Article

Predictors and impact of early cerebral infarction after aneurysmal subarachnoid hemorrhage

February 2015
European Journal of Neurology 22(6)

DOI:10.1111/ene.12686

Source
PubMed

Authors:

Ramazan Jabbarli

University Hospital Essen

Matthias Reinhard

Klinikum Esslingen

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Cerebral infarction is a frequent and serious complication of aneurysmal subarachnoid hemorrhage (SAH). This study aimed to identify independent predictors of the timing of cerebral infarction and clarify its impact on disease course and patients' outcome. All consecutive patients with SAH admitted to our institution from January 2005 to December 2012 were analyzed. Serial computed tomography (CT) scans were evaluated for cerebral infarctions. Demographic, clinical, laboratory and radiological data of patients during hospitalization as well as clinical follow-ups 6 months after SAH were recorded. Of the 632 analyzed patients, 320 (51%) developed cerebral infarction on CT scans. 136 patients (21.5%) with early cerebral infarction (occurring within 3 days after SAH) had a significantly higher risk of unfavorable outcome than patients with late infarction [odds ratio (OR) 2.94; P = 0.008], a higher in-hospital mortality (OR 3.14; P = 0.0002) and poorer clinical outcome after 6 months (OR 0.54; P < 0.0001). The rates of decompressive craniectomy (OR 1.96, P = 0.0265), tracheostomy (OR 1.87, P = 0.0446), the duration of intensive care unit stay and mechanical ventilation were significantly higher in patients with early infarction. In multivariate analysis, Hunt and Hess grades 4 and 5 (OR 2.06, P = 0.008), Fisher grades 3 and 4 (OR 3.99, P = 0.014), sustained elevations of intracranial pressure >20 mmHg (OR 5.95, P < 0.0001) and early vasospasm on diagnostic angiograms (OR 3.01, P = 0.008) were predictors of early cerebral infarction. Early cerebral infarction after SAH is associated with severe clinical course and unfavorable outcome and can be reliably predicted by poor initial clinical condition, thick subarachnoid clot, early angiographic vasospasm and sustained elevations of intracranial pressure. © 2015 EAN.

Admission rate-pressure product as an early predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage

Article

Full-text available

Apr 2022
NEUROSURG REV

Early prediction of in-hospital mortality in aneurysmal subarachnoid hemorrhage (aSAH) is essential for the optimal management of these patients. Recently, a retrospective cohort observation has reported that the rate-pressure product (RPP, the product of systolic blood pressure and heart rate), an objective and easily calculated bedside index of cardiac hemodynamics, was predictively associated with in-hospital mortality following traumatic brain injury. We thus wondered whether this finding could also be generalized to aSAH patients. The current study aimed to examine the association of RPP at the time of emergency room (ER) admission with in-hospital mortality and its predictive performance among aSAH patients. We retrospectively included 515 aSAH patients who had been admitted to our ER between 2016 and 2020. Their baseline heart rate and systolic blood pressure at ER presentation were extracted for the calculation of the admission RPP. Meanwhile, we collected relevant clinical, laboratory, and neuroimaging data. Then, these data including the admission RPP were examined by univariate and multivariate analyses to identify independent predictors of hospital mortality. Eventually, continuous and ordinal variables were selected from those independent predictors, and the performance of these selected predictors was further evaluated and compared based on receiver operating characteristic (ROC) curve analyzes. We identified both low (< 10,000; adjusted odds ratio (OR) 3.49, 95% CI 1.93–6.29, p < 0.001) and high (> 15,000; adjusted OR 8.42, 95% CI 4.16–17.06, p < 0.001) RPP on ER admission to be independently associated with in-hospital mortality after aSAH. Furthermore, after centering the admission RPP by its median, the area under its ROC curve (0.761, 95% CI 0.722–0.798, p < 0.001) was found to be statistically superior to any of the other independent predictors included in the ROC analyzes (all p < 0.01). In light of the predictive superiority of the admission RPP, as well as its objectivity and easy accessibility, it is indeed a potentially more applicable predictor for in-hospital death in aSAH patients.

Early Vasospasm after Aneurysmal Subarachnoid Hemorrhage Predicts the Occurrence and Severity of Symptomatic Vasospasm and Delayed Cerebral Ischemia

Article

Feb 2016

Background: Cerebral vasospasm usually develops several days after subarachnoid hemorrhage (SAH) and is generally acknowledged as a strong outcome predictor. In contrast, much less is known about the nature and eventual consequences of early angiographic vasospasm (EAVS) seen on admission digital subtraction angiography (DSA). Therefore, we aimed at identifying the risk factors and clinical impact of EAVS after SAH. Methods: Five hundred and thirty-one SAH patients with admission DSA performed within 72 h after the bleeding event were selected from a comprehensive database containing all consecutive SAH patients treated at our institution between January 2005 and December 2012. Predictors of EAVS, as well as associations between EAVS and delayed vasospasm-related complications, and unfavorable outcome (defined as modified Rankin scale >3) were evaluated in univariate and multivariate analyses. Results: EAVS was seen on 60 DSAs (11.3%) and was independently correlated with delayed symptomatic vasospasm requiring intra-arterial spasmolysis (OR 5.24, p < 0.0001), angioplasty (OR 2.56, p = 0.015) and repetitive endovascular treatment (OR 4.71, p < 0.0001). EAVS also increased the risk for multiple versus single territorial infarction on the follow-up CT scan(s) (OR 2.04, p = 0.047) and independently predicted unfavorable outcome (OR 2.93, p = 0.008). The presence of radiographic signs suspicious for fibromuscular dysplasia were independently associated with the occurrence of EAVS (OR 2.98, p = 0.026) and the need for repetitive endovascular vasospasm treatment (OR 3.95, p = 0.019). Conclusions: In view of the strong correlation with delayed symptomatic vasospasm and its ischemic complications, EAVS can be considered an alerting signal for severe symptomatic vasospasm. Therefore, more attention should be paid to the presence of EAVS on admission DSA.

Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Article

Nov 2016

Background and Purpose Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts. Methods A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated. Results Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99-11.57; P=0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15-0.48; P<0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03-3.13; P=0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18-4.67; P=0.015). Conclusions Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00111085.

Intracranial pressure and outcome in critically ill patients with aneurysmal subarachnoid hemorrhage: A systematic review

Article

Full-text available

Apr 2016
MINERVA ANESTESIOL

Background: Evidences supporting the use of ICP monitoring after aneurysmal subarachnoid hemorrhage (aSAH) are limited. The aim of our paper is to examine whether elevated intracranial pressure (ICP) and ICP-derived variables predict mortality and functional outcomes after aSAH. Methods: A systematic review of the literature was performed through PubMed and Cochrane databases up to June 2015. Population was restricted to aSAH patients requiring admission to the intensive care unit. ICP was included in the analysis as absolute value as well as variables derived from ICP monitoring (pressure reactivity index, ICP pulse wave amplitude, ICP-arterial blood pressure wave amplitude correlation and ICP variability). Outcomes included mortality, neurological recovery and delayed cerebral ischemia (DCI). Quality of evidence was rated using the GRADE system. Results: Twenty-six studies were examined. Due to heterogeneity in qualifying studies, a meta-analysis could not be generated. We found a correlation between elevated ICP and mortality. However, ICP absolute values were not independent predictors of long-term functional outcomes (low quality of evidence). A variable relationship between elevated ICP and DCI was found (very low quality of evidence). ICP-derived variables had higher accuracy than ICP absolute values in predicting functional outcomes (moderate quality of evidence). Conclusions: Elevated ICP was associated with higher mortality however absolute ICP values per se were not independent predictors of functional recovery. Variables derived from ICP monitoring are more accurate than ICP absolute values in predicting outcome. Given the absence of good quality data, additional large studies may help to better define the prognostic value of ICP after aSAH.

The predictors and clinical impact of intraventricular hemorrhage in patients with aneurysmal subarachnoid hemorrhage

Article

Jan 2016

Background: Intraventricular hemorrhage is known to complicate the course and outcome of aneurysmal subarachnoid hemorrhage. Aims: To identify independent risk factors for intraventricular hemorrhage development and its severity during aneurysm rupture. Methods: Six hundred and twenty-five subarachnoid hemorrhage patients treated at our institution between January 2005 and December 2012 were included. The severity of intraventricular hemorrhage was assessed according to the original Graeb score. Clinical and radiographic features of patients present at the bleeding event were tested as potential risk factors for intraventricular hemorrhage. The characteristics of intraventricular hemorrhage were correlated with the clinical course and outcome. Results: Intraventricular hemorrhage was present in 206 patients (33%) and was independently predicted by patient's age (p = 0.001, odds ratio (OR) = 1.02/year of age increase), aneurysm size (p = 0.031, OR = 1.05/mm increase), and location (p < 0.0001, OR = 3.2 for aneurysms of posterior circulation). The severity of intraventricular hemorrhage was predicted by aneurysm size (p = 0.023) and location (higher severity for aneurysms of anterior circulation, p = 0.01). The presence of intraventricular hemorrhage (p < 0.0001, OR = 4.1) and intraventricular hemorrhage severity of >3 points on the Graeb score (p = 0.029, OR = 3.4) was independently associated with poor outcome. Shunt dependency was associated only with the occurrence of intraventricular hemorrhage (p < 0.0001, OR = 2.8) while the severity of intraventricular hemorrhage influenced the timing of shunt placement (p = 0.0156). Conclusions: Increasing age, aneurysm size, and location in the posterior circulation are the main risk factors for occurrence of aneurysmal intraventricular hemorrhage, which is independently associated with poor outcome. The severity of intraventricular hemorrhage, however, is higher if the aneurysm is located in the anterior circulation and has impact on functional outcome, but not on shunt dependency.

Outcome Prediction after Non-aneurysmal Non-traumatic Subarachnoid Hemorrhage

Article

Jun 2015

Contrary to aneurysmal bleeding, non-aneurysmal non-traumatic subarachnoid hemorrhage (NASAH) is rarely associated with unfavorable clinical outcome, cerebral infarction and vasospasm. We aimed to identify independent predictors for a poor clinical course and outcome after NASAH. All patients with NASAH treated at our institution between January 2005 and December 2012 were retrospectively analyzed. Collected demographic, clinical and radiographic variables were divided into primary (admission) and secondary (follow-up) parameters. Independent predictors of unfavorable outcome (defined as modified Rankin scale=3-6), cerebral infarction and development of vasospasm were identified. In addition, a risk score for the estimation of clinical outcome was designed. Out of population with 157 NASAH patients, unfavorable outcome was documented in 57 cases (36.3%) at discharge and in 17 cases (10.8%) after 6 months. Cerebral infarction(s) were found in 7 patients (4.3%). In multivariate analyses, higher age (≥65 years), poorer initial clinical condition measured by Hunt & Hess grade and diffuse basal bleeding pattern were independent outcome predictors and therefore included in the risk score (1-8 points). The risk score correlated with outcome at discharge (p<0.0001) and clinical improvement after 6 months (p=0.0238). A diffuse basal bleeding pattern predicted the detection of vasospasm by transcranial Doppler (p=0.001). Poor initial clinical condition (p=0.028) and vasospasm (p=0.031) were associated with the occurrence of cerebral infarction. NASAH patients with higher age, bad clinical condition on admission and diffuse bleeding pattern are prone to unfavorable outcome. The proposed risk score helps to identify patients with poor prognosis after NASAH.

Effect of Early Brain Infarction After Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Article

Apr 2018

Objective: Aneurysmal subarachnoid haemorrhage (aSAH) is an acute cerebrovascular event that leads to devastating consequences. Early brain infarction (EBI) develops very early, within the first 72 hours after bleeding, but may have a significant impact on long-term outcomes. The incidence and impact of EBI in the prognosis of aSAH remain uncertain. We performed a systematic review and meta-analysis to evaluate the incidence of EBI in patients with aSAH and determine the effect of EBI on mortality and functional outcomes. Methods: We performed a systematic review and meta-analysis. Inclusion criteria were: Studies that performed a brain imaging study up to 72 hours of haemorrhage; both computed tomography (CT) or magnetic resonance imaging (MRI); and included a description of the findings of the brain imaging study (whether an infarct was present or not). Results: Ten studies that met the criteria were included. The incidence of EBI was 17%. The risk ratio (RR) for 3-month mortality was 2.18 (95% CI 1.48 - 3.30). The overall RR for poor outcome was 2.26 (95% CI 1.75 - 2.93). Conclusions: EBI plays an important role in the outcome of patients with aSAH. Its significant impact could represent a new therapeutic frontier for improving outcomes of these patients.

Inhibition of caspase-1-mediated inflammasome activation reduced blood coagulation in cerebrospinal fluid after subarachnoid haemorrhage

Article

Full-text available

Jan 2022

Background: Neuroinflammation and blood coagulation responses in cerebrospinal fluid (CSF) contribute to the poor outcome associated with subarachnoid haemorrhage (SAH). We explored the role of caspase-1-mediated inflammasome activation on extrinsic blood coagulation in CSF after SAH. Methods: Post-SAH proteomic changes and correlation between caspase-1 with extrinsic coagulation factors in human CSF after SAH were analysed. Time course and cell localisation of brain inflammasome and extrinsic coagulation proteins after SAH were explored in a rat SAH model. Pharmacological inhibition of caspase-1 via VX-765 was used to explore the role of caspase-1 in blood clearance and CSF circulation after SAH in rats. Primary astrocytes were used to evaluate the role of caspase-1 in haemoglobin-induced pyroptosis and tissue factor (TF) production/release. Findings: Neuroinflammation and blood coagulation activated after SAH in human CSF. The caspase-1 levels significantly correlated with the extrinsic coagulation factors. The activated caspase-1 and extrinsic coagulation initiator TF was increased on astrocytes after SAH in rats. VX-765 attenuated neurological deficits by accelerating CSF circulation and blood clearance through inhibiting pyroptotic neuroinflammation and TF-induced fibrin deposition in the short-term, and improved learning and memory capacity by preventing hippocampal neuronal loss and hydrocephalus in the long-term after SAH in rats. VX-765 reduced haemoglobin-induced pyroptosis and TF production/release in primary astrocytes. Interpretation: Inhibition of caspase-1 by VX-765 appears to be a potential treatment against neuroinflammation and blood coagulation in CSF after SAH. Funding: This study was supported by National Institutes of Health of United States of America, and National Natural Science Foundation of China.

DISRUPTION OF THE MIRROR NEURON SYSTEM AFTER SUBARACHNOID HEMORRHAGE.

Conference Paper

Sep 2015

Background Nearly 20% of patients who suffer a subarachnoid hemorrhage (SAH) present cognitive impairment even after a year of follow-up. In this sense, visuospatial and visuoperceptive domains have not been fully studied in these patients. Furthermore, they have been associated with the activity in the so-called mirror neuron system (MNS). Objective To analyze the pattern of brain activity with a MNS task-based functional magnetic resonance imaging (fMRI) study in SAH patients. Methods A complete neuropsychological assessment and fMRI study (with observation and execution conditions) were both performed in patients with a history of SAH registered in the database of the Hospital Universitario de Canarias. They must fulfill all the inclusion criteria for the study (less than 40 years old; SAH with Fisher score 1-3; no vasospasm or ischemia; minimum follow-up of one year). Results Twelve patients were completely neuropsychologically studied. Four of them presented visuospatial/visuoperceptive impairment. fMRI study demonstrated the presence of higher activity in MNS regions in these patients than in patients with normal visuospatial/visuoperceptive functions. Furthermore, there was a negative correlation between the test scores and the extent of activation in premotor regions of the studied patients. Conclusion SAH patients with visuospatial/visuoperceptive impairment present an increase of activity in the MNS regions. This may be associated with a subcortical dysfunction, leading to a disruption of neural activity and a less efficient behavior of this brain network.

The CHESS score: A simple tool for early prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

Article

Feb 2016
EUR J NEUROL

Background and purpose: Acute hydrocephalus is an early and common complication of aneurysmal subarachnoid hemorrhage (SAH). However, considerably fewer patients develop chronic hydrocephalus requiring shunt placement. Our aim was to develop a risk score for early identification of patients with shunt dependency after SAH. Methods: Two hundred and forty-two SAH individuals who were treated in our institution between January 2008 and December 2013 and survived the initial impact were retrospectively analyzed. Clinical parameters within 72 h after the ictus were correlated with shunt dependency. Independent predictors were summarized into a new risk score which was validated in a subsequent SAH cohort treated between January and December 2014. Results: Seventy-five patients (31%) underwent shunt placement. Of 23 evaluated variables, only the following five showed independent associations with shunt dependency and were subsequently used to establish the Chronic Hydrocephalus Ensuing from SAH Score (CHESS, 0-8 points): Hunt and Hess grade ≥IV (1 point), location of the ruptured aneurysm in the posterior circulation (1 point), acute hydrocephalus (4 points), the presence of intraventricular hemorrhage (1 point) and early cerebral infarction on follow-up computed tomography scan (1 point). The CHESS showed strong correlation with shunt dependency (P = 0.0007) and could be successfully validated in both internal SAH cohorts tested. Patients scoring ≥6 CHESS points had significantly higher risk of shunt dependency (P < 0.0001) than other patients. Conclusion: The CHESS may become a valuable diagnostic tool for early estimation of shunt dependency after SAH. Further evaluation and external validation will be required in prospective studies.

Intracranial dural arteriovenous fistula as a cause for symptomatic superficial siderosis: A report of two cases and review of the literature

Article

Full-text available

Apr 2016

Background: Superficial siderosis (SS) is the occult deposition of hemosiderin within the cerebral cortex due to repeat microhemorrhages within the central nervous system. The collection of hemosiderin within the pia and superficial cortical surface can lead to injury to the nervous tissue. The most common presentation is occult sensorineural hearing loss although many patients have been misdiagnosed with diseases such as multiple sclerosis and amyotrophic lateral sclerosis before being diagnosed with SS. Only one case report exists in the literature describing an intracranial dural arteriovenous fistula (dAVF) as the putative cause for SS. Case description: We describe two cases of SS caused by a dAVF. Both patients had a supratentorial, cortical lesion supplied by the middle meningeal artery with venous drainage into the superior sagittal sinus. In both patients, symptoms improved after endovascular embolization. The similar anatomic relationship of both dAVFs reported presents an interesting question about the pathogenesis of SS. Similar to the pathologic changes seen in the formation of intracranial arterial aneurysms; it would be possible that changes in the blood vessel lining and wall might predispose a patient to chronic, microhemorrhage resulting in SS. Conclusions: We describe the second and third cases of a dAVF as the cause of SS, and the first cases of successful treatment of SS-associated dAVF with endovascular embolization. As noninvasive imaging techniques become more sensitive and easily obtained, one must consider their limitations in detecting occult intracranial vascular malformations such as dAVF as a possible etiology for SS.

Rate and risk factors for a hyperactivity delirium in patients with aneurysmal subarachnoid haemorrhage

Article

Full-text available

Jun 2019
NEUROSURG REV

Hyperactive delirium (agitation) is a common complication in patients on intensive care units and can be assessed by the Richmond Agitation and Sedation Scale (RASS) in principle. However, the role of agitation in patients with aneurysmal subarachnoid haemorrhage (SAH) is poorly understood. We performed a retrospective analysis to identify risk factors for the development of a hyperactive delirium and its functional consequences for neurological outcome. Three hundred thirty-eight patients with SAH were screened in this study resulting in 212 patients which reached at least once a RASS of 0 and were eligible for further analysis. Clinical characteristics were analysed towards the occurrence of a hyperactive delirium. Neurological outcome at discharge and follow-up was assessed using the Glasgow Outcome Scale. Seventy-eight of 212 patients (36.8%) developed a hyperactive delirium; the duration ranged from 1 to 11 days. Multivariate regression revealed initial hydrocephalus (odds ratio (OR) 3.21 95% confidence interval (CI) [1.33–7.70]; p = 0.01), microsurgical clipping (OR 3.70 95%CI 1.71–8.01]; p = 0.001), male gender (OR 1.97 95%CI [1.05–3.85]; p = 0.047) and a higher Graeb score (OR 1.11 95%CI [1.00–1.22]; p = 0.043) to be significantly associated with the development of agitation. Medical history of psychiatric disorders, alcohol or nicotine abuse showed no correlation with agitation. Cox regression analysis revealed no significant influence of agitation towards unfavourable outcome at discharge or follow-up. We provide four independent risk factors for the development of agitation in SAH patients. Our study emphasizes the specific entity of agitation in patients with SAH and underscores its relevance in neurological patients.

Time Is Brain! Analysis of 245 Cases with Decompressive Craniectomy due to Subarachnoid Hemorrhage

Article

Dec 2016

Objective: Decompressive craniectomy (DC) may become a life-saving measure for patients with subarachnoid hemorrhage (SAH). However, the benefit of early DC has not been shown yet. We aimed at identifying the clinical value of DC timing. Methods: We retrospectively analyzed 245 SAH patients who underwent DC between January 2003 and December 2015. The cohort was stratified into primary (at admission, n=171) and secondary DC (n=74). Moreover, primary DC was also subdivided into early (≤24 hours after ictus, n=120) and delayed (n=51) primary DC. Results: There was no difference between primary and secondary DC (65.5% and 74.3% respectively, p=0.1828) with regard to unfavorable outcome at 6 months post-SAH (defined as modified Rankin scale>3). However, individuals with early primary DC presented with significantly better functional outcome than the remaining cohort (p=0.014, OR=2.02) and even compared to the subgroup with delayed primary DC (p=0.023, OR=2.42). Among individuals with World Federation of Neurosurgical Societies Grade <5 at admission, the benefits of early DC were more impressive: lower rates of unfavorable outcome (p=0.003, OR=0.28), in-hospital mortality (p=0.031, OR=0.37) and cerebral infarctions (p=0.028, OR=0.38) on the follow-up computed tomography scans. Conclusion: Not the timing of DC indication (primary/secondary), but rather the actual time left between the ictus and DC is crucial for the functional improvement of SAH patients requiring DC. Especially, individuals without the signs of severe early brain injury strongly benefit from early DC.

Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage

Article

Dec 2016

OBJECTIVE An asymmetry of the A 1 segments (A1SA) of the anterior cerebral arteries (ACAs) is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs). It is unknown whether A1SA is also clinically relevant after aneurysm rupture. The authors of this study investigated the impact of A1SA on the clinical course and outcome of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS The authors retrospectively analyzed data on consecutive SAH patients treated at their institution between January 2005 and December 2012. The occurrence and severity of cerebral infarctions in the ACA territories were evaluated on follow-up CT scans up to 6 weeks after SAH. Moreover, the risk for an unfavorable outcome (defined as > 3 points on the modified Rankin Scale) at 6 months after SAH was assessed. RESULTS A total of 594 patients were included in the final analysis. An A1SA was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4). CONCLUSIONS An A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome. Clinical trial registration no.: DRKS00005486 ( http://www.drks.de/ )

A novel score to predict shunt dependency after aneurysmal subarachnoid hemorrhage

Article

Jun 2017
J NEUROSURG

OBJECTIVE Feasible clinical scores for predicting shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) are scarce. The chronic hydrocephalus ensuing from SAH score (CHESS) was introduced in 2015 and has a high predictive value for SDHC. Although this score is easy to calculate, several early clinical and radiological factors are required. The authors designed the retrospective analysis described here for external CHESS validation and determination of predictive values for the radiographic Barrow Neurological Institute (BNI) scoring system and a new simplified combined scoring system. METHODS Consecutive data of 314 patients with aSAH were retrospectively analyzed with respect to CHESS parameters and BNI score. A new score, the shunt dependency in aSAH (SDASH) score, was calculated from independent risk factors identified with multivariate analysis. RESULTS Two hundred twenty-five patients survived the initial phase after the hemorrhage, and 27.1% of these patients developed SDHC. The SDASH score was developed from results of multivariate analysis, which revealed acute hydrocephalus (aHP), a BNI score of ≥ 3, and a Hunt and Hess (HH) grade of ≥ 4 to be independent risk factors for SDHC (ORs 5.709 [aHP], 6.804 [BNI], and 4.122 [HH]; p < 0.001). All 3 SDHC scores tested (CHESS, BNI, and SDASH) reliably predicted chronic hydrocephalus (ORs 1.533 [CHESS], 2.021 [BNI], and 2.496 [SDASH]; p ≤ 0.001). Areas under the receiver operating curve (AUROC) for CHESS and SDASH were comparable (0.769 vs 0.785, respectively; p = 0.447), but the CHESS and SDASH scores were superior to the BNI grading system for predicting SDHC (BNI AUROC 0.649; p = 0.014 and 0.001, respectively). In contrast to CHESS and BNI scores, an increase in the SDASH score coincided with a monotonous increase in the risk of developing SDHC. CONCLUSIONS The newly developed SDASH score is a reliable tool for predicting SDHC. It contains fewer factors and is more intuitive than existing scores that were shown to predict SDHC. A prospective score evaluation is needed.

Sex differences in delayed cerebral ischemia after subarachnoid hemorrhage

Article

Full-text available

Sep 2017
J NEUROSURG

OBJECTIVE In this study the authors sought to investigate the sex differences in the risk of delayed cerebral ischemia (DCI), delayed cerebral infarction, and the role of hormonal status. METHODS Ten studies included in the SAHIT (SAH International Trialists) repository were analyzed using a fitting logistic regression model. Heterogeneity between the studies was tested using I ² statistics, and the results were pooled using a random-effects model. Multivariable analysis was adjusted for the effects of neurological status and fixed effect of study. An additional model was examined in which women and men were split into groups according to an age cut point of 55 years, as a surrogate to define hormonal status. RESULTS A pooled cohort of 6713 patients was analyzed. The risk of DCI was statistically significantly higher in women than in men (OR 1.29, 95% CI 1.12–1.48); no difference was found with respect to cerebral infarction (OR 1.17, 95% CI 0.98–1.40). No difference was found in the risk of DCI when comparing women ≤ 55 and > 55 years (OR 0.87, 95% CI 0.74–1.02; p = 0.08) or when comparing men ≤ 55 and > 55 years (p = 0.38). Independent predictors of DCI were World Federation of Neurosurgical Societies (WFNS) grade, Fisher grade, age, and sex. Independent predictors of infarction included WFNS grade, Fisher grade, and aneurysm size. CONCLUSIONS Female sex is associated with a higher risk of DCI. Sex differences may play a role in the pathogenesis of DCI but are not associated with menopausal status. The predictors of DCI and cerebral infarction were identified in a very large cohort and reflect experience from multiple institutions.

Cerebral artery myogenic reactivity: The next frontier in developing effective interventions for subarachnoid hemorrhage

Article

Nov 2017

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating cerebral event that kills or debilitates the majority of those afflicted. The blood that spills into the subarachnoid space stimulates profound cerebral artery vasoconstriction and consequently, cerebral ischemia. Thus, once the initial bleeding in SAH is appropriately managed, the clinical focus shifts to maintaining/improving cerebral perfusion. However, current therapeutic interventions largely fail to improve clinical outcome, because they do not effectively restore normal cerebral artery function. This review discusses emerging evidence that perturbed cerebrovascular “myogenic reactivity,” a crucial microvascular process that potently dictates cerebral perfusion, is the critical element underlying cerebral ischemia in SAH. In fact, the myogenic mechanism could be the reason why many therapeutic interventions, including “Triple H” therapy, fail to deliver benefit to patients. Understanding the molecular basis for myogenic reactivity changes in SAH holds the key to develop more effective therapeutic interventions; indeed, promising recent advancements fuel optimism that vascular dysfunction in SAH can be corrected to improve outcome.

Early Identification of Individuals at High Risk for Cerebral Infarction after Aneurysmal Subarachnoid Hemorrhage: The BEHAVIOR Score

Article

Apr 2015
J CEREBR BLOOD F MET

Cerebral infarction (CI) is a crucial complication of aneurysmal subarachnoid hemorrhage (SAH) associated with poor clinical outcome. We aimed at developing an early risk score for CI based on clinical characteristics available at the onset of SAH. Out of a database containing 632 consecutive patients with SAH admitted to our institution from January 2005 to December 2012, computed tomography (CT) scans up to day 42 after ictus were evaluated for CIs. Different parameters from admission up to aneurysm treatment were collected with subsequent construction of a risk score. Seven clinical characteristics were independently associated with CI and included in the Risk score (BEHAVIOR Score, 0 to 11 points): Blood on CT scan according to Fisher grade ⩾3 (1 point), Elderly patients (age ⩾55 years, 1 point), Hunt&Hess grade ⩾4 (1 point), Acute hydrocephalus requiring external liquor drainage (1 point), Vasospasm on initial angiogram (3 points), Intracranial pressure elevation >20 mm Hg (3 points), and treatment of multiple aneurysms ('Overtreatment', 1 point). The BEHAVIOR score showed high diagnostic accuracy with respect to the absolute risk for CI (area under curve=0.806, P<0.0001) and prediction of poor clinical outcome at discharge (P<0.0001) and after 6 months (P=0.0002). Further validation in other SAH cohorts is recommended.Journal of Cerebral Blood Flow & Metabolism advance online publication, 29 April 2015; doi:10.1038/jcbfm.2015.81.

Clinical significance and efficacy analysis of atorvastatin in the treatment of patients with cerebral infarction and aspiration pneumonia

Article

Full-text available

Oct 2018

Therapeutic efficacy of the use of oral atorvastatin in the treatment of patients with aspiration pneumonia complicated with cerebral infarction was investigated. Three hundred and fourteen cerebral infarction patients complicated with aspiration pneumonia who were admitted to the emergency department of Beijing Chaoyang Hospital Jingxi Branch from May 2015 to July 2017 were retrospectively analyzed. Among them, 160 patients who took atorvastatin were treated as observation group, and the remaining 154 patients were the control group. Patients were given basic treatment after diagnosis, and atorvastatin was also used for patients in the observation group. Venous blood was extracted to detect blood lipids and inflammatory cytokines. Patients were followed up for a period of six months, and the mortality was recorded. After treatment, blood lipid function and inflammatory factors in both groups were significantly improved (P<0.05). Hospital stay in the observation group (86.88%) was significantly shorter than that in the control group (76.33%) (P<0.01). After treatment, levels of TC, LDL, TG and CRP in the observation group (86.25%) were significantly lower than those in the control group (76.32%) (P=0.01). However, after treatment, level of HDL-C in the observation group (11.88%) was significantly higher than that in the control group (23.38%) (P=0.01). After treatment, levels of IL-6, IL-8 and TNF-α in the observation group were significantly lower than those in the control group (P<0.01). Total effective rate in the observation group was significantly higher than that of the control group (P=0.01). Total death rate in the observation group was significantly lower than that in the control group (P=0.02). In conclusion, atorvastatin is effective in the treatment of cerebral infarction patients complicated with aspiration pneumonia.

The Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) as radiographic marker of clinically relevant intracranial hypertension and unfavorable outcome after subarachnoid hemorrhage

Article

Full-text available

Jul 2021

Objective The severity of early brain edema after aneurysm rupture was reported to be strongly associated with the risk of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Using the recently developed SEBES (Subarachnoid Hemorrhage Early Brain Edema Score), we analyzed the predictors of early brain edema and its impact on the complications related to intracranial pressure (ICP) increase after SAH and poor outcome. Methods All consecutive SAH cases treated between January 2003 and June 2016 with assessable SEBES were included (n=745). Data on demographic characteristics, previous medical history, initial severity of SAH, need for conservative ICP treatment and decompressive craniectomy, the occurrence of cerebral infarctions and unfavorable outcome at 6 months (mRS>2) were collected. Univariable and multivariable analyses were performed. Results Younger age (<55 years, adjusted odds ratio [aOR]=3.16, 95% confidence interval [CI]=2.28-4.38), female sex (aOR=1.64, 95% CI=1.16-2.31), poor initial clinical condition (WFNS=4-5, aOR= 1.74, 95% CI=1.23-2.46), presence of intracerebral hemorrhage (aOR=1.63, 95% CI=1.12-2.36), hypothyroidism (aOR=0.60, 95% CI=0.37-0.98) and renal comorbidity (aOR=0.29, 95% CI=0.11-0.78) were independently associated with the SEBES (scores 3-4). There was an independent association between the SEBES=3-4 and the need for conservative ICP treatment (aOR=2.43, 95% CI=1.73-3.42), decompressive craniectomy (aOR=2.68, 95% CI=1.84-3.89), development of cerebral infarcts (aOR=2.24, 95% CI=1.53-3.29) and unfavorable outcome (aOR=1.48, 95% CI=1.0-2.17). Conclusions The SEBES is a reliable predictor of ICP-related complications and poor outcome of SAH. Our findings highlight the need for further research of the impact of patients’ demographic characteristics and comorbidities on the severity of early brain edema after SAH.

Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

Article

May 2019

Background Cerebral autoregulation (CA) impairment after aneurysmal subarachnoid hemorrhage (SAH) has been associated with delayed cerebral ischemia and an unfavorable outcome. We investigated whether the early transient hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method, can predict functional outcome 6 months after aneurysmal SAH. Methods This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between January 2016 and February 2017. CA was evaluated within 72 h of hemorrhage by THRT, which describes the changes in cerebral blood flow velocity after a brief compression of the ipsilateral common carotid artery. CA was considered to be preserved when an increase ≥ 9% of baseline systolic velocity was present. According to the modified Rankin Scale (mRS: 4–6), the primary outcome was unfavorable 6 months after hemorrhage. Secondary outcomes included cerebral infarction, vasospasm on TCD, and an unfavorable outcome at hospital discharge. Results Forty patients were included (mean age = 54 ± 12 years, 70% females). CA was impaired in 19 patients (47.5%) and preserved in 21 (52.5%). Impaired CA patients were older (59 ± 13 vs. 50 ± 9, p = 0.012), showed worse neurological conditions (Hunt&Hess 4 or 5–47.4% vs. 9.5%, p = 0.012), and clinical initial condition (APACHE II physiological score—12 [5.57–13] vs. 3.5 [3, 4, 5], p = 0.001). Fourteen patients in the impaired CA group and one patient in the preserved CA group progressed to an unfavorable outcome (73.7% vs. 4.7%, p = 0.0001). The impaired CA group more frequently developed cerebral infarction than the preserved CA group (36.8% vs. 0%, p = 0.003, respectively). After multivariate analysis, impaired CA (OR 5.15 95% CI 1.43–51.99, p = 0.033) and the APACHE II physiological score (OR 1.67, 95% CI 1.01–2.76, p = 0.046) were independently associated with an unfavorable outcome. Conclusions Early CA impairment detected by TCD and admission APACHE II physiological score independently predicted an unfavorable outcome after SAH.

Nimodipine reduces delayed cerebral vasospasm after intracranial tumor surgery,a retrospective study

Preprint

Full-text available

Jun 2020

Background Cerebral vasospasm (CVS) is a serious neurosurgical complication. This retrospective study was performed to analyze if nimodipine can improve prognosis and reduces ischemia secondary to delayed CVS after intracranial tumor surgery. Methods Retrospective analysis of 94 patients with an anterior cranial fossa tumor and underwent intracranial tumor surgery was performed, with 42 cases treated with normal saline and 52 cases treated with nimodipine solution. Transcranial Doppler ultrasonography was used to measure velocity in the middle cerebral artery (MCA) and distal extracranial internal carotid artery (eICA). An examination was conducted 1 day before surgery and 1, 3, 5, 7, and 14 days after surgery. Follow-up was performed using the Glasgow Outcome Scale (GOS) 3 months after discharge. Results We showed that in the nimodipine group, CVS occurred in 13 (25%) patients who did not have CVS in the first three days after operation; nine patients had CVS between 4 and 7 days, and 4 had CVS between 8 and 14 days. In the normal saline group, nineteen (45%) patients had CVS, 3 presented with CVS within 3 days, 11 between 4–7 days and 5 between 8–14 days. A significant difference in the occurrence of CVS was observed between the two groups. Preoperative and postoperative MCA velocities were compared, revealing a significant change in the normal saline group (P < 0.05) but not in the nimodipine group. Furthermore, significant differences in the outcome were observed between the two groups at the 3-month follow-up (P < 0.05). Conclusions Nimodipine markedly improves prognosis and significantly reduces ischemia secondary to delayed CVS after intracranial tumor surgery, as well as the risks of mortality and morbidity.

Nimodipine reduces delayed cerebral vasospasm after intracranial tumor surgery: a retrospective study

Preprint

Full-text available

Jun 2020

Background：Cerebral vasospasm (CVS) is a serious neurosurgical complication. This retrospective study was performed to analyze if nimodipine can improve prognosis and reduces ischemia secondary to delayed CVS after intracranial tumor surgery. Methods：Retrospective analysis of 94 patients with an anterior cranial fossa tumor and underwent intracranial tumor surgery was performed, with 42 cases treated with normal saline and 52 cases treated with nimodipine solution. Transcranial Doppler ultrasonography was used to measure velocity in the middle cerebral artery (MCA) and the distal extracranial internal carotid artery (eICA). An examination was conducted 1 day before surgery and 1, 3, 5, 7, and 14 days after surgery. Follow-up was performed using the Glasgow Outcome Scale (GOS) 3 months after discharge. Results：We showed that in the nimodipine group, CVS occurred in 13 (25%) patients who did not have CVS in the first three days after operation; nine patients had CVS between 4 and 7 days, and 4 had CVS between 8 and 14 days. In the normal saline group, nineteen (45%) patients had CVS, 3 presented with CVS within 3 days, 11 between 4-7 days and 5 between 8-14 days. A significant difference in the occurrence of CVS was observed between the two groups. Preoperative and postoperative the MCA velocities were compared, revealing a significant change in the normal saline group (P < 0.05) but not in the nimodipine group. Furthermore, significant differences in the outcome were observed between the two groups at the 3-month follow-up (P < 0.05). Conclusions：Nimodipine markedly improves prognosis and significantly reduces ischemia secondary to delayed CVS after intracranial tumor surgery, as well as the risks of mortality and morbidity.

Factors Influencing 1-year Functional Outcome after Surgery in Aneurysmal Subarachnoid Hemorrhage Patients: A Single-center Series

Article

Sep 2021

Objective: The objective of the study was to evaluate the outcome and related factors in patients with aneurysmal subarachnoid hemorrhage (aSAH). Materials and methods: Clinical data of 221 patients who were diagnosed with spontaneous SAH due to ruptured intracranial aneurysm and surgically treated at Vajira Hospital between January 2013 and May 2016 were retrospectively reviewed. Patient and aneurysm characteristics, clinical status at presentation, treatment, and status at discharge and 1 year after discharge were recorded. Outcomes 1 year after surgery were assessed using the Glasgow Outcome Scale (GOS). Patients were divided into two groups according to the GOS score: the favorable outcome group (GOS scores 4 and 5) and unfavorable outcome group (GOS scores 1-3). Results: Among the 221 study patients, 158 were classified in the favorable outcome group and 63 in the unfavorable outcome group. Patient age, Hunt and Hess grade, aneurysm size, use of Vitamin C solution irrigation in the subarachnoid space, and GOS score 1 year after surgery significantly differed between the two groups. Conclusions: Numerous factors analyzed in this study were significantly associated with 1-year outcome in surgically treated aSAH patients, including subarachnoid Vitamin C irrigation. Further study of subarachnoid Vitamin C irrigation is warranted.

The PRESSURE score to predict decompressive craniectomy after aneurysmal subarachnoid hemorrhage

Article

Full-text available

Sep 2020

The prognosis of patients with aneurysmal subarachnoid haemorrhage requiring decompressive craniectomy is usually poor. Proper selection and early performing of decompressive craniectomy might improve the patients' outcome. We aimed at developing a risk score for prediction of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. All consecutive aneurysmal subarachnoid haemorrhage cases treated at the University Hospital of Essen between January 2003 and June 2016 (test cohort) and the University Medical Center Freiburg between January 2005 and December 2012 (validation cohort) were eligible for this study. Various parameters collected within 72 h after aneurysmal subarachnoid haemorrhage were evaluated through univariate and multivariate analyses to predict separately primary (PrimDC) and secondary decompressive craniectomy (SecDC). The final analysis included 1376 patients. The constructed risk score included the following parameters: intracerebral ('Parenchymal') haemorrhage (1 point), 'Rapid' vasospasm on angiography (1 point), Early cerebral infarction (1 point), aneurysm Sac > 5 mm (1 point), clipping (' S urgery', 1 point), age U nder 55 years (2 points), Hunt and Hess grade ≥ 4 ('Reduced consciousness', 1 point) and External ventricular drain (1 point). The PRESSURE score (0-9 points) showed high diagnostic accuracy for the prediction of PrimDC and SecDC in the test (area under the curve = 0.842/0.818) and validation cohorts (area under the curve = 0.903/0.823), respectively. 63.7% of the patients scoring ≥6 points required decompressive craniectomy (versus 12% for the PRESSURE < 6 points, P < 0.0001). In the subgroup of the patients with the PRESSURE ≥6 points and absence of dilated/fixed pupils, PrimDC within 24 h after aneurysmal subarachnoid haemorrhage was independently associated with lower risk of unfavourable outcome (modified Rankin Scale >3 at 6 months) than in individuals with later or no decompressive craniectomy (P < 0.0001). Our risk score was successfully validated as reliable predictor of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. The PRESSURE score might present a background for a prospective randomized clinical trial addressing the utility of early prophylactic decompressive craniectomy in aneurysmal subarachnoid haemorrhage.

Nimodipine reduces delayed cerebral vasospasm after intracranial tumor surgery: a retrospective study

Preprint

Full-text available

Jun 2020

Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage

Article

Dec 2021

One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.

Initial intracranial pressure is an independent predictor of unfavorable functional outcomes after aneurysmal subarachnoid hemorrhage

Article

Dec 2021
J CLIN NEUROSCI

The authors sought to evaluate whether initial intracranial pressure was associated with functional outcomes following aneurysmal subarachnoid hemorrhage. This retrospective analysis consisted of 54 consecutive patients with aneurysmal subarachnoid hemorrhage and acute symptomatic hydrocephalus requiring emergent placement of an external ventricular drain. Patient demographics, clinical data, intracranial pressure parameters, and radiographic imaging were collected. Functional outcomes were evaluated at 3 months using the modified Rankin Scale and dichotomized as favorable (modified Rankin Scale 0–2) or unfavorable (modified Rankin Scale 3–6). Univariate and multivariate logistic regression analyses were performed to investigate parameters independently associated with functional outcomes. In an adjusted multivariate logistic regression model, initial intracranial pressure (OR: 1.371, 95% CI: 1.119–1.679; p = 0.002) was found to be an independent predictor of unfavorable functional outcomes at 3 months. Receiver operating characteristic curve analysis for the prediction of unfavorable functional outcomes demonstrated that initial intracranial pressure exhibited an acceptable area under the curve (AUC = 0.901, 95% CI: 0.818–0.985; p < 0.001). The optimal predictive threshold to distinguish between favorable and unfavorable functional outcomes was identified at an initial intracranial pressure of 25 mmHg.

Ergebnisse in der operativen Behandlung von zerebralen inzidentellen gegenüber rupturierten Aneurysmen älterer Patienten (>65 Lebensjahre)

Thesis

Jan 2021

Celia Monika Markert

1.1 Hintergrund und Ziele Aufgrund der alternden Bevölkerung steigen die Fallzahlen aneurysmatischer subarachnoidaler Blutungen (aSAB) der älteren Patienten (Alter ≥ 65 Jahre) stetig an. Die Therapie mittels minimalinvasiver Coilembolisation steht sowohl bei rupturierten als auch nicht rupturierten Aneurysmen älterer Patienten im Vordergrund, sie ist technisch jedoch nicht immer möglich. Die Frage ist allerdings, ob das Clipping über eine Trepanation im erhöhten Lebensalter eine gleichwertige Behandlungsalternative darstellt. Diese retrospektive Studie vergleicht klinische und radiologische Parameter sowie das klinische Outcome nach der offenen Aneurysmaklippung zwischen jüngeren Patienten mit denen von über 65 Jährigen. 1.2 Methoden In dieser retrospektiven Single Center Studie der Universitätsklinik Erlangen wurden 347 Patienten (107 männlich, 240 weiblich; Durchschnittsalter 53,2 Jahre ± 11,4, Spanne 16-83 Jahre) in einem Zeitraum von 7 Jahren aufgrund inzidenteller und rupturierter akuter Aneurysmen analysiert. Die Kontrollgruppe (n=290) bestand in Patienten, die das 65. Lebensjahr noch nicht erreicht hatten, darunter 197 Frauen und 93 Männer, mit einem Durchschnittsalter von 49,7±8,8 (Median: 50,0; Variationsbreite: 16-64). Die Altersgruppe der älteren Patienten (n=57) bestand aus zum Zeitpunkt der Einlieferung 65 Jahre oder älterer Patienten (14 männlich, 43 weiblich; Durchschnittsalter: 70,9±4,4 Jahre, Altersmedian: 70,0, Variationsbreite: 65-83 Jahre). Innerhalb der älteren Patientenkohorte wurden mittels chirurgischem Aneurysmaclipping 26 Patienten nach akuter subarachnoidaler Blutung und 28 Patienten aufgrund inzidenteller Aneurysmen operiert. In der Kontrollgruppe wurden 146 Patienten nach akuter Blutung und 104 zur präventiven Versorgung inzidenteller Aneurysmen mittels Clipping versorgt. Klinische Einschätzung und radiologisches Ausmaß der SAB sowie klinisches Outcome wurden anhand des Hunt und Hess Klassifikation, der Fisher-CT-Klassifikation sowie dem Glasgow Outcome Wert (GOS Klassifikation) verglichen. 1.3 Ergebnisse Nach erfolgter klinischer Aufnahme wurden die Patienten anhand der Hunt und Hess Klassifizierung (Grad 1-5; leichte Kopfschmerzen und Meningismus bis hin zu Koma und Dezerebrationszeichen) eingeteilt. Es zeigte sich kein signifikanter Unterschied zwischen den Werten älterer SAB Patienten und der Kontrollgruppe (3,0 vs 2,4) nach akuter Blutung (p=0.067). Es ließ sich unabhängig von der Altersgruppe ein gegengerichteter Zusammenhang mit dem GOS-Wert nach akuter SAB feststellen. Je schlechter die Einteilung im Hunt und Hess Score ausfiel (Annäherung an Grad=5), desto niedriger waren die Werte des GOS (Annäherung an Grad=1) (p<0,001 r=-0,431), das heißt, desto schlechter war das klinische Outcome der betroffenen Patienten. Es konnte gefolgert werden, dass der klinische Zustand der Patienten zum Zeitpunkt der Einlieferung maßgeblich für deren spätere Prognose war. Zudem ließ sich kein signifikanter Unterschied des Fisher-CT-Scores zwischen den beiden Altersgruppen (3,1 versus 3,1) ermitteln (p=0.574). Somit war die im CT sichtbar ausgetretene subarachnoidale Blutmenge von ähnlichem Ausmaß. Doch auch hier zeigte sich insgesamt ein altersunabhängiger, gegengerichteter Zusammenhang zwischen der Fisher-CT-Einteilung sowie dem zu erwartenden klinischen Outcome nach akuter SAB. Je höher die Einstufung im Fisher-CT-Score war, das heißt, je mehr Blut vorhanden war, desto schlechter waren die Werte beim GOS und ungünstiger die individuelle Prognose (p<0.001, r=-0,268). Ohne weitere Signifikanz stellte sich die Aneurysmagröße im Vergleich beider Altersgruppen dar (rupturierte Aneurysmen älterer Patienten 6,1mm; inzidentelle Aneurysmen älterer Patienten 6,4mm versus rupturierte Aneurysmen der Kontrollgruppe 6,7mm und inzidentelle Aneurysmen der Kontrollgruppe 6,2mm; p=0.440). Somit waren die technischen Herausforderungen in beiden Gruppen gleich. In den meisten Fällen präsentierten sich akut blutende Aneurysmen der Kontrollgruppe an der A. communicans anterior (Kontrollgruppe: n=75; 42,6%), hingegen zeigten sich rupturierte Aneurysmen der älteren Patienten überwiegend an der A. cerebri media (n=12; 41,4%) und nur zu 24,1% (n=7) an der A. communicans anterior (p=0.119). Innerhalb der Kontrollgruppe handelte es sich bei inzidentellen Gefäßaussackungen gehäuft um Aneurysmen der A. cerebri media (n=54;47,4%) sowie bei den älteren Patienten um Aneurysmen der A. communicans anterior (n=13; 46,4%) (p=0.111). Diese Unterschiede innerhalb der Altersgruppen waren nicht signifikant. Sowohl bei akuten SAB Patienten als auch bei inzidentellen Aneurysmen konnte kein signifikanter Zusammenhang zwischen dem Alter und der Lokalisation nachgewiesen werden. Das Alter der Patienten hatte nach akuter SAB signifikante Auswirkung auf das zu erwartende Outcome (p<0.001). In der Kontrollgruppe betrug der durchschnittliche GOS-Wert nach akuter SAB 4,14±1,16 (Median: 5,00), wohingegen der durchschnittliche GOS-Wert nach akuter SAB der älteren Patientenkohorte bei 3,03±1,43 (Median: 3,00) lag. Je älter die Patienten bei einsetzender Blutung waren, desto schlechter deren Prognose. Nach Clipping inzidenteller Aneurysmen wurde das Outcome älterer Patienten mit einem durchschnittlichen GOS-Wert von 4,5±0,8 (Median: 5,0; Variationsbreite: 2-5) bemessen. Im Vergleich dazu lag der GOS-Wert der jüngeren Patientengruppe bei 4,8±0,4 (Median: 5,0; Variationsbreite: 4-5) nach Clipping inzidenteller Aneurysmen. 1.4 Schlussfolgerung Entsprechend der neurologischen Verfassung zum Zeitpunkt der Einlieferung und nach computertomographischer Bildgebung ließen sich unabhängig vom Alter erste Aussagen über das Outcome nach SAB treffen. Je schlechter die neurologische Verfassung der Patienten und je größer die gefundene Blutmenge im CT war, desto schlechter war die zu erwartende Prognose. Zudem zeigte der ermittelte Glasgow Outcome Scale bei chirurgischer Versorgung mittels Clippings akuter Aneurysmen älterer Patienten signifikant schlechtere Ergebnisse als bei identischer Versorgung jüngerer Patienten. Davon abzuleiten war das steigende Alter bei akuter SAB als ein Indikator einer ungünstigeren Prognose. Hingegen ließ sich kein signifikanter Unterschied beider Altersklassen hinsichtlich des Outcomes nach operativer Versorgung inzidenteller Aneurysmen nachweisen. Das Outcome nach chirurgischem Clipping inzidenteller Aneurysmen war in beiden Altersgruppen gleich gut. Somit spielte das Alter der Patienten in der präventiven Versorgung blander Gefäßaussackungen nur eine untergeordnete Rolle und folglich ist bei älteren Patienten – wenn eine Coilembolisation nicht möglich ist – auch die Operation eine gute Behandlungsalternative. Nur in der Gruppe der älteren Patienten nach rupturierten Aneurysmen mit akuter Subarachnoidalblutung zeigte sich ein signifikanter Unterschied mit schlechterem Outcome gegenüber der jüngeren Gruppe, was am Ehesten der Multimorbidität älterer Patienten geschuldet scheint. In dieser Patientengruppe ist die minimalinvasive Coilembolisation in jedem Fall, wenn möglich, vorzuziehen.

Intracranial Pressure Monitoring in Poor-Grade Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Coiling

Article

Sep 2021

Objectives The main objective of this study was to analyze intracranial (ICP) and cerebral perfusion pressure (CPP) changes during coiling. We also evaluated the prevalence of rebleeding and outcome in patients monitored earlier (before coiling) and in patients monitored later, after coiling. Methods Ninety-nine consecutive poor-grade patients with aneurysmal subarachnoid hemorrhage (aSAH) (grades IV-V of the WFNS) were enrolled in this prospective observational study. In 31 patients ICP/CPP monitoring started immediately after diagnosis of aSAH and values were recorded every 15 minutes during coiling (early ICP group), while in 68 patients ICP/CPP were monitored after coiling (late ICP group). Outcome was evaluated at 90 days using the modified Rankin Scale. Results At the beginning of coiling, ICP was more than 20 mmHg in 10 (35.7%) patients, and median ICP was 18 mmHg (range 5-60); CPP was less than 60 mmHg in 6 patients (24%) and median CPP was 70 mmHg (range 30-101). Despite the medical treatment and/or cerebrospinal fluid drainage, 51.6% of patients monitored during coiling had at least one episode of intracranial hypertension (defined as ICP>20 mmHg) and 51.6% had at least one episode of reduced CPP (defined as CPP<60 mmHg). Early monitoring (before aneurysm repair) was not associated with rebleeding. At 90 days the functional recovery was better in the early ICP group (p=0.004). Conclusions During coiling, patients with poor-grade aSAH may develop episodes of intracranial hypertension and reduced CPP. Early and appropriate treatment of elevated ICP was not associated with rebleeding and might have improved the outcome.

Nimodipine reduces delayed cerebral vasospasm after intracranial tumor surgery: A Retrospective Study

Article

Full-text available

Aug 2021

Cerebral vasospasm (CVS) is a frequent and serious neurosurgical complication, without sufficient therapy. This retrospective study was performed to analyze if nimodipine can improve prognosis and reduces ischemia secondary to delayed CVS after intracranial tumor surgery. A retrospective review was performed over the years 2011 to 2012 for patients with an anterior cranial fossa tumor and underwent intracranial tumor surgery. And the surgical field was soaked with nimodipine solution or normal saline. Transcranial Doppler ultrasonography was used to measure velocity in the middle cerebral artery (MCA) and the distal extracranial internal carotid artery (eICA). Follow-up was performed using the Glasgow Outcome Scale (GOS) after discharge. 94 patients that met the inclusion criteria. They included 50 males and 44 females, with a mean age of 49.6 yr. In the nimodipine group, CVS occurred in 13 patients; 9 patients had CVS between 4 and 7 days, and 4 had CVS between 8 and 14 days. In the normal saline group, 19 patients had CVS, 3 presented with CVS within 3 days, 11 between 4-7 days and 5 between 8-14 days. A significant difference in the occurrence of CVS was observed between the two groups. Preoperative and postoperative the MCA velocities were compared, revealing a significant change in the normal saline group but not in the nimodipine group. Nimodipine markedly improves prognosis and significantly reduces ischemia secondary to delayed CVS after intracranial tumor surgery, as well as the risks of mortality and morbidity.

Advances in neurological research and practice

Article

Dec 2016
EUR J NEUROL

Anthony H Schapira

Subarachnoid hemorrhage and visuospatial and visuoperceptive impairment: disruption of the mirror neuron system

Article

Full-text available

Oct 2016

Nearly 20 % of patients who suffer a subarachnoid hemorrhage (SAH) still display cognitive impairment even a year after follow-up. Visuospatial and visuoperceptive domains may be impaired in this cognitive impairment and may not have been fully studied in these patients. Furthermore, these cognitively impaired domains have been associated with activity in the so-called mirror neuron system (MNS). The aim of the study is to analyze the pattern of brain activity with an MNS task-based functional magnetic resonance imaging (fMRI) study in SAH patients. A complete neuropsychological assessment and fMRI study (with observation and execution conditions) were performed in patients with a history of SAH registered in the database of the Hospital Universitario de Canarias and a healthy control group. The patients had to meet all the following inclusion criteria for the study (less than 50 years old; SAH with a Fisher score 1–3; no vasospasm or ischemia; minimum follow-up of one year). Twelve SAH patients were studied. Three of which displayed visuospatial/visuoperceptive impairment. fMRI study showed the presence of higher activity in MNS regions in these patients than in patients with normal visuospatial/visuoperceptive functions. Furthermore, there was a negative correlation between the test scores and brain activity in premotor regions of the studied patients. SAH patients with visuospatial/visuoperceptive impairment have greater activity in the MNS regions. This finding may be associated with a subcortical dysfunction, leading to a disruption of neural activity and less efficient behavior of this brain network.

In Reply to the Letter to the Editor Regarding “Effect of Early Brain Infarction After Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis”

Article

Apr 2019

Incidence and Predictors of Angiographic Vasospasm, Symptomatic Vasospasm and Cerebral Infarction in Chinese Patients with Aneurysmal Subarachnoid Hemorrhage

Article

Full-text available

Dec 2016
PLOS ONE

Introduction Cerebral vasospasm (CVS) is the most common neurological complication after aneurysmal subarachnoid hemorrhage (aSAH) and associated with poor functional outcome and mortality. Reports on incidence and predictors of CVS in Chinese patients with aSAH were scarce. We aimed to estimate the incidence and predictors of angiographic vasospasm (AV), symptomatic vasospasm (SV), and cerebral infarction in Chinese patients with aSAH. Methods We retrospectively reviewed the medical records of 542 consecutive aSAH patients admitted to neurosurgery department of the First Affiliated Hospital of Xinjiang Medical University in Urumqi city of China between January 1, 2011 and December 31, 2015. AV, SV and cerebral infarction were defined based on clinical data and neuroimaging findings. Univariate and multivariate analyses were performed to identify predictors of AV, SV or cerebral infarction. Results 343 (63.3%) patients fulfilled the inclusion and exclusion criteria. Of them, 182(53.1%) developed AV, 99 (28.9%) developed SV, and 87 (25.4%) developed cerebral infarction. A history of hypertension, poor modified Fisher grade (3–4) and poor Hunt-Hess grade (4–5) on admission were common risk factors for AV, SV and cerebral infarction. Patients from Uyghur ethnic group or other minorities were less likely to develop AV, SV or cerebral infarction, compared to those from Han ethic group after adjustment of other potential confounders. Additionally, age ≥53 years, leukocyte count ≥11× 10⁹/L on admission and being current or former smokers were independent risk factors of cerebral infarction. Leukocyte count ≥11× 10⁹/L on admission and aneurysm size ≥ 10 mm were independent risk factors of SV. Serum glucose level ≥7.0 mmol/L on admission was an independent risk factor of AV. Conclusion Risk factors of different definitions of CVS were diverse in Chinese patients with aSAH; however, risk factors of SV and cerebral infarction seem to be similar. We recommend early and aggressive therapy in these patients at-risk of CVS.

Perioperative Management of Aneurysmal Subarachnoid Hemorrhage

Article

Sep 2020

Deepak Sharma

Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.

Elevated hemoglobin is associated with cerebral infarction in Tibetan patients with primary hemorrhagic neurovascular diseases

Article

Jun 2017

Objectives: Although many studies have focused on primary hemorrhagic neurovascular diseases (PHNVDs) in different races, studies of PHNVDs in the plateau area of China are still insufficient. Chinese Tibetan people are the largest population living in the plateau area. Previous studies have shown that Tibetan PHNVD patients have a significantly higher incidence of cerebral infarction, but the mechanism remains uncertain. This study aimed to develop a better understanding on the mechanism of their high risk of cerebral infarction. Patients and methods: In this retrospective case control study, we used a hospital information system to search for consecutive Tibetan patients with PHNVDs from January 2012 to June 2016. Intra-hospital data including baseline information and complications were recorded, and the risk factors for cerebral infarction were analyzed. Results: Univariate analysis and cox proportional hazard multivariate regression analysis revealed that elevated hemoglobin (HGB) concentration was positively associated with an increased incidence of cerebral infarction (P<0.001). The cutoff value that maximized the ability to predict in-hospital infarction in Tibetans with PHNVDs was 15.2g/dL. Tibetan PHNVD patients with an increased HGB concentration were more likely to present with cerebral infarction within the first 5days after onset of PHNVDs, and the probability was highest on the 3rd day. Conclusions: HGB levels could be used to predict in-hospital cerebral infarction in Tibetan patients with PHNVDs. These patients are more likely to develop in-hospital infarction when the HGB concentration is higher than 15.2g/dL. For Tibetan PHNVD patients with an elevated HGB concentration, most cerebral infarctions occurred within the first five days after onset, with more incidents occurring on the third day.

Long-Term Outcomes of Elderly Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Article

Sep 2020

Objective: Long-term outcomes after surgical treatment and intensive care have not been investigated in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to analyze 12-month outcomes and prognostic factors of patients with poor-grade aSAH who were at least 70 years of age. Methods: We performed a single-center, retrospective study including poor-grade (World Federation of Neurological societies [WFNS] grades IV and V) aSAH patients who were at least 70 years of age, were admitted to our stroke center, and received aneurysmal treatment between April 2012 and September 2018. The clinical outcomes were evaluated at months 3 and 12. Univariate/multivariate analyses were performed to identify the independent prognostic factors of good neurological outcomes (modified Rankin Scale [mRS] score 0-3). These factors included sex, age, WFNS grade, Fisher group, delayed cerebral ischemia, aneurysm treatment, aneurysm size, aneurysm location, and blood examination data in the 14 days post SAH. Results: The proportion of patients with good outcomes (mRS score 0-3) was increased at 12 months compared to that at 3 months. No intracerebral hemorrhage (ICH) was a significant predictor of good neurological outcomes at 3 months (P=0.03). The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from normal sodium levels were significant predictors of good neurological outcomes at months 3 and 12 (P=0.04 and P=0.03, respectively). Conclusions: The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from the normal sodium levels were independently associated with good neurological outcomes at 12 months in elderly patients. ICH did not appear to affect long-term outcomes. These findings suggest that elderly patients with severe SAH should not be excluded from receiving surgical treatment on the basis of their age alone.

Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation?

Article

Sep 2017

Objective: Patients with non-traumatic rupture of an aneurysm located at the anterior communicating artery (ACoA) often experience cognitive disabilities. It is unknown whether location of aneurysm also affects the possibility for improvement in functional independence compared to patients with an aneurysmal subarachnoid hemorrhage (a-SAH) located elsewhere. The aim was to explore the association between location of aneurysm (ACoA versus other) and level of functional independence, measured by Functional Independence Measure (FIM), at discharge from rehabilitation. Additionally, age and FIM at admission were explored. Method: Historical cohort study among 107 patients with a-SAH based on data from a clinical database and a population-based register. Data were analyzed using multivariable logistic regression. Results: Patients with ACoA were admitted with poorer cognitive FIM (median 6 (IQR 5–14) compared to patients with aneurysms located elsewhere (median 12 (IQR 6–23) (p = 0.0129); no difference at discharge. No association between aneurysm location and functional independence was observed. Higher age was associated with poorer outcome in bowel management OR 0.54 (95% CI 0.31–0.92), bladder management OR 0.59 (95% CI 0.35–0.98), comprehension OR 0.53 (95% CI 0.30–0.94), and memory OR 0.48 (95% CI 0.25–0.93). Overall, FIM at admission was associated with functional independence at discharge with the exception of stair walking and bladder management which did not reach statistical significance. Conclusion: ACoA was not associated with poorer level of functional independence compared to patients with a-SAH located elsewhere. Higher age was associated with poorer outcome in continence, comprehension, and memory, whereas higher FIM was associated with better functional independence across items at discharge.

Magnetic Resonance Imaging in Aneurysmal Subarachnoid Hemorrhage: Current Evidence and Future Directions

Article

Apr 2018

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with an unacceptably high mortality and chronic disability in survivors, underscoring a need to validate new approaches for treatment and prognosis. The use of advanced imaging, magnetic resonance imaging (MRI) in particular, could help address this gap given its versatile capacity to quantitatively evaluate and map changes in brain anatomy, physiology and functional activation. Yet there is uncertainty about the real value of brain MRI in the clinical setting of aSAH. Methods: In this review, we discuss current and emerging MRI research in aSAH. PubMed was searched from inception to June 2017, and additional studies were then chosen on the basis of relevance to the topics covered in this review. Results: Available studies suggest that brain MRI is a feasible, safe, and valuable testing modality. MRI detects brain abnormalities associated with neurologic examination, outcomes, and aneurysm treatment and thus has the potential to increase knowledge of aSAH pathophysiology as well as to guide management and outcome prediction. Newer pulse sequences have the potential to reveal structural and physiological changes that could also improve management of aSAH. Conclusion: Research is needed to confirm the value of MRI-based biomarkers in clinical practice and as endpoints in clinical trials, with the goal of improving outcome for patients with aSAH.

Intracranial pressure after subarachnoid hemorrhage

Article

Full-text available

Jan 2015
CRIT CARE MED

Intracranial Pressure After Subarachnoid Hemorrhage

Article

Full-text available

Mar 2013
CRIT CARE

Objectives: To describe mean intracranial pressure after aneurysmal subarachnoid hemorrhage, to identify clinical factors associated with increased mean intracranial pressure, and to explore the relationship between mean intracranial pressure and outcome. Design: Analysis of a prospectively collected observational database. Setting: Neuroscience ICU of an academic hospital. Patients: One hundred sixteen patients with subarachnoid hemorrhage and intracranial pressure monitoring. Interventions: None. Measurements and main results: Episodes of intracranial pressure greater than 20 mm Hg lasting at least 5 minutes and the mean intracranial pressure for every 12-hour interval were analyzed. The highest mean intracranial pressure was analyzed in relation to demographic characteristics, acute neurologic status, initial radiological findings, aneurysm treatment, clinical vasospasm, and ischemic lesion. Mortality and 6-month outcome (evaluated using a dichotomized Glasgow Outcome Scale) were also introduced in multivariable logistic models. Eighty-one percent of patients had at least one episode of high intracranial pressure and 36% had a highest mean intracranial pressure more than 20 mm Hg. The number of patients with high intracranial pressure peaked 3 days after subarachnoid hemorrhage and declined after day 7. Highest mean intracranial pressure greater than 20 mm Hg was significantly associated with initial neurologic status, aneurysmal rebleeding, amount of blood on CT scan, and ischemic lesion within 72 hours from subarachnoid hemorrhage. Patients with highest mean intracranial pressure greater than 20 mm Hg had significantly higher mortality. When death, vegetative state, and severe disability at 6 months were pooled, however, intracranial pressure was not an independent predictor of unfavorable outcome. Conclusions: High intracranial pressure is a common complication in the first week after subarachnoid hemorrhage in severe cases admitted to ICU. Mean intracranial pressure is associated with the severity of early brain injury and with mortality.

Infarct Volume Predicts Delayed Recovery in Patients with Subarachnoid Hemorrhage and Severe Neurological Deficits

Article

Full-text available

Jul 2013
NEUROCRIT CARE

Recovery is common after subarachnoid hemorrhage (SAH), even in patients who are severely disabled at hospital discharge. Little is known about predictors of late recovery in such patients, even though such knowledge may influence treatment decisions. We hypothesized that cerebral infarction volume would be associated with 3 months outcomes in patients who are severely disabled at 14 days. We prospectively identified consecutive aneurysmal SAH patients, documented the development of cerebral infarction, and ascertained the modified Rankin Scale (mRS) at 14 days and 3 months. We included patients with mRS 4 or 5 and NIH Stroke Scale (NIHSS) at least 8 on hospital day 14 (i.e., severe neurologic impairment) and calculated infarct volume in a semi-automated fashion using CT imaging. We explored outcome determinants with ordinal regression. At 14 days, 66 patients were severely disabled, 65 (98.5 %) of whom had mRS of 5; the median NIHSS was 21 [14-24]. At 3 months, 20 (32.8 %) of the 61 patients with known outcomes were independent. Larger infarction volumes were associated with death (20.4 vs. 0.85 mL, P = 0.02). In ordinal regression, increased infarct volume was associated with the worse mRS after correction for WFNS grade, age, and withdrawal of life support (OR 1.01 per mL of infarct, 95 % CI 1.01-1.03, P = 0.01). After SAH, even with severe neurological injury at 14 days, good recovery is frequent and is associated with lower infarction volume. These data may help clinicians inform surrogate decision makers as they plan the future care of such severely disabled patients.

Predictors of Severity of Cerebral Vasospasm caused by Aneurysmal Subarachnoid Hemorrhage

Article

Full-text available

Feb 2013

Background: Cerebral vasospasm is one of the leading causes of poor outcome after aneurysmal subarachnoid hemorrhage. The risk factors for the development of vasospasm have been evaluated in many clinical studies. However, it remains unclear if vasospasm severity can be predicted. The purpose of this study was to determine if different demographic and clinical factors that appear to be predictors of vasospasm can also prognosticate the severity of cerebral vasospasm. Methods: We retrospectively analyzed consecutive patients with subarachnoid hemorrhage who underwent endovascular vasospasm treatment in a single center. In order to define predictors of vasospasm severity, we studied the demographic and clinical characteristics of these patients. Vasospasm severity was defined by cerebral angiography, transcranial Doppler ultrasound, and therapeutic response on endovascular treatment. Statistical analyses were performed to determine significant predictors. Results: A total of 70 patients with vasospasm were included. Early onset of mean flow velocities>160 cm/second on transcranial Doppler ultrasound correlated with severity of angiographic vasospasm (P=.0469) and resistance against intra-arterial papaverine (P=.0277). Younger age (<51 years of age) was significantly associated with severity of vasospasm regarding extension on angiography (P=.0422), the need for repetitive endovascular treatment (P=.0084), persistence of transcranial Doppler ultrasound vasospasm after endovascular treatment (P=.0004), and resistance against intra-arterial papaverine (P=.0341). Conclusions: Younger age and early onset of vasospasm on transcranial Doppler ultrasound are important predictors for vasospasm severity. We recommend early and aggressive therapy in this subgroup.

Early cerebral infarction as a risk factor for poor outcome after aneurysmal subarachnoid haemorrhage

Article

Full-text available

Sep 2011
EUR J NEUROL

After aneurysmal subarachnoid haemorrhage, severity of bleeding, and occurrence of rebleeding and cerebral infarcts are the main factors predicting outcome. We investigated predictive risk factors for both early and late cerebral infarcts, and whether time of appearance of infarct is associated with outcome. Previous diseases as well as clinical, laboratory and radiological variables including serial CT scans were recorded for 173 patients admitted within 48 h after bleeding and with ruptured aneurysm occlusion by open surgery within 60 h. Factors predicting occurrence of cerebral infarct and poor outcome at 3 months according to the Glasgow Outcome Scale were tested using multiple logistic regression. Of several potential predictors, poor outcome was independently predicted by patient age, rebleeding, intraventricular haemorrhage, intracerebral haematoma, delayed cerebral ischaemia with fixed symptoms and early new ischaemic lesion on CT scan appearing on the 1st post-operative morning (P<0.01 for each factor). After adjustment for confounding factors, occurrence of early infarct (odds ratio 12.5; 95% confidence interval 3.2-48.7; P<0.01), both early and late infarct (6.6; 1.1-40.4; P<0.05), and late infarct only (2.4; 0.6-9.1) increased risk for poor outcome. Adjusted independent significant risk factors for early infarction were duration of artery occlusion during surgery (1.4/min; 1.1-1.7, P<0.01) and admission plasma glucose level (1.3 per mM; 1.0-1.6, P<0.05) and for late infarction amount of subarachnoid blood (4.5; 1.3-14.9, P<0.05). Early infarction after surgical aneurysm occlusion seems to have different risk factors and worse prognosis than late infarct which is mostly associated with delayed cerebral ischaemia.

Metamorphosis of Subarachnoid Hemorrhage Research: from Delayed Vasospasm to Early Brain Injury

Article

Full-text available

Feb 2011

Delayed vasospasm that develops 3-7 days after aneurysmal subarachnoid hemorrhage (SAH) has traditionally been considered the most important determinant of delayed ischemic injury and poor outcome. Consequently, most therapies against delayed ischemic injury are directed towards reducing the incidence of vasospasm. The clinical trials based on this strategy, however, have so far claimed limited success; the incidence of vasospasm is reduced without reduction in delayed ischemic injury or improvement in the long-term outcome. This fact has shifted research interest to the early brain injury (first 72 h) evoked by SAH. In recent years, several pathological mechanisms that activate within minutes after the initial bleed and lead to early brain injury are identified. In addition, it is found that many of these mechanisms evolve with time and participate in the pathogenesis of delayed ischemic injury and poor outcome. Therefore, a therapy or therapies focused on these early mechanisms may not only prevent the early brain injury but may also help reduce the intensity of later developing neurological complications. This manuscript reviews the pathological mechanisms of early brain injury after SAH and summarizes the status of current therapies.

Definition of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage as an Outcome Event in Clinical Trials and Observational Studies: Proposal of a Multidisciplinary Research Group

Article

Full-text available

Oct 2010
STROKE

In clinical trials and observational studies there is considerable inconsistency in the use of definitions to describe delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. A major cause for this inconsistency is the combining of radiographic evidence of vasospasm with clinical features of cerebral ischemia, although multiple factors may contribute to DCI. The second issue is the variability and overlap of terms used to describe each phenomenon. This makes comparisons among studies difficult. An international ad hoc panel of experts involved in subarachnoid hemorrhage research developed and proposed a definition of DCI to be used as an outcome measure in clinical trials and observational studies. We used a consensus-building approach. It is proposed that in observational studies and clinical trials aiming to investigate strategies to prevent DCI, the 2 main outcome measures should be: (1) cerebral infarction identified on CT or MRI or proven at autopsy, after exclusion of procedure-related infarctions; and (2) functional outcome. Secondary outcome measure should be clinical deterioration caused by DCI, after exclusion of other potential causes of clinical deterioration. Vasospasm on angiography or transcranial Doppler can also be used as an outcome measure to investigate proof of concept but should be interpreted in conjunction with DCI or functional outcome. The proposed measures reflect the most relevant morphological and clinical features of DCI without regard to pathogenesis to be used as an outcome measure in clinical trials and observational studies.

Risk factors for ischemic lesions following aneurysmal subarachnoid hemorrhage

Article

Full-text available

Mar 2005
J NEUROSURG

The aim of this study was to test whether enoxaparin treatment (40 mg subcutaneously once daily) reduces the risk of cerebral infarction after subarachnoid hemorrhage (SAH) and to investigate predictive risk factors for permanent ischemic lesions visible on follow-up computerized tomography (CT) scans obtained 3 months after SAH. After undergoing surgery for a ruptured aneurysm, 170 patients were randomized in a prospective, double-blind, placebo-controlled trial to test the effect of enoxaparin on the occurrence of ischemic lesions, which were demonstrated on follow-up CT scans available for 156 patients. The presence of lesions correlated highly with an impaired outcome, as assessed using both the Glasgow Outcome and modified Rankin Scales (p < 0.01). Lesions occurred in 101 (65%) of the 156 patients. In half of the patients (51 patients) no lesion was visible on the CT scan obtained on the 1st postoperative day in 51 patients. On univariate analysis, the presence of lesions at 3 months post-SAH was not associated with enoxaparin treatment but did correlate with several clinical, radiological, and prehemorrhage variables. Significant independent risk factors for lesions consisted of an impaired initial clinical condition (odds ratio [OR] 2.63, 95% confidence interval [CI] 1.03-6.73), amount of subarachnoid blood (OR 6.51, 95% CI 2.27-18.65), nocturnal occurrence of SAH (that is, between 12:01 a.m. and 8:00 a.m.; OR 4.32, 95% CI 1.28-14.52), fixed symptoms of delayed ischemia (OR 5.21, 95% CI 1.02-26.49), duration of temporary artery occlusion during surgery (OR 1.66 per minute, 95% CI 1.20-2.31), and body mass index (OR 1.13/kg/m2, 95% CI 1.01-1.28). The presence of ischemic lesions can be predicted by the severity of bleeding, delayed cerebral ischemia, excess weight, duration of temporary artery occlusion, and occurrence of nocturnal aneurysm rupture.

Acute physiological derangement is associated with early radiographic cerebral infarction after subarachnoid haemorrhage

Article

Full-text available

Jan 2007
J NEUROL NEUROSUR PS

Cerebral infarction after aneurysmal subarachnoid haemorrhage (SAH) is presumed to be due to cerebral vasospasm, defined as arterial lumen narrowing from days 3 to 14. We reviewed the computed tomography scans of 103 patients with aneurysmal SAH for radiographic cerebral infarction and controlled for other predictors of outcome. A blinded neuroradiologist reviewed the angiograms. Cerebral infarction from vasospasm was judged to be unlikely if it was visible on computed tomography within 2 calendar days of SAH or if angiography showed no vasospasm in a referable vessel, or both. Cerebral infarction occurred in 29 (28%) of 103 patients with SAH. 18 patients had cerebral infarction that was unlikely to be due to vasospasm because it was visible on computed tomography by day 2 (6 (33%)) or because angiography showed no vasospasm in a referable artery (7 (39%)), or both (5 (28%)). In a multivariate model, cerebral infarction was significantly related to World Federation of Neurologic Surgeons grade (odds ratio (OR) 1.5/grade, 95% confidence interval (CI) 1.1 to 2.01, p = 0.006) and SAH-Physiologic Derangement Score (PDS) >2 (OR 3.7, 95% CI 1.4 to 9.8, p = 0.01) on admission. Global cerebral oedema (OR 4.3, 95% CI 1.5 to 12.5, p = 0.007) predicted cerebral infarction. Patients with cerebral infarction detectable by day 2 had a higher SAH-PDS than patients with later cerebral infarction (p = 0.025). Many cerebral infarctions after SAH are unlikely to be caused by vasospasm because they occur too soon after SAH or because angiography shows no vasospasm in a referable artery, or both. Physiological derangement and cerebral oedema may be worthwhile targets for intervention to decrease the occurrence and clinical impact of cerebral infarction after SAH.

Early ischemic lesion on computed tomography: Predictor of poor outcome among survivors of aneurysmal subarachnoid hemorrhage

Article

Full-text available

Jan 2008
J NEUROSURG

Identifying ischemic lesions after subarachnoid hemorrhage (SAH) is important because the appearance of these lesions on follow-up imaging correlates with a poor outcome. The effect of ischemic lesions seen on computed tomography (CT) scans during the first days of treatment remains unknown, however. In 156 patients with SAH, clinical course and outcome, as well as the appearance of ischemic lesions on serial CT scans, were prospectively monitored for 3 months. At 3 months after SAH, magnetic resonance imaging was performed to detect permanent lesions that had not been visible on CT. Of the 53 patients with no lesions on any of the follow-up CT scans, four (8%) had a poor outcome. Of the 52 patients with a new hypodense lesion on the first postoperative day CT, 23 (44%) had a poor outcome. Among the remaining 51 patients with a lesion appearing later than the first postoperative morning, 10 (20%) had a poor outcome (p < 0.001). After adjusting for patient age; clinical condition on admission; amounts of subarachnoid, intracerebral, and intraventricular blood; and plasma glucose and D-dimer levels, a hypodense lesion on CT on the first postoperative morning was an independent predictor of poor outcome after SAH (odds ratio 7.27, 95% confidence interval 1.54-34.37, p < 0.05). A new hypodense lesion on early postoperative CT seems to be an independent risk factor for poor outcome after SAH, and this early lesion development may be more detrimental to clinical outcome than a later lesion occurrence.

Clinical utility and cost-effectiveness of CT-angiography in the diagnosis of nontraumatic subarachnoid hemorrhage

Article

Jul 2014

Introduction CT-angiography gains an increasing role in the initial diagnosis of patients with nontraumatic subarachnoid hemorrhage (SAH). However, the implementation of CT-angiography does not always exclude the necessity of conventional angiography. Our objective was to determine the practical utility and cost-effectiveness of CT-angiography. Methods All patients with nontraumatic subarachnoid hemorrhage admitted to our university hospital after implementation of CT-angiography between June 1, 2011 and June 30, 2012 were retrospectively analyzed in regard to factors of treatment flow, radiation exposure, harms of contrast medium loading, and diagnostic costs. A control group of the same size was assembled from previously admitted SAH patients, who did not undergo pretreatment CT-angiography. Furthermore, cost-effectiveness analysis was performed. Results The final analysis consisted of 93 patients in each group. Of 93 patients with pretreatment CT-angiography, 74 had to undergo conventional angiography for diagnostic and/or therapeutic purposes. CT-angiography had significant impact on the reduction of collective effective radiation dose by 4.419 mSv per person (p = 0.0002) and was not associated with additional harms. Despite the significantly earlier detection of aneurysms with CT-angiography (p

Early vs Delayed Cerebral Infarction After Aneurysm Repair After Subarachnoid Hemorrhage

Article

Jun 2013
NEUROSURGERY

Cerebral infarction is a major contributor to poor outcome after subarachnoid hemorrhage (SAH). While usually considered a complication of delayed cerebral ischemia (DCI), infarcts may also occur early, in relation to initial brain injury or aneurysm-securing procedures. We analyzed the relative frequency and volume of early vs. delayed infarcts after SAH and their relationship to hospital outcome. Retrospective review of consecutive patients admitted with aneurysmal SAH over 4-years who had follow-up brain imaging ≥7 days after admission. Imaging 24-48-hours after aneurysm-securing procedures was reviewed to classify infarcts seen on final imaging as early or delayed. Infarct volumes were measured by perimeter tracing and infarct burden calculated for each patient. 205 of 250 eligible patients had follow-up imaging. Infarcts were present in 61. Of these, 29 had early infarcts, 16 had delayed infarcts, and 5 had both early and delayed infarcts. 11 patients with infarcts lacked post-procedure CT; these were presumptively classified as late infarcts. Early and delayed infarcts contributed equally to infarct burden. Early infarcts were associated with aneurysm clipping (OR 4.2, 95% CI 1.8-9.5 compared to coiling), while delayed infarcts were almost always seen in association with angiographic vasospasm (OR 3.3, 1.5-7.3). Patients with early as well as late infarcts, especially those with infarct burden over 30 cm had worse hospital discharge disposition. Early infarction occurs frequently after SAH and contributes as much as DCI to infarct burden and hospital outcome. Efforts to better understand and modify contributors to early infarction appear warranted.

Delayed Cerebral Ischemia After Subarachnoid Hemorrhage A Systematic Review of Clinical, Laboratory, and Radiological Predictors

Article

Dec 2012
STROKE

Background and purpose: Established predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage are large amounts of extravasated blood and poor clinical condition on admission. The predictive value of other factors is uncertain. Methods: We searched MEDLINE (1960-2012) for clinical, laboratory, and radiological predictors routinely available within 72 hours after subarachnoid hemorrhage. The studies were categorized according to methodological quality. Crude data and effect estimates (odds ratio [OR], hazard ratios, and risk ratio) with 95% CI were extracted, (re-)calculated and pooled if possible. For every potential predictor we assessed all effect estimates on consistency (point estimates in equal direction) and clinical relevance (size and 95% CI). Results: Fifty-two studies on 33 potential predictors were included. There was strong evidence (≥3 high-quality studies) for a higher risk of delayed cerebral ischemia in smokers (pooled OR, 1.2; 95% CI, 1.1-1.4), and moderate evidence (2 high-quality studies) for an increased risk in patients with hyperglycemia (OR, 3.2; 1.8-5.8 and hazard ratios, 1.7; 1.1-2.5), hydrocephalus (OR, 1.3; 1.1-1.5 and OR, 2.6; 1.2-5.5), history of diabetes mellitus (pooled OR, 6.7; 1.7-26), and early systemic inflammatory response syndrome (pooled OR, 2.1; 1.4-3.3). Evidence was limited for increased risk in women (pooled OR, 1.3; 1.1-1.6) and in patients with history of hypertension (pooled OR, 1.5; 1.3-1.7). The evidence on initial loss of consciousness, history of migraine, previous use of selective serotonin reuptake inhibitors, hypomagnesemia, low hemoglobin, or high blood flow on early transcranial Doppler was also limited. Conclusions: There is strong evidence that smoking is a predictor of delayed cerebral ischemia. For several other potential predictions the evidence is moderate, limited, or inconsistent.

Cerebral inflammatory response and predictors of admission clinical grade after aneurysmal subarachnoid hemorrhage

Article

Jan 2010

Poor admission clinical grade is the most important determinant of outcome after aneurysmal subarachnoid hemorrhage (aSAH); however, little attention has been focused on independent predictors of poor admission clinical grade. We hypothesized that the cerebral inflammatory response initiated at the time of aneurysm rupture contributes to ultra-early brain injury and poor admission clinical grade. We sought to identify factors known to contribute to cerebral inflammation as well as markers of cerebral dysfunction that were associated with poor admission clinical grade. Between 1997 and 2008, 850 consecutive SAH patients were enrolled in our prospective database. Demographic data, physiological parameters, and location and volume of blood were recorded. After univariate analysis, significant variables were entered into a logistic regression model to identify significant associations with poor admission clinical grade (Hunt–Hess grade 4–5). Independent predictors of poor admission grade included a SAH sum score >15/30 (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.5–3.6), an intraventricular hemorrhage sum score >1/12 (OR 3.1, 95% CI 2.1–4.8), aneurysm size >10 mm (OR 1.7, 95% CI 1.1–2.6), body temperature ⩾38.3 °C (OR 2.5, 95% CI 1.1–5.4), and hyperglycemia >200 mg/dL (OR 2.7, 95% CI 1.6–4.5). In a large, consecutive series of prospectively enrolled patients with SAH, the inflammatory response at the time of aneurysm rupture, as reflected by the volume and location of the hemoglobin burden, hyperthermia, and perturbed glucose metabolism, independently predicts poor admission Hunt–Hess grade. Strategies for mitigating the inflammatory response to aneurysmal rupture in the hyper-acute setting may improve the admission clinical grade, which may in turn improve outcomes.

Angiographic Vasospasm Is Strongly Correlated With Cerebral Infarction After Subarachnoid Hemorrhage

Article

Feb 2011
STROKE

The long-standing concept that delayed cerebral infarction after aneurysmal subarachnoid hemorrhage results exclusively from large artery vasospasm recently has been challenged. We used data from the CONSCIOUS-1 trial to determine the relationship between angiographic vasospasm and cerebral infarction after subarachnoid hemorrhage. We performed a post hoc exploratory analysis of the CONSCIOUS-1 data. All patients underwent catheter angiography before treatment and 9±2 days after subarachnoid hemorrhage. CT was performed before and after aneurysm treatment, and 6 weeks after subarachnoid hemorrhage. Angiograms and CT scans were assessed by centralized blinded review. Angiographic vasospasm was classified as none/mild (0%-33% decrease in arterial diameter), moderate (34%-66%), or severe (≥67%). Infarctions were categorized as secondary to angiographic vasospasm, other, or unknown causes. Logistic regression was conducted to determine factors associated with infarction. Complete data were available for 381 of 413 patients (92%). Angiographic vasospasm was none/mild in 209 (55%) patients, moderate in 118 (31%), and severe in 54 (14%). Infarcts developed in 6 (3%) of 209 with no/mild, 12 (10%) of 118 patients with moderate, and 25 (46%) of 54 patients with severe vasospasm. Multivariate analysis found a strong association between angiographic vasospasm and cerebral infarction (OR, 9.3; 95% CI, 3.7-23.4). The significant association persisted after adjusting for admission neurological grade and aneurysm size. Method of aneurysm treatment was not associated with a significant difference in frequency of infarction. A strong association exists between angiographic vasospasm and cerebral infarction. Efforts directed at further reducing angiographic vasospasm are warranted.

Interobserver Agreement for the Assessment of Handicap in Stroke Patients

Article

Jun 1988

Interobserver agreement for the assessment of handicap in stroke patients was investigated in a group of 10 senior neurologists and 24 residents from two centers. One hundred patients were separately interviewed by two physicians in different combinations. The degree of handicap was recorded by each observer on the modified Rankin scale, which has six grades (0-5). The agreement rates were corrected for chance (kappa statistics). Both physicians agreed on the degree of handicap in 65 patients; they differed by one grade in 32 patients and by two grades in 3 patients. Kappa for all pairwise observations was 0.56; the value for weighted kappa (with quadratic disagreement weights) was 0.91. Our results confirm the value of the modified Rankin scale in the assessment of handicap in stroke patients; nevertheless, further improvements are possible.

Surgical Risk as Related to Time of Intervention in the Repair of Intracranial Aneurysms

Article

Feb 1968
J NEUROSURG

Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis

Article

May 1982

Sixty-eight patients with intraventricular hemorrhage (IVH) diagnosed by computed tomography (CT) were reviewed retrospectively to determine the etiology and prognosis, relationship to delayed hydrocephalus, and effect on neurological outcome. The most common causes were a ruptured aneurysm, trauma, and hypertensive hemorrhage. Ruptured aneurysms of the anterior communicating artery can often be predicted from the nonenhanced CT scan. The total mortality rate was 50%; however, 21% of patients returned to normal or had only mild disability. Patients in whom no cause was identified had a better prognosis. Delayed hydrocephalus was related to the effects of subarachnoid hemorrhage rather than obstruction of the ventricular system by blood. IVH per se is seldom a major factor in the neurological outcome.

Relation of Cerebral Vasospasm to Subarachnoid Hemorrhage Visualized by Computerized Tomographic Scanning

Article

Feb 1980

In 47 cases of verified ruptured saccular aneurysm, we investigated the relationship of the amount and distribution of subarachnoid blood detected by computerized tomography to the later development of cerebral vasospasm. When the subarachnoid blood was not detected or was distributed diffusely, severe vasospasm was almost never encounters (1 of 18 cases). In the presence of subarachnoid blood clots larger than 5 X 3 mm (measured on the reproduced images) or layers of blood 1 mm or more thick in fissures and vertical cisterns, severe spasm followed almost invariably (23 of 24 cases). There was an almost exact correspondence between the site of the major subarachnoid blood clots and the location of severe vasospasm. Every patient with severe vasospasm manifested delayed symptoms and signs. Excellent correlation existed between the particular artery in vasospasm and the delayed clinical syndrome. Severe vasospasm involved the anterior cerebral artery in 20 cases and the middle cerebral artery in only 14. As the grading system used is partly subjective, the findings should be regarded as preliminary. The results, if confirmed, indicate that blood localized in the subarachnoid space in sufficient amount at specific sites is the only important etiological factor in vasospasm. It should be possible to identify patients in jeopardy from vasospasm and institute early preventive measures. (Neurosurgery, 6: 1--9, 1980)

The ABCs of Measuring Intracerebral Hemorrhage Volumes

Article

Sep 1996

Hemorrhage volume is a powerful predictor of 30-day mortality after spontaneous intracerebral hemorrhage (ICH). We compared a bedside method of measuring CT ICH volume with measurements made by computer-assisted planimetric image analysis. The formula ABC/2 was used, where A is the greatest hemorrhage diameter by CT, B is the diameter 90 degrees to A, and C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness. The ICH volumes for 118 patients were evaluated in a mean of 38 seconds and correlated with planimetric measurements (R2 = 9.6). Interrater and intrarater reliability were excellent, with an intraclass correlation of .99 for both. We conclude that ICH volume can be accurately estimated in less than 1 minute with the simple formula ABC/2.

Predictors of Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage

Article

Aug 2004
STROKE

Clinical and radiologic predictors of cerebral infarction occurrence and location after aneurysmal subarachnoid hemorrhage have been seldom studied. We evaluated all patients admitted to our hospital with aneurysmal subarachnoid hemorrhage between 1998 and 2000. Cerebral infarction was defined as a new hypodensity located in a vascular distribution on computed tomography (CT) scan. Fifty-seven of 143 patients (40%) developed a cerebral infarction. On univariate analysis, occurrence of cerebral infarction was associated with a worse World Federation of Neurological Surgeons grade (P=0.01), use of ventriculostomy catheter (P=0.01), preoperative vasospasm (P=0.03), surgical clipping (P=0.02), symptomatic vasospasm (P<0.01), and vasospasm on transcranial Doppler ultrasonography (TCD) or repeat angiogram (P<0.01). On multivariable analysis, only presence of symptoms ascribed to vasospasm (P<0.01) and evidence of vasospasm on TCD or angiogram predicted cerebral infarction (P<0.01). TCD and angiogram agreed on the diagnosis of vasospasm in 73% of cases (95% CI, 63% to 81%), but the diagnostic accuracy of this combination of tests was suboptimal for the prediction of cerebral infarction occurrence (sensitivity, 0.72; specificity, 0.68; positive predictive value, 0.67; negative predictive value, 0.72). Location of the cerebral infarction on delayed CT was predicted by neurological symptoms in 74%, by aneurysm location in 77%, and by angiographic vasospasm in 67%. Evidence of vasospasm on TCD and angiogram is predictive of cerebral infarction on CT scan but sensitivity and specificity are suboptimal. Cerebral infarction location cannot be predicted in one quarter to one third of patients by any of the studied clinical or radiological variables.

Early Vasospasm on Admission Angiography in Patients with Aneurysmal Subarachnoid Hemorrhage Is a Predictor for In-Hospital Complications and Poor Outcome

Article

Dec 2004
STROKE

Early vasospasm (EVSP), defined here as arterial narrowing seen on diagnostic angiography within the first 48 hours of aneurysmal rupture, is a rarely reported and poorly defined phenomenon in patients with subarachnoid hemorrhage (SAH). The purpose of this study was to characterize EVSP in a large database of such patients. We analyzed the relationship of EVSP to clinical characteristics, in-hospital complications, and outcome at 3 months among 3478 patients entered into 4 prospective, randomized, double-blind, placebo-controlled trials of tirilazad conducted in neurosurgical centers around the world between 1991 and 1997. Three hundred thirty-nine (10%) of 3478 patients had EVSP. EVSP was significantly more likely in patients with poor neurological grade on admission, history of SAH, intracerebral hematoma, larger aneurysm, thick SAH on cranial computed tomography, and intraventricular hemorrhage. EVSP was not associated with delayed cerebral vasospasm. After adjustment for differences in admission characteristics, EVSP was associated with cerebral infarction (adjusted odds ratios [OR]=1.51; 95% CI, 1.18 to 1.94; P=0.001), neurological worsening (OR=1.41; 95% CI, 1.10 to 1.81; P=0.007), and unfavorable outcome (OR=1.51; 95% CI, 1.15 to 2.00; P=0.003). In addition, there was a trend for patients with increasingly severe EVSP to have unfavorable outcome (OR=1.84 for mild and OR=2.66 for moderate/severe EVSP). EVSP was seen in 10% of SAH patients and was predictive of cerebral infarction and neurological worsening as well as unfavorable outcome at 3 months. EVSP was not associated with late vasospasm. EVSP may be as important as delayed vasospasm in predicting complications and long-term morbidity in SAH patients.

Predictors of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage

Article

Apr 2007
NEUROSURGERY

Cerebral infarction would be expected to be associated with poor outcome after aneurysmal subarachnoid hemorrhage (SAH), although there are few data on which to base this assumption. The goals of this study were to determine the impact of cerebral infarction on outcome and to examine predictors of infarction in these patients. Univariate and multivariable statistical methods were used to examine the impact of cerebral infarction on the Glasgow Outcome Scale score 3 months after SAH among 3567 patients entered into four prospective, randomized, double-blind, placebo-controlled trials of tirilazad conducted in neurosurgical centers around the world between 1991 and 1997. Patient demographics, clinical variables, radiographic characteristics, and treatment variables associated with cerebral infarction were also determined by the same methods. Seven hundred and seven (26%) out of 2741 patients with complete data had cerebral infarction on computed tomographic scans 6 weeks after SAH. Multivariable logistic regression showed that cerebral infarction increased the odds of unfavorable outcome by a factor of 5.4 (adjusted odds ratio, 5.4; 95% confidence interval, 4.2-6.8; P < 0.0001), which was a higher odds ratio than all other factors associated with outcome. The proportion of explained variance in outcome was also highest for cerebral infarction and accounted for 39% of the explained variance. Multivariable analysis found that cerebral infarction was significantly associated with increasing patient age, worse neurological grade on admission, history of hypertension or diabetes mellitus, larger aneurysm, use of prophylactically or therapeutically induced hypertension, temperature more than 38 degrees C 8 days after SAH, and symptomatic vasospasm. Cerebral infarction was strongly associated with poor outcome after aneurysmal SAH. The most important potentially treatable factor associated with infarction was symptomatic vasospasm.

Cerebral infarction associated with acute subarachnoid hemorrhage

Article

Jul 2007

Cerebral infarction is a common complication of aneurysmal subarachnoid hemorrhage (SAH), but usually occurs several days after onset as a complication of vasospasm or aneurysm repair. The frequency, causes, and clinical impact of acute infarction associated with the primary hemorrhage are poorly understood. We evaluated the presence of cerebral infarction on admission CT in 487 patients admitted within 3 days of SAH onset to our center between July 1996 and September 2002. Infarctions due to angiography or treatment complications were rigorously excluded. Outcome at 3 months was assessed with the modified Rankin Scale. A total of 17 patients (3%) had acute infarction on admission CT; eight had solitary and nine had multiple infarcts. Solitary infarcts usually appeared in the vascular territory distal to the ruptured aneurysm, whereas multiple infarcts tended to be territorial and symmetric. Global cerebral edema (P < 0.001), coma on presentation (P = 0.001), intraventricular hemorrhage (P = 0.002), elevated APACHE-II physiological subscores (P = 0.026) and loss of consciousness at onset (P = 0.029) were associated with early cerebral infarction. Mortality (P = 0.003) and death or moderate-to-severe disability (mRS 4-6, P = 0.01) occurred more frequently in the early cerebral infarction group. Early cerebral infarction on CT is a rare but devastating complication of acute SAH. The observed associations with coma, global cerebral edema, intraventricular hemorrhage, and loss of consciousness at onset suggest that intracranial circulatory arrest may play a role in the pathogenesis of this disorder.

Predictors and impact of early cerebral infarction after aneurysmal subarachnoid hemorrhage

Abstract

No full-text available

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