Article
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Medical complications occur frequently after subarachnoid hemorrhage (SAH). Their impact on outcome remains poorly defined. Inception cohort study. Five-hundred eighty patients enrolled in the Columbia University SAH Outcomes Project between July 1996 and May 2002. Neurologic intensive care unit. Patients were treated according to standard management protocols. Poor outcome was defined as death or severe disability (modified Rankin score, 4-6) at 3 months. We calculated the frequency of medical complications according to prespecified criteria and evaluated their impact on outcome, using forward stepwise multiple logistic regression after adjusting for known predictors of poor outcome. Thirty-eight% had a poor outcome; mortality was 21%. The most frequent complications were temperature>38.3 degreesC (54%), followed by anemia treated with transfusion (36%), hyperglycemia>11.1 mmol/L (30%), treated hypertension (>160 mm Hg systolic; 27%), hypernatremia>150 mmol/L (22%), pneumonia (20%), hypotension (<90 mm Hg systolic) treated with vasopressors (18%), pulmonary edema (14%), and hyponatremia<130 mmol/L (14%). Fever (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.4; p=.02), anemia (OR, 1.8; 95% CI, 1.1-2.9; p=.02), and hyperglycemia (OR, 1.8; 95% CI, 1.1-3.0; p=.02) significantly predicted poor outcome after adjustment for age, Hunt-Hess grade, aneurysm size, rebleeding, and cerebral infarction due to vasospasm. Fever, anemia, and hyperglycemia affect 30% to 54% of patients with SAH and are significantly associated with mortality and poor functional outcome. Critical care strategies directed at maintaining normothermia, normoglycemia, and prevention of anemia may improve outcome after SAH.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... The impact of treatment on intensive care units (ICU) after SAH is also recognized to be a significant factor regarding the outcome after SAH [9,[16][17][18]. Typical SAH related complications like hydrocephalus, pneumonia and sepsis were detected as critical determinants of outcome [9,16,17]. ...
... Typical SAH related complications like hydrocephalus, pneumonia and sepsis were detected as critical determinants of outcome [9,16,17]. Critical care strategies are suggested which focus on maintaining normothermia, normoglycemia and prevention of anemia, as well as the implementation of infection-control measures in order to improve outcome after SAH [17,18]. ...
... This is in line with a publication of Wartenberg et al. who analyzed 580 patients and had similar outcome data to those of our cohort. Fever, anemia and hyperglycemia were associated with mortality and poor functional outcome, but not pneumonia and diabetes insipidus [18]. However, there are some publications which found a significant association between pneumonia and reduced outcome or poor quality of life [9,16,17]. ...
Article
Full-text available
Background This observational study was performed to show the impact of complications and interventions during neurocritical care on the outcome after aneurysmal subarachnoid hemorrhage (SAH). Methods We analyzed 203 cases treated for ruptured intracranial aneurysms, which were classified regarding clinical outcome after one year according to the modified Rankin Scale (mRS). We reviewed the data with reference to the occurrence of typical complications and interventions in neurocritical care units. Results Decompressive craniectomy (odds ratio 21.77 / 6.17 ; p < 0.0001 / p = 0.013), sepsis (odds ratio 14.67 / 6.08 ; p = 0.037 / 0.033) and hydrocephalus (odds ratio 3.71 / 6.46 ; p = 0.010 / 0.00095) were significant predictors for poor outcome and death after one year beside “World Federation of Neurosurgical Societies” (WFNS) grade (odds ratio 3.86 / 4.67 ; p < 0.0001 / p < 0.0001) and age (odds ratio 1.06 / 1.10 ; p = 0.0030 / p < 0.0001) in our multivariate analysis (binary logistic regression model). Conclusions In summary, decompressive craniectomy, sepsis and hydrocephalus significantly influence the outcome and occurrence of death after aneurysmal SAH.
... ÖZ (5).Bu olgu sunumunda başlangıç semptomu deliryum olan ve etiyolojide SAA ilişkili SAK saptanan olgunun klinik ve radyolojik özellikleri değerlendirilmiştir. ...
... Kan laboratuvar incelemelerinde beyaz küre (WBC)=10,7 K/uL (3,5-10,5), hemoglobin=12,2 g/dL (13,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)5), trombosit=248 K/uL (150-450), B12=189,1 pg/mL (191-663), folik asit=5,76 ng/mL (3,1-17,5) bulundu. Kan şekeri=121 mg/dL (70-110), üre=38 mg/dL (18-55), HbA1C=5,8 (4-6) olarak belirlendi. ...
... Kan laboratuvar incelemelerinde beyaz küre (WBC)=10,7 K/uL (3,5-10,5), hemoglobin=12,2 g/dL (13,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)5), trombosit=248 K/uL (150-450), B12=189,1 pg/mL (191-663), folik asit=5,76 ng/mL (3,1-17,5) bulundu. Kan şekeri=121 mg/dL (70-110), üre=38 mg/dL (18-55), HbA1C=5,8 (4-6) olarak belirlendi. ...
... Endovasküler tedavi veya klipleme kararının verilebilmesi için DSA gerekli olabilmektedir. Hiperglisemi klinik sonlanımı etkilemektedir (29). Hipergliseminin düzeltilmesinin klinik sonlanıma katkı sağlayıp sağlamadığı tartışmalı olmakla beraber 10 mmol/l (180 mg/dL) üzerindeki glukoz tedavi edilmelidir (30). ...
... (Kanıt düzeyi III/ Öneri düzeyi C) 4. Vücut Sıcaklığı: Ağrı için verilen parasetamol tedavisine rağmen SAK hastalarının yaklaşık yarısında ateş yükselebilir. Ateş, bağımsız olarak klinik sonlanıma etki etmektedir (29). Ateş tedavi edilmelidir fakat bu tedavinin klinik sonlanıma olan etkisi bilinmemektedir. ...
... Fever of both infectious and noninfectious origin is a common complication of SAH [47][48][49][50], particularly in those with a poor neurological status on admission, and was associated with poor outcomes, such as hospital mortality, reduced functional recovery, increase length of stay and risk of vasospasm or delayed cerebral ischemia [9,48,[51][52][53][54]. Moreover, even a single episode of fever was associated with poor neurological outcome in SAH patients with good clinical status on admission MCC 280212 [49]. ...
Article
Purpose of review: Fever is common after acute brain injury and is associated with poor prognosis in this setting. Recent findings: Achieving normothermia is feasible in patients with ischemic or hemorrhagic stroke, subarachnoid hemorrhage and traumatic brain injury. Pharmacological strategies (i.e. paracetamol or nonsteroidal anti-inflammatory drugs) are frequently ineffective and physical (i.e. cooling devices) therapies are often required. There are no good quality data supporting any benefit from therapeutic strategies aiming at normothermia in all brain injured patients when compared with standard of care, where mild-to-moderate fever is tolerated. However, recent guidelines recommended fever control in this setting. Summary: As fever is considered a clinically relevant secondary brain damage, we have provided an individualized therapeutic approach to treat it in brain injured patients, which deserved further validation in the clinical setting.
... The variation in management reported by respondents to our questionnaire is consistent with that reported by other studies of diagnosis and management of hyponatraemia after SAH. [16][17][18] Many of these studies have been observational, small, retrospective, at risk of bias, and used variable outcome measures which has hindered meta-analysis. 19 Guidelines ESO guidelines for SAH recommend monitoring serum sodium at least every other day. ...
Article
Full-text available
Background Hyponatraemia is a common complication of aneurysmal subarachnoid haemorrhage (SAH). We aimed to determine current neurosurgical practice for the identification, investigation and management of hyponatraemia after SAH. Methods An online questionnaire was completed by UK and Irish neurosurgical trainees and consultant collaborators in the Sodium after Subarachnoid Haemorrhage (SaSH) audit. Results Between August 2019 and June 2020, 43 responses were received from 31 of 32 UK and Ireland adult neurosurgical units (NSUs). All units reported routine measurement of serum sodium either daily or every other day. Most NSUs reported routine investigation of hyponatraemia after SAH with paired serum and urinary osmolalities (94%), urinary sodium (84%), daily fluid balance (84%), but few measured glucose (19%), morning cortisol (13%), or performed a short Synacthen test (3%). Management of hyponatraemia was variable, with units reporting use of oral sodium supplementation (77%), fluid restriction (58%), hypertonic saline (55%), and fludrocortisone (19%). Conclusions Reported assessment of serum sodium after SAH was consistent between units, whereas management of hyponatraemia varied. This may reflect the lack of a specific evidence-base to inform practice.
... Au cours de HSA, dans une série de 298 patients, une hyper natrémie était présente chez 19% des patients [50], cela était confirmé dans une cohorte de 580 patients comportant 22% d'hyper natrémie (78,57% dans notre série). (51) Dans une étude de 130 patients avec TCG, une hyper natrémie était présente chez 51% des patients. Cette proportion reflétant une intrication évidente avec les pratiques de soins, notamment l'osmothérapie par mannitol ou le SS hypertonique [79], qu'il s'agissait de patient avec TCG ou HSA. ...
... • Comorbidities: Medical comorbidities and their severity are critical determinants of patient outcome and should be taken into account in prognostic tools [124][125][126]. Premorbid cognition, mental health, and personality are under-ascertained yet may similarly contribute to patient-centered outcomes [127,128]. ...
Article
Full-text available
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
... Until now, there are large numbers of studies focusing on the impact of anaemia and RBC transfusions in subarachnoid haemorrhage or traumatic brain injury [11][12][13][14]. In meningiomas so far, the impact of anaemia and RBC transfusions has only been investigated in a small patient population with skull base meningiomas [10]. ...
Article
Full-text available
Transfusion of red blood cells (RBC) in patients undergoing major elective cranial surgery is associated with increased morbidity, mortality and prolonged hospital length of stay (LOS). This retrospective single center study aims to identify the clinical outcome of RBC transfusions on skull base and non-skull base meningioma patients including the identification of risk factors for RBC transfusion. Between October 2009 and October 2016, 423 patients underwent primary meningioma resection. Of these, 68 (16.1%) received RBC transfusion and 355 (83.9%) did not receive RBC units. Preoperative anaemia rate was significantly higher in transfused patients (17.7%) compared to patients without RBC transfusion (6.2%; p = 0.0015). In transfused patients, postoperative complications as well as hospital LOS was significantly higher (p < 0.0001) compared to non-transfused patients. After multivariate analyses, risk factors for RBC transfusion were preoperative American Society of Anaesthesiologists (ASA) physical status score (p = 0.0247), tumor size (p = 0.0006), surgical time (p = 0.0018) and intraoperative blood loss (p < 0.0001). Kaplan-Meier curves revealed significant influence on overall survival by preoperative anaemia, RBC transfusion, smoking, cardiovascular disease, preoperative KPS ≤ 60% and age (elderly ≥ 75 years). We concluded that blood loss due to large tumors or localization near large vessels are the main triggers for RBC transfusion in meningioma patients paired with a potential preselection that masks the effect of preoperative anaemia in multivariate analysis. Further studies evaluating the impact of preoperative anaemia management for reduction of RBC transfusion are needed to improve the clinical outcome of meningioma patients.
... Cardiopulmonary dysfunction is common after aSAH and is related to catecholamine release and sympathetic overstimulation [53][54][55]. Higher grade aSAH have an increased risk of cardiopulmonary dysfunction. The cardiac dysfunction can manifest as changes in the electrocardiogram, for example, T-wave inversion, ST depressions, or even ST elevations among others [55,56]. ...
Article
Full-text available
Purpose of Review Aneurysmal subarachnoid hemorrhage remains a devastating disease process despite medical advances made over the past 3 decades. Much of the focus was on prevention and treatment of vasospasm to reduce delayed cerebral ischemia and improve outcome. In recent years, there has been a shift of focus onto early brain injury as the precursor to delayed cerebral ischemia. This review will focus on the most recent data surrounding the pathophysiology of aneurysmal subarachnoid hemorrhage and current management strategies. Recent Findings There is a paucity of successful trials in the management of subarachnoid hemorrhage likely related to the targeting of vasospasm. Pathophysiological changes occurring at the time of aneurysmal rupture lead to early brain injury including cerebral edema, inflammation, and spreading depolarization. These events result in microvascular collapse, vasospasm, and ultimately delayed cerebral ischemia. Summary Management of aneurysmal subarachnoid hemorrhage has remained the same over the past few decades. No recent trials have resulted in new treatments. However, our understanding of the pathophysiology is rapidly expanding and will advise future therapeutic targets.
... Common post-traumatic complications include fever, hyperglycemia, anemia and hypernatremia. Unsurprisingly, these findings are strongly associated with poor outcome and increased mortality (40). ...
Article
Full-text available
Moderate and severe traumatic brain injury (TBI) are major causes of disability and death. In addition, when TBI occurs during pregnancy, it can lead to miscarriage, premature birth, and maternal/fetal death, engendering clinical and ethical issues. Several recommendations have been proposed for the management of TBI patients; however, none of these have been specifically applied to pregnant women, which often have been excluded from major trials. Therefore, at present, evidence on TBI management in pregnant women is limited and mostly based on clinical experience. The aim of this manuscript is to provide the clinicians with practical suggestions, based on 10 rules, for the management of moderate to severe TBI during pregnancy. In particular, we firstly describe the pathophysiological changes occurring during pregnancy; then we explore the main strategies for the diagnosis of TBI taking in consideration the risks related to mother and fetus, and finally we discuss the most appropriate approaches for the management in this particular condition. Based on the available evidence, we suggest a stepwise approach consisting of different tiers of treatment and we describe the specific risks according to the severity of the neurological and systemic conditions of both fetus and mother in relation to each trimester of pregnancy. The innovative feature of this approach is the fact that it focuses on the vulnerability and specificity of this population, without forgetting the current knowledge on adult non-pregnant patients, which has to be applied to improve the quality of the care process.
... In brain injury patients, respiratory failure is the most common non-neurologic organ system failure. It is associated with poor neurological recovery and death in this population [16][17][18]. ...
Article
In the intensive care unit (ICU), weaning from mechanical ventilation follows a step-by-step process that has been well established in the general ICU population. However, little data is available in brain injury patients, who are often intubated to protect airways and prevent central hypoventilation. In this narrative review, we describe the general principles of weaning and how these principles can be adapted to brain injury patients. We focus on three major issues regarding weaning from mechanic ventilation in brain injury patients: (1) sedation protocol, (2) weaning and extubation protocol and criteria, (3) criteria, timing and technique for tracheostomy.
... Outcomes after SAH depend mainly on the initial severity of the hemorrhage. Nonneurological complications can also contribute to a worse prognosis [3,4]. ...
Article
Introduction: Electrolyte disturbances, such as dysnatremia, hypokalemia, and hypomagnesemia, are frequently observed during acute spontaneous subarachnoid hemorrhage (sSAH). However, there are limited data concerning hypophosphatemia. Objective: To analyze the frequency of phosphate (Pi) disturbances in sSAH patients and assess their influence on neurological outcomes compared with that in patients without sSAH. Methods: We conducted a retrospective study of patients with sSAH admitted to a neurocritical care unit in two years. We also included nonneurocritical patients admitted to a general intensive care unit (ICU). Serum Pi levels and daily Pi repletion data were collected during the first 10 days after admission. The primary endpoint was neurologic outcome using the Glasgow Outcome Scale at six months (GOS-6M) and the Glasgow Coma Scale at ICU discharge (GCS-ICUd). The effect of phosphatemia variability on mortality and ICU length of stay (ICU-LOS) was also analyzed. Results: Patients with sSAH had lower mean Pi level and median Pi dose repletion than that of nonneurocritical patients (3.1 ± 0.4 vs. 3.9 ± 1.3, p < 0.001). In the sSAH group, patients with hypophosphatemia had lower GCS-ICUd (12 ± 3.3 vs. 14 ± 2.4). Also, GOS-6M was lower in patients with hypophosphatemia but was not statistically significant (p = 0.09). By contrast, a higher mean Pi level in nonneurocritical patients was significantly associated with higher ICU mortality (4.8 ± 1.6 mg/dL vs. 3.6 ± 1.0 mg/dL, p = 0.003) and higher ICU-LOS (r = 0.231, p = 0.028). In the sSAH group, we found the opposite. In a multivariate analysis of the sSAH group, the increase in the Pi level was associated with higher GCS-ICUd (unstandardized coefficient in multiple linear regression [B] 1.79; 95% CI 0.43-3.15). The opposite was found in nonneurocritical patients. A Pi concentration higher than 2.5 mg/dL was associated with a better GCS-ICUd. We also found that creatinine, urea, chloride, need for Pi substitution, therapy intensity level, and pH were independent predictors of the mean Pi level during ICU stay in the sSAH group. Conclusions: Patients with sSAH had lower mean Pi levels and required significantly higher daily Pi replacement compared with those of nonneurocritical patients. Since hypophosphatemia may be associated with poor neurological outcomes, patients with sSAH need cautious phosphate repletion.
... 3 Relationship between blood HGB concentration on admission and incidence of in-hospital DCI and DVT before and after PSM whether blood HGB concentrations can predict patients' prognosis is unclear. Previous studies demonstrated that anemia was associated with worse outcomes in aSAH patients [18,43]. Therefore, we excluded patients who were anemic on admission to investigate whether blood HGB concentrations in nonanemic patients were associated with outcomes. ...
Article
Full-text available
Hemoglobin (HGB), a potent spasmogen, may cause irreversible damage to the brain after aneurysm rupture. However, there is no clinical evidence to reveal the relationship between blood HGB concentrations on admission and the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively reviewed all aSAH patients admitted to our institution between January 2015 and December 2020. Functional outcome was assessed at 90 days after discharge using the modified Rankin scale (mRS). Independent risk factors associated with 90-day unfavorable outcomes were derived from a forward stepwise multivariate analysis. Receiver operating characteristic curve analysis was conducted to identify the best cutoff value of HGB to discriminate 90-day unfavorable outcomes. Then, patients were divided into two groups according to the cutoff value of HGB, and to account for imbalances in baseline characteristics, propensity score matching (PSM) was carried out to assess the impact of HGB on in-hospital complications. A total of 800 aSAH patients without anemia on admission were retrospectively enrolled in this study. Elevated blood HGB (OR = 1.02, 95% CI = 1.00-1.03, p = 0.018) on admission was identified as an independent risk factor associated with 90-day unfavorable outcomes, and the cutoff value was 149.5 g/L. After PSM, patients with an HGB > 149.5 g/L had a higher incidence of in-hospital delayed cerebral ischemia (DCI) (33.9% vs. 22.0%, p = 0.013) and deep vein thrombosis (DVT) (11.9% vs. 4.0%, p = 0.006). Patients with a blood HGB > 149.5 g/L on admission might develop more DCI and DVT during hospitalization, leading to 90-day unfavorable outcomes in aSAH patients. ClinicalTrials.gov Identifier: NCT04785976. 2021/03/05, retrospectively registered.
... The retrospective cohort study of Chang et al [21] concluded that brainstem compression is the predictor of mortality within 6-months in patients with spontaneous cerebellar hemorrhage, which is consistent with our findings. Prognosis of the patients with perioperative mechanical ventilation largely depends on the comorbidities [22]. Pneumonia or other pulmonary complications are often the cause of mechanical ventilation in the cerebrovascular patients following surgeries. ...
Article
Background: The prognosis of cerebrovascular diseases treated with mechanical ventilation during perioperative has not been clearly reported. Aim: To analyze mortality and functional disability and to determine predictors of unfavorable outcome in the patients with cerebrovascular diseases treated with mechanical ventilation. Methods: A retrospective follow-up study of 111 cerebrovascular disease patients who underwent mechanical ventilation during the perioperative period in the First Hospital of Jilin University from June 2016 to June 2019 was performed. Main measurements were mortality and functional outcome in-hospital and after 3-month follow-up. According to the modified rankin scale (mRS), the functional outcome was divided into three groups: Good recovery (mRS ≤ 3), severe disability (mRS = 4 or 5) and death (mRS = 6). Univariate analysis was used to compare the differences between three functional outcomes. Multivariate logistic regression analysis was used to for risk factors of mortality and severe disability. Results: The average age of 111 patients was 56.46 ± 12.53 years, 59 (53.15%) were males. The mortality of in-hospital and 3-month follow-up were 36.9% and 45.0%, respectively. Of 71 discharged patients, 46.47% were seriously disabled and 12.67% died after three months follow-up. Univariate analysis showed that preoperative glasgow coma scale, operation start time and ventilation reasons had statistically significant differences in different functional outcomes. Multiple logistic regression analysis showed that the cause of ventilation was related to the death and poor prognosis of patients with cerebrovascular diseases. Compared with brainstem compression, the risk of death or severe disability of pulmonary disease, status epilepticus, impaired respiratory center function, and shock were 0.096 (95%CI: 0.028-0.328), 0.026 (95%CI: 0.004-0.163), 0.095 (95%CI: 0.013-0.709), 0.095 (95%CI: 0.020-0.444), respectively. Conclusion: The survival rate and prognostic outcomes of patients with cerebrovascular diseases treated with mechanical ventilation during the perioperative period were poor. The reason for mechanical ventilation was a statistically significant predictor for mortality and severe disability.
... Thus, in neurosurgical patients, preoperative anaemia has been shown to be an independent risk factor for postoperative mortality and increased risk of RBC transfusion [24]. Anaemia is common in aSAH patients [8,14,30,33] and in ICH patients [16,17]. In this study, the prevalence of preoperative anaemia in both groups (aSAH 28.3% and ICH 40.9%) was higher than described in previous publications (aSAH 5.5% and ICH 24.1-25.8%) ...
Article
Full-text available
Purpose Anaemia is common in patients presenting with aneurysmal subarachnoid (aSAH) and intracerebral haemorrhage (ICH). In surgical patients, anaemia was identified as an idenpendent risk factor for postoperative mortality, prolonged hospital length of stay (LOS) and increased risk of red blood cell (RBC) transfusion. This multicentre cohort observation study describes the incidence and effects of preoperative anaemia in this critical patient collective for a 10-year period. Methods This multicentre observational study included adult in-hospital surgical patients diagnosed with aSAH or ICH of 21 German hospitals (discharged from 1 January 2010 to 30 September 2020). Descriptive, univariate and multivariate analyses were performed to investigate the incidence and association of preoperative anaemia with RBC transfusion, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Results A total of n = 9081 patients were analysed (aSAH n = 5008; ICH n = 4073). Preoperative anaemia was present at 28.3% in aSAH and 40.9% in ICH. RBC transfusion rates were 29.9% in aSAH and 29.3% in ICH. Multivariate analysis revealed that preoperative anaemia is associated with a higher risk for RBC transfusion (OR = 3.25 in aSAH, OR = 4.16 in ICH, p < 0.001), for in-hospital mortality (OR = 1.48 in aSAH, OR = 1.53 in ICH, p < 0.001) and for several postoperative complications. Conclusions Preoperative anaemia is associated with increased RBC transfusion rates, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Trial registration ClinicalTrials.gov, NCT02147795, https://clinicaltrials.gov/ct2/show/NCT02147795
Article
Introduction The benefits of correcting anemia using red blood cell transfusion (RBCT) after subarachnoid hemorrhage (SAH) are controversial. We aimed to evaluate the role of anemia and RBCT on neurological outcome after SAH using a restrictive transfusion policy. Objective We reviewed our institutional database of adult patients admitted to the Department of Intensive Care (ICU) after non-traumatic SAH over a 5-year period. We recorded hemoglobin (Hb) levels daily for a maximum of 20 days, as well as the use of RBCT. Unfavorable neurological outcome (UO) was defined as a Glasgow Outcome Score of 1-3 at 3 months. Results Among 270 eligible patients, UO was observed in 40% of them. Patients with UO had lower Hb over time and received RBCT more frequently than others (15/109, 14% vs. 6/161, 4% - p<0.01). Pre-RBCT median Hb values were similar in UO and FO patients (6.9 [6.6-7.1] vs. 7.3 [6.3-8.1] g/dL – p=0.21). The optimal discriminative Hb threshold for UO was 9 g/dL. In a multivariable analysis, neither anemia nor RBCT were independently associated with UO. Conclusion In this retrospective single center study using a restrictive strategy of RBCT in SAH patients was not associated with worse outcome in 3 months.
Article
Objective: to study cognitive functions in patients in the long-term period of microsurgical treatment of cerebral aneurysms. Materials methods: on the basis of the University Clinic of the Moscow State Medical University. A.I. Evdokimov and the Department of Emergency Neurosurgery of the N.V. Sklifosovsky Research Institute for Emergency Medicine, an analysis of cognitive functions was carried out in 212 patients operated on by a microsurgical method since 2013. Results: in the long-term period of surgical treatment of cerebral aneurysms, cognitive impairments of varying severity were detected in 78 patients (37 %). The main factors negatively affecting cognitive functions were the severity of the patient’s condition before surgery, corresponding to Hunt-Kosnik III–V, the age of patients over 60 years old, body mass index over 30, localization of the aneurysm in the basin of the anterior cerebral artery and vertebrobasilar basin, patients’ condition discharge according to the Glasgow Grade IV–III Outcome Scale. No significant dependence of cognitive impairment on the severity of subarachnoid hemorrhage and the gender of patients was found. On the contrary, the severity of anxiety and depression, which was assessed on the HADS scale, was twice as likely to be observed in female patients as compared with male patients. Conclusion: it is obvious that the persistence of cognitive deficit and mental disorders, in the form of anxiety and depression, in the long-term period of surgical treatment of cerebral aneurysms dictates the need for long-term dispensary observation and correction of the revealed disorders.
Objective: Rebleeding of aneurysmal subarachnoid hemorrhage (aSAH) is one of the significant risk factors for poor clinical outcome. The rebleeding risk is the highest during the acute phase with an approximate rebleeding rate of 9-17% within the first 24 h. Theoretically, general anesthesia can stabilize a patient's vital signs; however, its effectiveness as initial management for preventing post-aSAH rebleeding remains unclear. The purpose of this study was to determine the feasibility and safety of ultra-early general anesthesia induction for reducing the rebleeding rates among patients with aSAH. Materials and methods: We retrospectively evaluated patients with aSAH who were admitted to our department between January 2013 and December 2019. All the patients underwent ultra-early general anesthesia induction as initial management regardless of their severity. We evaluated the rebleeding rate before definitive treatment, factors influencing rebleeding, and general anesthesia complications. Results: We included 191 patients with two-third of them having a poor clinical grade (World Federation of Neurological Society [WFNS] grade IV or V). The median duration from admission to general anesthesia induction was 22 min. Rebleeding before definitive treatment occurred in nine patients (4.7%). There were significant differences in the Glasgow Coma Scale score (p = 0.047), WFNS grade (p = 0.02), and dissecting aneurysm (p <0.001) between the rebleeding and non-rebleeding patients. There were no cases of unsuccessful tracheal intubation or rebleeding during general anesthesia induction. Conclusion: Ultra-early general anesthesia induction could be performed safely in patients with aSAH, regardless of the WFNS grade; moreover, it resulted in lower rebleeding rate than that reported in previous epidemiological reports.
Article
There is no unified management of patients with the consequences of subarachnoid hemorrhage in the long term. Purpose of the study. To study the nature and severity of SAH, the clinical manifestation of hemorrhage, the choice of the intervention technique in the acute period of the disease for the long-term results of the treatment of aneurysms. Materials and methods. In the long-term period, at an average time of 3.5 years after aneurysmal subarachnoid hemorrhage, 100 patients were examined who underwent microsurgical intervention (n = 48), endovascular exclusion of the aneurysm from the bloodstream (n = 14), simultaneous intervention, including microsurgical intervention and extra-intracranial vascular bypass (n = 23), as well as microsurgical intervention followed by the introduction of a fibrinolytic agent into the subarachnoid space (n = 15). Results. Risk factors for unfavorable clinical recovery of patients, as well as the development of cognitive and mental disorders, were: intracerebral hematoma, dislocation syndrome, duration of temporary clipping more than 7 minutes, the volume of intraoperative blood loss of more than 300 ml. The best functional recovery in the long-term period was noted in patients who underwent microsurgical clipping of the aneurysm, supplemented by surgical revascularization (p = 0.003). Conclusion. The results of our study demonstrated the persistence of the consequences of surgical intervention for the rupture of cerebral aneurysms for a long time, which necessitates long-term observation of patients, the development of individual programs of physical and psychological rehabilitation, and clinical examination of persons at high risk.
Article
The work is devoted to assessing the results of the analysis of world literature for a period of more than 50 years: it reflects the data on the nature of the occurrence of mental disorders developing in patients with tumors of the chiasmal-sellar region against the background of water-electrolyte disorders both before and after surgery. The presented data shed light on the occurrence of the variants of mental disorders in such a specific category of neurosurgical patients, which may allow the clinician to timely determine the appropriate treatment tactics and reduce the severity of complications in the postoperative period.
Article
The article covers the current concepts of cerebral edema development, the mechanisms of cerebral oxygenation and perfusion impairments, as well as delayed morphological and cognitive disorders in non-traumatic subarachnoid hemorrhage due to the rupture of intracranial aneurysms.
Article
OBJECTIVE More than 10 years have passed since the two best-known clinical trials of ruptured aneurysms (International Subarachnoid Aneurysm Trial [ISAT] and Barrow Ruptured Aneurysm Trial [BRAT]) indicated that endovascular coiling (EC) was superior to surgical clipping (SC). However, in recent years, the development of surgical techniques has greatly improved; thus, it is necessary to reanalyze the impact of the differences in treatment modalities on the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS The authors retrospectively reviewed all aSAH patients admitted to their institution between January 2015 and December 2020. The functional outcomes at discharge and 90 days after discharge were assessed using the modified Rankin Scale (mRS). In-hospital complications, hospital charges, and risk factors derived from multivariate logistic regression were analyzed in the SC and EC groups after 1:1 propensity score matching (PSM). The area under the receiver operating characteristic curve was used to calculate each independent predictor’s prediction ability between treatment groups. RESULTS A total of 844 aSAH patients were included. After PSM to control for sex, aneurysm location, Hunt and Hess grade, World Federation of Neurosurgical Societies (WFNS) grade, modified Fisher Scale grade, and current smoking and alcohol abuse status, 329 patients who underwent SC were compared with 329 patients who underwent EC. Patients who underwent SC had higher incidences of unfavorable discharge and 90-day outcomes (46.5% vs 33.1%, p < 0.001; and 19.6% vs 13.8%, p = 0.046, respectively), delayed cerebral ischemia (DCI) (31.3% vs 20.1%, p = 0.001), intracranial infection (20.1% vs 1.2%, p < 0.001), anemia (42.2% vs 17.6%, p < 0.001), hypoproteinemia (46.2% vs 21.6%, p < 0.001), and pneumonia (33.4% vs 24.9%, p = 0.016); but a lower incidence of urinary tract infection (1.2% vs 5.2%, p = 0.004) and lower median hospital charges ($12,285 [IQR $10,399–$15,569] vs $23,656 [IQR $18,816–$30,025], p < 0.001). A positive correlation between the number of in-hospital complications and total hospital charges was indicated in the SC (r = 0.498, p < 0.001) and EC (r = 0.411, p < 0.001) groups. The occurrence of pneumonia and DCI, WFNS grade IV or V, and age were common independent risk factors for unfavorable outcomes at discharge and 90 days after discharge in both treatment modalities. CONCLUSIONS EC shows advantages in discharge and 90-day outcomes, in-hospital complications, and the number of risk factors but increases the economic cost on patients during their hospital stay. Severe in-hospital complications such as pneumonia and DCI may have a long-lasting impact on the prognosis of patients.
Article
Lipocalin-2 mediates neuro-inflammation and iron homeostasis in vascular injuries of the central nervous system (CNS) and is upregulated in extra-CNS systemic inflammation. We postulate that cerebrospinal fluid (CSF) and blood lipocalin-2 levels are associated with markers of inflammation and functional outcome in subarachnoid hemorrhage (SAH). We prospectively enrolled 67 SAH subjects, serially measured CSF and plasma lipocalin-2, matrix metallopeptidase 9 (MMP-9), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) on post-SAH days 1-5 and assessed outcome by modified Rankin Scale (mRS) every 3 months. Unfavorable outcome is defined as mRS > 2. Twenty non-SAH patients undergoing lumbar drain trial were enrolled as controls. Lipocalin-2 was detectable in the CSF and significantly higher in SAH compared to controls (p < 0.0001). Higher CSF LCN2 throughout post-SAH days 1-5 was associated with unfavorable outcome at 3 (p = 0.0031) and 6 months (p = 0.014). Specifically, higher CSF lipocalin-2 on post-SAH days 3 (p = 0.036) and 5 (p = 0.016) were associated with unfavorable 3-month outcome. CSF lipocalin-2 levels positively correlated with CSF IL-6, TNF-α and MMP-9 levels. Higher plasma lipocalin-2 levels over time were associated with worse 6-month outcome. Additional studies are required to understand the role of lipocalin-2 in SAH and to validate CSF lipocalin-2 as a potential biomarker for SAH outcome.
Article
Objective: Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients. Data sources: We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies. Study selection: English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence. Data extraction: Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed. Data synthesis: Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes. Conclusions: Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways.
Article
Subarachnoid hemorrhage (SACH) is one of the most severe types of strokes accompanied by high mortality and disability. It is known that half of the patients who underwent SACH retain incomplete functional recovery and cognitive impairment; however, the predictors of these changes and their structure have not been sufficiently studied. Objective. To study the long-term results of surgical treatment in patients operated on for cerebral aneurysms and their effect on functional recovery, as well as restoration of cognitive functions and social adaptation in the long-term period. Material and methods. A multivariate regression analysis of the long-term results of surgical treatment of 123 patients for cerebral aneurysms was carried out (on average, 2.3 years after microsurgical clipping of the aneurysms). In the long-term period a clinical neurological study was carried out that included an assessment of the disability value (using the Bartel index and the modified Rankin scale), cognitive (using the MMSE test) and mental functions (using the HADS scale). Results. Long-term adverse outcomes were more frequent in patients operated on in the acute period of SACH compared with patients operated on in the «cold» period for an un-ruptured aneurysm. Severe condition on admission according to the Hunt - Hess scale was associated with disability in the long-term period after the intervention (p=0.05). An inverse correlation (p<0.05) was found between age at the time of rupture of the aneurysm and cognitive function according to the MMSE scale: with an increase in age by 1 year the score decreased by 0.13 points. A relationship was established between the level of anxiety of depression on the HADS scale and the presence of intracerebral hemorrhage (ICH): in female patients with ICH the level of anxiety and depression increased by 7 points compared with patients diagnosed with other forms of hemorrhage (p<0.05). In patients with ICH at the onset of the disease the probability of hypertension development in the long-term period increased (p<0.05). Among the risk factors the arterial hypertension (in 65% of cases) and smoking (45%) prevailed that persisted with a high frequency in the longterm period after intervention. Disability in the long-term period was established in 48 (39%) patients; 55 (44.7%) patients were unable to fulfill their professional duties (37 patients operated on for rupture of cerebral aneurysms, 18 - for aneurysms without rupture). Male patients operated on for un-ruptured cerebral aneurysm showed a tendency towards a more pronounced disability level and dependence on others. Conclusion. Symptoms of disability, dependence in everyday life on others, impaired cognitive functions, changes in the psychoemotional sphere persist for a long time in patients who underwent intervention for cerebral aneurysms that necessitates dispensary observation. Rehabilitation of patients is a complex problem; the neurologists should not only take part in rehabilitation but also rehabilitation specialists, occupational therapists, speech therapists, neuropsychologists, and social workers.
Article
Patients with poor-grade subarachnoid hemorrhage have a very poor prognosis, especially those with cardiopulmonary arrest and/or bilateral dilated pupils. Therapeutic indications for patients with poor-grade subarachnoid hemorrhage vary depending on the institution; however, we perform clipping or coil embolization in these patients with very poor-grade subarachnoid hemorrhage if their vital signs are stable at the time of admission. In this study, we summarize the outcomes of 31 patients with poor-grade subarachnoid hemorrhage seen between January 2015 and April 2017. Among the 31 patients, 13 patients had cardiopulmonary arrest at the time of admission and/or prehospital, and 15 patients had bilateral dilated pupils. Among these 13 patients with cardiopulmonary arrest, seven patients underwent clipping or coil embolization because their vital signs could be stabilized. The functional outcomes of these seven patients were very poor: mRS 1 (1 patient), mRS 4 (1 patient), and mRS 5 (5 patients); however, all of these patients survived 30 days after the subarachnoid hemorrhage onset. Meanwhile, the other nine patients with unstable vital signs and who could therefore not undergo clipping or coil embolization died within 30 days after the subarachnoid hemorrhage onset. In conclusion, although the functional outcomes of patients with poor grade subarachnoid hemorrhage and cardiopulmonary arrest were very poor, a minority of these patients had good functional outcomes.
Article
Background: Multiple studies demonstrate that fever/elevated temperature is associated with poor outcomes in patients with vascular brain injury; however, there are no conclusive studies that demonstrate that fever prevention/controlled normothermia is associated with better outcomes. The primary objective of the INTREPID (Impact of Fever Prevention in Brain-Injured Patients) trial is to test the hypothesis that fever prevention is superior to standard temperature management in patients with acute vascular brain injury. Methods: INTREPID is a prospective randomized open blinded endpoint study of fever prevention versus usual care in patients with ischemic or hemorrhagic stroke. The fever prevention intervention utilizes the Arctic Sun System and will be compared to standard care patients in whom fever may spontaneously develop. Ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage patients will be included within disease-specific time-windows. Both awake and sedated patients will be included, and treatment is initiated immediately upon enrollment. Eligible patients are expected to require intensive care for at least 72 h post-injury, will not be deemed unlikely to survive without severe disability, and will be treated for up to 14 days, or until deemed ready for discharge from the ICU, whichever comes first. Fifty sites in the USA and worldwide will participate, with a target enrollment of 1176 patients (1000 evaluable). The target temperature is 37.0 °C. The primary efficacy outcome is the total fever burden by °C-h, defined as the area under the temperature curve above 37.9 °C. The primary secondary outcome, on which the sample size is based, is the modified Rankin Scale Score at 3 months. All efficacy analyses including the primary and key secondary endpoints will be primarily based on an intention-to-treat population. Analysis of the as-treated and per protocol populations will also be performed on the primary and key secondary endpoints as sensitivity analyses. Discussion: The INTREPID trial will provide the first results of the impact of a pivotal fever prevention intervention in patients with acute stroke ( www.clinicaltrials.gov ; NCT02996266; registered prospectively 05DEC2016).
Chapter
Anemia is a prevalent disease in patients in the intensive care unit (ICU), as well as in brain-injured patients. Its pathophysiology remains uncertain and has been associated with an increased risks of poor outcomes. Moreover, it is unknown if anemia reflects only a higher severity of the underlying disease or is a significant determinant of neurological recovery in these patients. Currently, most centers use a hemoglobin (Hb) threshold between 7.0 g/dL and 9.0 g/dL to indicate transfusion of red blood cell concentrates in brain-injured patients. This practice is based on the result of physiological studies that showed that increasing hemoglobin from 8.7 g/dL to 10.2 g/dL is associated with an increase in cerebral oxygenation in 75% of brain-injured patients. In contrast, transfusion of red blood cells has been associated with worst outcomes, increased mortality, lung injury, increased rates of infection, and renal failure in these patients. In this scenario, the best hemoglobin level to trigger red blood transfusion in brain-injured patients has not been outlined yet. In addition, there is insufficient evidence to provide strong recommendations regarding which hemoglobin level to target and which associated transfusion strategy should be selected in this patient population.
Article
Objective Fever in aneurysmal subarachnoid hemorrhage (aSAH) has been associated with delayed cerebral ischemia (DCI), but its relevance in risk stratification has not been explored. This study investigates if early temperature elevation following aSAH predicts impending clinical deterioration caused by DCI. Methods Relevant cases were identified from a prospectively maintained database for consecutive aSAH patients treated at our center between July 2015 and January 2020. Two hourly temperature readings for individual patients from admission through to day 14 were recorded and analyzed. Demographic, clinical, treatment and angiographic data were extracted from the electronic medical record. The primary end point was the occurrence of DCI (clinical and radiographic vasospasm). Multivariate logistic regression analyses were performed to account for patient age, smoking status, and VASOGRADE. Results On hundred and seventy-five patients (124 female) with aSAH were treated. The median age at diagnosis was 55.4 years (range 20.5 to 87.2 years). Clinical DCI occurred in 58 patients, of which 2 (1.1%) responded to hemodynamic augmentation and 56 (32.0%) required intraarterial therapy. Temperature graphs showed a marked divergence on day 4 between clinical DCI and non-DCI groups (1.12 °C ± 0.15 and 0.76°C ± 0.08 respectively, p=0.007). Patients with temperature elevation ≥2.5°C on day 4 or 5 compared to their admission temperature were more likely to clinically deteriorate due to DCI (OR 4.55 95% CI 1.31 – 15.77, p=0.017). Conclusion Temperature elevation of 2.5°C or more on day 4 or 5 compared to baseline suggests a greater risk of clinical deterioration due to DCI.
Article
Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.
Article
We retrospectively examined the course of serum sodium levels in 180 patients with acute aneurysmal subarachnoid hemorrhage (SAH) who had been admitted to the anesthesiologic-neurosurgical intensive care unit of the University Medical Center Regensburg, Germany, between January 2014 and December 2018. Each patient file was analyzed regarding the frequency and intensity of hyponatremic episodes and the administered medication. At admission to the intensive care unit (ICU), 18 patients had shown initial hyponatremia (<135 mmol/L) and 4 patients hypernatremia (greater than145 mmol/L). 88 (48.9%) of the 158 patients with normal serum sodium levels developed at least one hyponatremic episode during ICU treatment. The number of hyponatremic episodes was similar between patients with higher-grade and lower-grade aneurysmal SAH (P = 0.848). At the end of ICU treatment, outcome did not differ between patients with and without hyponatremia (40/88, 45.5% vs. 38/70, 54.3%, P = 0.270). At 6 months after SAH, however, good outcome (Glasgow outcome scale, GOS 4–5) was more frequently observed in patients with hyponatremia (26/88, 29.5% vs. 32/70, 45.7%, P = 0.036). Medication with sodium chloride, fludrocortisone, or tolvaptan was initiated in 75.4% patients with mild hyponatremia (130–134 mmol/L) and in 92.9% with moderate hyponatremia (125–129 mmol/L). At 6 months after SAH, patients treated with tolvaptan had a lower rate of poor outcome than patients who had not received tolvaptan (1/14, 7.1% vs. 25/74, 33.8%, P = 0.045). In patients with acute aneurysmal SAH and hyponatremic episodes, consequent treatment of hyponatremia prevented impaired outcome. Because administration of tolvaptan rapidly normalized serum sodium levels, this therapy seems to be a promising treatment approach.
Article
Background Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality. Methods For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014. Results The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25–4.69] and OR, 2.69 [95% CI 1.43–5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital. Conclusions Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.
Article
Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient’s behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.
Article
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.
Chapter
Aneurysmal subarachnoid hemorrhage is a critical and complex neurovascular disease associated with significant morbidity and mortality. In the acute phase, prompt diagnosis and appropriate management can have a significant impact on final patient outcomes. Beyond the acute treatment of increased intracranial pressure and acute hydrocephalus, the critical care management of various other systems is essential. This includes airway protection, blood pressure control, seizure treatment, volume resuscitation, and treatment of neurogenic cardiac and pulmonary conditions. In this chapter, we discuss the details of the challenges faced by the SAH patient from ictus to definitive treatment of securing the aneurysm. Additionally, we outline technical aspects of external ventricular drain insertion and nuances of its management.
Thesis
Hintergrund und Ziele: Subarachnoidalblutungen (SAB) gehen nicht selten mit intrazerebralen Blutanteilen (ICB) einher, welche den klinischen Zustand und Krankheitsverlauf zusätzlich beeinträchtigen können. Die Bedeutung begleitender ICB für das langfristige Outcome ebenso wie ihre Behandlung blieben bislang jedoch im Wesentlichen ungeklärt. Zwar empfehlen die aktuellen Leitlinien bei massenwirksamen Blutungen eine chirurgische Hämatomevakuation (CHE), die Evidenz für dieses Vorgehen ist allerdings limitiert. Methoden: Retrospektiv ausgewertet wurden die Daten von allen konsekutiven Patienten, welche in einem Zeitraum von 5 Jahren (2008–2012) aufgrund einer atraumatischen SAB in der Neurologischen und Neurochirurgischen Klinik des Universitätsklinikums Erlangen behandelt worden sind. Neben klinischen Parametern und dem Ausmaß der SAB wurden die Häufigkeit und Lokalisation von ICB erfasst und ihr Volumen anhand der ABC/2-Formel abgeschätzt. Die Beurteilung des Outcomes nach 12 Monaten umfasste funktionelle Einschränkungen (modified Rankin Scale (mRS)), die gesundheitsbezogene Lebensqualität (EQ-5D-VAS) sowie Langzeitkomplikationen (u.a. Epilepsie). Zur besseren Vergleichbarkeit von Patienten mit und ohne ICB wurde ein Propensity Score Matching (PSM; Ratio 1:1, Caliper 0,1) durchgeführt. Ferner erfolgten Subanalysen, um den Einfluss verschiedener Behandlungsverfahren (chirurgische Hämatomevakuation versus konservative Behandlung) auf das Outcome zu überprüfen. Ergebnisse und Beobachtungen: Von insgesamt 494 Patienten mit atraumatischer SAB wiesen initial 85 (17,2 %) Patienten intrazerebrale Blutanteile auf. Diese hatten zum Zeitpunkt der Aufnahme einen schlechteren klinischen Zustand und ein größeres Ausmaß subarachnoidaler und intraventrikulärer Blutanteile (IVB) (mFisher, Median (IQR): ICB 3 (2–4) vs. ØICB 2 (1– 3); p = 0,001; IVB: ICB 74,1 % vs. ØICB 57,0 %; p = 0,004; Graeb Score, Median (IQR): ICB 4 (2–8) vs. ØICB 2,5 (2–4); p < 0,001)). Das mediane intrazerebrale Blutvolumen betrug 11,0 (5,4–31,8) ml, wobei die größten ICB-Volumina mit rupturierten Aneurysmen der Arteria cerebri media (MCA) verbunden waren (31,6 ml (16,3–43,2)). Nach Adjustierung mittels PSM erlangten ICB-Patienten nicht nur seltener ein günstiges funktionelles Outcome (mRS 0–2: ICB 31,8 % vs. ØICB 57,7 %; p < 0,001), sie litten auch häufiger an einer Epilepsie (ICB 23,4 % vs. ØICB 7,3 %; p = 0,03), konnten seltener beruflich wiedereingegliedert werden (ICB 12,7 % vs. ØICB 32,1 %; p = 0,008) und schätzten ihre eigene Gesundheit schlechter ein (EQ-5D-VAS: ICB 50 (30–70) vs. ØICB 80 (65–95); p < 0,001). Die Behandlung mit einer chirurgischen Hämatomevakuation, ungeachtet des Alters oder der Aneurysmalokalisation, war häufiger mit einem günstigen Outcome nach 12 Monaten assoziiert als eine konservative Behandlung (CHE 14/28 (50,0 %) vs. konservativ 14/57 (24,6 %); adjustierte Odds Ratio (OR, 95 % KI): 1,34 (1,08–1,66); p = 0,001). Dieser Vorteil zeigte sich den Subgruppen- Analysen nach insbesondere für Patienten mit frontal lokalisierten ICB (OR 1,59 (1,14– 2,23)), großen ICB-Volumina (> 10 ml; OR 1,39 (1,09–1,79)) und bei Patienten, die frühzeitig einer CHE unterzogen wurden (≤ 600 min nach Blutungsbeginn; OR 1,42 (1,03–1,94)). Schlussfolgerungen: Intrazerebrale Blutanteile sind häufige Komplikationen einer SAB, die gravierende funktionelle sowie subjektive Einschränkungen nach sich ziehen. Möglicherweise könnten diese Patienten von einer frühzeitigen chirurgischen Hämatomevakuation profitieren.
Chapter
Spontaneous subarachnoid haemorrhage in the majority of patients is due to the rupture of cerebral aneurysms. There is a decreasing trend in the incidence of aSAH (aneurysmal subarachnoid haemorrhage). The current global incidence is 6.1/100,000 population. There are various modifiable risk factors such as hypertension, smoking, alcohol abuse, dyscholesterolemia, recreational drug abuse, and low body mass index. The non-modifiable risk factors for aSAH are gender, familial, and connective tissue disorders.
Chapter
Subarachnoid haemorrhage is a haemorrhagic stroke, commonly caused by the rupture of a cerebral aneurysm. Although the mortality rate shows a decreasing trend, the aneurysmal subarachnoid haemorrhage (aSAH) is a catastrophic medical disease with higher morbidity and mortality. A quarter (25%) of aSAH patients die within 24 h of bleeding, even with medical management. The aSAH is a significant cause of increased morbidity and financial burden to the society as it requires more extended hospitalization, prolonged patient care, and loss of productivity. The aSAH causes both primary neurological damage, cognitive and psychological disorders, and secondary medical complications leading to distal non-neuro organ dysfunction.
Chapter
The blood circulation in the brain is unique and different from the rest of the organs in the body. The arterial supply to the brain is from three arteries, a pair of internal carotid arteries, also called anterior circulation of brain and posteriorly situated basilar artery supplying blood to the posterior portion of cerebrum and called posterior circulation. The circle of Willis (COW) is formed by 3 above mentioned arteries to have constant blood supply to the brain and have a compensatory mechanism if one of the arteries is having pathology. Six arteries will leave the COW, namely two anterior cerebral arteries, two middle cerebral arteries, and a pair of posterior cerebral arteries. Three arteries completing the COW are one anterior cerebral and two posterior communicating arteries. The cerebral arteries can abnormally out pouch due to increased hemodynamic stress resulting in the formation of cerebral aneurysms.
Chapter
Aneurysmal subarachnoid hemorrhage (aSAH) is devastating cerebrovascular insult which is associated with high morbidity and mortality. Although the management strategies improved significantly in the last 30 years, the 30-day mortality and before admission death remain high, around 35% and 15%, respectively. The outcome of aSAH patients depends on the severity of the initial insult and potential neurological and non-neurological complications. Neurological complications include re-bleeding, delayed cerebral ischemia, hydrocephalus, brain edema, and seizures, while non-neurological complications are cardiac complications, electrolyte disturbances, fever, hyperglycemia, anemia, and deep venous thrombosis. In order to offer optimal care, clinicians must grasp the pathophysiology, recognition, risk factors, and therapeutic options of these complications. This chapter discusses different workup modalities, investigations, and both pharmacological and interventional management and the strength of medical evidence behind each (de Oliveira Manoel et al., Crit Care 20:21, 2016).
Article
Background: The pathological mechanisms of early brain injury (EBI) have remained obscure. Several studies have reported on the neuroradiological findings of EBI. However, to our knowledge, no study has attempted to explore the mechanism of EBI after subarachnoid hemorrhage (SAH). Therefore, this study evaluates whether the initial plasma D-dimer levels were associated with EBI, classifies magnetic resonance imaging (MRI) findings, and speculates about the mechanism of EBI. Methods: This study included 97 patients hospitalized within 24 h from the onset of nontraumatic SAH. The patients underwent MRI within 0-5 days from onset (before vasospasm) to detect EBI. EBI was radiologically defined as diffusion-weighted imaging (DWI)-positive lesions that appear dark on apparent diffusion coefficient maps, excluding procedure-related lesions. EBI, plasma D-dimer levels, and clinical features were retrospectively investigated. Results: Elevated D-dimer levels were associated with poor outcomes. Patients with EBI had significantly higher D-dimer levels than those without EBI. EBI was detected in 24 patients (27.3%) of all, and in 22 (45%) of 49 patients with World Federation of Neurosurgical Societies (WFNS) grade 4-5 SAH. EBI was frequently observed in the paramedian frontal lobe. There were several types of the pathology in EBI, including widespread symmetrical cerebral cortex lesions, focal cortex lesions, periventricular injury, and other lesions impossible to classify due to unknown mechanisms such as thrombotic complication and microcirculatory disturbance, ultra-early spasm, and spreading depolarization. Conclusions: This study suggests that D-dimer levels predict poor outcomes in patients with SAH and that EBI was associated high D-dimer levels.
Chapter
Full-text available
The management of ischemic stroke has been marked by three major advances that transformed the approach to its diagnosis and treatment: (1) creation of stroke units, (2) IV thrombolytic (IVT) use, and (3) mechanical thrombectomy.
Article
Introduction Alkaline phosphatase (ALP) levels are often elevated in cerebrovascular and cardiovascular disease. Their prognostic role after subarachnoid hemorrhage (SAH) remains to be elucidated. Methods We performed a retrospective single center study of patients with non-traumatic SAH admitted to the intensive care unit (ICU) of Erasme Hospital (Brussels, Belgium) from 2006 to 2019. Exclusion criteria were previous history of liver cirrhosis or malignancies and early death (i.e. within 24 hours from ICU admission). Baseline information, clinical data, radiologic data were collected, the occurrence of DCI as well as serum ALP levels during the first 12 days of ICU stay. Unfavorable neurological outcome (UO) at 3 months was defined as a Glasgow Outcome Scale of 1-3. Results Six hundred and fifty patients were included; ALP levels increased from baseline after day 6 from admission, in particular among patients with an initial poor clinical status. There was no difference in the ALP levels between patients with or without DCI over time. Patients with UO had higher ALP levels over time than others; however, in the multivariable analysis, nor ALP levels on admission or the highest ALP value during the ICU stay were independently associated with UO. Conclusions The results of this study suggested that ALP levels had no prognostic role in SAH patients. Other possible prognostic biomarkers should be evaluated in this setting.
Article
Background: Delayed cerebral vasospasm is a feared complication of aneurysmal subarachnoid hemorrhage (SAH). Objective: To investigate the relationship of systemic inflammation, measured using the systemic immune-inflammation (SII) index, with delayed angiographic or sonographic vasospasm. We hypothesize that early elevations in SII index serve as an independent predictor of vasospasm. Methods: We retrospectively reviewed the medical records of 289 SAH patients for angiographic or sonographic evidence of delayed cerebral vasospasm. SII index [(neutrophils × platelets/lymphocytes)/1000] was calculated from laboratory data at admission and dichotomized based on whether or not the patient developed vasospasm. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to determine the ability of SII index to predict the development of vasospasm. Results: A total of 246 patients were included in our study, of which 166 (67.5%) developed angiographic or sonographic evidence of cerebral vasospasm. Admission SII index was elevated for SAH in patients with vasospasm compared to those without (P < .001). In univariate logistic regression, leukocytes, neutrophils, lymphocytes, neutrophil-lymphocyte ratio (NLR), and SII index were associated with vasospasm. After adjustment for age, aneurysm location, diabetes mellitus, hyperlipidemia, and modified Fisher scale, SII index remained an independent predictor of vasospasm (odds ratio 1.386, P = .003). ROC analysis revealed that SII index accurately distinguished between patients who develop vasospasm vs those who do not (area under the curve = 0.767, P < .001). Conclusion: Early elevation in SII index can independently predict the development of delayed cerebral vasospasm in aneurysmal SAH.
Article
The influence of the consequences of aneurysmal subarachnoid hemorrhage on the human body in the long-term period has been insufficiently studied. Most studies indicate a high risk of developing cognitive impairment. Until now, there is no unified algorithm for the management of patients with aneurysmal subarachnoid hemorrhage, who need long-term comprehensive rehabilitation and supervision of specialists in various fields. Aim of study. To study the influence of the nature, severity, features of the clinical manifestation of aneurysmal subarachnoid hemorrhage, as well as the choice of the method of intervention in the acute period of the disease on the long-term results of treatment of aneurysms. Material and methods. In the presented study, the observation group included 74 patients who were operated on in the emergency neurosurgery department of the N.V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health Department from 2013 to 2019 in the acute period of subarachnoid hemorrhage (during the first 14 days after the rupture of the cerebral aneurysm). The average age of patients at the time of surgery was 47 [Me=46; min=27; max=76] years old. The ruptured aneurysm was turned off from the bloodstream by one of the following methods: microsurgical intervention with the application of a clip to the aneurysm neck (50 (67,6%) patients), the simultaneous open intervention of aneurysm clipping, and the formation of an extra-intracranial micro anastomosis from the side of the aneurysm access (8 (10,8%) patients), endovascular exclusion of the cerebral aneurysm from the bloodstream (16 (21,6%) patients). On average, after 2,4 [Me=2,5; min=1; max=6] years, patients were invited for a clinical and neurological examination, which included testing according to the Modified Rankin Scale (MRS), the Bartel Index questionnaire, the Mini-Mental Status Scale (MMSS), and the Hospital Anxiety and Depression Scale (HADS). We analysed the changes in the professional activity and habitual lifestyle of patients, as well as the influence of the most common risk factors: arterial hypertension, diabetes mellitus, smoking, on long-term outcomes. Results. In the long-term period of surgical treatment of cerebral aneurysms, on average after 2,4 [Me=2,5; min=1; max=6] years after subarachnoid hemorrhage, 30 (40,5%) patients scored 0 points on the Modified Rankin Scale, 27 (36,5%) patients — 1 point, 6 (8,1%) patients — 2 points, in 6 (8,1%) patients — 3 points, in 4 (5,4%) patients — 4 points and in 1 (1,4%) patient — 5 points. A significant dependence of the degree of disability according to the modified Rankin scale in the long-term period of subarachnoid hemorrhage on the severity of the patient’s condition at discharge from the hospital was revealed according to the Glasgow Outcome Scale (p<0,001). The patient’s age at the time of rupture of the aneurysm independently influenced cognitive functions and the ability to self-care in the long-term period. With an increase in age by 1 year, the score on the short scale of mental status and on the Bartel questionnaire decreased by 0,08 (p=0,03) and by 0,3 (p=0,04), respectively. With the simultaneous presence of intracerebral hemorrhage and the severity of subarachnoid hemorrhage corresponding to grade III according to the Fisher classification, the likelihood of developing anxiety and depressive mental disorders according to the hospital scale of anxiety and depression increased significantly (p><0,01). The development of intracerebral hematoma with aneurysmal hemorrhage contributed to the appearance of hypertension (p><0,05). Conclusion The revealed disorders that persist for several years after the intervention indicate the need for long-term follow-up of patients who underwent intervention for subarachnoid hemorrhage, the development of individual programs for physical and psychological rehabilitation, and clinical examination of persons at high risk. Keywords: subarachnoid hemorrhage, aneurysm, follow-up, low-flow bypass, endovascular intervention>˂ 0,001). The patient’s age at the time of rupture of the aneurysm independently influenced cognitive functions and the ability to self-care in the long-term period. With an increase in age by 1 year, the score on the short scale of mental status and on the Bartel questionnaire decreased by 0,08 (p=0,03) and by 0,3 (p=0,04), respectively. With the simultaneous presence of intracerebral hemorrhage and the severity of subarachnoid hemorrhage corresponding to grade III according to the Fisher classification, the likelihood of developing anxiety and depressive mental disorders according to the hospital scale of anxiety and depression increased significantly (p˂ 0,01). The development of intracerebral hematoma with aneurysmal hemorrhage contributed to the appearance of hypertension (p<0,05). Conclusion The revealed disorders that persist for several years after the intervention indicate the need for long-term follow-up of patients who underwent intervention for subarachnoid hemorrhage, the development of individual programs for physical and psychological rehabilitation, and clinical examination of persons at high risk. Keywords: subarachnoid hemorrhage, aneurysm, follow-up, low-flow bypass, endovascular intervention>˂ 0,01). The development of intracerebral hematoma with aneurysmal hemorrhage contributed to the appearance of hypertension (p˂ 0,05). Conclusion. The revealed disorders that persist for several years after the intervention indicate the need for long-term follow-up of patients who underwent intervention for subarachnoid hemorrhage, the development of individual programs for physical and psychological rehabilitation, and clinical examination of persons at high risk.
Article
Full-text available
Background: Aggressive behavior refers to multiple factors that cause harm to another individual who does not wish to be harmed. It can occur as self-aggressive or hetero-aggressive behavior and present a number of causes. Case presentation: Previously healthy patient presented with aggressive behavior after traumatic brain injury. Surgical procedure involving multiple targets was performed for the treatment of aggressiveness. Discussion: Several anatomical structures are involved in the genesis of aggressiveness. Therefore, different surgical procedures have already been proposed and performed in an attempt to improve the aggressive behavior. Conclusion: A single surgical procedure using multiple targets, considered feasible, safe, and effective, can reduce family stress as well as the costs of hospitalization due to a number of surgeries. In the reported case, anterior capsulotomy, subcaudate tractotomy, and nucleus accumbens ablation were performed in the same procedure. The patient evolved without complications and the surgical procedure resulted in satisfactory therapeutic response.
Article
Full-text available
TroponinT levels are frequently elevated after subarachnoid hemorrhage (SAH). However, their clinical impact on long term outcomes still remains unclear. This study evaluates the association of TroponinT and functional outcomes 3 months after SAH. Data were obtained in the frame of a randomized controlled trial exploring the association of Goal-directed hemodynamic therapy and outcomes after SAH (NCT01832389). TroponinT was measured daily for the first 14 days after admission or until discharge from the ICU. Outcome was assessed using Glasgow Outcome Scale (GOS) 3 months after discharge. Logistic regression was used to explore the association between initial TroponinT values stratified by tertiles and admission as well as outcome parameters. TroponinT measurements were analyzed in 105 patients. TroponinT values at admission were associated with outcome assessed by GOS in a univariate analysis. TroponinT was not predictive of vasospasm or delayed cerebral ischemia, but an association with pulmonary and cardiac complications was observed. After adjustment for age, history of arterial hypertension and World Federation of Neurosurgical Societies (WFNS) grade, TroponinT levels at admission were not independently associated with worse outcome (GOS 1–3) or death at 3 months. In summary, TroponinT levels at admission are associated with 3 months-GOS but have limited ability to independently predict outcome after SAH.
Chapter
Initial treatment paradigms for patients suffering from aneurysmal subarachnoid hemorrhage focus on early surgical aneurysm treatment to prevent rebleeding. After aneurysm treatment, secondary treatment efforts focus on early detection and treatment of delayed cerebral ischemia to prevent secondary brain injury. Specialized neurocritical care centers can provide close neurological monitoring to assess for early signs of delayed cerebral ischemia to implement cerebral perfusion augmentation strategies. However, patients who do not have reliable neurological exams to follow are often those that are at higher risk of developing delayed cerebral ischemia and require surrogate measures of continuous monitoring to evaluate for early signs of secondary brain injury. Here we provide an overview of aneurysmal subarachnoid hemorrhage, delayed cerebral ischemia, as well as the role and use of multimodality monitoring in certain subarachnoid hemorrhage patients in efforts to detect and implement treatment strategies to prevent delayed cerebral ischemia and secondary brain injury.
Article
Purpose Intraoperative cerebral aneurysm rupture (IOR) is a common phenomenon with a frequency of around 19%. Research regarding IOR lacks an analysis of its predictors. Methods We retrospectively examined all saccular aneurysms, in 198 patients with subarachnoid hemorrhage, surgically treated from 2013 to 2019. Operative reports, patient histories, blood test results, discharge summaries, and radiological data were reviewed. IOR was defined as any bleeding from the aneurysm during surgery, preceding putting a clip on its neck, regardless of how trivial. Results The frequency of IOR was 20.20%. Patients with IOR had higher aneurysm dome size (9.43 ± 8.39 mm vs. 4.96 ± 2.57 mm; p < 0.01). The presence of blood clot on the aneurysm dome was significantly associated with IOR (12.50% vs. 2.53%; p < 0.01). We also associated lamina terminalis fenestration during surgery (7.50% vs. 21.52%; p = 0.04) and multiple aneurysms (5.00% vs. 18.35%; p = 0.038) with a lower risk of IOR. Glucose blood levels were also elevated in patients with IOR (7.47 ± 2.78 mmol/l vs. 6.90 ± 2.22 mmol/l; p = 0.04). Multivariate analysis associated that urea blood levels (OR 0.55, 0.33 to 0.81, p < 0.01) and multiple aneurysms (OR 0.04, 0.00 to 0.37, p = 0.014) were protective factors against the occurrence of IOR. Conclusion Large dome size of an aneurysm, a blood clot on the aneurysm dome and elevated glucose blood levels can be IOR predictive. Lamina terminalis fenestration, the appearance of multiple aneurysms, and high urea blood levels may be associated with a lower risk of such an event.
Article
Full-text available
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
Article
Full-text available
Erythropoietin (EPO) promotes neuronal survival after hypoxia and other metabolic insults by largely unknown mechanisms. Apoptosis and necrosis have been proposed as mechanisms of cellular demise, and either could be the target of actions of EPO. This study evaluates whether antiapoptotic mechanisms can account for the neuroprotective actions of EPO. Systemic administration of EPO (5,000 units/kg of body weight, i.p.) after middle-cerebral artery occlusion in rats dramatically reduces the volume of infarction 24 h later, in concert with an almost complete reduction in the number of terminal deoxynucleotidyltransferase-mediated dUTP nick-end labeling of neurons within the ischemic penumbra. In both pure and mixed neuronal cultures, EPO (0.1–10 units/ml) also inhibits apoptosis induced by serum deprivation or kainic acid exposure. Protection requires pretreatment, consistent with the induction of a gene expression program, and is sustained for 3 days without the continued presence of EPO. EPO (0.3 units/ml) also protects hippocampal neurons against hypoxia-induced neuronal death through activation of extracellular signal-regulated kinases and protein kinase Akt-1/protein kinase B. The action of EPO is not limited to directly promoting cell survival, as EPO is trophic but not mitogenic in cultured neuronal cells. These data suggest that inhibition of neuronal apoptosis underlies short latency protective effects of EPO after cerebral ischemia and other brain injuries. The neurotrophic actions suggest there may be longer-latency effects as well. Evaluation of EPO, a compound established as clinically safe, as neuroprotective therapy in acute brain injury is further supported.
Article
Full-text available
Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known. We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter [4.4 and 6.1 mmol per liter]) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter [11.9 mmol per liter] and maintenance of glucose at a level between 180 and 200 mg per deciliter [10.0 and 11.1 mmol per liter]). At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P=0.005). The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus. Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care. Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.
Article
Full-text available
We designed a 15-item neurologic examination stroke scale for use in acute stroke therapy trials. In a study of 24 stroke patients, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77). Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at 3 months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid. We discuss methods for improving the reliability and validity of brief examination scales to be used in stroke therapy trials.
Article
Full-text available
Using logistic regression, we analyzed the predictive value of a number of entry variables with respect to the outcome variables delayed cerebral ischemia, rebleeding, and poor outcome (death or severe disability) in patients with aneurysmal subarachnoid hemorrhage. The entry variables were clinical condition on admission (grades on the Glasgow Coma Scale, Hunt and Hess system), the amount of subarachnoid and intraventricular blood and the presence of hydrocephalus on the admission computed tomogram, and antifibrinolytic treatment with tranexamic acid. We used data from a prospectively studied population of 176 patients admitted within 72 hours after subarachnoid hemorrhage. The risk of delayed cerebral ischemia was best predicted by the amount of subarachnoid blood, intraventricular blood, and antifibrinolytic treatment irrespective of clinical condition and hydrocephalus. The site of delayed cerebral ischemia was not related to the location of the subarachnoid hemorrhage. Antifibrinolytic treatment was the only entry variable (negatively) predicting the risk of rebleeding. Death or severe disability after 3 months was best predicted by the amount of subarachnoid blood and the initial clinical condition reflected by the grade on the Glasgow Coma Scale.
Article
Full-text available
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
Article
Full-text available
To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome. A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded. The proportion of patients that was operated on early--that is, within three days after SAH--was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome. In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.
Article
Full-text available
Based on the results of earlier studies it is agreed that the significance of aneurysm location and surgery for neuropsychological impairments after subarachnoid hemorrhage (SAH) is secondary to the effects of the bleeding itself. Therefore, the present study was performed to evaluate whether bleeding, acute clinical course, and surgery have persistent effects on health-related quality of life (QOL) after SAH. A series of 116 patients was examined for 4 to 5 years (mean 52.2 months) after aneurysmal SAH by means of a QOL questionnaire. Eighty-six patients (74.1%) had undergone surgery early (< or = 72 hours post-SAH). There were 77 women (66.4%) and 39 men (33.6%) in the study group, and the mean age of the patients was 50.3+/-13.3 years (range 30-69 years). Patients who had undergone surgery for a left-sided middle cerebral artery (MCA) aneurysm complained of significantly more impairments in social contact, communication, and cognition than those treated for a right-sided MCA aneurysm. No other effects of aneurysm location (including the anterior communicating artery) emerged. Multiple aneurysms, intraoperative aneurysm rupture, and partial resection of the gyrus rectus had no adverse effects on later daily life. Only temporary clipping was associated with increased complaints in some QOL areas. Disturbances of the circulation of cerebrospinal fluid and the presence of intraventricular hemorrhage led to more impairments in daily life. Specific effects of the anatomical pattern of the bleeding could be identified, but no adverse effects of vasospasm were found. Multivariate analyses revealed, in particular, that patient age and admission neurological status (Hunt and Hess grade) are substantial predictors of the psychosocial sequelae of SAH. In contrast to the mild effects of aneurysm surgery, patient's age, initial neurological state on admission, and the bleeding pattern substantially influence late QOL after SAH.
Article
Full-text available
Factors related to prognosis after subarachnoid haemorrhage (SAH) have been mainly extracted from surgical series, and only few authors have considered these factors in total management or population series. Though the level of consciousness is a major determinant of outcome after subarachnoid haemorrhage, there is not a consensus about which classification should be used to define it. The objective of this study was twofold. Firstly to find which factors recorded on hospital admission relate to outcome determining their relative importance in a non-selected series of patients suffering from aneurysmal SAH admitted to our centre, and secondly to assess the validity of the WFNS clinical scale for predicting the final result. A series of 294 patients consecutively admitted to Hospital 12 de Octubre Madrid between January 1990 and June 2000 with the diagnosis of aneurysmal SAH were retrospectively reviewed. All factors possibly related to prognosis were recorded on hospital admission. Outcome was measured by means of the Glasgow Outcome Scale measured one month after hospital discharge. Relationship between factors and outcome was evaluated by univariate and logistic regression multivariate analysis. Although several factors, appeared related to prognosis in the univariate analysis, only the age. the level of consciousness defined by the WFNS scale and the presence of global brain hypodensity on the initial CT scan had a significant prognostic influence in the logistic regression model. Global brain hypodensity was strongly related to mortality. Since a number of factors associated with poor outcome in the univariate analysis are related to age, their influence could be explained by the difficulty of recovery of the ageing brain. The WFNS grading scale failed to predict significant differences in outcome between some of its grades. Age and clinical grade on admission are the most important factors influencing the final outcome of patients suffering aneurysmal SAH. A reappraisal of the WFNS grading scale should be considered as no significant differences in outcome were found between some of its grades.
Article
Full-text available
To assess the frequency of hyperthermia in a population of acute neurosurgical patients; to assess the relation between brain temperature (ICT) and core temperature (Tc); to investigate the effect of changes in brain temperature on intracranial pressure (ICP). The study involved 20 patients (10 severe head injury, eight subarachnoid haemorrhage, two neoplasms) with median Glasgow coma score (GCS) 6. ICP and ICT were monitored by an intraventricular catheter coupled with a thermistor. Internal Tc was measured in the pulmonary artery by a Swan-Ganz catheter. Mean ICT was 38.4 (SD 0.8) and mean Tc 38.1 (SD 0.8) degrees C; 73% of ICT and 57.5% of Tc measurements were > or =38 degrees C. The mean difference between ICT and Tc was 0.3 (SD 0.3) degrees C (range -0.7 to 2.3 degrees C) (p=0. 0001). Only in 12% of patients was Tc higher than ICT. The main reason for the differences between ICT and Tc was body core temperature: the difference between ICT and Tc increased significantly with body core temperature and fell significantly when this was lowered. The mean gradient between ICT and Tc was 0.16 (SD 0.31) degrees C before febrile episodes (ICT being higher than Tc), and 0.41 (SD 0.38) degrees C at the febrile peak (p<0.05). When changes in temperature were considered, ICT had a profound influence on ICP. Increases in ICT were associated with a significant rise in ICP, from 14.9 (SD 7.9) to 22 (SD 10.4) mm Hg (p<0.05). As the fever ebbed there was a significant decrease in ICP, from 17.5 (SD 8.62) to 16 (SD 7.76) mm Hg (p=0.02). Fever is extremely frequent during acute cerebral damage and ICT is significantly higher than Tc. Moreover, Tc may underestimate ICT during the phases when temperature has the most impact on the intracranial system because of the close association between increases in ICT and ICP.
Article
Full-text available
Anemia is common in critically ill patients and results in a large number of red blood cell (RBC) transfusions. Recent data have raised the concern that RBC transfusions may be associated with worse clinical outcomes in some patients. To assess the efficacy in critically ill patients of a weekly dosing schedule of recombinant human erythropoietin (rHuEPO) to decrease the occurrence of RBC transfusion. A prospective, randomized, double-blind, placebo-controlled, multicenter trial conducted between December 1998 and June 2001. A medical, surgical, or a medical/surgical intensive care unit (ICU) in each of 65 participating institutions in the United States. A total of 1302 patients who had been in the ICU for 2 days and were expected to be in the ICU at least 2 more days and who met eligibility criteria were enrolled in the study; 650 patients were randomized to rHuEPO and 652 to placebo. Study drug (40 000 units of rHuEPO) or placebo was administered by subcutaneous injection on ICU day 3 and continued weekly for patients who remained in the hospital, for a total of 3 doses. Patients in the ICU on study day 21 received a fourth dose. The primary efficacy end point was transfusion independence, assessed by comparing the percentage of patients in each treatment group who received any RBC transfusion between study days 1 and 28. Secondary efficacy end points identified prospectively included cumulative RBC units transfused per patient through study day 28; cumulative mortality through study day 28; change in hemoglobin from baseline; and time to first transfusion or death. Patients receiving rHuEPO were less likely to undergo transfusion (60.4% placebo vs 50.5% rHuEPO; P<.001; odds ratio, 0.67; 95% confidence interval [CI], 0.54-0.83). There was a 19% reduction in the total units of RBCs transfused in the rHuEPO group (1963 units for placebo vs 1590 units for rHuEPO) and reduction in RBC units transfused per day alive (ratio of transfusion rates, 0.81; 95% CI, 0.79-0.83; P =.04). Increase in hemoglobin from baseline to study end was greater in the rHuEPO group (mean [SD], 1.32 [2] g/dL vs 0.94 [1.9] g/dL; P<.001). Mortality (14% for rHuEPO and 15% for placebo) and adverse clinical events were not significantly different. In critically ill patients, weekly administration of 40 000 units of rHuEPO reduces allogeneic RBC transfusion and increases hemoglobin. Further study is needed to determine whether this reduction in RBC transfusion results in improved clinical outcomes.
Article
Full-text available
To determine the effect of pneumonia on 30-day mortality in patients hospitalized for acute stroke. Subjects in the initial cohort were 14,293 Medicare patients admitted for stroke to 29 greater Cleveland hospitals between 1991 and 1997. The relative risk (RR) of pneumonia for 30-day mortality was determined in a final cohort (n = 11,286) that excluded patients dying or having a do not resuscitate order within 3 days of admission. Clinical data were obtained from chart abstraction and were merged with Medicare Provider Analysis and Review files to obtain deaths within 30 days. A predicted-mortality model (c-statistic = 0.78) and propensity score for pneumonia (c-statistic = 0.83) were used for risk adjustment in logistic regression analyses. Pneumonia was identified in 6.9% (n = 985) of all patients and in 5.6% (n = 635) of the final cohort. The rates of pneumonia were higher in patients with greater stroke severity and features indicating general frailty. Unadjusted 30-day mortality rates were six times higher for patients with pneumonia than for those without (26.9% vs 4.4%, p < 0.001). After adjusting for admission severity and propensity for pneumonia, RR of pneumonia for 30-day death was 2.99 (95% CI 2.44 to 3.66), and population attributable risk was 10.0%. In this large community-wide study of stroke outcomes, pneumonia conferred a threefold increased risk of 30-day death, adding impetus to efforts to identify and reduce the risk of pneumonia in patients with stroke.
Article
Objective: To investigate the causes of fever in subarachnoid hemorrhage (SAH) and examine its relationship to outcome. Background: Fever adversely affects outcome in stroke. Patients with SAH are at risk for cerebral ischemia due to vasospasm (VSP). In these patients, fever may he both caused by, and potentiate, VSP-mediated brain injury. Methods: The authors prospectively studied patients admitted to a neurologic intensive care unit with nontraumatic SAH, documenting Hunt-Hess grade, Fisher group, Glasgow Coma Score, bacterial culture data, daily transcranial Doppler mean velocities, and maximum daily temperatures. Patients were classified as febrile (temperature above 38.3 degreesC for at least 2 consecutive days) or afebrile (no fever or isolated episodes of temperature above 38.3 degreesC). VSP was verified by either transcranial Doppler or angiographic criteria. Rankin scale scores on discharge were dichotomized into good (0 to 2) or poor (3 to 6) outcomes. Results: Ninety-two consecutive patients were studied. Thirty-eight patients were classified as febrile. No source for infection was found in 10 of 38 (26%) patients. In a multivariate analysis, three variables independently predicted fever occurrence: ventriculostomy (OR, 8.5 [CI, 2.4 to 29.7]), symptomatic VSP (OR, 5.0 [CI, 1.03 to 24.5]), and older age (OR, 1.75 per 10 years [CI, 1.02 to 3.0]). Poor outcome was I elated to fever (OR, 1.4 per each day febrile [CI, 1.1 to 1.88]), older age (OR, 1.64 per 10 years [CI, 1.04 to 2.58]), and intubation (OR, 21.8 [CI, 5.6 to 84.5]). Conclusion: Fever in SAH is associated with vasospasm and poor outcome independently of hemorrhage severity or presence of infection.
Article
Subarachnoid hemorrhage (SAH) following ruptured intracranial aneurysm affects 28,000 people each year in the United States. Despite advances in surgical treatment and a significant reduction in mortality over the past two decades, SAH remains a devastating disease. Although most survivors are free of physical handicap, a large percentage suffer from significant long-term cognitive and emotional disturbances. These may include deficits in memory, executive function, attention and concentration, psychomotor speed, language, anxiety, and depression. The severity of these deficits is attested to by the fact that over 50% of patients employed full time before SAH do not return to the same level of work. This article presents a review of the clinical presentation of SAH and the significant areas of neurological and cognitive dysfunction that occur after the hemorrhage.
Data
Objectives-To assess the frequency of hyperthermia in a population of acute neurosurgical patients; to assess the relation between brain temperature (ICT) and core temperature (Tc); to investigate the effect of changes in brain temperature on intracranial pressure (ICP). Methods-The study involved 20 patients (10 severe head injury, eight subarachnoid haemorrhage, two neoplasms) with median Glasgow coma score (GCS) 6. ICP and ICT were monitored by an intraventricular catheter coupled with a thermistor. Internal Tc was measured in the pulmonary artery by a Swan-Ganz catheter. Results-Mean ICT was 38.4 (SD 0.8) and mean Tc 38.1 (SD 0.8)degreesC; 73% of ICT and 57.5% of Tc measurements were greater than or equal to 38 degreesC. The mean difference between ICT and Tc was 0.3 (SD 0.3)degreesC (range -0.7 to 2.3 degreesC) (p=0. 0001). Only in 12% of patients was Tc higher than ICT. The main reason for the differences between ICT and Tc was body core temperature: the difference between ICT and Tc increased significantly with body core temperature and fell significantly when this was lowered. The mean gradient between ICT and Tc was 0.16 (SD 0.31)degreesC before febrile episodes (ICT being higher than Tc), and 0.41 (SD 0.38)degreesC at the febrile peak (p<0.05). When changes in temperature were considered, ICT had a profound influence on ICP. Increases in ICT were associated with a significant rise in ICP, from 14.9 (SD 7.9) to 22 (SD 10.4) mm Hg (p<0.05). As the fever ebbed there was a significant decrease in ICP, from 17.5 (SD 8.62) to 16 (SD 7.76) mm. Hg (p=0.02). Conclusions-Fever is extremely frequent during acute cerebral damage and ICT is significantly higher than Tc. Moreover, Te may underestimate ICT during the phases when temperature has the most impact on the intracranial system because of the close association between increases in ICT and ICP.
Article
In this review, recent advances pertaining to the intensive care management of subarachnoid hemorrhage are discussed. The calcium channel blocker nimodipine has become a cornerstone of therapy for the prevention of ischemic deficits resulting from vasopasm. Recent trials suggest that nicardipine confers siimilar clinical benefits, but with more side effects. Transcranial Doppler sonography is widely used to diagnose and monitor cerebral vasopasm, but is of limited value for predicting which patients will develop ischemic deficits. Imaging modalities that reflect the adequacy of tissue perfusion or autoregulation, such as magnetic resonance spectroscopy and single photon emisson computed tomography, may eventually provide a more accurate means of identifying patients at risk for delayed ischemia. Hypertensive-hypervolemic hemodilution is widely employed to reverse cerebral ischemia from vasopasm but further studies are needed to elucidate the relative effects of hypertension, cardiac output augmentation, and hemodilution on cerebral blood flow. Neurogenic cardiac injury has become an increasingly recognized complication of acute, severe subarachnoid hemorrhage. Although significant hemodynamic instability can result, good outcomes can be achieved with aggressive intensive care unit management. (C) Lippincott-Raven Publishers.
Article
To judge the efficacy of new, putative stroke therapies, we need a method to measure neurological deficit accurately in groups of patients before and after treatment. No single measurement technique has yet proven to be universally acceptable, but one approach is the use of rating instruments that summarize the neurological deficit found on clinical examination. Currently, stroke assessment scales may be based on the examination of physical deficits, an inventory of activities of daily living, or a global evaluation of functional outcome. Scientific methods for authenticating stroke scales are available in the psychometric and statistical literature. We review currently available stroke scales for their validity and reliability and propose investigations needed to refine further the standardized measurement of neurological deficit following stroke. We suggest that clinical stroke trials include a physical deficit scale and a global rating during the acute phase and that an activities of daily living scale be added at later points in recovery.
Article
Hydrocephalus, defined as a bicaudate index above the 95th percentile for age, was found in 34 (20%) of 174 prospectively studied patients with subarachnoid hemorrhage (SAH) who survived the first 24 hours and who underwent computerized tomography (CT) scanning within 72 hours. The occurrence of acute hydrocephalus was related to the presence of intraventricular blood, and not to the extent of cisternal hemorrhage. The level of consciousness was depressed in 30 of the 34 patients. Characteristic clinical features were present in 19 patients, including a gradual obtundation after the initial hemorrhage in 16 patients and small nonreactive pupils in nine patients (all with a Glasgow Coma Scale score of 7 or less). In the remaining 15 patients (44%), the diagnosis could be made only by CT scanning. After 1 month, 20 of the 34 patients had died: six from rebleeding (four after shunting), 11 from cerebral infarction (eight after an initial improvement), and three from other or mixed causes. Only one of nine patients in whom a shunt was placed survived, despite rapid improvement in all immediately after shunting. The mortality rate among patients with acute hydrocephalus was significantly higher than in those without, with the higher incidence caused by cerebral infarction (11 of 34 versus 12 of 140 cases, respectively; p less than 0.001). Death from infarction could not be attributed to the extent of cisternal hemorrhage, the use of antifibrinolytic drugs, or failure to apply surgical drainage, but could often be explained by the development of hyponatremia, probably accompanied by hypovolemia.
Article
A clinical scale has been evolved for assessing the depth and duration of impaired consciousness and coma. Three aspects of behaviour are independently measured—motor responsiveness, verbal performance, and eye opening. These can be evaluated consistently by doctors and nurses and recorded on a simple chart which has proved practical both in a neurosurgical unit and in a general hospital. The scale facilitates consultations between general and special units in cases of recent brain damage, and is useful also in defining the duration of prolonged coma.
Article
The result of 42 blood volume determinations made with autologous red blood cells labeled with chromium-51 are reported. The subjects consisted of 11 control patients and 25 patients with recent subarachnoid hemorrhage (SAH). The mean red blood cell volume (RBCV) and the total blood volume (TBV) for female patients after SAH were significantly lower than corresponding control values (P less than 0.01). No depression of blood volume was found in males as a group. Seventy-two per cent of females had below-normal RBCV and 50% had below-normal TBV. Fifteen patients demonstrated angiographic vasospasm or signs of cerebral ischemia. Only 1 patient with asymptomatic vasospasm had a below-normal RBCV or TBV, whereas 6 of 7 patients with symptomatic vasospasm had a subnormal RBCV or TBV. The mean RBCV and mean TBV for female patients with symptomatic vasospasm were significantly lower than corresponding control values (P less than 0.02) and lower than values for female patients with asymptomatic vasospasm (P less than 0.05). The data suggest that volume status may be the important differential between asymptomatic and symptomatic vasospasm. Delayed ischemic deficits can be expected to develop in patients who have both spasm of the intracranial vessels and decreased TBV. Patients with normal blood volume are far less likely to experience cerebral ischemia, even if vasospasm develops.
Article
The prognostic value of the level of consciousness and the patient's age for the outcome of aneurysmal subarachnoid haemorrhage (SAH) is studied in 74 patients admitted on day (D)0 to D3 after aneurysm rupture. For the level of consciousness three groups of patients are compared: grade I+II (alert patients), grade III+IV (drowsy patients), and grade V (comatose patients). For the age, two groups are compared: patients aged under 50, and patients aged 50 and over. The timing of surgery was: D0–D3 51%, D4–D6 20%, D7 and later 18%, and No surgery 11%. The overall management results were: Good (satisfactory result) 43%, Fair (moderately disabled) 18%, Poor (severely disabled+vegetative survival) 19%, and Death 20%. The outcome was strongly related to the level of consciousness, the rates of Good result decreasing from 71% (grades I–II) to 14% (grades III–IV) and to zero (grade V), and the mortality rates increasing respectively from 5% to 14% and 61%. The relationship between outcome and age was less marked: 54% Good result under 50 and 30% over 50. Out of the Grade V group, 56% could be operated upon and 44% died before surgery. No patient from the other two groups died before surgery. The literature concerning the Grading Systems published so far and the various prognostic factors are discussed.
Article
This report examines the frequency, type, and prognostic factors of medical (nonneurologic) complications after subarachnoid hemorrhage in a large, prospective study. The influences of contemporary neurosurgical, neurological, and critical care practice on mortality and morbidity rates after aneurysmal subarachnoid hemorrhage are evaluated. A study of medical complications observed in the placebo limb of a large, randomized, controlled trial of the calcium antagonist, nicardipine, after subarachnoid hemorrhage. Patients were recruited from 50 hospitals in 41 neurosurgical centers in the United States and Canada. A total of 457 patients with subarachnoid hemorrhage, > or = 18 yrs of age, were randomly assigned to the placebo group. All patients arrived at the participating center within 7 days (mean 1.0 +/- 1.8 [SD] days) of rupture of an angiographically documented saccular aneurysm. The frequency rates of symptomatic vasospasm, rebleeding, and total mortality rate after subarachnoid hemorrhage at 3-month follow-up were 46%, 7%, and 19%, respectively. The frequency of having at least one severe (life-threatening) medical complication was 40%. The proportion of deaths from medical complications was 23%. This value was comparable with the proportion of deaths attributed to the direct effects of the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture. The frequency of life-threatening cardiac arrhythmias was 5%; less ominous rhythm disturbances occurred in 30% of the patients. There was an increased frequency of cardiac arrhythmias on the day of, or day after, aneurysm surgery. Pulmonary edema occurred in 23% of the patients, with a 6% occurrence rate incidence of severe pulmonary edema. There was a wide variation from center to center, with the greatest frequency on days 3 through 7. There was a nonsignificant association of pulmonary edema with the use of hypertensive hypervolemic therapy (p = .10), and a significant association with the timing of surgery (p < .05). Some degree of hepatic dysfunction was noted in 24% of patients, the majority with only mild abnormalities of hepatic enzymes with no clinical accompaniment (4% frequency of severe hepatic dysfunction). Thrombocytopenia occurred in 4% of patients, usually in the setting of sepsis. Renal dysfunction was reported in 7% of the patients, with 15% of that figure deemed to be of life-threatening severity. There was an association (p = .001) with antibiotic therapy. Potentially preventable medical complications after ruptured cerebral aneurysm add to the total mortality rate of patients, and may increase length of hospital stay in the critical care setting. The proportion of deaths after subarachnoid hemorrhage from medical complications equals those deaths from either direct effects, rebleeding, or vasospasm individually. Pulmonary complications are the most common nonneurologic cause of death. Cardiac arrhythmia, although frequent, was not associated with significant mortality. The frequency of cardiac arrhythmia and pulmonary edema increased on the day of, or day after, aneurysm surgery. Renal and hepatic dysfunction, and blood dyscrasias, were also observed, underscoring the need for meticulous monitoring for metabolic and hematologic derangements.
Article
Plasma glucose levels were studied in 616 patients admitted within 72 hours after subarachnoid hemorrhage (SAH). Glucose levels measured at admission showed a statistically significant association with Glasgow Coma Scale scores, Botterell grade, deposition of blood on computerized tomography (CT) scans, and level of consciousness at admission. Elevated glucose levels at admission predicted poor outcome. A good recovery, as assessed by the Glasgow Outcome Scale at 3 months, occurred in 70.2% of patients with normal glucose levels (< or = 120 mg/dl) and in 53.7% of patients with hyperglycemia (> 120 mg/dl) (p = 0.002). The death rates for these two groups were 6.7% and 19.9%, respectively (p = 0.001). The association was still maintained after adjusting for age (> or < or = 50 years) and thickness of clot on CT scans (thin or thick) in the subset of patients who were alert/drowsy at admission. Increased mean glucose levels between Days 3 and 7 also predicted a worse outcome; good recovery was observed in 132 (73.7%) of 179 patients who had normal mean glucose levels (< or = 120 mg/dl) and 160 (49.7%) of 322 who had elevated mean glucose levels (> 120 mg/dl) (p < 0.0001). Death occurred in 6.7% and 20.8% of the two groups, respectively (p < 0.0001). It is concluded that admission plasma glucose levels can serve as an objective prognostic indicator after SAH. Elevated glucose levels during the 1st week after SAH also predict a poor outcome. However, a causal link between hyperglycemia and outcome after delayed cerebral ischemia, although suggested by experimental data, cannot be established on the basis of this study.
Article
Advanced age is a recognized prognostic indicator of poor outcome after subarachnoid hemorrhage (SAH). The relationship of age to other prognostic factors and outcome was evaluated using data from the multicenter randomized trial of nicardipine in SAH conducted in 21 neurosurgical centers in North America. Among the 906 patients who were studied, five different age groups were considered: 40 years or less, 41 to 50, 51 to 60, 61 to 70, and more than 71 years. Twenty-three percent of the individuals enrolled were older than 60 years of age. Women outnumbered men in all age groups. Level of consciousness (p = 0.0002) and World Federation of Neurological Surgeons grade (p = 0.0001) at admission worsened with advancing age. Age was also related to the presence of a thick subarachnoid clot (p = 0.0001), intraventricular hemorrhage (p = 0.0003), and hydrocephalus (p = 0.0001) on an admission computerized tomography scan. The rebleeding rate increased from 4.5% in the youngest age group to 16.4% in patients more than 70 years of age (p = 0.002). As expected, preexisting medical conditions, such as diabetes (p = 0.028), hypertension (p = 0.0001), and pulmonary (p = 0.0084), myocardial (p = 0.0001), and cerebrovascular diseases (p = 0.0001), were positively associated with age. There were no age-related differences in the day of admission following SAH, timing of the surgery and/or location, and size (small vs. large) of the ruptured aneurysm. During the treatment period, the incidence of severe complications (that is, those complications considered life threatening by the reporting investigator) increased with advancing age, occurring in 28%, 33%, 36%, 40%, and 46% of the patients in each advancing age group, respectively (p = 0.0002). No differences were observed in the reported frequency of surgical complications. No age-related differences were found in the overall incidence of angiographic vasospasm; however, symptomatic vasospasm was more frequently reported in the older age groups (p = 0.01). Overall outcome, assessed using the Glasgow Outcome Scale at 3 months post-SAH, was poorer with advancing age (p < 0.001). Multivariate analysis of overall outcome, adjusting for the different prognostic factors, did not remove the age effect, which suggests that the aging brain has a less optimal response to the initial bleeding. Age as a risk factor is a continuum; however, there seems to be a significant increased risk of poor outcome after the age of 60 years.
Article
We have examined prognostic factors in delayed ischaemic deficit attributed to vasospasm following subarachnoid haemorrhage (SAH) and early aneurysm surgery. Among 605 patients with SAH, 201 patients developed a delayed ischaemic deficit and 137 of these underwent early surgery. These 137 patients were classified into groups A and B by outcome at 3 months after SAH (group A: the delayed ischaemic deficit was associated with an adverse outcome; group B: no adverse outcome). Factors indicating an unfavourable outcome were as follows: (i) older age; (ii) poor WFNS grade on admission; (iii) Fisher's scale of 4; (iv) intracerebral haemorrhage; (v) delayed ischaemic deficit following rerupture; (vi) complications of surgical intervention; (vii) delayed ischaemic deficit with disturbance of consciousness; (viii) lack of immediate improvement with hypervolaemic therapy; and (ix) intracranial complications after hypervolaemic therapy. We suggest that the reversibility of a delayed ischaemic deficit is determined by preceding brain damage and/or surgical complications.
Article
Prediction of patient outcome is an important aspect of the management and study of aneurysmal subarachnoid hemorrhage (SAH). In the present study, we evaluated the prognostic value of two multivariate approaches to risk classification, Classification and Regression Trees (CART) and multiple logistic regression, and compared them with the best single predictor of outcome, level of consciousness. Data prospectively collected in the first Cooperative Aneurysm Study of intravenous nicardipine after aneurysmal SAH (NICSAH I, n = 885) were used to develop the prediction models. Low-, medium-, and high-risk groups for unfavorable outcome were devised using CART and a stepwise logistic regression analysis. Admission factors incorporated into both classification schemes were: level of consciousness, age, location of aneurysm (basilar versus other), and the Glasgow Coma Score. The CART prediction tree also branched on a dichotomy of admission glucose level. The two multivariate classifications were then compared with a prediction scheme based on the single best performing prognostic factor, level of consciousness in an independent series, NICSAH II (n = 353), and also in the original training dataset. A similar discrimination of risk was achieved by the three classification systems in the testing sample (NICSAH II). The 8%, 19%, and 52% rates of unfavorable outcome obtained from low-, medium-, and high-risk groups defined by LOC approximated those obtained using the more complex multivariate systems. Although multivariate classification systems are useful to characterize the relationship of multiple risk factors to outcome, the simple clinical measure LOC is favored as a concise and practical classification for predicting the probability of unfavorable outcome after aneurysmal SAH.
Article
Moderate elevations of brain temperature, when present during or after ischemia or trauma, may markedly worsen the resulting injury. We review these provocative findings, which form the rationale for our recommendation that physicians treating acute cerebral ischemia or traumatic brain injury diligently monitor their patients for incipient fever and take prompt measures to maintain core-body temperature at normothermic levels. In standardized models of transient forebrain ischemia, intraischemic brain temperature elevations to 39 degrees C enhance and accelerate severe neuropathological alterations in vulnerable brain regions and induce damage to structures not ordinarily affected. Conversely, the blunting of even mild spontaneous postischemic hyperthermia confers neuroprotection. Mild hyperthermia is also deleterious in focal ischemia, particularly in reversible vascular occlusion. The action of otherwise neuroprotective drugs in ischemia may be nullified by mild hyperthermia. Even when delayed by 24 hours after an acute insult, moderate hyperthermia can still worsen the pathological and neurobehavioral outcome. Hyperthermia acts through several mechanisms to worsen cerebral ischemia. These include (1) enhanced release of neurotransmitters; (2) exaggerated oxygen radical production; (3) more extensive blood-brain barrier breakdown; (4) increased numbers of potentially damaging ischemic depolarizations in the focal ischemic penumbra; (5) impaired recovery of energy metabolism and enhanced inhibition of protein kinases; and (6) worsening of cytoskeletal proteolysis. Recent studies demonstrate the feasibility of direct brain temperature monitoring in patients with traumatic and ischemic injury. Moderate to severe brain temperature elevations, exceeding core-body temperature, may occur in the injured brain. Cerebral hyperthermia also occurs during rewarming after hypothermic cardiopulmonary bypass procedures. Several studies have now shown that elevated temperature is associated with poor outcome in patients with acute stroke. Finally, recent clinical trials in severe closed head injury have shown a beneficial effect of moderate therapeutic hypothermia. The acutely ischemic or traumatized brain is inordinately susceptible to the damaging influence of even modest brain temperature elevations. While controlled clinical investigations will be required to establish the therapeutic efficacy and safety of frank hypothermia in patients with acute stroke, the available evidence is sufficiently compelling to justify the recommendation, at this time, that fever be combatted assiduously in acute stroke and trauma patients, even if "minor" in degree and even when delayed in onset. We suggest that body temperature be maintained in a safe normothermic range (eg, 36.7 degrees C to 37.0 degrees C [98.0 degrees F to 98.6 degrees F]) for at least the first several days after acute stroke or head injury.
Article
Five pretreatment variables (P<0.1 univariate analysis), including serum glucose (>300 mg/dL), predicted symptomatic intracerebral hemorrhage (ICH) in the National Institute of Neurological Disorders and Stroke rtPA trial. We retrospectively studied stroke patients treated <3 hours from onset with intravenous rtPA at 2 institutions to evaluate the role of these variables in predicting ICH. Baseline characteristics, including 5 prespecified variables (age, baseline glucose, smoking status, National Institutes of Health Stroke Scale [NIHSS] score, and CT changes [>33% middle cerebral artery territory hypodensity]), were reviewed in 138 consecutive patients. Variables were evaluated by logistic regression as predictors of all hemorrhage (including hemorrhagic transformation) and symptomatic hemorrhage on follow-up CT scan. Variables significant at P<0.25 level were included in a multivariate analysis. Diabetes was substituted for glucose in a repeat analysis. Symptomatic hemorrhage rate was 9% (13 of 138). Any hemorrhage rate was 30% (42 of 138). Baseline serum glucose (5.5-mmol/L increments) was the only independent predictor of both symptomatic hemorrhage [OR, 2.26 (CI, 1.05 to 4.83), P=0.03] and all hemorrhage [OR, 2.26 (CI, 1.07 to 4.69), P=0.04]. Serum glucose >11.1 mmol/L was associated with a 25% symptomatic hemorrhage rate. Baseline NIHSS (5-point increments) was an independent predictor of all hemorrhage only [OR, 12.42 (CI, 1.64 to 94.3), P=0.01]. Univariate analysis demonstrated a trend for nonsmoking as a predictor of all hemorrhage [OR, 0.45 (CI, 0.19 to 1. 08), P=0.07]. Diabetes was also an independent predictor of ICH when substituted for glucose in repeat analysis. Serum glucose and diabetes were predictors of ICH in rtPA-treated patients. This novel association requires confirmation in a larger cohort.
Article
To study the relation between acute blood glucose level and outcome from ischemic stroke. Hyperglycemia may augment acute ischemic brain injury and increase the risk of hemorrhagic transformation of the infarct. The authors analyzed the relation between admission blood glucose level (within 24 hours from ischemic stroke onset) and clinical outcome in 1,259 patients enrolled in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST)-a placebo-controlled, randomized, double-blind trial to test the efficacy of a low-molecular weight heparinoid in acute ischemic stroke. Very favorable outcome was defined as a Glasgow Outcome Scale score of 1 and a modified Barthel index of 19 or 20. Neurologic improvement at 3 months was defined as a decrease by > or =4 points on the NIH Stroke Scale compared with baseline or a final score of 0. Hemorrhagic transformation of infarct was assessed within 10 days after onset of stroke with repeat cerebral CT. Stroke subtype as lacunar or nonlacunar (atherothromboembolic, cardioembolic, and other or undetermined etiology) was classified by one investigator after completion of stroke evaluation according to study protocol. In all strokes combined (p = 0.03) and in nonlacunar strokes (p = 0.02), higher admission blood glucose levels were associated with worse outcome at 3 months according to multivariate logistic regression analysis adjusted for stroke severity, diabetes mellitus, and other vascular risks. In lacunar strokes, the relationship between acute blood glucose level and outcome was related to treatment. In the placebo group, higher admission blood glucose levels were associated with better outcome at 3 months. However, in the active drug group, as the glucose level increased from 50 to 150 mg/dL, the probability of a very favorable outcome decreased sharply and remained relatively unchanged as the glucose level increased further (p = 0.002, for overall effect of glucose on outcome). Acute blood glucose level was not associated with symptomatic hemorrhagic transformation of infarcts or with neurologic improvement at 3 months. During acute ischemic stroke hyperglycemia may worsen the clinical outcome in nonlacunar stroke, but not in lacunar stroke, and is not associated with an increased risk of hemorrhagic transformation of the infarct.
Article
A retrospective study was carried out to evaluate the effect of hypertonic (3%) saline chloride/acetate on various hemodynamic parameters in mildly hyponatremic patients with symptomatic vasospasm following aneurysmal subarachnoid hemorrhage (SAH). We identified 29 hyponatremic (serum sodium < 135 mEq/L) patients who received hypertonic (3%) sodium chloride/acetate as a continuous infusion. Administration of hypertonic (3%) sodium chloride/acetate resulted in higher central venous pressures and positive fluid balance, with a concomitant increase in serum sodium and chloride concentrations without metabolic acidosis. There were no changes in mean cerebral blood flow velocities after infusion of hypertonic (3%) sodium chloride/acetate. We found no reports of congestive heart failure, pulmonary edema, metabolic acidosis, coagulopathy, intracranial hemorrhages, or central pontine myelinolysis in any of these patients. We conclude that hypertonic (3%) sodium chloride/acetate can be administered to patients with mild hyponatremia in the setting of symptomatic vasospasm following SAH without untoward effects. Sample size and limitations of a retrospective analysis preclude conclusions about safety and efficacy of hypertonic (3%) sodium chloride/acetate administration in this patient population. However, our results support justification for a prospective, randomized, double-blind trial of hypertonic (3%) sodium chloride/acetate versus normal saline in patients with symptomatic vasospasm following SAH.