Article

Impact of medical complications on outcome after subarachnoid hemorrhage

March 2006
Critical Care Medicine 34(3):617-23; quiz 624

DOI:10.1097/01.CCM.0000201903.46435.35

Source
PubMed

Authors:

Katja E Wartenberg

Martin Luther University Halle-Wittenberg

J. Michael Schmidt

Columbia University

Jan Claassen

Columbia University

Richard E Temes

Rush University Medical Center

Show all 9 authorsHide

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.

Complications extraneurologiques des hémorragies sousarachnoïdiennes anévrismalesExtra-neurologic complications of subarachnoid hemorrhage

Article

Nov 2017

Subarachnoid hemorrhage is a pathology that affects mainly healthy young women. It can get complicated by secondary neurologic injuries like hydrocephalus, intracranial hypertension, seizure, and vasospasm. Subarachnoid hemorrhages may cause complication on extracerebral organs by catecholamine-mediated injury and systemic inflammatory response syndrome. These complications may be neurocardiogenic injury (e.g., cardiac dysfunction, electric modification), pulmonary (e.g., VAP, neurogenic pulmonary edema), and metabolic (e.g., electrolyte imbalance, acute kidney injury, hyperglycemia).

Sex-specific extracerebral complications in patients with aneurysmal subarachnoid hemorrhage

Article

Full-text available

May 2023

Background Extracerebral complications in patients with aneurysmal subarachnoid hemorrhage (aSAH) often occur during their stay at the neurocritical care unit (NCCU). Their influence on outcomes is poorly studied. The identification of sex-specific extracerebral complications in patients with aSAH and their impact on outcomes might aid more personalized monitoring and therapy strategies, aiming to improve outcomes. Methods Consecutive patients with aSAH admitted to the NCCU over a 6-year period were evaluated for the occurrence of extracerebral complications (according to prespecified criteria). Outcomes were assessed with the Glasgow Outcome Scale Extended (GOSE) at 3 months and dichotomized as favorable (GOSE 5–8) and unfavorable (GOSE 1–4). Sex-specific extracerebral complications and their impact on outcomes were investigated. Based on the results of the univariate analysis, a multivariate analysis with unfavorable outcomes or the occurrence of certain complications as dependent variables was performed. Results Overall, 343 patients were included. Most of them were women (63.6%), and they were older than men. Demographics, presence of comorbidities, radiological findings, severity of bleeding, and aneurysm-securing strategies were compared among the sexes. More women than men suffered from cardiac complications ( p = 0.013) and infection ( p = 0.048). Patients with unfavorable outcomes were more likely to suffer from cardiac ( p < 0.001), respiratory ( p < 0.001), hepatic/gastrointestinal ( p = 0.023), and hematological ( p = 0.021) complications. In the multivariable analysis, known factors including age, female sex, increasing number of comorbidities, increasing World Federation of Neurosurgical Societies (WFNS), and Fisher grading were expectedly associated with unfavorable outcomes. When adding complications to these models, these factors remained significant. However, when considering the complications, only pulmonary and cardiac complications remained independently associated with unfavorable outcomes. Conclusion Extracerebral complications after aSAH are frequent. Cardiac and pulmonary complications are independent predictors of unfavorable outcomes. Sex-specific extracerebral complications in patients with aSAH exist. Women suffered more frequently from cardiac and infectious complications potentially explaining the worse outcomes.

Prevention and Correction of Dysnatremia After Aneurysmal Subarachnoid Hemorrhage

Article

May 2023

Background Dysnatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). The mechanisms for development of sodium dyshomeostasis are complex, including the cerebral salt-wasting syndrome, the syndrome of inappropriate secretion of antidiuretic hormone, diabetes insipidus. Iatrogenic occurrence of altered sodium levels plays a role, as sodium homeostasis is tightly linked to fluid and volume management.Methods Narrative review of the literature.ResultsMany studies have aimed to identify factors predictive of the development of dysnatremia, but data on associations between dysnatremia and demographic and clinical variables are variable. Furthermore, although a clear relationship between serum sodium serum concentrations and outcomes has not been established—poor outcomes have been associated with both hyponatremia and hypernatremia in the immediate period following aSAH and set the basis for seeking interventions to correct dysnatremia. While sodium supplementation and mineralocorticoids are frequently administered to prevent or counter natriuresis and hyponatremia, evidence to date is insufficient to gauge the effect of such treatment on outcomes.Conclusions In this article, we reviewed available data and provide a practical interpretation of these data as a complement to the newly issued guidelines for management of aSAH. Gaps in knowledge and future directions are discussed.

Systematic review and meta-analysis of outcome-relevant anemia in patients with subarachnoid hemorrhage

Article

Full-text available

Dec 2022

Anemia is a common, treatable condition in patients with aneurysmal subarachnoid hemorrhage (SAH) and has been associated with poor outcome. As there are still no guidelines for anemia management after aneurysm rupture, we aimed to identify outcome-relevant severity of anemia in SAH. We systematically searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library for publications before Oct 23rd, 2022, reporting on anemia in SAH patients. The presence and severity of anemia were assessed according to the reported hemoglobin values and/or institutional thresholds for red blood cells transfusion (RBCT). Out of 1863 original records, 40 full-text articles with a total of 14,701 patients treated between 1996 and 2020 were included in the final analysis (mean 445.48 patients per study). A substantial portion of patients developed anemia during SAH (mean pooled prevalence 40.76%, range 28.3–82.6%). RBCT was administered in a third of the cases (mean 32.07%, range 7.8–88.6%), with institutional threshold varying from 7.00 to 10.00 g/dL (mean 8.5 g/dL). Anemia at the onset of SAH showed no impact on SAH outcome. In contrast, even slight anemia (nadir hemoglobin < 11.0–11.5 g/dL) occurring during SAH was associated with the risk of cerebral infarction and poor outcome at discharge and follow-up. The strongest association with SAH outcome was observed for nadir hemoglobin values ranging between 9.0 and 10.0 g/dL. The effect of anemia on SAH mortality was marginal. The development of anemia during SAH is associated with the risk of cerebral infarction and poor outcome at discharge and follow-up. Outcome-relevant severity of post-SAH anemia begins at hemoglobin levels clearly above the thresholds commonly set for RBCT. Our findings underline the need for further studies to define the optimal management of anemia in SAH patients.

Microsurgery versus embolization: different risk factors for short- and longterm outcomes of patients with ruptured aneurysms

Article

Full-text available

Nov 2022
ACTA CIR BRAS

Purpose To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS). Results Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group. Conclusions Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome. Key words Intracranial Aneurysm; Subarachnoid Hemorrhage; Plaque; Atherosclerotic; Aneurysms; Follow-Up Studies; Prognosis

SUBARAKNOİD KANAMA VE ACİL YÖNETİMİ

Chapter

Jun 2022

Ece Uysal

Prediction of stress-related gastrointestinal bleeding in patients with aneurysmal subarachnoid hemorrhage using caudate Hounsfield unit value in ASPECT score

Article

Full-text available

Sep 2023

Background Stress-related gastrointestinal bleeding (SRGB) is one of the major complications after aneurysmal subarachnoid hemorrhage (aSAH), and it can present challenges in patient care and treatment. The aim of this study was to explore the clinical significance of the caudate Hounsfield unit (HU) value in the Alberta Stroke Program Early CT (ASPECT) score for predicting SRGB in patients with aSAH. Methods We retrospectively analyzed the data of 531 aSAH patients admitted to our institution between 2019 and 2022. Potential predictors of SRGB were identified using multivariate Cox regression analysis. We used a restricted cubic spline (RCS) to evaluate whether there is a nonlinear relationship between the right caudate HU value and SRGB. MaxStat analysis (titled as maximally selected rank statistics) was performed to identify the optimal cutoff point for the right caudate HU value. Another Kaplan–Meier method with the log-rank test was used to analyze the right caudate HU value in predicting the occurrence of SRGB. Results The incidence rate of SRGB was 17.9%. In the multivariate Cox regression analysis, the right caudate HU value was an independent predictor of SRGB [Hazard ratio (HR) = 0.913; 95% confidence interval (CI): 0.847–0.983, and p = 0.016]. The RCS indicated that the incidence of developing SRGB reduces with increasing right caudate HU values (nonlinear p = 0.78). The optimal cut-off value of the right caudate HU was 25.1. Conclusion Among aSAH patients, lower right caudate HU values indicated a higher risk of developing SRGB. Our findings provide further evidence for the relationship between the gastrointestinal system and the brain.

Brain Oxygenation Response to Hypercapnia in Patients with Acute Brain Injury

Article

Full-text available

Sep 2023

Background Cerebral hypoxia is a frequent cause of secondary brain damage in patients with acute brain injury. Although hypercapnia can increase intracranial pressure, it may have beneficial effects on tissue oxygenation. We aimed to assess the effects of hypercapnia on brain tissue oxygenation (PbtO2).Methods This single-center retrospective study (November 2014 to June 2022) included all patients admitted to the intensive care unit after acute brain injury who required multimodal monitoring, including PbtO2 monitoring, and who underwent induced moderate hypoventilation and hypercapnia according to the decision of the treating physician. Patients with imminent brain death were excluded. Responders to hypercapnia were defined as those with an increase of at least 20% in PbtO2 values when compared to their baseline levels.ResultsOn a total of 163 eligible patients, we identified 23 (14%) patients who underwent moderate hypoventilation (arterial partial pressure of carbon dioxide [PaCO2] from 44 [42–45] to 50 [49–53] mm Hg; p < 0.001) during the study period at a median of 6 (4–10) days following intensive care unit admission; six patients had traumatic brain injury, and 17 had subarachnoid hemorrhage. A significant overall increase in median PbtO2 values from baseline (21 [19–26] to 24 [22–26] mm Hg; p = 0.02) was observed. Eight (35%) patients were considered as responders, with a median increase of 7 (from 4 to 11) mm Hg of PbtO2, whereas nonresponders showed no changes (from − 1 to 2 mm Hg of PbtO2). Because of the small sample size, no variable independently associated with PbtO2 response was identified. No correlation between changes in PaCO2 and in PbtO2 was observed.Conclusions In this study, a heterogeneous response of PbtO2 to induced hypercapnia was observed but without any deleterious elevations of intracranial pressure.

Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study

Article

Full-text available

Aug 2023
NEUROSURG REV

Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.

Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage

Article

Full-text available

Jun 2023

Aneurysmal subarachnoid hemorrhage is a medical emergency that necessitates direct transfer to a tertiary referral center specialized in the diagnosis and treatment of this condition. The initial hours after aneurysmal rupture are critical for patients with aneurysmal subarachnoid hemorrhage, both in terms of rebleeding and combating the effect of early brain injury. No good treatment options are available to reduce the risk of rebleeding before aneurysm occlusion. Lowering the blood pressure may reduce the risk of rebleeding but carries a risk of inducing delayed cerebral ischemia or aggravating the consequences of early brain injury. Early brain injury after aneurysmal rupture has an important effect on final clinical outcome. Proper cerebral perfusion is pivotal in these initial hours after aneurysmal rupture but threatened by complications such as neurogenic pulmonary edema and cardiac stunning, or by acute hydrocephalus, which may necessitate early drainage of cerebrospinal fluid.

Effect of xenon on brain injury, neurological outcome, and survival in patients after aneurysmal subarachnoid hemorrhage—study protocol for a randomized clinical trial

Article

Full-text available

Jun 2023
TRIALS

Background Aneurysmal subarachnoid hemorrhage (aSAH) is a neurological emergency, affecting a younger population than individuals experiencing an ischemic stroke; aSAH is associated with a high risk of mortality and permanent disability. The noble gas xenon has been shown to possess neuroprotective properties as demonstrated in numerous preclinical animal studies. In addition, a recent study demonstrated that xenon could attenuate a white matter injury after out-of-hospital cardiac arrest. Methods The study is a prospective, multicenter phase II clinical drug trial. The study design is a single-blind, prospective superiority randomized two-armed parallel follow-up study. The primary objective of the study is to explore the potential neuroprotective effects of inhaled xenon, when administered within 6 h after the onset of symptoms of aSAH. The primary endpoint is the extent of the global white matter injury assessed with magnetic resonance diffusion tensor imaging of the brain. Discussion Despite improvements in medical technology and advancements in medical science, aSAH mortality and disability rates have remained nearly unchanged for the past 10 years. Therefore, new neuroprotective strategies to attenuate the early and delayed brain injuries after aSAH are needed to reduce morbidity and mortality. Trial registration ClinicalTrials.gov NCT04696523. Registered on 6 January 2021. EudraCT, EudraCT Number: 2019-001542-17. Registered on 8 July 2020.

Mechanical ventilation in patients with acute brain injury: a systematic review with meta-analysis

Article

Full-text available

Jun 2023

Abstract Objective To describe the potential effects of ventilatory strategies on the outcome of acute brain-injured patients undergoing invasive mechanical ventilation. Design Systematic review with an individual data meta-analysis. Setting Observational and interventional (before/after) studies published up to August 22nd, 2022, were considered for inclusion. We investigated the effects of low tidal volume Vt = 8 ml/Kg of IBW, positive end-expiratory pressure (PEEP) = 5 cmH2O and protective ventilation (association of both) on relevant clinical outcomes. Population Patients with acute brain injury (trauma or haemorrhagic stroke) with invasive mechanical ventilation for ≥ 24 h. Main outcome measures The primary outcome was mortality at 28 days or in-hospital mortality. Secondary outcomes were the incidence of acute respiratory distress syndrome (ARDS), the duration of mechanical ventilation and the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio. Results The meta-analysis included eight studies with a total of 5639 patients. There was no difference in mortality between low and high tidal volume [Odds Ratio, OR 0.88 (95%Confidence Interval, CI 0.74 to 1.05), p = 0.16, I 2 = 20%], low and moderate to high PEEP [OR 0.8 (95% CI 0.59 to 1.07), p = 0.13, I 2 = 80%] or protective and non-protective ventilation [OR 1.03 (95% CI 0.93 to 1.15), p = 0.6, I 2 = 11]. Low tidal volume [OR 0.74 (95% CI 0.45 to 1.21, p = 0.23, I 2 = 88%], moderate PEEP [OR 0.98 (95% CI 0.76 to 1.26), p = 0.9, I 2 = 21%] or protective ventilation [OR 1.22 (95% CI 0.94 to 1.58), p = 0.13, I 2 = 22%] did not affect the incidence of acute respiratory distress syndrome. Protective ventilation improved the PaO2/FiO2 ratio in the first five days of mechanical ventilation (p

Brain Oxygenation Response to Hypercapnia in Acute Brain Injured Patients

Preprint

Full-text available

May 2023

Background Cerebral hypoxia is a frequent cause of secondary brain damage in patients with acute brain injury. Although hypercapnia can increase intracranial pressure, it may have beneficial effects on tissue oxygenation. We aimed to assess the effects of hypercapnia on brain tissue oxygenation (PbtO2). Methods This single-center retrospective study (November 2014-June 2022) included all patients admitted to the Intensive Care Unit (ICU) after acute brain injury who required multimodal monitoring including PbtO2 and who underwent induced moderate hypoventilation and increased PaCO2, according to the decision of the treating physician. Patients with imminent brain death were excluded. “Responders” to hypercapnia were defined as those with an increase of at least 20% in PbtO2 values when compared to their baseline levels. Results On a total of 163 eligible patients, we identified 23 (14%) patients who underwent moderate hypoventilation (PaCO2 from 44 [42–45] to 50 [49–53] mmHg; p < 0.001) during the study period at a median of 6 (4–10) days following ICU admission; 6 patients had traumatic brain injury (TBI) and 17 had subarachnoid hemorrhage (SAH). A significant overall increase in median PbtO2 values from baseline [21 (19–26) to 24 (22–26) mmHg; p = 0.02] was observed. Eight (35%) patients were considered as “responders”, with a median increase of 7 (from 4 to 11) mmHg of PbtO2, while non-responders showed no changes (from − 1 to 2 mmHg of PbtO2). Due to the small sample size, no variable independently associated with PbtO2 response was identified. No correlation between the change in PaCO2 and in PbtO2 was observed. Conclusions In this study, a heterogeneous response of brain tissue oxygenation to induced hypercapnia was observed, but without any deleterious elevations of ICP.

Real-world data of clazosentan for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study

Preprint

Full-text available

Apr 2023

Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm which is significantly associated with morbidity and mortality. Clazosentan, an endothelin-1 receptor antagonist, has been shown to reduce cerebral vasospasm-related morbidity and all-cause mortality compared to placebo in patients with aSAH. To investigate effectiveness of clazosentan combination therapy we conducted a multicenter, retrospective, observational cohort study of Japanese patients with aSAH (35 female; age 64.4 ± 15.0 years old) between June 2022 and March 2023. Of the 47 cases, 29 (61.7%) had favorable outcomes and 9 (19.1%) had unfavorable outcomes. For postoperative aSAH management, clazosentan, cilostazol, and statins were typically used. Fasudil and ozagrel were used in 18 (38.3%) and 15 cases (31.9%), respectively. In 16 cases (34.0%), vasospasm occurred, but vasospasm-related delayed cerebral ischemia (DCI) was reported in only 4 cases (8.5%). Complications of pulmonary edema and hypotension occurred in 19 cases (40.4%) and 16 cases (34.0%), respectively. Risk factors of pulmonary edema were older age, clazosentan discontinuation, positive fluid balance, and lower serum albumin levels. Lower BMI, higher WFNS grade, lower urine output, lower serum albumin were risk factors of hypotension. The risk factors of vasospasm-related DCI were clazosentan discontinuation and positive fluid balance. Hypotension and vasospasm-related DCI were related to unfavorable outcomes. Combination therapy with clazosentan could be effective in preventing post-aSAH vasospasm-related DCI. However, caution must be taken as combination therapy may increase the risk of hypotension and pulmonary edema compared with clazosentan single therapy. Perioperative fluid balance management may be critical for preventing unfavorable outcomes.

Cerebro-spinal fluid glucose and lactate concentrations changes in response to therapies in patIents with primary brain injury: the START-TRIP study

Article

Full-text available

Mar 2023

Introduction Altered levels of cerebrospinal fluid (CSF) glucose and lactate concentrations are associated with poor outcomes in acute brain injury patients. However, no data on changes in such metabolites consequently to therapeutic interventions are available. The aim of the study was to assess CSF glucose-to-lactate ratio (CGLR) changes related to therapies aimed at reducing intracranial pressure (ICP). Methods A multicentric prospective cohort study was conducted in 12 intensive care units (ICUs) from September 2017 to March 2022. Adult (> 18 years) patients admitted after an acute brain injury were included if an external ventricular drain (EVD) for intracranial pressure (ICP) monitoring was inserted within 24 h of admission. During the first 48–72 h from admission, CGLR was measured before and 2 h after any intervention aiming to reduce ICP (“intervention”). Patients with normal ICP were also sampled at the same time points and served as the “control” group. Results A total of 219 patients were included. In the intervention group ( n = 115, 53%), ICP significantly decreased and CPP increased. After 2 h from the intervention, CGLR rose in both the intervention and control groups, although the magnitude was higher in the intervention than in the control group (20.2% vs 1.6%; p = 0.001). In a linear regression model adjusted for several confounders, therapies to manage ICP were independently associated with changes in CGLR. There was a weak inverse correlation between changes in ICP and CGRL in the intervention group. Conclusions In this study, CGLR significantly changed over time, regardless of the study group. However, these effects were more significant in those patients receiving interventions to reduce ICP.

Association between serum sodium and in-hospital mortality among critically ill patients with spontaneous subarachnoid hemorrhage

Article

Full-text available

Oct 2022

Objective The aim of this study was to retrospectively explore the relationship between serum sodium and in-hospital mortality and related factors in critically ill patients with spontaneous subarachnoid hemorrhage (SAH).Methods Data were collected from the Medical Information Mart for Intensive Care IV database. Restricted cubic splines were used to explore the relationship between serum sodium and in-hospital mortality. Receiver operating characteristic analysis was used to calculate the optimal cutoff value of sodium fluctuation, and decision curve analysis was plotted to show the net benefit of different models containing serum sodium.ResultsA total of 295 patients with spontaneous SAH were included in the retrospective analysis. The level of sodium on ICU admission and minimum sodium in the ICU had a statistically significant non-linear relationship with in-hospital mortality (non-linear P-value < 0.05, total P-value < 0.001). Serum sodium on ICU admission, minimum serum sodium during ICU, and sodium fluctuation were independently associated with in-hospital mortality with odds ratios being 1.23 (95% confidence interval (CI): 1.04–1.45, P = 0.013), 1.35 (95% CI: 1.18-1.55, P < 0.001), and 1.07 (95% CI: 1.00–1.14, P = 0.047), respectively. The optimal cutoff point was 8.5 mmol/L to identify in-hospital death of patients with spontaneous SAH with sodium fluctuation, with an AUC of 0.659 (95% CI 0.573-0.744).Conclusion Among patients with spontaneous SAH, we found a J-shaped association between serum sodium on ICU admission and minimum sodium values during ICU with in-hospital mortality. Sodium fluctuation above 8.5 mmol/L was independently associated with in-hospital mortality. These results require being tested in prospective trials.

Impact of Anemia Severity on the Outcome of an Aneurysmal Subarachnoid Hemorrhage

Article

Full-text available

Oct 2022

Objective: Previous reports indicate a negative impact of anemia on the outcome of an aneurysmal subarachnoid hemorrhage (SAH). We aimed to identify the outcome-relevant severity of post-SAH anemia. Methods: SAH cases treated at our institution between 01/2005 and 06/2016 were included (n = 640). The onset, duration, and severity (nadir hemoglobin (nHB) level) of anemia during the initial hospital stay were recorded. Study endpoints were new cerebral infarctions, a poor outcome six months post-SAH (modified Rankin scale > 3), and in-hospital mortality. To assess independent associations with the study endpoints, different multivariable regression models were performed, adjusted for relevant patient and baseline SAH characteristics as well as anemia-associated clinical events during the SAH. Results: The rates of anemia were 83.3%, 67.7%, 40.0%, 15.9%, and 4.5% for an nHB < 11 g/dL, < 10 g/dL, < 9 g/dL, < 8 g/dL, and < 7 g/dL, respectively. The higher the anemia severity, the later was the onset (post-SAH days 2, 4, 5.4, 7.6 and 8, p < 0.0001) and the shorter the duration (8 days, 6 days, 4 days, 3 days, and 2 days, p < 0.0001) of anemia. In the final multivariable analysis, only an nHB < 9 g/dL was independently associated with all study endpoints: adjusted odds ratio 1.7/3.22/2.44 for cerebral infarctions/in-hospital mortality/poor outcome. The timing (post-SAH day 3.9 vs. 6, p = 0.001) and duration (3 vs. 5 days, p = 0.041) of anemia with an nHB < 9 g/dL showed inverse associations with the risk of in-hospital mortality, but not with other study endpoints. Conclusions: Anemia is very common in SAH patients affecting four of five individuals during their hospital stay. An nHB decline to < 9 g/dL was strongly associated with all study endpoints, independent of baseline characteristics and SAH-related clinical events. Our data encourage further prospective evaluations of the value of different transfusion strategies in the functional outcomes of SAH patients.

Prognostic significance of combined score of fibrinogen and neutrophil-lymphocyte ratio for functional outcome in patients with aneurysmal subarachnoid hemorrhage

Article

Full-text available

Aug 2022

Objective To explore the relationship between fibrinogen and neutrophil to lymphocyte ratio (F-NLR) score and functional outcomes after aneurysmal subarachnoid hemorrhage (aSAH).MethodA retrospective study was conducted that involved all consecutive patients with aSAH admitted to our institution from March 2018 to October 2021. Factors, such as demographics, comorbidities, clinical characteristics, neuroradiological data, and laboratory parameters, were collected from institutional databases. All patients achieved neurological assessment using the modified Rankin Scale (mRS) score 3 months after discharge to clarify the functional outcomes. The results were classified as favorable (mRS score 0–2) and unfavorable (mRS score 3–6). Univariate and multivariable analyses were performed to identify the relevant factors between inflammatory markers and functional outcomes after aSAH. Subsequently, a receiver operating characteristic (ROC) curve analysis was conducted to evaluate the predicting performance of variables. A propensity score match (PSM) was performed to correct imbalances in patients' baseline characteristics.ResultsFinally, 256 patients with aSAH were included in the study cohort. A total of 94 (36.7%) patients had an unfavorable outcome. F-NLR scores were 0 [interquartile range (IQR) 0–1] and 1 (IQR 1–2) in patients with favorable and unfavorable outcomes, respectively (p < 0.001). After adjustment, the F-NLR score on admission remained significantly associated with unfavorable outcomes in patients with aSAH. In the multivariable analysis, the F-NLR score was regarded as an independent risk factor of unfavorable outcomes [odds ratio (OR) 3.113, 95% CI 1.755–5.523, p < 0.001]. In ROC analysis, the optimal cutoff value of the F-NLR score was 0.5 points. Two cohorts (n = 86 in each group) obtained from PSM with low F-NLR scores (0 points) and high F-NLR scores (1–2 points) were used for analysis. A significantly higher unfavorable functional outcome rate was observed in patients with high F-NLR scores (33.7 vs. 9.3%, p < 0.001). The area under the curve (AUC) values of F-NLR scores before and after PSM were 0.767 and 0.712, respectively.Conclusion Fibrinogen and neutrophil to lymphocyte ratio score was an independent risk parameter associated with unfavorable functional outcomes at 3 months after aSAH. A higher F-NLR score predicts the occurrence of poor functional outcomes.

Lesión cerebral precoz en la hemorragia subaracnoídea aneurismática

Article

Full-text available

Jun 2022

La hemorragia subaracnoídea aneurismática (HSA), considerada por muchos como una de las más graves enfermedades del sistema nervioso central sigue siendo una afección devastadora. Es una enfermedad que se presenta con consecuencias complejas en la fisiopatología intracraneal, y que evolucionan desde el momento en que se rompe el aneurisma cerebral, con múltiples complicaciones neurológicas y extra-neurológicas posteriores. En esta revisión se efectúa una actualización de los principales fenómenos fisiopatológicos que ocurren en las primeras 72 horas de evolución de la HSA, conocido como Lesión Cerebral Precoz (LCP), y se reseñan las principales evaluaciones diagnósticas y medidas terapéuticas de acuerdo a las evidencias y literatura reciente.

Ten Rules for the Management of Moderate and Severe Traumatic Brain Injury During Pregnancy: An Expert Viewpoint

Article

Full-text available

Jun 2022

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.

Risk factors of mortality and severe disability in the patients with cerebrovascular diseases treated with perioperative mechanical ventilation

Article

Full-text available

Jun 2022

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.

Recovery of cognitive functions and self-service in patients with rupture of cerebral aneurysms

Article

May 2022

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.

Global research trends on temperature management in critical ill: a visualization analysis

Preprint

Full-text available

Nov 2023

Background Temperature management has been shown to be important in different diseases, and our study analyzes the research trends and future directions of temperature management in critically ill patients. Methods Literatures in our study were searched from the Web of Science core collection database (WoSCC), timeline was confined from the earliest time of the database to the latest time of literature search (October 22, 2023). R-studio and Citespace were used to perform the visualization analysis. Results A total of 529 publications from the WoSCC were analyzed. According to our research, there has been a rapid increase in publications since 2013. The largest number of articles produced by corresponding authors in the United States is as high as 161. Resuscitation had the highest number of publications among journals worldwide, with 23 publications representing 4.59% of all publications. Most of the keywords were related to cardiac arrest, critical care, hypothermia, targeted temperature management and therapeutic hypothermia. Latest burst words are neuron specific enolase, prognostication, septic shock and ambient temperature. This suggests that there may be more groundbreaking reports in these directions. Conclusions Temperature management is crucial in the clinical treatment of critically ill patients. Future studies should analyze more aspects of specific implementation in different diseases that can be controlled by temperature management target temperature, treatment timing, induction mode, induction speed, duration, rewarming mode and speed.

Accurately predicting the risk of unfavorable outcomes after endovascular coil therapy in patients with aneurysmal subarachnoid hemorrhage: an interpretable machine learning model

Article

Aug 2023
NEUROL SCI

Background: Despite endovascular coiling as a valid modality in treatment of aneurysmal subarachnoid hemorrhage (aSAH), there is a risk of poor prognosis. However, the clinical utility of previously proposed early prediction tools remains limited. We aimed to develop a clinically generalizable machine learning (ML) models for accurately predicting unfavorable outcomes in aSAH patients after endovascular coiling. Methods: Functional outcomes at 6 months after endovascular coiling were assessed via the modified Rankin Scale (mRS) and unfavorable outcomes were defined as mRS 3-6. Five ML algorithms (logistic regression, random forest, support vector machine, deep neural network, and extreme gradient boosting) were used for model development. The area under precision-recall curve (AUPRC) and receiver operating characteristic curve (AUROC) was used as main indices of model evaluation. SHapley Additive exPlanations (SHAP) method was applied to interpret the best-performing ML model. Results: A total of 371 patients were eventually included into this study, and 85.4% of them had favorable outcomes. Among the five models, the DNN model had a better performance with AUPRC of 0.645 (AUROC of 0.905). Postoperative GCS score, size of aneurysm, and age were the top three powerful predictors. The further analysis of five random cases presented the good interpretability of the DNN model. Conclusion: Interpretable clinical prediction models based on different ML algorithms have been successfully constructed and validated, which would serve as reliable tools in optimizing the treatment decision-making of aSAH. Our DNN model had better performance to predict the unfavorable outcomes at 6 months in aSAH patients compared with Yan's nomogram model.

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial

Article

Full-text available

Jun 2023

Importance After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. Objective To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. Design, Setting, and Participants The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. Intervention A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Main Outcomes and Measures Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Results Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, −0.12; 95% CI, −0.23 to −0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, −0.11; 95% CI, −0.22 to 0; P = .04). Conclusion and Relevance In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. Trial Registration ClinicalTrials.gov Identifier: NCT01258257

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

Article

May 2023
STROKE

Aim: The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. Methods: A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Hematology and Coagulation

Chapter

Jan 2013

Monisha A. Kumar

Association of chloride-rich fluids and medication diluents on the incidence of hyperchloremia and clinical consequences in aneurysmal subarachnoid hemorrhage

Article

Full-text available

Dec 2022

Background: Chloride-rich fluid administration is frequently employed in the management of aneurysmal subarachnoid hemorrhage (aSAH). However, the incidence and consequences of hyperchloremia in aSAH remain poorly defined. This study aimed to describe the incidence of hyperchloremia in aSAH, the contribution of fluid sources to chloride exposure, and the potential associations of hyperchloremia with patient outcomes.Methods: This was a single-center retrospective cohort study of patients admitted to a neurointensive care unit with aSAH. The primary outcome was incidence of hyperchloremia (chloride >109 mEq/L). Secondary outcomes included incidence of severe hyperchloremia (chloride >115 mEq/L), incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), intensive care unit (ICU) length of stay (LOS), hospital LOS, and in-hospital mortality.Results: Of the 234 patients included in the analysis, hyperchloremia occurred in 75% (n=175), and 58% (n=101) developed severe hyperchloremia. Median time to onset was 3 days (interquartile range, 1–5) after admission. Hyperchloremia was associated with prolonged ICU LOS (12 vs. 8 days, P<0.001), duration of mechanical ventilation (16 vs. 10 days, P<0.001), hospital LOS (15 vs. 9 days, P<0.001), and in-hospital mortality (14.3% vs. 0%, P=0.002) compared to no hyperchloremia. No significant difference was observed in the incidence of AKI or the need for RRT. Maintenance intravenous fluids accounted for the highest proportion of the cumulative chloride burden.Conclusion: Hyperchloremia occurs at a high frequency in aSAH and is associated with poor patient outcomes. Maintenance intravenous fluids accounted for the highest proportion of cumulative chloride burden.

Small intracranial aneurysms of the anterior circulation – A negligible risk?

Article

Nov 2022

Background: According to the ISUIA, small (<7 mm) unruptured intracranial aneurysms (IA) of the anterior circulation (aC) carry a neglectable 5-years rupture risk. In contrast, some studies report frequencies of more than 20% of all ruptured IA being small IA of the aC. This contradiction was addressed in this study by analyzing the rates and risk factors for rupture of small IA within the aC. Methods: Of the institutional observational cohort 1676 small IA of the aC were included. Different demographic, clinical, laboratory and radiographic characteristics were collected. A rupture risk score was established using all independent prognostic factors. The score performance was checked using receiver operating characteristic curve analysis. Results: Of all registered small IA of the aC, 20.1% were ruptured. The developed SIAAC score (range: -4 to +13 points) contained five major risk factors: IA location and size, arterial hypertension, alcohol abuse, and chronic renal failure. In addition, three putative protective factors were also included in the score: hypothyroidism, dyslipidemia and peripheral arterial disease. Increasing rates of ruptured IA with increasing SIAAC scores were observed: from 0% (≤-1 points) through >50% (≥8 points), and up to 100% in patients scoring ≥12 points. The SIAAC score achieved excellent discrimination (AUCSIAAC =0.803) and performed better than the PHASES score. Conclusions: Small IA of the aC carry a considerable rupture risk. After external validation, the proposed rupture risk score might provide a basis for better decision-making regarding the treatment of small unruptured IA of the aC.

Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country

Article

Nov 2022

Background: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country. Methods: This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes. Results: From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0-9). Median age was 55 years (interquartile range 46-62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), hypertension (adjusted OR 1.81, 95% CI 1.04-3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85-8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31-6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32-4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81-5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13-7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42-5.05). Conclusions: Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.

Respiratory care of the ICH patient

Chapter

Jun 2014

New and groundbreaking therapeutic options for the critical care of patients with cerebrovascular disease have improved patient management, minimized morbidity, reduced in-patient care, improved quality of life, and had a positive economic impact on health service provision. This volume integrates these approaches and suggests the best therapy option for all cerebrovascular conditions. The early chapters of the book focus on monitoring techniques and interventions. Subsequent sections address the critical care of a wide range of cerebrovascular diseases: ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, arteriovenous malformations, cerebral venous thrombosis and traumatic injury. The editors and authors are internationally recognized experts in their field, and the text is supplemented by tables and illustrations to demonstrate important clinical findings. This book will meet the needs of stroke physicians, neurologists, neurosurgeons, neurointensivists and interventional neuroradiologists seeking to maximize positive outcomes for their patients.

Common risk factors and prevention

Chapter

Jul 2014

This concise and informative Textbook of Stroke Medicine is aimed at doctors preparing to specialize in stroke care and strokologists looking for concise but in-depth scientific guidance on stroke management. Its practical approach covers all important issues of prevention, diagnosis, and treatment of cerebrovascular diseases. Dedicated chapters give a thorough review of all clinical issues. Fully revised throughout, the new edition has expanded sections on topics of rising practical importance, such as diagnostic imaging, stroke unit management, monitoring and management of complications including infections, recommendations for thrombolysis, interventions and neurosurgical procedures, and clear and balanced recommendations for secondary prevention. Neuropsychological syndromes are explained and an up-to-date view on neurorehabilitation is presented. The authors are all experts in their field and many of them have been working together in a teaching faculty for the European Master in Stroke Medicine Programme, which is supported by the European Stroke Organization.

Secondary prevention

Chapter

Jul 2014

Imaging for prediction of functional outcome and for assessment of recovery

Chapter

Jul 2014

Wolf-Dieter Heiss

Intracerebral hemorrhage

Chapter

Jul 2014

Stroke and dementia

Chapter

Jul 2014

Subarachnoid hemorrhage

Chapter

Jul 2014

Cardiac diseases relevant to stroke

Chapter

Jul 2014

Infections in stroke

Chapter

Jul 2014

Ultrasound in acute ischemic stroke

Chapter

Jul 2014

László Csiba

Common causes of ischemic stroke

Chapter

Jul 2014

Bo Norrving

Plasma anion gap and risk of in-hospital mortality in patients with spontaneous subarachnoid hemorrhage

Article

Full-text available

Oct 2022

Background The association between the serum anion gap (AG) and prognosis of patients with spontaneous subarachnoid hemorrhage (SAH) remains unknown. Thus, this study aimed to explore the association between AG levels and mortality in patients with SAH in the intensive care unit (ICU). Methods This was a retrospective analysis of data stored in the Medical Information Mart for Intensive Care–IV and eICU Collaborative Research databases. Critically ill patients diagnosed with spontaneous SAH were included. The primary outcome measure was in-hospital all-cause mortality. A multivariate Cox proportional hazards regression model and a restricted cubic spline were used to evaluate the relationship between AG concentration and outcomes. Kaplan–Meier curves were used to compare cumulative survival among patients with AG levels. Results A total of 1,114 patients were enrolled. AG concentration was significantly associated with in-hospital all-cause mortality [hazard ratio ([HR], 1.076 (95% confidence interval (CI), 1.021–1.292; p = 0.006)]. The risk of mortality was higher in the Category 2 group (AG ≥10 mmol/L and <13 mmol/L; HR, 1.961; 95% CI, 1.157–3.324; p = 0.0) and the Category 3 group (AG ≥13 mmol/L; HR, 2.151; 95% CI, 1.198–3.864; p = 0.010) than in the Category 1 group (AG < 10 mmol/L). Cumulative survival rates were significantly lower in patients with higher AG levels (log-rank p < 0.001). Conclusions In-hospital and ICU mortalities increase with increasing AG concentration in patients with SAH. An increased serum AG level is an independent, significant, and robust predictor of all-cause mortality. Thus, serum AG levels may be used in the risk stratification of SAH.

The prognostic value of hyperglycemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Article

Full-text available

Sep 2022
NEUROSURG REV

Recent studies have demonstrated that hyperglycemia may result in a poor prognosis following aneurysmal subarachnoid hemorrhage (aSAH). However, the association between hyperglycemia and the clinical outcome of aSAH has not been clearly established thus far. Therefore, we performed a systematic review and meta-analysis to investigate the association between hyperglycemia and the development of aSAH. We completed a literature search in four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) up to November 1, 2021, including all eligible studies investigating the prognostic value of hyperglycemia in patients with aSAH. We performed a quality assessment of included studies using the Newcastle–Ottawa Quality Assessment Scale. The pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to assess the association of hyperglycemia in aneurysmal subarachnoid hemorrhage. A total of 35 studies with 11,519 patients were finally included in the meta-analysis. Nineteen studies reported the association between hyperglycemia and poor outcome, 12 studies reported the association between hyperglycemia and all-cause mortality, 7 studies reported the association between hyperglycemia and cerebral vasospasm, and 9 studies reported the association between hyperglycemia and cerebral infarction. The pooled data of these studies suggested that hyperglycemia was significantly associated with poor functional outcomes (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.17–1.42; P < 0.00001; I² = 83%), all-cause mortality (OR, 1.02; 95% CI, 1.01–1.04; P = 0.0006; I² = 89%), cerebral vasospasm (OR, 1.02; 95% CI, 1.01–1.02; P = 0.0002; I² = 35%), and cerebral infarction (OR, 1.16; 95% CI, 1.09–1.23; P < 0.00001; I² = 10%) in aSAH patients. These findings suggested that assessing for hyperglycemia at admission may help clinicians to identify critically ill patients and complete patient stratification early, which may achieve better management and improve the prognosis of patients with aSAH.

Safety of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage: A retrospective cohort study

Article

Nov 2022
J Stroke Cerebrovasc Dis

Objective To investigate the safety and efficacy of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients. Methods One hundred eleven patients with aSAH admitted between April 2015 and March 2019, were retrospectively evaluated. The early rehabilitation program was introduced in April 2017 to actively promote mobilization and walking training for aSAH patients. Therefore, patients were divided into two groups (The conventional group (n = 55) and the early rehabilitation group (n == 56). Clinical characteristics, mobilization progression, and treatment variables were analyzed. Complications (rebleeding, symptomatic cerebral vasospasm, hydrocephalus, disuse complications,) and a modified Rankin Scale (mRS) at 90 days were compared in two groups. Factors associated with favorable outcomes (mRS≤2) at 90 days were also assessed. Results The early rehabilitation group had a significantly shorter span to first walking (9 vs. 5 days; P = 0.007). The prevalence of complications was not significantly increased in the early rehabilitation group. Approximately 40% of patients in both groups had pneumonia and urinary tract infections but significantly reduced antibiotic-administration days (13 vs. 6 days; P < 0.001). mRS at 90 days also showed significant improvement in the early rehabilitation group (3 vs. 2; P=0.01). Multivariate logistic regression analysis of favorable outcomes associated that the administration of the early rehabilitation program has a significant independent factor (odds ratio, 3.03; 95% confidence interval, 1.1-8.37). Conclusions Early rehabilitation for patients with aSAH can be feasible without increasing complication occurrences. The early rehabilitation program with active mobilization and walking training reduced antibiotic use and was associated with improved independence.

Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland

Article

Full-text available

Sep 2022

Background: Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH. Methods: We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression. Results: 175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I-III, modified Fisher 2-4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia. Conclusions: In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care.

Noninvasive and invasive mechanical ventilation for neurologic disorders

Chapter

Aug 2022

Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain–Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.

Predictors of intraoperative intracranial aneurysm rupture in patients with subarachnoid hemorrhage: a retrospective analysis

Article

Jun 2022
ACTA NEUROL BELG

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.

Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations

Article

Full-text available

Jun 2022

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.

Temperature Management in the ICU

Article

Apr 2022
CRIT CARE MED

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.

Prognostication and shared decision making in neurocritical care

Article

Apr 2022
Br Med J

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.

APACHE II

Article

Full-text available

Oct 1985
CRIT CARE MED

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.

Siren AL, Fratelli M, Brines M, Goemans C, Casagrande S, Lewczuk P, Keenan S, Gleiter C, Pasquali C, Capobianco A, Mennini T, Heumann R, Cerami A, Ehrenreich H, Ghezzi PErythropoietin prevents neuronal apoptosis after cerebral ischemia and metabolic stress. Proc Natl Acad Sci USA 98:4044-4049

Article

Full-text available

Mar 2001
P NATL ACAD SCI USA

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.

Intensive Insulin Therapy in Critically Ill Patients

Article

Full-text available

Nov 2001
NEW ENGL J MED

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.

Measurements of acute cerebral infarction: A clinical examination scale

Article

Full-text available

Aug 1989

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.

Hijdra A, van Gijn J, Nagelkerke NJ, Vermeulen M, van Crevel HPrediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. Stroke 19:1250-1256

Article

Full-text available

Nov 1988

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.

APACHE II: a severity of disease classification system

Article

Full-text available

Nov 1985
CRIT CARE MED

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.

Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: Rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery

Article

Full-text available

Nov 1997

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

Mar 2001
J NEUROSURG

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.

Prognostic Factors on Hospital Admission after Spontaneous Subarachnoid Haemorrhage

Article

Full-text available

Feb 2001

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.

Brain temperature, body core temperature, and intracranial pressure in acute cerebral damage

Article

Full-text available

Oct 2001

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.

Efficacy of Recombinant Human Erythropoietin in Critically Ill Patients

Article

Full-text available

Dec 2002

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.

The effect of pneumonia on mortality among patients hospitalized for acute stroke

Article

Full-text available

Feb 2003
NEUROLOGY

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.

Fever in subarachnoid hemorrhage - Relationship to vasospasm and outcome

Article

May 2001

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.

Predictors of hyperacute clinical worsening in acute ischemic stroke patients receiving thrombolysis

Conference Paper

Jan 2003

Intensive Insulin therapy in critically ill patients

Article

May 2002

Fever after subarachnoid hemorrhage: Predictors and impact on outcome

Article

Dec 2002
CRIT CARE MED

Subarachnoid Hemorrhage: Clinical Presentation and Neuropsychological Outcome

Article

Jun 1998

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.

Brain temperature, body core temperature, and intracranial pressure in acute cerebral damage

Data

Oct 2001

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)°C; 73% of ICT and 57.5% of Tc measurements were ⩾38°C. The mean difference between ICT and Tc was 0.3 (SD 0.3)°C (range −0.7 to 2.3°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)°C before febrile episodes (ICT being higher than Tc), and 0.41 (SD 0.38)°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). CONCLUSIONS 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.

Intensive care management of subarachnoid hemorrhage

Article

Apr 1995

Stephan Mayer

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.

A critical appraisal of stroke evaluation and rating scales

Article

Dec 1991

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.

Severity of Disease Classification System

Article

Mar 1991
CRIT CARE MED

Acute hydrocephalus after aneurysmal haemorrhage

Article

Oct 1985
J NEUROSURG

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.

Assessment of Coma and Impaired Consciousness. A Practical Scale

Article

Aug 1974

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.

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

Article

Feb 1968
J NEUROSURG

Depression of Circulating Blood Volume in Patients after Subarachnoid Hemorrhage: Implications for the Management of Symptomatic Vasospasm

Article

Oct 1984

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.

Level of consciousness and age as prognostic factors in aneurysmal SAH

Article

Feb 1995

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.

Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study

Article

Jul 1995
CRIT CARE MED

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.

Plasma glucose levels and outcome after aneurysmal subarachnoid hemorrhage

Article

Jan 1994
J NEUROSURG

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.

Age and outcome after aneurysmal subarachnoid hemorrhage: Why do older patients fare worse?

Article

Oct 1996
J NEUROSURG

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.

Prognostic factors in delayed ischaemic deficit with vasospasm in patients undergoing early aneurysm surgery

Article

Jul 1997

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.

Risk classification after aneurysmal subarachnoid hemorrhage

Article

Mar 1998
SURG NEUROL

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.

Combating Hyperthermia in Acute Stroke : A Significant Clinical Concern

Article

Mar 1998

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.

Serum Glucose Level and Diabetes Predict Tissue Plasminogen Activator Related Intracerebral Hemorrhage in Acute Ischemic Stroke

Article

Jan 1999

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.

Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators

Article

Feb 1999

Askiel Bruno

Impact of medical complications on outcome after subarachnoid hemorrhage

Abstract

No full-text available