippled after (presumably) a subarachnoid haemorrhage. Two of these patients had a haemorrhage from an aneurysm of a cerebral artery; after clipping of the vessel they recovered without sequelae. The third patient had magnetic resonance (MR) angiography performed, which revealed no aneurysm. The prevalence of intracranial, saccular aneurysms in patients with autosomal dominant polycystic kidney disease (ADPKD) is about 10%. ADPKD patients with questions about the risk of a subarachnoid haemorrhage should be informed about the need of blood pressure control and the possibility of screening by MR angiography. Diagnosed aneurysms can be treated neurosurgically or endovascularly. Since aneurysms develop in the course of life, screening as a rule is only necessary from the age of 20 years, and its repetition every 5 years should be considered.
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Affiliation(s)
- M A van Dijk
- Afd. Nefrologie, Leids Universitair Medisch Centrum, Leiden
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26
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Linn FH, Rinkel GJ, Algra A, van Gijn J. The notion of "warning leaks" in subarachnoid haemorrhage: are such patients in fact admitted with a rebleed? J Neurol Neurosurg Psychiatry 2000; 68:332-6. [PMID: 10675215 PMCID: PMC1736819 DOI: 10.1136/jnnp.68.3.332] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Often patients with subarachnoid haemorrhage (SAH) recall a recent episode of acute severe headache, usually interpreted as a "warning headache" or first SAH. An alternative explanation is recall bias. The clinical and radiological features of patients with SAH were studied in relation to previous headaches or later rebleeding. METHODS Patients with either a previous headache episode or a subsequent rebleed were selected from the SAH database in Utrecht within 1 month of the index SAH. The clinical condition was graded on the World Federation of Neurological Surgeons (WFNS) scale. The CT was reviewed and the amounts of subarachnoid blood, hydrocephalus, and intraventricular, intracerebral, and subdural blood were rated. Proportions were compared by unpaired or paired t test. RESULTS Forty four of 390 patients (11%) had had a severe headache before their index SAH (11 of these had a subsequent rebleed); 31 other patients had a rebleed in hospital but no preceding headache. Patients with and without preceding headache did not differ in level of consciousness (14 of 44 v 11 of 31 were comatose), nor in any of the radiological features. After rebleeding (42 patients), 37 of 42 patients were comatose (v 11 of 42 before), and CT showed higher proportions of intracerebral haemorrhage (17%), intraventricular haemorrhage, (27%), and hydrocephalus (12%) than baseline scans. Intraventricular haemorrhage was twice as frequent after rebleeding than at baseline. CONCLUSIONS The clinical and radiological features of patients admitted with SAH after a preceding bout of headache did not differ from those without such an episode, and are clearly dissimilar from those after documented rebleeds. The findings challenge the existence of minor "warning headaches".
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Affiliation(s)
- F H Linn
- University Department of Neurology, Utrecht, The Netherlands.
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27
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Hop JW, Rinkel GJ, Algra A, Berkelbach van der Sprenkel JW, van Gijn J. Randomized pilot trial of postoperative aspirin in subarachnoid hemorrhage. Neurology 2000; 54:872-8. [PMID: 10690979 DOI: 10.1212/wnl.54.4.872] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the safety and feasibility of a clinical trial on the effectiveness of acetylsalicylic acid (ASA) in subarachnoid hemorrhage (SAH). BACKGROUND Several studies have indicated that increased platelet activity might be involved in the pathogenesis of delayed cerebral ischemia (DCI) after SAH. METHOD Fifty patients who had early surgery (< or =4 days) for a ruptured aneurysm were enrolled in this randomized, double-blind, placebo-controlled trial. Trial medication, consisting of suppositories with 100 mg ASA versus placebo, was started immediately after surgical clipping of the aneurysm and continued for 21 days. End points were functional outcome and quality of life at 4 months, clinical deterioration after operation, development of DCI, hypodense lesion on postoperative CT, and hemorrhagic complications. RESULTS One-third of all patients with aneurysmal SAH were eligible for the trial. Fifteen of 26 patients receiving placebo deteriorated clinically versus 10 of 24 patients receiving ASA; 4 patients in each group deteriorated from DCI. Postoperative hypodensities on CT were observed in 27 patients, distributed equally in both groups. Functional outcome and quality-of-life scores were slightly in favor of patients who had received ASA, but not to a significant degree (p = 0.22). Two patients in the ASA group had an asymptomatic hemorrhagic complication, and one patient in the placebo group had a fatal and another a symptomatic hemorrhagic complication. CONCLUSION This pilot study shows that a clinical trial of acetylsalicylic acid (ASA) in subarachnoid hemorrhage (SAH) is feasible and probably safe. The effectiveness of ASA on functional outcome and delayed cerebral ischemia has to be studied in a larger trial.
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Affiliation(s)
- J W Hop
- University Department of Neurology, Utrecht, The Netherlands
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28
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Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A. Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol 2000; 247:117-21. [PMID: 10751114 DOI: 10.1007/pl00007792] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe intraventricular hemorrhage caused by extension from subarachnoid hemorrhage or intracerebral hemorrhage leads to hydrocephalus and often to poor outcome. We conducted a systematic review to compare conservative treatment, extraventricular drainage, and extraventricular drainage combined with fibrinolysis. We carried out a search in Medline of the literature between January 1966 and December 1998 and an additional hand-search from January 1990 to December 1998. Pharmaceutical companies were contacted to gather unpublished data. We reviewed the reference lists of all relevant articles. Two authors independently assessed eligibility of the studies and extracted data on characteristics of study design, patients, and treatment. Patients with primary intraventricular hemorrhage were excluded. Main outcome measures were death and poor outcome (defined as death or dependency) at the end of follow-up. No randomized clinical trial has yet been conducted so far, and we therefore reviewed only observational studies. The case fatality rate for conservative treatment (ten studies) was 78%. For extraventricular drainage (seven studies) it was 58% [relative risk versus conservative treatment (RR) 0.74; 95% confidence interval (CI) 0.55-0.99]. For extraventricular drainage with fibrinolytic agents (five studies) the case fatality rate was 6% (RR 0.08; 95% CI 0.02-0.24). The poor outcome rate for conservative treatment was 90%, that for extraventricular drainage 89% (RR 0.98; 95% CI 0.75-1.30) and that for extraventricular drainage with fibrinolytic agents 34% (RR 0.38; 95% CI 0.21-0.68). All RR values remained essentially the same after adjusting for age, sex, World Federation of Neurological Surgeons scale, study design, and year of publication for the studies that provided these data. Outcome is thus poor in patients with intraventricular extension of subarachnoid or intracerebral hemorrhage. This meta-analysis suggests that treatment with ventricular drainage combined with fibrinolytics may improve outcome for such patients, although this impression is derived only from an indirect comparison between observational studies. A randomized clinical trial is warranted.
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Affiliation(s)
- D J Nieuwkamp
- Department of Neurology, University Hospital Utrecht, The Netherlands
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29
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Reijneveld JC, Wermer M, Boonman Z, van Gijn J, Rinkel GJ. Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: frequency and characteristics. J Neurol 2000; 247:112-6. [PMID: 10751113 DOI: 10.1007/pl00007791] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In many patients with subarachnoid hemorrhage (SAH) there is a delay between the onset of symptoms and admission to hospital. An important cause for the delay is an initially erroneous diagnosis. The goal of this study was to determine the frequency of acute confusional state (ACS) as a presenting symptom of SAH and to describe the clinical and radiological characteristics of these patients. We studied all 717 patients registered from January 1989 to July 1997 in the SAH database of the University Medical Center Utrecht. For patients who presented with ACS we reviewed the computed tomography scans for baseline characteristics: the amount of cisternal blood, intraventricular or intracerebral hemorrhage, and hydrocephalus. Details about features of onset were known for 646 patients. Nine patients (1.4%) presented with ACS. In five patients ACS was either preceded by a period of loss of consciousness or accompanied by severe headache. Subtle focal deficits were found at initial neurological examination in four patients. Computed tomography demonstrated a frontal hematoma in three patients and hydrocephalus in four. The site of the ruptured aneurysm was at the anterior communicating artery in four patients, at the internal carotid artery in two, and at the basilar artery in two. In our series, one per 70 patients with SAH presents with ACS. Keys to early diagnosis of SAH in patients presenting with ACS are a preceding period of loss of consciousness and severe headache on neurological assessment.
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Affiliation(s)
- J C Reijneveld
- Department of Neurology, University Medical Center Utrecht, The Netherlands.
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30
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Abstract
BACKGROUND Patients with subarachnoid haemorrhage who develop spasm of the cerebral arteries may suffer from delayed cerebral ischaemia. This may be exacerbated by reduced circulatory volume. Intravenous fluid therapy to expand the circulating volume might reduce the risk of delayed cerebral ischaemia and so reduce the risk of neurological disability. OBJECTIVES The object of this review was to determine whether there is evidence that volume expansion therapy improves outcome in patients with aneurysmal subarachnoid haemorrhage. SEARCH STRATEGY The Cochrane Stroke Group's Specialised Register was searched for trials relevant to this review (last searched: March 1999). Trialists were also contacted. SELECTION CRITERIA All randomized controlled trials of volume expansion therapy in patients with aneurysmal subarachnoid haemorrhage. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. MAIN RESULTS Two trials were identified. For one trial the decision about inclusion is pending because clinical data on follow up have not been provided yet. In the other trial, outcome assessment was done at the day of operation (7 to 10 days after subarachnoid haemorrhage); data on longer follow up have not been collected. REVIEWER'S CONCLUSIONS The effects of volume expansion therapy have not been studied properly in patients with aneurysmal subarachnoid haemorrhage. At present, there is no sound evidence for or against the use of volume expansion therapy in patients with aneurysmal subarachnoid haemorrhage.
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Affiliation(s)
- V L Feigin
- Department of Neurology, University Hospital Utrecht, PO Box 85500, Utrecht, Netherlands, 3508 GA.
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31
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Vrancken AF, Braun KP, de Valk HW, Rinkel GJ. [Epilepsy, disturbances of behavior and consciousness in presence of normal thyroxine levels: still, consider the thyroid gland]. Ned Tijdschr Geneeskd 2000; 144:5-8. [PMID: 10665296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Three patients, one man aged 51 years, and two women aged 49 and 52 years, had severe fluctuating and progressive neurological and psychiatric symptoms. All three had normal thyroxine levels but elevated thyroid stimulating hormone levels and positive thyroid antibodies. Based on clinical, laboratory, MRI and EEG findings they were eventually diagnosed with Hashimoto's encephalopathy, associated with Hashimoto thyroiditis. Treatment with prednisone in addition to thyroxine suppletion resulted in a remarkable remission of their neuropsychiatric symptoms. The disease is probably under-recognized.
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Affiliation(s)
- A F Vrancken
- Afd. Neurologie, Universitair Medisch Centrum Utrecht
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32
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Abstract
BACKGROUND Rupture of an intracranial aneurysm causes bleeding into the subarachnoid space, which may lead to spasm of the cerebral arteries and ischaemic damage to the brain. Prophylactic use of calcium antagonists in patients with ruptured intracranial aneurysms might reduce the risk of ischaemic damage. OBJECTIVES This review aimed to determine whether calcium antagonists improve outcome in patients with aneurysmal subarachnoid haemorrhage (SAH). SEARCH STRATEGY The Cochrane Stroke Group trials register (last searched: March 1999) plus hand searching and personal contacts with trialists and pharmaceutical companies marketing calcium antagonists. SELECTION CRITERIA All completed, unconfounded, truly randomised controlled trials comparing any calcium antagonist with control, within ten days of SAH onset. Eleven trials that met the inclusion criteria were included in the overview. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed trial quality. Trialists were contacted to obtain missing information. MAIN RESULTS We analysed 11 trials totalling 2804 randomized patients with subarachnoid haemorrhage (1376 in the treatment and 1428 in the control group). The drugs analyzed were: nimodipine (eight trials, 1574 patients), nicardipine (two trials, 954 patients), and AT877 (one trial, 276 patients). In 92% of the patients aneurysms were confirmed by angiography or autopsy. Overall, calcium antagonists significantly reduce the risk of poor outcome after subarachnoid haemorrhage: relative risk (RR) 0.82 (95% CI 0. 72-0.93); the absolute risk reduction was 5.1%, the corresponding number of patients needed to treat to prevent a single poor outcome event is 20. For oral nimodipine alone the RR was 0.69 (0.58-0.84). The RR of death on treatment with calcium antagonists was 0.94 (95% CI 0.80-1.10), that of ischaemic neurological deficits 0.67 (95% CI 0.59-0.76), and that of CT-scan documented cerebral infarction 0.80 (95% CI 0.71-0.89). REVIEWER'S CONCLUSIONS Calcium antagonists reduce the proportion of patients with poor outcome and ischemic neurological deficits after aneurysmal SAH; the risk reduction for case fatality alone is not statistically significant. The results for 'poor outcome' are statistically robust, but depend mainly on trials with oral nimodipine; the evidence for nicardipine and AT877 is inconclusive. The intermediate factors through which nimodipine exerts its beneficial effect after aneurysmal SAH remain uncertain.
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Affiliation(s)
- G J Rinkel
- Department of Neurology, University Hospital Utrecht, PO Box 85500, Utrecht, Netherlands, 3508 GA.
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33
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Raaymakers TW, Buys PC, Verbeeten B, Ramos LM, Witkamp TD, Hulsmans FJ, Mali WP, Algra A, Bonsel GJ, Bossuyt PM, Vonk CM, Buskens E, Limburg M, van Gijn J, Gorissen A, Greebe P, Albrecht KW, Tulleken CA, Rinkel GJ. MR angiography as a screening tool for intracranial aneurysms: feasibility, test characteristics, and interobserver agreement. AJR Am J Roentgenol 1999; 173:1469-75. [PMID: 10584784 DOI: 10.2214/ajr.173.6.10584784] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE MR angiography may be an appropriate tool to screen for unruptured intracranial aneurysms. Feasibility, test characteristics, and interobserver agreement in evaluation of MR angiograms were assessed by members of the MARS (Magnetic resonance Angiography in Relatives of patients with Subarachnoid hemorrhage) Study Group. SUBJECTS AND METHODS We screened 626 first-degree relatives of a consecutive series of 193 patients with subarachnoid hemorrhage examined at two institutions. We used MR imaging and MR angiography (three-dimensional time-of-flight imaging at both institutions and additional three-dimensional phase-contrast imaging at one institution). Three observers independently assessed the MR angiograms. Conventional angiography was performed in relatives with possible or definite aneurysms on MR angiography and was considered the standard of reference. RESULTS Thirty-three aneurysms were found in 25 (4%; 95% confidence interval [CI], 3-6%) of 626 relatives. Thirteen (8%) of 169 relatives who refused screening had MR-related reasons; an additional six persons could not be screened because of contraindications for MR imaging (pregnancy, n = 1; claustrophobia, n = 5). The positive predictive value of MR angiography was 100% (95% CI, 79-100%) for "definite" aneurysms and 58% (95% CI, 28-85%) for "possible" aneurysms. Sensitivity of MR angiography was estimated at 83% (95% CI, 65-94%) and specificity at 97% (95% CI, 94-98%). Interobserver agreement in the evaluation of MR angiograms was poor (kappa < .30), probably because different diagnostic strategies used by individual observers resulted in different use of the assessment category "possible aneurysm." CONCLUSION MR angiography is a feasible screening tool for detection of intracranial aneurysms. Positive predictive value, sensitivity, and specificity are acceptable when at least two neuroradiologists independently assess MR angiograms.
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Affiliation(s)
- T W Raaymakers
- Department of Neurology, University Hospital Utrecht, The Netherlands
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34
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Velthuis BK, Van Leeuwen MS, Witkamp TD, Ramos LM, Berkelbach van Der Sprenkel JW, Rinkel GJ. Computerized tomography angiography in patients with subarachnoid hemorrhage: from aneurysm detection to treatment without conventional angiography. J Neurosurg 1999; 91:761-7. [PMID: 10541232 DOI: 10.3171/jns.1999.91.5.0761] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to determine prospectively whether and to what extent computerized tomography (CT) angiography can serve as the sole imaging method for a preoperative workup in patients with ruptured intracranial aneurysms. METHODS During a 1-year period, all patients who presented to the authors' hospital with subarachnoid hemorrhage demonstrated by unenhanced CT scanning or lumbar puncture underwent CT angiography. Two radiologists evaluated the CT angiography source images and maximum intensity projection slabs and arrived at a consensus. They categorized the quality of the CT angiography as adequate or inadequate and classified aneurysms that were detected as definitely or possibly present. The parent artery of anterior communicating artery aneurysms was identified by asymmetrical anterior cerebral artery size and asymmetrical aneurysm location. The parent artery was indicated by the larger A1 segment in cases of asymmetrical A1 size. Only CT angiograms of adequate quality that revealed aneurysms classified as definitely present and with an unequivocal parent artery were presented to the neurosurgeons, who decided whether preoperative digital subtraction (DS) angiography should still be performed. Forty-nine of the 100 studied patients did not undergo surgery because of poor clinical condition, nonaneurysmal cause of the hemorrhage, or endovascular treatment of the ruptured aneurysm. Of the 51 patients who underwent surgery, radiologists required DS angiography in 17 patients; the imaging technique provided greater certainty in 13 instances. The neurosurgeons required DS angiography 11 times; this provided additional information in two instances. Twenty-three (45%) of the 51 patients were surgically treated successfully on the basis of CT angiography findings alone. CONCLUSIONS Computerized tomography angiography can replace DS angiography as the preoperative neuroimaging technique in a substantial proportion of patients with ruptured intracranial aneurysms.
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Affiliation(s)
- B K Velthuis
- Department of Radiology, Utrecht University Hospital, The Netherlands.
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35
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Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. We studied the prognostic value for DCI of 2 factors: the duration of unconsciousness after the hemorrhage and the presence of risk factors for atherosclerosis. METHODS In 125 consecutive patients admitted within 4 days after hemorrhage, we assessed the presence and duration of unconsciousness after the hemorrhage, the neurological condition on admission, the amount of subarachnoid blood, the size of the ventricles, and a history of smoking, hypertension, stroke, or myocardial infarction. The relationship between these variables and the development of DCI was analyzed by means of the Cox proportional hazards model. RESULTS The univariate hazard ratio (HR) for the development of DCI in patients who had lost consciousness for >1 hour was 6.0 (95% CI 3.0 to 12.0) compared with patients who had no loss or a <1-hour loss of consciousness. The presence of any risk factor for atherosclerosis yielded an HR of 1.4 (95% CI 0.6 to 3.5). The HR for unconsciousness remained essentially the same after adjustment for other risk factors for DCI. The HR for a poor World Federation of Neurological Surgeons score (grade IV or V) on admission was 2.9 (95% CI 1.5 to 5. 5); that for a large amount of subarachnoid blood on CT was 3.4 (95% CI 1.6 to 7.3). CONCLUSIONS The duration of unconsciousness after subarachnoid hemorrhage is a strong predictor for the occurrence of DCI. This observation may contribute to a better understanding of the pathogenesis of DCI and increased attention for patients at risk.
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Affiliation(s)
- J W Hop
- University Department of Neurology, Utrecht, The Netherlands.
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36
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Abstract
Follow-up studies of idiopathic thunderclap headache (ITH) have found no subsequent subarachnoid hemorrhage (SAH) or other serious neurological disease, but the effect on life-style has not been studied. To assess the long-term outcome of patients with ITH in general practice we prospectively followed 93 patients with an episode of ITH during 1988-1993, of whom 77 were referred to hospital. ITH was defined as a sudden, unusually severe headache that started within 1 min, lasted at least 1 h, and for which no underlying cause was found. These patients were treated in 252 general practices. Outcome measures were subsequent SAH, subsequent headaches, absence from work, and diminished daily functioning. Patients were followed up by their general practitioner for a median of 5 years (range 1-10). Three patients died, all from non-neurological diseases. No subsequent SAH was diagnosed in any of the 93 patients. Recurrent attacks of ITH occurred in 8 patients, and 13 developed new tension headache or migraine. Absence from work because of headache was recorded in 11 patients, and in the overall group 6 patients were dependent on welfare. In only one-half of patients (n=52) did the general practitioner judge the level of daily functioning to be similar to that before the index episode of ITH. Thus, although no episodes of SAH occurred after ITH during long-term follow-up, one-half of patients with ITH had a lower level of daily functioning, and one-eighth had reduced working capacity, specifically because of headache.
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Affiliation(s)
- F H Linn
- University Department of Neurology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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37
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van der Meulen MF, Rinkel GJ, Witkamp TD, van Gijn J. A man with progressive weakness in his legs. Lancet 1999; 354:830. [PMID: 10485726 DOI: 10.1016/s0140-6736(99)80014-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M F van der Meulen
- Department of Neurology, University Medical Centre, Utrecht, The Netherlands.
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38
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Abstract
BACKGROUND AND PURPOSE It is important to recognize a perimesencephalic pattern of hemorrhage in patients with subarachnoid hemorrhage (SAH), because in 95% of these patients the cause is nonaneurysmal and the prognosis is excellent. The purpose of this study was to investigate whether CT angiography can accurately exclude vertebrobasilar aneurysms in patients with perimesencephalic patterns of hemorrhage and therefore replace digital subtraction angiography (DSA) in this setting. METHODS In 40 patients with posterior fossa SAH as shown on unenhanced CT, 2 radiologists independently evaluated unenhanced CT for distinguishing between perimesencephalic and nonperimesencephalic pattern of hemorrhage and assessed CT angiography for detection of aneurysms. All patients subsequently underwent DSA or autopsy. RESULTS Observers agreed in 38 of 40 patients (95%) in differentiating perimesencephalic and nonperimesencephalic patterns of hemorrhage on unenhanced CT. On the CT angiograms, both observers detected a vertebrobasilar aneurysm in 16 patients and no aneurysm in 24 patients. These findings were confirmed by DSA or autopsy. No patients with a perimesencephalic pattern of hemorrhage were found to have an aneurysm on either CT angiography or DSA. CONCLUSIONS Good recognition of a perimesencephalic pattern of hemorrhage is possible on unenhanced CT, and CT angiography accurately excludes and detects vertebrobasilar aneurysms. DSA can be withheld in patients with a perimesencephalic pattern of hemorrhage and negative CT angiography.
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Affiliation(s)
- B K Velthuis
- Departments of Radiology, Utrecht University Hospital, Utrecht, The Netherlands
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39
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Linn FH, Rinkel GJ, van Gijn J. [Acute severe headache: a subarachnoidal hemorrhage?]. Ned Tijdschr Geneeskd 1999; 143:545-50. [PMID: 10321270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Five patients, three women aged 87, 50, and 31 years, and two men aged 31 and 32 years, presented with severe headache of sudden onset. A sudden onset of unusually severe headache is suggestive of an intracranial haemorrhage or other serious disease, even in the absence of focal neurologic deficits. The diagnoses were subdural haematoma, cerebral venous sinus thrombosis, idiopathic thunderclap headache, subarachnoid haemorrhage, and viral meningitis, respectively. There are no characteristics from history or examination that accurately discriminate among all these causes; idiopathic thunderclap headache and subarachnoid haemorrhage are commonest. Consultation of a neurologist and further ancillary investigations are necessary for proper diagnosis and treatment.
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Affiliation(s)
- F H Linn
- Academisch Ziekenhuis, afd. Neurologie, Utrecht
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40
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Abstract
BACKGROUND Embolization with coils is increasingly used for the treatment of intracranial aneurysms. To assess the percentage of complications, the percentage of aneurysm occlusion, and the short-term outcome, we performed a systematic review of studies on embolization with controlled detachable or pushable coils. SUMMARY OF REVIEW To find studies on embolization with coils, we performed a MEDLINE search from January 1990 to March 1997, checked all reference lists of the studies found, performed a Science Citation Index search on Guglielmi, and hand searched recent volumes of 25 journals. Two authors independently extracted data by means of a standardized data extraction form from 48 eligible studies totalling 1383 patients. Permanent complications of embolization with controlled detachable coils occurred in 46 of 1256 patients (3.7%; 95% CI, 2.7% to 4.9%); 400 of 744 aneurysms (54%; 95% CI, 50% to 57%) were completely occluded. By means of weighted linear regression, no relation between baseline characteristics and outcome measurements was found. The results in the prespecified subgroups of patients with a ruptured aneurysm, an unruptured aneurysm, or a basilar bifurcation aneurysm were essentially the same as the overall results. CONCLUSIONS Short-term results indicate that embolization with coils is a reasonably safe treatment for patients with an unruptured aneurysm and for patients with aneurysmal subarachnoid hemorrhage. The effectiveness in terms of complete occlusion of the aneurysm is moderate. Randomized trials are warranted to compare surgical clipping with embolization with coils.
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Affiliation(s)
- E H Brilstra
- University Department of Neurology, Utrecht, The Netherlands.
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41
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Roos YB, Vermeulen M, Rinkel GJ, Algra A, Van Gijn J, Algra A. Systematic review of antifibrinolytic treatment in aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1998; 65:942-3. [PMID: 9854979 PMCID: PMC2170374 DOI: 10.1136/jnnp.65.6.942] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, The Netherlands.
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42
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Affiliation(s)
- M Padberg
- Department of Neurology, Lucas Andreas Hospital, Amsterdam, The Netherlands
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43
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Abstract
One third of patients with aneurysmal subarachnoid haemorrhage (ASAH) present with headache only. A prompt diagnosis is crucial, but these patients must be distinguished from patients with non-haemorrhagic benign thunderclap headache (BTH). The headache characteristics and associated features at onset in subarachnoid haemorrhage and benign thunderclap headache were studied to delineate the range of early features in these conditions. In this prospective study, one of two observers interviewed 102 patients with acute severe headache by means of a standard questionnaire. The patients were alert on admission and had no focal deficits. ASAH was subsequently diagnosed in 42 patients, non-aneurysmal perimesencephalic haemorrhage (PMH) in 23 patients, and BTH in 37 patients. Headache developed almost instantaneously in 50% of patients with ASAH, 35% of patients with PMH, and 68% of patients with BTH and within 1 to 5 minutes in 19%, 35%, and 19%, respectively. Loss of consciousness was reported in 26% of patients with ASAH, 4% of patients with PMH and 16% of patients with BTH, and transient focal symptoms in 33%, 9%, and 22% respectively. Seizures and double vision had occurred only in ASAH. Vomiting and physical exertion preceding the onset of headache were more frequent in patients with ASAH (69% and 50%) and those with PMH (83% and 39%) than in those with BTH (43% and 22%). Headache developed almost instantaneously in only half the patients with aneurysmal rupture and in two thirds of patients with benign thunderclap headache. In patients with acute severe headache, female sex, the presence of seizures, a history of loss of consciousness or focal symptoms, vomiting, or exertion increases the probability of ASAH, but these characteristics are of limited value in distinguishing ASAH from BTH. Aneurysmal rupture should be considered even if focal signs are absent and the headache starts within minutes.
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Affiliation(s)
- F H Linn
- University Department of Neurology, Utrecht, The Netherlands
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44
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Abstract
OBJECTIVES Although long term outcome of patients with perimesencephalic haemorrhage, a benign subset of subarachnoid haemorrhage, is excellent, some patients report an episode of amnesia for the first hours to days after the ictus. The relation between the occurrence of amnesia and the size of the ventricles on CT, including the temporal horns, were studied in patients with perimesencephalic haemorrhage. METHODS Twenty seven consecutive patients with perimesencephalic haemorrhage were asked about the occurrence of amnesia. Age adjusted bicaudate indices and third ventricle sizes were calculated. Linear measurements of the temporal horn were taken in three directions: anterior-posterior, medial-lateral, and oblique. Additionally, enlargement of the temporal horns was assessed with the "naked eye". RESULTS Ten of the 27 patients reported an episode of transient amnesia; in these patients the mean sizes of the temporal horns were larger than in patients without amnesia, ranging from a factor of 1.7 for the medial-lateral measurement to a factor of 2.3 for the anterior-posterior measurement. Most of the patients with amnesia had relative bicaudate indices and relative third ventricle sizes> 1, and all had enlarged temporal horns at "naked eye" assessment. CONCLUSION About one third of patients with perimesencephalic haemorrhage have an episode of amnesia shortly after the bleed. The occurrence of amnesia is associated with enlargement of the temporal horns, and might be explained by temporary hippocampal dysfunction.
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Affiliation(s)
- J W Hop
- University Department of Neurology, Utrecht, The Netherlands.
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45
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Abstract
BACKGROUND AND OBJECTIVE In families with two or more relatives with subarachnoid hemorrhage (SAH), other first-degree relatives have an increased risk of SAH. We studied the presence of unruptured intracranial aneurysms in 125 members of 23 families with familial SAH, defined as two or more affected first-degree relatives, in a cross-sectional design. METHODS MR angiography was performed in 116 relatives; CT angiography was performed in the remaining 9 relatives because they had been treated for intracranial aneurysms in the past. RESULTS Overall, we found 16 aneurysms in 10 of 125 relatives (8%; 95% CI, 4 to 14%). Of the nine patients with previous surgery for ruptured or unruptured intracranial aneurysms, three had new aneurysms. Two factors were associated with a significantly higher risk of intracranial aneurysms: 1) a history of treatment for ruptured or unruptured intracranial aneurysms (relative risk 5.5; 95% CI, 1.7 to 17.8) and 2) having three or more affected relatives (relative risk 3.3; 95% CI, 1.0 to 10.6). Siblings tended to have a higher risk of intracranial aneurysms than did children of SAH patients, although the difference was not significant. CONCLUSIONS Because the yield is high, screening is recommended in first-degree members of families with familial SAH. Repeated screening should be considered in relatives who have been treated for familial intracranial aneurysms.
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Affiliation(s)
- T W Raaymakers
- Department of Neurology, University Hospital Utrecht, The Netherlands.
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46
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Abstract
BACKGROUND AND PURPOSE Greater availability and improvement of neuroradiological techniques have resulted in more frequent detection of unruptured aneurysms. Because prognosis of subarachnoid hemorrhage is still poor, preventive surgery is increasingly considered as a therapeutic option. Elective surgery requires reliable data on its risks. Therefore, we performed a meta-analysis on the mortality and morbidity of surgery for unruptured intracranial aneurysms. METHODS Through Medline and additional searches by hand, we retrieved studies on clipping of unruptured (additional, symptomatic, or incidental) aneurysms published from 1966 through June 1996. Two authors independently extracted data. We used weighted linear regression for data analysis. RESULTS We included 61 studies that involved 2460 patients (57% female; mean age, 50 years) and at least 2568 unruptured aneurysms (27% >25 mm, 30% located in the posterior circulation). Mortality was 2.6% (95% confidence interval [CI], 2.0% to 3.3%). Permanent morbidity occurred in 10.9% (95% CI, 9.6% to 12.2%) of patients. Postoperative mortality was significantly lower in more recent years for nongiant aneurysms and aneurysms with an anterior location; the last 2 characteristics were also associated with a significantly lower morbidity. CONCLUSIONS In studies published between 1966 and 1996 on clipping of unruptured aneurysms, mortality was 2.6% and morbidity was 10.9%. In calculating the pros and cons of preventive surgery, these proportions should be taken into account.
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Affiliation(s)
- T W Raaymakers
- Department of Neurology, Academic Hospital Utrecht, The Netherlands.
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47
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Velthuis BK, Rinkel GJ, Ramos LM, Witkamp TD, Berkelbach van der Sprenkel JW, Vandertop WP, van Leeuwen MS. Subarachnoid hemorrhage: aneurysm detection and preoperative evaluation with CT angiography. Radiology 1998; 208:423-30. [PMID: 9680571 DOI: 10.1148/radiology.208.2.9680571] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate if computed tomographic (CT) angiography can replace digital subtraction angiography (DSA) for aneurysm detection and as preoperative work-up in patients with subarachnoid hemorrhage (SAH). MATERIALS AND METHODS Prospectively, 100 patients with SAH underwent CT angiography; 80 also underwent DSA. Two observers independently evaluated CT angiographic source images and maximum intensity projection slabs. Neurosurgeons compared CT angiograms and DSA images for presurgical evaluation. RESULTS On CT angiograms, the observers detected 73 and 70 of 75 symptomatic aneurysms; 96% of the detected aneurysms were classified as definitely present. Of 16 incidental aneurysms, 12 and 10 were detected by the observers. With adequate CT angiographic quality, parent artery side of anterior communicating aneurysms was correctly predicted in 100% (95% confidence interval [CI]: 87%, 100%). Neurosurgeons assessed CT angiography as equal or superior to DSA in 83% (95% CI: 73%, 90%) of 87 aneurysms, and in 74% (95% CI: 63%, 82%) operation might have been based on CT angiographic findings alone. CONCLUSION CT angiography depicted 90% of all aneurysms, and 90% were classified as definitely present. CT angiography must be of high quality with adequate depiction of the aneurysm and the parent artery for surgery to be performed on the basis of CT angiographic findings alone.
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Affiliation(s)
- B K Velthuis
- Department of Radiology, Utrecht University Hospital, The Netherlands
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48
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Feigin VL, Rinkel GJ, Algra A, Vermeulen M, van Gijn J. Calcium antagonists in patients with aneurysmal subarachnoid hemorrhage: a systematic review. Neurology 1998; 50:876-83. [PMID: 9566366 DOI: 10.1212/wnl.50.4.876] [Citation(s) in RCA: 197] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND PURPOSE It has been reported that nimodipine reduces the frequency of secondary ischemia and improves outcome after aneurysmal SAH, but definitive evidence concerning all available calcium antagonists is lacking. METHODS Systematic overview of randomized trials that were completed by January 1996 compared calcium antagonists with control and started treatment within 10 days after onset of subarachnoid hemorrhage (SAH) was performed. All calcium antagonists studied thus far (nimodipine, nicardipine, and AT877) were included. RESULTS We analyzed 10 trials totaling 2756 patients. The relative risk (RR) reduction of poor outcome (death or dependency) was 16% (95% CI, 6 to 27%) and that of case fatality was 10% (95% CI, -6 to 25%). To prevent one poor outcome, 19 (12 to 59) patients need to be treated. Calcium antagonists give a 33% (95%, CI 25 to 41) RR reduction in the frequency of ischemic neurologic deficit and a 20% (95% CI, 11 to 28) RR reduction in the frequency of CT-scan documented cerebral infarction. Eight (6 to 11) patients need to be treated to prevent one ischemic neurologic deficit. In the analyses for nimodipine only, treatment was associated with a 24% RR reduction of poor outcome (95% CI, 12 to 38). To prevent one poor outcome, 13 (8 to 30) patients need to be treated with nimodipine. The RR reduction of angiographically detected cerebral vasospasm was statistically significant for AT877 (38%; 95% CI, 17 to 54%) and nicardipine (21%; 95% CI, 6 to 34%) but not for nimodipine (9%; 95% CI, -2 to 19%). CONCLUSION Calcium antagonists reduce the proportion of ischemic neurologic deficits and nimodipine improves overall outcome within 3 months of aneurysmal SAH; evidence for a reduction of poor outcome from all causes by nicardipine and AT877 is inconclusive. The intermediate factors by which nimodipine exerts its beneficial effect remain uncertain.
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Affiliation(s)
- V L Feigin
- University Department of Neurology, Utrecht, The Netherlands
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Abstract
BACKGROUND AND PURPOSE Outcome after subarachnoid hemorrhage (SAH) is often graded as "poor," "fair," or "good." Such categories are usually based on physicians' assessments of physical abilities of patients rather than on how patients themselves perceive their physical, psychological, and social well-being. We assessed functional outcome and quality of life (QoL) in patients with SAH and their partners. METHODS In a consecutive series of 64 patients and 51 partners studied 4 months after the SAH, we assessed functional outcome by means of the Rankin Scale, and QoL by means of the SF-36, the Sickness Impact Profile (SIP), and a visual analogue scale. Additionally, we asked two "simple questions" about dependency and recovery. All questionnaires were completed in an interview setting. The scores on the QoL instruments from patients and partners were stratified according to the Rankin grades of the patients and were compared with data from a Dutch reference population. RESULTS Only patients who had no symptoms at all (Rankin grade 0) had no reduction in QoL compared with the reference population; some of these patients even indicated an improvement in QoL from before the SAH according to the visual analogue scale. Patients who had symptoms but were independent (Rankin grades 1 to 3) and therefore usually designated as having "good outcome" often had reductions in QoL, on both the physical and psychosocial subscores of the SIP and SF-36. The QoL of partners was considerably reduced in several psychosocial domains. CONCLUSIONS SAH has a considerable impact on the QoL of patients and their partners. Only patients without residual symptoms (Rankin grade 0) have a good outcome in terms of physical performance and QoL.
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Affiliation(s)
- J W Hop
- University Department of Neurology, Utrecht, The Netherlands.
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Notermans NC, Lokhorst HM, Wielaard R, Biesma DH, Rinkel GJ. [Clinical judgment and decision making in medical practice. A retiree with fatigue and foot drop]. Ned Tijdschr Geneeskd 1998; 142:174-9. [PMID: 9557022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A 64-year-old former civil servant consulted his general practitioner because of severe fatigue. Later he began to lose weight and gradually developed chronic sensorimotor polyneuropathy characterized by sensory nerve loss which started in his legs. After a year he needed a wheel chair and developed cachexia. IgG paraprotein was detected. Morbid-anatomical examination of enlarged supraclavicular lymph nodes revealed plasma cell angiofollicular hyperplasia, characteristic of Castleman's disease. Treatment with corticosteroids led to marked improvement of the patient's condition. He was able to walk again, using an ankle orthosis on both legs.
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