Effect of HHH-Therapy on Regional CBF after Severe Subarachnoid Hemorrhage Studied by Bedside Xenon-Enhanced CT

Introduction. Multiple aneurysms are detected in patients with non-traumatic subarachnoid hemorrhage (nSAH) in 14–45% of cases. The diagnostic algorithm for this pathology can be shortened by performing the non-enhanced CT of head, CT-angiography, and if the localization of hemorrhage according to non-enhanced CT data matches, there is enough evidence to perform direct surgery without obtaining preoperative DCA.Objective. Determination of the diagnostic efficiency of CT and CTA of brachiocephalic arteries (CTA BCA) for planning the surgical treatment in the case of multiple aneurysms of intracranial arteries in the acute period of non-traumatic ICH in an emergency room.Material and methods. Retrospective analysis of the records of radiological examinations in the preoperative period in patients in an acute period of non-traumatic subarachnoid hemorrhage in the acute period performed in an emergency room of the Research Institute — Ochapovsky Regional Hospital no. 1. in the period from September 2017 to July 2018 (cerebral angiography, non-enhanced CT of the brain, CTA BCA).Results. According to the CTA BCA, 60 aneurysms were found: 21 patients had 2 aneurysms each one, 2 patients had 3 aneurysms, one patient had 8 aneurysms, and 4 patients had one aneurysm each. In comparison with DCA, which was performed in 10 patients, additionally there were found 3 miliary aneurysms, one aneurysm was excluded. For patients who did not obtain DCA, CTA scans were compared with intraoperative data on the side of surgical intervention (n=18). According to the CTA BCA, 18 aneurysms were found, according to the intraoperative record were found 17 aneurysms, while in one case a large bilobulated aneurysm was defined by a radiologist as two oppositely directed. The rest of the data was consistent.Conclusion. The presence of nICH on the non-contrast CT of the brain, and the correspondence of the localization of hemorrhage according to the results of CT-angiography, is sufficient for direct surgery without obtaining preoperative DCA, which is especially important in difficult patients. The use of DCA in patients with multiple aneurysms is recommended only in controversial and difficult cases.

Download Full-text

CBF changes and cerebral energy metabolism during hypervolemia, hemodilution, and hypertension therapy in patients with poor-grade subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.11.jns192759 ◽

2020 ◽

pp. 1-10 ◽

Cited By ~ 1

Author(s):

Henrik Engquist ◽

Anders Lewén ◽

Lars Hillered ◽

Elisabeth Ronne-Engström ◽

Pelle Nilsson ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Mitochondrial Dysfunction ◽

Reference Group ◽

Time Windows ◽

Delayed Cerebral Ischemia ◽

Cerebral Microdialysis ◽

Metabolic Pattern ◽

Poor Grade ◽

Hhh Therapy ◽

Severe Ischemia

OBJECTIVEDespite the multifactorial pathogenesis of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), augmentation of cerebral blood flow (CBF) is still considered essential in the clinical management of DCI. The aim of this prospective observational study was to investigate cerebral metabolic changes in relation to CBF during therapeutic hypervolemia, hemodilution, and hypertension (HHH) therapy in poor-grade SAH patients with DCI.METHODSCBF was assessed by bedside xenon-enhanced CT at days 0–3, 4–7, and 8–12, and the cerebral metabolic state by cerebral microdialysis (CMD), analyzing glucose, lactate, pyruvate, and glutamate hourly. At clinical suspicion of DCI, HHH therapy was instituted for 5 days. CBF measurements and CMD data at baseline and during HHH therapy were required for study inclusion. Non-DCI patients with measurements in corresponding time windows were included as a reference group.RESULTSIn DCI patients receiving HHH therapy (n = 12), global cortical CBF increased from 30.4 ml/100 g/min (IQR 25.1–33.8 ml/100 g/min) to 38.4 ml/100 g/min (IQR 34.2–46.1 ml/100 g/min; p = 0.006). The energy metabolic CMD parameters stayed statistically unchanged with a lactate/pyruvate (L/P) ratio of 26.9 (IQR 22.9–48.5) at baseline and 31.6 (IQR 22.4–35.7) during HHH. Categorized by energy metabolic patterns during HHH, no patient had severe ischemia, 8 showed derangement corresponding to mitochondrial dysfunction, and 4 were normal. The reference group of non-DCI patients (n = 11) had higher CBF and lower L/P ratios at baseline with no change over time, and the metabolic pattern was normal in all these patients.CONCLUSIONSGlobal and regional CBF improved and the cerebral energy metabolic CMD parameters stayed statistically unchanged during HHH therapy in DCI patients. None of the patients developed metabolic signs of severe ischemia, but a disturbed energy metabolic pattern was a common occurrence, possibly explained by mitochondrial dysfunction despite improved microcirculation.

Download Full-text

Monitoring of hypervolemic hemodilution and hypertensive (HHH) therapy in subarachnoid hemorrhage (SAH) patients with pulmonary artery catheter (PAC)

Critical Care ◽

10.1186/cc198 ◽

1998 ◽

Vol 2 (Suppl 1) ◽

pp. P068

Author(s):

JL Nates ◽

M Jauss ◽

S Singh ◽

D Krieger

Keyword(s):

Subarachnoid Hemorrhage ◽

Pulmonary Artery ◽

Pulmonary Artery Catheter ◽

Hypervolemic Hemodilution ◽

Hhh Therapy

Download Full-text

Detection of aneurysmal subarachnoid hemorrhage 3 months after initial bleeding: evaluation of T2* and FLAIR MR sequences at 3 T in comparison with initial non-enhanced CT as a gold standard

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011819 ◽

2015 ◽

Vol 8 (8) ◽

pp. 813-818 ◽

Cited By ~ 4

Author(s):

Sébastien Mulé ◽

Sébastien Soize ◽

Azzedine Benaissa ◽

Christophe Portefaix ◽

Laurent Pierot

Keyword(s):

Subarachnoid Hemorrhage ◽

Gold Standard ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Predictive Values ◽

Hemosiderin Deposition ◽

Enhanced Ct ◽

Fluid Attenuated Inversion Recovery ◽

Interhemispheric Fissure ◽

Hemosiderin Deposits ◽

Mr Sequences

ObjectiveTo investigate the ability of T2* and fluid-attenuated inversion recovery (FLAIR) MR sequences to detect hemosiderin deposition 3 months after aneurysmal subarachnoid hemorrhage (SAH) in comparison with early non-enhanced CT (NECT) as a gold standard.Materials and methodsFrom September 2008 through May 2013, patients with aneurysmal SAH were included if a NECT less than 24 h after the onset of symptoms showed a SAH, and MRI, including T2* and FLAIR sequences, was performed 3 months later. All aneurysms were treated endovascularly. NECT and MR sequences were blindly analyzed for the presence of SAH (NECT) or hemosiderin deposition (MRI). When positive, details of the spatial distribution of SAH or hemosiderin deposits were noted. Sensitivities were calculated for each patient. Sensitivities, specificities, and positive predictive values (PPVs) were calculated for each location.ResultsForty-nine patients (mean age 52.9 years) were included. Bleeding-related patterns were identified in 43 patients (87.8%) on T2* and 10 patients (20.4%) on FLAIR. T2* was highly predictive of the location of the initial hemorrhage, especially in the Sylvian cisterns (PPVs 95% and 100%) and the anterior interhemispheric fissure (PPV 90%).ConclusionsThe T2* sequence can detect and localize a previous SAH a few months after aneurysmal bleeding.

Download Full-text

Intraprocedural predictors of post-stent retriever thrombectomy subarachnoid hemorrhage in middle cerebral artery stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013873 ◽

2018 ◽

Vol 11 (2) ◽

pp. 127-132 ◽

Cited By ~ 6

Author(s):

Perry P Ng ◽

Theodore C Larson ◽

Christopher W Nichols ◽

Mark M Murray ◽

Karen L Salzman ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Mass Effect ◽

Stent Retriever ◽

Enhanced Ct ◽

Observational Cohort ◽

Group 2 ◽

Angiographic Findings ◽

Group 1

BackgroundStent retriever thrombectomy (SRT) in acute thromboembolic stroke can result in post-thrombectomy subarachnoid hemorrhage (PTSAH). Intraprocedural findings associated with PTSAH are not well defined.ObjectiveTo identify angiographic findings and procedural factors during SRT that are associated with PTSAH.Materials and methodsThis was a retrospective, observational cohort study of consecutive patients with middle cerebral artery (MCA) acute ischemic stroke treated with SRT. Inclusion criteria were: (1) age ≥18 years; (2) thromboembolic occlusion of the MCA; (3) at least one stent retriever pass beginning in an M2 branch; (4) postprocedural CT or MRI scan within 24 hours; (5) non-enhanced CT Alberta Stroke Program Early CT Score >5. Exclusion criteria included multi-territory stroke before SRT.ResultsEighty-five patients were enrolled; eight patients had PTSAH (group 1) and 77 did not (group 2). Baseline demographic and clinical characteristics were comparable between the two groups. In group 1, a significantly greater proportion of patients had more than two stent retriever passes (62.5% vs 18.2%, P=0.01), a stent retriever positioned ≥2 cm along an M2 branch (100% vs 30.2%, P=0.002), and the presence of severe iatrogenic vasospasm before SRT pass (37.5% vs 5.2%, P=0.02). One patient with PTSAH and associated mass effect deteriorated clinically.ConclusionsAn increased number of stent retriever passes, distal device positioning, and presence of severe vasospasm were associated with PTSAH. Neurological deterioration with PTSAH can occur.

Download Full-text