Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment

Reversible segmental narrowing of the intracranial arteries has been described since several decades in numerous clinical settings, using variable nosology. Twenty-one years ago, we tentatively proposed the unifying concept that these entities, based on similar clinical-imaging features, represented a single cerebrovascular syndrome. This "reversible cerebral vasoconstriction syndrome" or RCVS has now come of age. A new International Classification of Diseases code, (ICD-10, I67.841) has been established, enabling larger-scale studies. The RCVS2 scoring system provides high accuracy in confirming RCVS diagnosis and excluding mimics such as primary angiitis of the central nervous system. Several groups have characterized its clinical-imaging features. RCVS predominantly affects women. Recurrent worst-ever (thunderclap) headaches are typical at onset. While initial brain imaging is often normal, approximately one-third to half develop complications such as convexity subarachnoid hemorrhages, lobar hemorrhages, ischemic strokes located in arterial "watershed" territories and reversible edema, alone or in combination. Vasoconstriction evolves over hours to days, first affecting distal and then the more proximal arteries. An overlap between RCVS and primary thunderclap headache, posterior reversible encephalopathy syndrome, Takotsubo cardiomyopathy, transient global amnesia, and other conditions has been recognized. The pathophysiology remains largely unknown. Management is mostly symptomatic: headache relief with analgesics and oral calcium-channel blockers, removal of vasoconstrictive factors, and avoidance of glucocorticoids that can significantly worsen outcome. Intra-arterial vasodilator infusions provide variable success. Overall, 90-95% of admitted patients achieve complete or major resolution of symptoms and clinical deficits within days to weeks. Recurrence is exceptional, although 5% can later develop isolated thunderclap headaches with or without mild cerebral vasoconstriction.

Reversible cerebral Vasoconstriction syndrome intERnational CollaborativE (REVERCE) network: Study protocol and rationale of a multicentre research collaboration

INTRODUCTION

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare, but increasingly recognised cerebrovascular condition with an estimated annual age-standardised incidence of approximately three cases per million. Knowledge about risk factors and triggering conditions and information about prognosis and optimal treatment in these patients are limited.

METHODS

The REversible cerebral Vasoconstriction syndrome intERnational CollaborativE (REVERCE) project aims to elucidate the epidemiological and clinical characteristics of RCVS by collecting individual patient data from four countries (France, Italy, Taiwan and South Korea) in the setting of a multicentric study. All patients with a diagnosis of definite RCVS will be included. Data on the distribution of risk factors and triggering conditions, imaging data, neurological complications, functional outcome, risk of recurrent vascular events and death and finally the use of specific treatments will be collected. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and geographical region of residence.

ETHICS AND DISSEMINATION

Ethical approval for the REVERCE study will be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of clinical and epidemiological characteristics of RCVS patients.

The prognostic value of systemic immune-inflammation index in patients with aneurysmal subarachnoid hemorrhage: a systematic review

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and life-threatening stroke subtype, that has a high disability and fatality rate. By the use of the systemic immune-inflammation index (SII), it is possible to understand the pathophysiology that underlies immune and inflammatory responses and anticipate consequences including delayed cerebral ischemia (DCI), delayed cerebral vasospasm, and functional outcome. A systematic search of the English-language literature in PubMed and Embase was performed to locate articles addressing the usage of SII in aSAH patients. The cutoff value, sensitivity, specificity, and area-under-the curve (AUC) of the receiver operating characteristic (ROC) curve were collected. Four publications were reviewed after applying the exclusion criteria from the 53 included articles. All the studies indicated that higher SII on admission was significantly associated with poor prognosis. The research examined in this paper provides the earliest indications that higher SII predicts DCI, delayed cerebral vasospasm, and functional outcome, even though other medical subspecialties have used this ratio for a long time to make such predictions.

Vasoconstriction and long-term headache in reversible cerebral vasoconstriction syndrome

BACKGROUND

Angiographic vasoconstriction in reversible cerebral vasoconstriction syndrome (RCVS) is often undetectable at symptom onset and the diagnosis relies on clinical presentation. Although thunderclap headache is a hallmark feature of RCVS, the incidence and predictors of long-term headaches (LTH) are incompletely understood. Our study aims were twofold: to examine the sensitivity and specificity of a recently developed score (RCVS₂) for vasoconstriction detection in a real-world clinical context and describe the incidence and predictors of LTH beyond the acute phase of RCVS.

METHODS

Retrospective analysis of consecutive patients with clinical diagnosis of RCVS in a tertiary hospital between 2017 and 2021. We examined associations between demographic factors, comorbidities, medications, imaging characteristics, and LTH (defined as at least one episode present at greater than 6-months follow-up necessitating medication). We separately examined the association between RCVS₂ score and angiographic vasoconstriction and computed its sensitivity, specificity, and negative and positive predictive value based on established cutoffs (certain ≥ 5, negative ≤ 2).

RESULTS

We included 55 patients, 50.5 (± 13.7) years; 41 (75%) female. 25 (49%) patients had LTH; only prior history of headache was significantly associated with LTH [OR 4.3, 95% CI (1.1-16.2), p = 0.03]. We found a significant association between RCVS₂ score and angiographic vasoconstriction [OR 1.49, 95% CI (1.18-1.88), p = 0.001]; sensitivity, specificity, and positive and negative predictive value were 64%, 94%, 95% and 58% respectively.

CONCLUSIONS

Approximately 50% of RCVS patients experienced LTH; only prior headache history was associated with its incidence. The RCVS2 score had a significant association with high specificity and positive predictive value for angiographic vasoconstriction in our cohort, validating its utility in improving the accuracy of diagnosis in the clinical setting.

Poor expression of miR-195-5p can assist the diagnosis of cerebral vasospasm after subarachnoid hemorrhage and predict adverse outcomes

OBJECTIVE

Patients with spontaneous subarachnoid hemorrhage (SAH) may develop refractory arterial cerebral vasospasm (CVS), which is the leading cause of death in SAH patients. This study explored the clinical diagnostic value of serum miR-195-5p levels in CVS after SAH (SAH + CVS) and its relationship with the prognosis of SAH + CVS.

METHODS

A total of 110 patients with spontaneous SAH were divided into the SAH group (N = 62) and SAH + CVS group (N = 58), with 60 healthy subjects as controls. The clinical data of blood glucose, blood sodium fluctuation, and serum lactic acid were recorded. miR-195-5p serum level was detected by RT-qPCR and its diagnostic value on SAH + CVS was analyzed by receiver operating characteristic curve. Serum levels of PDGF/IL-6/ET-1 and their correlation with miR-195-5p were analyzed using RT-qPCR, enzyme-linked immunosorbent assay, and Pearson's method. The patient prognosis was evaluated by Glasgow Outcome Scale. The effect of miR-195-5p levels on adverse prognosis was analyzed by Kaplan-Meier method and Cox regression analysis.

RESULTS

miR-195-5p was lowly expressed in the serum of SAH patients and lower in SAH + CVS patients. Serum miR-195-5p level assisted the diagnosis of SAH and SAH + CVS and was negatively correlated with PDGF/IL-6/ET-1 levels and was an independent risk factor together with ET-1 and blood glucose for SAH + CVS. miR-195-5p low expression predicted a higher cumulative incidence of adverse outcomes and was an independent predictor of adverse outcomes.

CONCLUSION

Poor expression of miR-195-5p can assist the diagnosis of SAH + CVS and predict higher adverse outcomes.

Transcranial Doppler ultrasound: Clinical applications from neurological to cardiological setting

Transcranial Doppler (TCD) ultrasonography is a rapid, noninvasive, real-time, and low-cost imaging technique. It is performed with a low-frequency (2 MHz) probe in order to evaluate the cerebral blood flow (CBF) and its pathological alterations, through specific acoustic windows. In the recent years, TCD use has been expanded across many clinical settings. Actually, the most widespread indication for TCD exam is represented by the diagnosis of paradoxical embolism, due to patent foramen ovale, in young patients with cryptogenic stroke. In addition, TCD has also found useful applications in neurological care setting, including the following: cerebral vasospasm following acute subarachnoid hemorrhage, brain trauma, cerebrovascular atherosclerosis, and evaluation of CBF and cerebral autoregulation after an ischemic stroke event. The present review aimed to describe the most recent evidences of TCD utilization from neurological to cardiological setting.

Clazosentan: First Approval

Clazosentan (PIVLAZ^™) is a small molecule, endothelin (ET) A receptor-selective antagonist being developed by Idorsia Pharmaceuticals. ET_A receptor inhibition by clazosentan decreases ET-related cerebral vasospasm, which may occur after an aneurysmal subarachnoid haemorrhage. Clazosentan has been approved in Japan for use in the prevention of cerebral vasospasm, vasospasm-related cerebral infarction and cerebral ischaemic symptoms after aneurysmal subarachnoid haemorrhage, following the results from the JapicCTI163369 and JapicCTI163368 phase III trials. This article summarises the milestones in the development of clazosentan leading to this first approval in this indication.

Activation of Platelets and Occurrence of Cerebral Vasospasm and Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage in a Prospective Pilot-Trial

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) often leads to poor outcome. The aim of the study was to assess platelet function in patients after SAH.

METHODS

In this prospective observational study in patients suffering from SAH, platelet count and aggregability were assessed by multiple electrode aggregometry (MEA) over 14 days.

RESULTS

In 12 of 18 patients, cerebral vasospasms (CVS) were diagnosed; of those, five developed delayed cerebral ischemia (DCI). We observed a significant increase in the platelet count compared to baseline from day 8 onwards (p < 0.037) and, in patients with CVS and DCI, a significant difference in outcome classified by the mRS (p = 0.047). Repeated measures ANOVA determined no differences in platelet aggregability in patients with or without CVS/DCI.

CONCLUSIONS

Besides an increase in platelet count, we detected no increase in platelet aggregability. Nevertheless, patients after SAH may have increased platelet aggregability, which is not reflected by MEA.

Longitudinal imaging and evaluation of SAH-associated cerebral large artery vasospasm in mice using micro-CT and angiography

Longitudinal in vivo imaging studies characterizing subarachnoid hemorrhage (SAH)-induced large artery vasospasm (LAV) in mice are lacking. We developed a SAH-scoring system to assess SAH severity in mice using micro CT and longitudinally analysed LAV by intravenous digital subtraction angiography (i.v. DSA). Thirty female C57Bl/6J-mice (7 sham, 23 SAH) were implanted with central venous ports for repetitive contrast agent administration. SAH was induced by filament perforation. LAV was assessed up to 14 days after induction of SAH by i.v. DSA. SAH-score and neuroscore showed a highly significant positive correlation (rsp = 0.803, p < 0.001). SAH-score and survival showed a negative significant correlation (rsp = -0.71, p < 0.001). LAV peaked between days 3-5 and normalized on days 7-15. Most severe LAV was observed in the internal carotid (Δmax = 30.5%, p < 0.001), anterior cerebral (Δmax = 21.2%, p = 0.014), middle cerebral (Δmax = 28.16%, p < 0.001) and basilar artery (Δmax = 23.49%, p < 0.001). Cerebral perfusion on day 5 correlated negatively with survival time (rPe = -0.54, p = 0.04). Arterial diameter of the left MCA correlated negatively with cerebral perfusion on day 3 (rPe = -0.72, p = 0.005). In addition, pseudoaneurysms arising from the filament perforation site were visualized in three mice using i.v. DSA. Thus, micro-CT and DSA are valuable tools to assess SAH severity and to longitudinally monitor LAV in living mice.

Representation Learning of 3D Brain Angiograms, an Application for Cerebral Vasospasm Prediction

Stroke is the fifth leading cause of death in the United States. Subarachnoid hemorrhage (SAH) is a type of stroke often caused by the spontaneous rupture of a cerebral aneurysm. About 30% of the SAH patients develop delayed cerebral ischemia (DCI) a serious secondary complication with devastating impact. Cerebral vasospasm is one of the major precursors of DCI. Predicting the risk of vasospasm would enable better treatment and improved outcomes. Our overarching goal is to find a brain vasculature representation that can be used to find predictive image-based biomarkers. We propose a new methodology that leverages sparse dictionary learning and covariance-based features in order to encode the whole vessel structure in a vector of fixed size. Using 3D brain angiograms, we use this vasculature representation to train a logistic regression model to predict the occurrence of cerebral vasospasm with an area under the ROC curve of 0.93.

Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.

Reversible Cerebral Vasoconstriction Syndrome Associated with Coronary Artery Vasospasm

Reversible cerebral vasoconstriction syndrome is a rare disorder associated with neurologic symptoms secondary to diffuse cerebral vasospasm. Cardiac involvement in this disease is exceedingly rare. A 50-year-old woman was admitted to our hospital for evaluation of chest pain. During a 3-year period, she had been admitted multiple times because of chest pain and elevated serum cardiac enzymes. Transthoracic echocardiograms showed transient wall-motion abnormalities; however, coronary angiograms revealed no coronary artery disease. At the current admission, she had a thunderclap headache, and cerebral angiograms revealed diffuse cerebral vasoconstriction that improved after verapamil infusion, confirming the diagnosis of reversible cerebral vasoconstriction syndrome. The patient was treated successfully with oral diltiazem and had no recurrence of symptoms. We describe what we think is the first reported case of coronary artery spasm in association with reversible cerebral vasoconstriction syndrome. Future research should be focused on identifying treatment options and defining the mechanisms by which the cerebral and coronary vasculature are affected.

Headache: Headache Emergencies

Among patients in the emergency department (ED), most severe, sudden-onset headaches are primary, such as migraine or tension-type headache. Only 10% to 15% of patients have serious underlying pathology. However, guidelines for evaluation of patients with severe headache emphasize detection of subarachnoid hemorrhage (SAH) and other cerebrovascular conditions. Reversible cerebral vasoconstriction syndrome (RCVS) often is unrecognized and may be as common as SAH in patients with severe, sudden-onset headache in the ED. Evaluation of patients with severe headache focuses on obtaining a description of the episode and investigating any risk factors, clinical features, and red flag signs and symptoms that could indicate the presence of a serious condition. Any abnormal finding on neurologic examination has an approximately 39% positive predictive value for intracranial pathology. Computed tomography (CT)scan without contrast within 6 hours of symptom onset is highly sensitive for SAH. Lumbar puncture is recommended for patients with late presentation of SAH and select patients with initially negative CT scan results. CT or magnetic resonance angiography of the brain that shows multiple focal areas of vasoconstriction is diagnostic of RCVS. Lumbar puncture is indicated for patients with suspected meningitis. The management, follow-up, and prognosis of patients with severe headache depend on the etiology.

Cough Headache Presenting with Reversible Cerebral Vasoconstriction Syndrome

Cough headache can be a primary benign condition or secondary to underlying etiologies. We herein describe a case of a 52-year-old woman with cough headache that presented as reversible cerebral vasoconstriction syndrome (RCVS). Some cases of RCVS are caused by an aberrant sympathetic response to activities that cause an intracranial pressure surge. Therefore, cough headache should be recognized as a possible presentation of RCVS, even without thunderclap headache or neurological deficits.

[A case of cerebral reversible vasoconstriction syndrome triggered by repetition transcranial magnetic stimulation]

A 75-year-old man was admitted for combined low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy. Five days after the initiation of rTMS, he developed hypotension and temporary exacerbation of the right hemiplegia with thunderclap headache. MRA showed segmental stenosis of the left middle cerebral artery, which findings were improved at 9 days after the onset of the headache. He was diagnosed as having the reversible cerebral vasoconstriction syndrome (RCVS). The rTMS was recognized as safe rehabilitation treatment. However, it is necessary to recognize that RCVS can become one of the precipitants. This is the first report of RCVS triggered by rTMS.

A segmentation-based volumetric approach to localize and quantify cerebral vasospasm based on tomographic imaging data

Introduction

Quantification of cerebral vasospasm after subarachnoid hemorrhage (SAH) is crucial in animal studies as well as clinical routine. We have developed a method for computer-based volumetric assessment of intracranial blood vessels from cross-sectional imaging data. Here we demonstrate the quantification of vasospasm from micro computed tomography (micro-CT) data in a rodent SAH model and the transferability of the volumetric approach to clinical data.

Methods

We obtained rodent data by performing an ex vivo micro-CT of murine brains after sham surgery or SAH by endovascular filament perforation on day 3 post hemorrhage. Clinical CT angiography (CTA) was performed for diagnostic reasons unrelated to this study. We digitally reconstructed and segmented intracranial vascular trees, followed by calculating volumes of defined vessel segments by standardized protocols using Amira^® software.

Results

SAH animals demonstrated significantly smaller vessel diameters compared with sham (MCA: 134.4±26.9μm vs.165.0±18.7μm, p<0.05). We could highlight this difference by analyzing vessel volumes of a defined MCA-ICA segment (SAH: 0.044±0.017μl vs. sham: 0.07±0.006μl, p<0.001). Analysis of clinical CTA data allowed us to detect and volumetrically quantify vasospasm in a series of 5 SAH patients. Vessel diameters from digital reconstructions correlated well with those measured microscopically (rodent data, correlation coefficient 0.8, p<0.001), or angiographically (clinical data, 0.9, p<0.001).

Conclusions

Our methodological approach provides accurate anatomical reconstructions of intracranial vessels from cross-sectional imaging data. It allows volumetric assessment of entire vessel segments, hereby highlighting vasospasm-induced changes objectively in a murine SAH model. This method could also be a helpful tool for analysis of clinical CTA.

Decreased CSF output as a clinical indicator of cerebral vasospasm following aneurysmal subarachnoid hemorrhage

OBJECTIVE

Vasospasm is a significant cause of morbidity and mortality among those with aneurysmal subarachnoid hemorrhage (aSAH). Treating increased intracranial pressure by drainage of cerebral spinal fluid through an external ventriculostomy is routine practice. The objective of this study is to evaluate the trends of CSF output in patients who experience vasospasm.

METHODS

Electronic medical charts were reviewed to identify two groups of patients with aSAH, 75 consecutive patients who developed vasospasm and 75 matched patients who did not develop vasospasm. CSF output was recorded within 3 days before and 3 days after the occurrence of vasospasm. CSF output was recorded for the same days after SAH in matched patients with no vasospasm.

RESULTS

Total CSF output was lower in patients with vasospasm as compared to patients without vasospasm matched for the same day (p<0.001). In patients with vasospasm, CSF output recordings were significantly higher prior to the occurrence of vasospasm (438ml/day) than the period following vasospasm (325.7ml/day), with a consistent decrease in CSF drainage from day 3 before vasospasm to day 3 after vasospasm (p=0.012). Decreasing CSF output was significantly associated with the occurrence of vasospasm (p=0.017). Youden indices demonstrated that daily CSF drainage <160ml was significantly associated with the occurrence of vasospasm. The sensitivity of this test was 64.79% and the specificity was 55.38%.

CONCLUSIONS

In addition to clinical exam findings, observation of a CSF output decline to less than 160ml/day may be used as additional support for the diagnosis of vasospasm.

Reversible Cerebral Vasoconstriction Syndrome: A Report on Three Cases

Reversible cerebral vasoconstriction syndrome (RCVS), a recently recognized syndrome, is defined as an intermittent segmental vasospasm of cerebral arteries accompanied by thunderclap headache. The major complications of RCVS include ischemic or hemorrhagic stroke, which may cause morbidity and mortality. It is important to detect RCVS in clinical practice because misdiagnosis may lead to inappropriate treatment. In Thailand, there are only two reported cases of RCVS, which may reflect an underdiagnosis of this syndrome. To raise awareness of RCVS, we reported a case series of three RCVS cases. Two of the presented cases had interesting precipitating factors, and two cases had an unusual delayed clinical course.

Triptan-induced Reversible Cerebral Vasoconstriction Syndrome: Two Case Reports with a Literature Review

We encountered two patients with sumatriptan-induced reversible cerebral vasoconstriction syndrome (RCVS). The present patients were taking sumatriptan for the first time because they had been tentatively diagnosed with a migraine. On reviewing the literature, we found nine other cases of triptan-induced RCVS, predominantly among women aged 30 to 40 years. RCVS has been precipitated by triptan at the first ever use, after daily use, and even with long-term use at a normal dose. Patients with acute onset of severe headache should be thoroughly evaluated, and triptan should be administered appropriately. If triptan-induced RCVS is suspected, vascular imaging should be repeated after several days.

Outcome of Patients with Long-Lasting Cerebral Vasospasm After Subarachnoid Hemorrhage: Is Prolonged Treatment for Cerebral Vasospasm Worthwhile? A Matched-Pair Analysis

OBJECTIVE

Cerebral vasospasm (CVS) occurs regularly between days 3 and 12 after subarachnoid hemorrhage (SAH). Yet, some patients suffering from SAH have long-lasting cerebral vasospasm (LL-CVS, i.e., longer than 14 days). The outcome of these patients with a very long treatment is unknown.

METHODS

Patients with SAH were entered into a prospectively collected database. In unconscious patients, CVS was treated until a reversal of CVS was confirmed by imaging. Outcome was assessed with the modified Rankin Scale (mRS; favorable [mRS 0-2] and unfavorable [mRS 3-6]) 6 months after SAH. Data were compared by matched pair analysis.

RESULTS

Of 1126 patients, 106 had LL-CVS (9.4%). The mean of treatment was until day 20 (range, 15-42). Of these patients, more than 30% needed treatment longer than 21 days after SAH; 29% had a small intracerebral hematoma (ICH; <50 mL). Hydrocephalus that required external ventricular drainage was present in 81%. Outcomes were favorable in 60%, and 8% died. In the multivariate logistic regression analysis, risk factors for an unfavorable outcome were elderly patients, poor admission status, and the presence of small ICH. Compared with the matched control group, who had "regular-lasting" CVS, patients with LL-CVS had a significant better outcome (60% vs. 49%) and a significant lower mortality rate (8% vs. 27%).

CONCLUSION

Patients with LL-CVS had a significant better outcome than patients with "regular-lasting" CVS. Risk factors for worse outcome of patients with LL-CVS were a worse admission status, elderly age, and the presence of small ICH. We recommend using an objective method to validate the reversal of CVS in unconscious patients.

Computerized Tomographic Angiography for Detection of Cerebral Vasospasm after Ruptured Intracranial Aneurysm

OBJECTIVE

Digital subtraction angiography (DSA) is the gold standard to diagnose cerebral vasospasm but it is usually not available due to lack of expertise and proper equipment. The present study aimed to compare the diagnostic accuracy of brain computerized tomographic angiography (CTA) in detecting cerebral vasospasm after intracranial aneurysmal rupture.

MATERIAL AND METHOD

Between January 2011 and October 2014, 20 patients who were suspected of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) were prospectively enrolled. All patients underwent brain CTA andDSA within 24 hours after clinical onset ofvasospasm. Separate reviewers independently reviewed the CTA and DSA.

RESULTS

Twenty patients were enrolled, including 7 males and 13 females. The patient characteristics did not have any relationship to the incidence of cerebral vasospasm. The CTA finding of vasospasm was well correlated to the DSA finding (Kappa 0.793). Diagnostic accuracy and false negative of the CTA were 90% and 5%, respectively. Sensitivity of the CTA was 94% and specificity was 100%. Positive predictive value ofthe CTA was 100% and negative predictive value was 66%. The vessels that showed the most correlation between the CTA and DSA findings were left A1 (Kappa 0.684) and left A2 (Kappa 0.663) segments of anterior cerebral artery, and left M1 (Kappa 0.503) segment of middle cerebral artery. Both CTA and DSA can detect mild vasospasm (< 50% luminal stenosis) located proximal to the circle of Willis.

CONCLUSION

Compared to the DSA, the CTA can be used for detecting cerebral vasospasm in patients with ruptured intracranial aneurysms with high sensitivity, specificity, and diagnostic accuracy.

Nimodipine for the prevention of cerebral vasospasm after subarachnoid hemorrhage in 12 children

INTRODUCTION

Subarachnoid hemorrhage is a rare, but life-threatening neurological emergency. Cerebral vasospasm is a complication of subarachnoid hemorrhage that contributes significantly to morbidity and mortality. Nimodipine has been used in adults to reduce the incidence of cerebral vasospasm after subarachnoid hemorrhage and improve long-term outcomes. There are, however, no data in children.

METHODS

Records of children with a confirmed diagnosis of subarachnoid hemorrhage who received nimodipine between January 1, 2005 and August 31, 2013 were reviewed. Dosing of nimodipine and associated hypotensive events were recorded. Transcranial Doppler ultrasonography, cranial computerized tomography, and angiography were followed as a measure of cerebral vasospasm, rebleeding, and subsequent infarction.

RESULTS

Twelve children (average age 11.8 ± 3.3 years, age range 3.5 to 17.3 years) were included. Aneurysm was responsible for the highest percentage (41.7%) of subarachnoid hemorrhage events. The mean dose of oral nimodipine was 1 mg/kg every 4 hours and was associated with a high rate of hypotension requiring intervention or dose modification. Clinical outcomes while on nimodipine therapy varied; evidence of vasospasm was observed in 67%, new infarction in 33%, and rebleeding in 17%. Functional and cognitive deficits were minor in two-thirds and absent in the remaining individuals. All patients survived until hospital discharge.

CONCLUSIONS

Oral nimodipine after subarachnoid hemorrhage in children does not eliminate vasospasm, rebleeding, or infarction and is associated with significant hypotension. Nevertheless, clinical outcomes appear favorable relative to the adult population who receive nimodipine. Further study, with dose titration, is warranted.

MR angiography follow-up 10 years after cryptogenic nonperimesencephalic subarachnoid hemorrhage

Objectives

Long-term magnetic resonance angiography (MRA) follow-up studies regarding cryptogenic nonperimesencephalic subarachnoid hemorrhage (nSAH) are scarce. This single-centre study identified all patients with angiographically verified cryptogenic nSAH from 1998 to 2007: The two main objectives were to prospectively assess the incidence of de novo aneurysm with 3.0-MRI years after cryptogenic nSAH in patients without evidence for further hemorrhage, and retrospectively assess patient demographics and outcome.

Methods

From prospectively maintained report databases all patients with angiographically verified cryptogenic nSAH were identified. 21 of 29 patients received high-resolution 3T-MRI including time-of-flight and contrast-enhanced angiography, 10.2 ± 2.8 years after cryptogenic nSAH. MRA follow-up imaging was compared with initial digital subtraction angiography (DSA) and CT/MRA. Post-hemorrhage images were related to current MRI with reference to persistent lesions resulting from delayed cerebral ischemia (DCI) and post-hemorrhagic siderosis. Patient-based objectives were retrospectively abstracted from clinical databases.

Results

29 patients were identified with cryptogenic nSAH, 17 (59%) were male. Mean age at time of hemorrhage was 52.9 ± 14.4 years (range 4 – 74 years). 21 persons were available for long-term follow-up. In these, there were 213.5 person years of MRI-follow-up. No de novo aneurysm was detected. Mean modified Rankin Scale (mRS) during discharge was 1.28. Post-hemorrhage radiographic vasospasm was found in three patients (10.3%); DCI-related lesions occurred in one patient (3.4%). Five patients (17.2%) needed temporary external ventricular drainage; long-term CSF shunt dependency was necessary only in one patient (3.4%). Initial DSA retrospectively showed a 2 x 2 mm aneurysm of the right distal ICA in one patient, which remained stable. Post-hemorrhage siderosis was detected 8.1 years after the initial bleeding in one patient (4.8%).

Conclusion

Patients with cryptogenic nSAH have favourable outcomes and do not exhibit higher risks for de novo aneurysms. Therefore the need for long-term follow up after cryptogenic nSAH is questionable.

Value of transcranial Doppler, perfusion-CT and neurological evaluation to forecast secondary ischemia after aneurysmal SAH

INTRODUCTION

This study was conducted to prospectively evaluate the diagnostic value of detailed neurological evaluation, transcranial Doppler sonography (TCD) and Perfusion-CT (PCT) to predict delayed vasospasm (DV) and delayed cerebral infarction (DCI) within the following 3 days in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A total of 61 patients with aneurysmal SAH were included in the study. All patients were amenable for neurological evaluation throughout the critical phase to develop secondary ischemia after SAH. The neurological status was assessed three times a day according to a detailed examination protocol. Mean flow velocities (MFV) in intracranial vessel trunks were measured daily by TCD. Native CT and PCT were routinely acquired at 3-day intervals and, in addition, whenever it was thought to be of diagnostic relevance. The predictive values of abnormal PCT and accelerations in TCD (MFV > 140 cm/s) to detect angiographic DV and DCI within the following 2 days were calculated and compared to the predictive value of delayed ischemic neurological deficits (DIND).

RESULTS

The accuracy of TCD and PCT to predict DV or DCI was 0.65 and 0.63, respectively. In comparison, DIND predicted DV or DCI with an accuracy of 0.96. Pathological PCT findings had a higher sensitivity (0.93) and negative predictive value (0.98) than TCD (0.81 and 0.96).

CONCLUSION

Neurological assessment at close intervals is the most accurate parameter to detect DV and DCI in the following 3 days. However, DIND may not be reversible. The routine acquisition of PCT in addition to daily TCD examinations seems reasonable, particularly in patients who are not amenable to a detailed neurological examination since it has a higher sensitivity and negative predictive value than TCD and leaves a lower number of undetected cases of vasospasm and infarction.

The Effects of Vasospasm and Re-Bleeding on the Outcome of Patients with Subarachnoid Hemorrhage from Ruptured Intracranial Aneurysm

Vasospasm and re-bleeding after subarachnoid hemorrhage from ruptured intracranial aneurysm are devastating complication that can severely affect the outcome of the patients. We are presenting a series of total number of 224 patients treated and operated at our Department due to subarachnoid hemorrhage, out of which certain number developed vasospasm and re-bleeding. We are evaluating the effect of these complications on the outcome of the patients according to the Glasgow Outcome Scale at the day of discharge. In our experience both vasospasm and ReSAH can significantly influence the outcome of patients with subarachnoid hemorrhage from ruptured intracranial aneurysm.

A Delayed Cerebral Vasospasm with Infarction Is Secondary to Listeria monocytogenes Meningitis: MRI and MRA Are Diagnostically Useful

Among patients with bacterial meningitis, a cerebral vasospasm typically occurs during the acute phase. We experienced a case of delayed cerebral vasospasm with infarction that was secondary to Listeria monocytogenes meningitis. An 82-year-old woman with Listeria monocytogenes meningitis, whose symptoms had been improving after the initiation of antibacterial therapy, fell into a coma on day 15 and developed generalized seizure. Magnetic resonance imaging (MRI) and MR angiography (MRA) indicated a cerebral vasospasm with multiple infarctions. The risk of vascular complications following acute bacterial meningitis requires close follow-up to identify neurological changes and a low threshold for vascular evaluation. In such cases, MRI and MRA have diagnostic utility.

[Continuous EEG monitoring for aneurysmal subarachnoid hemorrhage]

Subarachnoid hemorrhage (SAH) still carries a high morbidity and mortality, despite improvement in surgical and medical management. Seizures and delayed cerebral ischemia (DCI) secondary to vasospasm or cortical spreading depression are frequent after SAH. Continuous EEG allows early detection of non-convulsive seizures or delayed cerebral ischemia and may become a promissing tool in the monitoring of SAH patients. However, its use in clinical practice is still limited because many resources are required for recording and analyzing continuous EEG. Moreover, we require more data to confirm the relationship between aggressive treatment of non-convulsive seizure or delayed cerebral ischemia triggered by continuous EEG and outcome.

[Prognostication of ischemic complications of cerebral vasospasm in surgical treatment of intracranial aneurysm in acute period of its rupture]

With objective to create a model of prognostication of ischemic complications, occurred due to cerebral vasospasm (CVS), the informativeness of some clinic-instrumental indices was investigated in 350 patients in an acute period of intracranial arterial aneurysm rupture, using mathematical processing of the data. The terms from the disease beginning (3 - 14th day), severe state of patient while stay in hospital, localization of rupture in internal carotid artery, conduction of operation in terms up to 11 days after the rupture occurrence, presence of intraoperative complications, pronounced spasm of 3 and more segments of arteries preoperatively in accordance to angiography data, the pronounced and critical spasm postoperatively in accordance to ultrasonography data have had evolved as a prognostically significant causes in the CVS ischemic complications occurrence. The proposed model of prognostication of a deferred ischemic complications of CVS have had sensitivity 85%, specificity 75%, what have oermitted to use it in clinical practice.

Cost-effectiveness of CT angiography and perfusion imaging for delayed cerebral ischemia and vasospasm in aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective.

MATERIALS AND METHODS

We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association" (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty.

RESULTS

The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of 0.27 quality-adjusted life years and cost savings of $7622 over the transcranial Doppler ultrasound strategy. Univariable and multivariable sensitivity analyses indicated that results were robust to plausible input parameter uncertainty. Probabilistic sensitivity analysis results yielded 96.8% of iterations in the right lower quadrant, representing higher benefits and lower costs.

CONCLUSIONS

Our model results suggest that CTA and CTP are the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.

Middle cerebral artery dissection: diagnostic and prognostic value of transcranial color-coded sonography

We report 2 patients with ischemic stroke related to an initial severe focal narrowed middle cerebral artery caused by a dissection mechanism, a presentation that has received little attention to date. Diagnostic modalities and follow-up using transcranial color-coded sonography are reported and discussed. Results with transcranial color-coded sonography were correlated with computed tomographic angiography, showing the great value of this radiation-free arterial monitoring process in this setting, especially in young adults.

Recommendations for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage

These are evidence based guidelines for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage, developed and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. They consist of recommendations for best monitoring, medical treatment and interventions based on the literature, evaluation of the results of large international clinical trials, and collective experience of the authors.

Genetic elimination of Nrf2 aggravates secondary complications except for vasospasm after experimental subarachnoid hemorrhage in mice

Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key endogenous protective regulator in the body. This study aimed to explore the role of Nrf2 in subarachnoid hemorrhage (SAH)-induced secondary complications. Wild type (WT) and Nrf2 knockout (KO) mice were subjected to experimental SAH by injecting fresh autologous blood into pre-chiasmatic cistern. The absence of Nrf2 function in mice resulted in exacerbated brain injury with increased brain edema, blood-brain barrier (BBB) disruption, neural apoptosis, and severe neurological deficits at 24h after SAH. Moreover, cerebral vasospasm was severe at 24h after SAH, but not significantly different between WT and Nrf2 KO mice after SAH. Meanwhile, Molondialdehyde (MDA) was increased and GSH/GSSG ratio was decreased in Nrf2 KO mice after SAH. Furthermore, higher expression of TNF-α and IL-1β was also found after SAH in Nrf2 KO mice. In conclusion, our results revealed that Nrf2 plays an important role in attenuating SAH-induced secondary complications by regulating excessive oxidative stress and inflammatory response.

Differentiating reversible cerebral vasoconstriction syndrome with subarachnoid hemorrhage from other causes of subarachnoid hemorrhage

IMPORTANCE

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical-angiographic syndrome characterized by recurrent thunderclap headaches and reversible segmental multifocal cerebral artery narrowing. More than 30% of patients with RCVS develop subarachnoid hemorrhage (SAH). Patients with RCVS with SAH (RCVS-SAH) are often misdiagnosed as having potentially ominous conditions such as aneurysmal SAH (aSAH) or cryptogenic "angiogram-negative" SAH (cSAH) owing to overlapping clinical and imaging features.

OBJECTIVE

To identify predictors that can distinguish RCVS-SAH from aSAH and cSAH at the time of clinical presentation.

DESIGN

Retrospective analysis of 3 patient cohorts: patients with RCVS (1998-2009), patients with aSAH (1995-2003), and patients with cSAH (1995-2003).

SETTING

Academic hospital and tertiary referral center.

PARTICIPANTS

Consecutive patients with RCVS-SAH (n = 38), aSAH (n = 515), or cSAH (n = 93) whose conditions were diagnosed using standard criteria.

MAIN OUTCOMES AND MEASURES

Multivariate logistic regression analysis was used to identify predictors that differentiate RCVS-SAH from aSAH and cSAH.

RESULTS

Predictors differentiating RCVS-SAH from aSAH were younger age, chronic headache disorder, prior depression, prior chronic obstructive pulmonary disease, lower Hunt-Hess grade, lower Fisher SAH group, higher number of affected arteries, and the presence of bilateral arterial narrowing. Predictors differentiating RCVS-SAH from cSAH were younger age, female sex, prior hypertension, chronic headache disorder, lower Hunt-Hess grade, lower Fisher SAH group, and the presence of bilateral arterial narrowing.

CONCLUSIONS AND RELEVANCE

We identified important clinical and imaging differences between RCVS-SAH, aSAH, and cSAH that may be useful for improving diagnostic accuracy, clinical management, and resource utilization.

[Reversible cerebral vasoconstriction syndrome]

Reversible cerebral vasoconstriction syndrome (RCVS) is increasingly recognized. The condition is characterized by multifocal vasoconstriction lesions in cerebral arteries. Headache is the central symptom, with an acute onset and paroxysmal occurrence. Some of the patients develop intracranial hemorrhage, ischemic disturbance of the cerebral circulation, hypertensive encephalopathy (PRES) or epileptic seizures as complications. The disease is most common in middle-aged women. Most patients have an underlying predisposing factor, most commonly vasoactive medications, drugs or puerperium. There is no evidence-based practice.

Whole brain CT perfusion combined with CT angiography in patients with subarachnoid hemorrhage and cerebral vasospasm

OBJECTIVE

To assess cerebral vasospasm (CVS) and monitor cerebral microcirculatory changes in patients with acute subarachnoid hemorrhage (SAH) via CT angiography (CTA) combined with whole-brain CT perfusion (CTP) techniques.

METHODS

Sixty patients with SAH (SAH group) and 10 patients without SAH (control group) were selected for a prospective study. CTP combined with CTA and digital subtraction angiography (DSA) studies were performed on patients with initial onset of SAH less than three days. CTA and DSA as well as the CTP parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time-to-peak (TTP) were acquired and analyzed. The relationship of CTA and CTP measurements was assessed in these acute SAH patients.

RESULTS

CTP techniques were used to achieve the perfusion maps of the whole brain in patients with acute SAH. Compared to the control group, mean CBF value was significantly lower while both MTT and TTP values were significantly higher in SAH group (all p<0.05). Further analysis revealed that mean CBF in patients with CVS, sCVS, Fisher III-IV and Hunt-Hess III-V significantly decreased when compared to patients with nCVS, asCVS, Fisher I-II and Hunt-Hess I-II (p<0.05). Furthermore both MTT and TTP values were also significantly reduced in patient with CVS, sCVS, Fisher III-IV and Hunt-Hess III-V (p<0.05).

CONCLUSION

The study demonstrated that changes of microcirculation in patients with SAH could be assessed by whole-brain CTP. CTP combined with CTA could detect both macroscopic evident vasospasm on CTA and alterations of microcirculation on CTP. Mean CBF was significantly lower in patients with SAH.

Current advances in the diagnosis of vasospasm

Symptomatic vasospasm leading to delayed ischemia and neurological deficits is one of the most serious complications after aneurysmal subarachnoid hemorrhage (SAH). Reliable and early detection of symptomatic vasospasm is one of the major goals in the management of patients with SAH. In awake patients, the close clinical neurological examination still remains the most important diagnostic measure. In comatous or sedated patients, cerebral angiography remains the mainstay of the diagnostic workup for vasospasm. However, angiography does not allow assessing the hemodynamic relevance of vasospasm and is not suited for early identification of cerebral hypoperfusion and ischemia. Therefore, a large panel of new monitoring techniques for the assessment of regional cerebral perfusion has been recently introduced into the clinical management of SAH patients. This article briefly reviews the most relevant methods for monitoring cerebral perfusion and discusses their clinical predictive value for the diagnosis of vasospasm. On the basis of the currently available monitoring technologies, an algorithm for the diagnosis of vasospasm is presented.

Use of the bilateral BIS monitor as an indicator of cerebral vasospasm in ICU patients

Earlier diagnosis of cerebral vasospasm and delayed cerebral ischemia (DCI) and treatment has the potential to decrease post-bleed morbidity after subarachnoid hemorrhage (SAH). Previous studies have shown that electroencephalogram (EEG) can detect blood flow changes associated with DCI sooner than other modalities potentially leading to earlier diagnosis. However, continual monitoring with raw EEG requires significant expertise and effort, and may be difficult due to the intermittent need for MRI studies in these patients. Here we describe a series of patients with subarachnoid hemorrhage in the Neurosurgical ICU who underwent monitoring with the Bilateral Bispectral Index (BIS) monitor.

Occurrence of vasospasm and infarction in relation to a focal monitoring sensor in patients after SAH: placing a bet when placing a probe?

INTRODUCTION

Vasospastic brain infarction is a devastating complication of aneurysmal subarachnoid hemorrhage (SAH). Using a probe for invasive monitoring of brain tissue oxygenation or blood flow is highly focal and may miss the site of cerebral vasospasm (CVS). Probe placement is based on the assumption that the spasm will occur either at the dependent vessel territory of the parent artery of the ruptured aneurysm or at the artery exposed to the focal thick blood clot. We investigated the likelihood of a focal monitoring sensor being placed in vasospasm or infarction territory on a hypothetical basis.

METHODS

From our database we retrospectively selected consecutive SAH patients with angiographically proven (day 7-14) severe CVS (narrowing of vessel lumen >50%). Depending on the aneurysm location we applied a standard protocol of probe placement to detect the most probable site of severe CVS or infarction. We analyzed whether the placement was congruent with existing CVS/infarction.

RESULTS

We analyzed 100 patients after SAH caused by aneurysms located in the following locations: MCA (n = 14), ICA (n = 30), A1CA (n = 4), AcoA or A2CA (n = 33), and VBA (n = 19). Sensor location corresponded with CVS territory in 93% of MCA, 87% of ICA, 76% of AcoA or A2CA, but only 50% of A1CA and 42% of VBA aneurysms. The focal probe was located inside the infarction territory in 95% of ICA, 89% of MCA, 78% of ACoA or A2CA, 50% of A1CA and 23% of VBA aneurysms.

CONCLUSION

The probability that a single focal probe will be situated in the territory of severe CVS and infarction varies. It seems to be reasonably accurate for MCA and ICA aneurysms, but not for ACA or VBA aneurysms.

Managing subarachnoid hemorrhage in the neurocritical care unit

Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors' experience, aimed at providing practical aid to those caring for patients with this disease.

[Regional cerebral blood flow monitoring using thermal diffusion flowmetry. Description of 3 cases]

Cerebral blood flow is the most important physiologic parameter in the setting of brain injury. A regional measurement of the flow (rCBF), can be obtained using continuous methods such as thermal diffusion flowmetry (TD-rCBF). This technology of monitoring allows us to detect and quantify ischemic events related with the temporary artery clipping or malposition of the definitive clip and in patients who have suffered a subarachnoid hemorrhage (SAH) or a traumatic brain injury. Likewise, the precocious detection of ischemic events might help us to adopt more rapidly therapeutic measures and more efficienty. Three cases show during aneurysm clipping procedures and at intensive care: the effects of different hypnotics on TD-rCBF values; the relationship between TD-rCBF and somatosensory and motor evoked potentials; and changes in TD-rCBF and transcranial Doppler ultrasonography (TDU) during a vasospasm. TD-rCBF showed in real-time flow variations induced by anaesthetics and detected changes of CBF earlier than evoked potentials and TDU.

Brain tissue oxygen monitoring to assess reperfusion after intra-arterial treatment of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a retrospective study

BACKGROUND AND PURPOSE

Cerebral vasospasm resistant to medical management frequently requires intra-arterial spasmolysis. Angiographic resolution of vasospasm does not provide physiologic data on the adequacy of reperfusion. We recorded pre- and postspasmolysis PbO(2) data in the endovascular suite to determine whether this physiologic parameter could be used to determine when successful reperfusion was established.

MATERIALS AND METHODS

Eight patients with 10 Licox monitors and cerebral vasospasm underwent intra-arterial spasmolysis. Pre- and postspasmolytic PbO(2) was recorded for comparison. Other physiologic parameters, such as CPP, ICP, SaO(2), and Fio(2), were also recorded.

RESULTS

Mean prespasmolysis PbO(2) recordings were 35.2 and 27.3 for the mild-to-moderate and moderate-to-severe vasospasm group, respectively. Mean postspasmolysis PbO(2) increased to 40.3 and 38.4, respectively, which was statistically significant (P < .05) for both groups. In 100% of instances in the moderate-to-severe group and 83% of instances in mild-to-moderate group, the mean PbO(2) increased after spasmolysis and correlated with improvement in angiographic vasospasm. Other physiologic parameters, such as CPP, ICP, SaO(2), and Fio(2), did not show any statistically significant difference before and after spasmolysis.

CONCLUSIONS

PbO(2) monitoring provides the interventionalist with an objective physiologic parameter to determine adequate spasmolysis. Further investigation is needed to establish target PbO(2) rates indicative of adequate reperfusion, which can be used in the endovascular suite.

Proof of concept: endogenous antiangiogenic factors predict the occurrence of symptomatic vasospasm post subarachnoid hemorrhage

BACKGROUND

The pathogenesis of vasospasm (VS) post aneurysmal subarachnoid hemorrhage (SAH) is multifactorial and not completely understood. The authors hypothesize that circulating antiangiogenic factors play an important role in brain injury post SAH and that elevated levels predict the occurrence of symptomatic vasospasm.

METHODS

In this study the authors measured the serum and cerebrospinal fluid (CSF) levels of soluble endoglin (sEng) and soluble fms-like tyrosine kinase 1 (sFlt1) in controls and SAH patients within 48 h of the bleed. Patients were prospectively followed and subcategorized into those with (sVS) and without symptomatic vasospasm (no-sVS).

RESULTS

Compared to healthy controls, SAH patients had higher CSF levels of sEng (0.037 vs. 0.251 ng/ml; P = 0.02) and sFlt1 (0.068 vs. 0.679 ng/ml; P = 0.001). In the subgroup analysis, sVS patients had higher CSF levels of sEng and sFlt1 than no-sVS patients (sEng: 0.380 vs. 0.159 ng/ml, P = 0.02; sFlt1: 1.277 vs. 0.343 ng/ml, P = 0.01). The serum levels of sEng and sFlt1 were not statistically different among the different groups.

CONCLUSIONS

Based on these results the authors conclude that elevated CSF levels of sFlt1 and sEng herald the occurrence of symptomatic VS post SAH.