367 Functional Outcome in Patients with Refractory Cerebral Vasospasm Treated with Repeat Instant Endovascular Interventions

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 285-286
Author(s):  
Lukas Andereggen ◽  
Juergen Beck ◽  
Werner Z’Graggen ◽  
Gerhard Schroth ◽  
Robert H Andres ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Functional Outcome ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Rescue Therapy ◽  
Inclusion Criteria ◽  
Significant Independent Predictor ◽  
Good Outcome ◽  
Endovascular Interventions

Abstract INTRODUCTION For patients suffering from cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular interventions often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the functional outcome of multiple repeated instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions. METHODS A single-center retrospective study of prospectively collected data on patients suffering from cerebral vasospasm refractory to therapies requiring at least 3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary endpoint was functional outcome at last follow-up (mRS <3). The secondary endpoint was angiographic response to endovascular therapies and appearance of cerebral infarctions. RESULTS >Over a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, <3 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with 3 or more interventions compared to 31 (61%) of those with 1 or 2 interventions (P = 0.82). The initial Hunt and Hess score <3 was a significant independent predictor of good outcome (OR 4.7, 95% CI, 1.2 18.5; P = 0.03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3 6; OR 13.5, 95% CI, 2.3 81.2; P = 0.004). CONCLUSION Repeated instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.

Persistent perioperative hyperglycemia as an independent predictor of poor outcome after aneurysmal subarachnoid hemorrhage

2007 ◽  
Vol 107 (6) ◽  
pp. 1080-1085 ◽  
Author(s):  
Matthew J. McGirt ◽  
Graeme F. Woodworth ◽  
Mohammed Ali ◽  
Khoi D. Than ◽  
Rafael J. Tamargo ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Univariate Analysis ◽  
Serum Glucose ◽  
Glucose Levels ◽  
Poor Outcome ◽  
Persistent Hyperglycemia

Object The authors of previous studies have shown that admission hyperglycemia or perioperative hyperglycemic events may predispose a patient to poor outcome after aneurysmal subarachnoid hemorrhage (SAH). The results of experimental evidence have suggested that hyperglycemia may exacerbate ischemic central nervous system injury. It remains to be clarified whether a single hyperglycemic event or persistent hyperglycemia is predictive of poor outcome after aneurysmal SAH. Methods Ninety-seven patients undergoing treatment for aneurysmal SAH were observed, and all perioperative variables were entered into a database of prospectively recorded data. Daily serum glucose values were retrospectively added. Patients were examined at hospital discharge (14–21 days after SAH onset), and Glasgow Outcome Scale (GOS) scores were prospectively documented. The GOS score at last follow-up was retrospectively determined. Serum glucose greater than 200 mg/dl for 2 or more consecutive days was defined as persistent hyperglycemia. Outcome was categorized as “poor” (dependent function [GOS Score 1–3]) or “good” (independent function [GOS Score 4 or 5]) at discharge. The independent association of 2-week and final follow-up outcome (GOS score) with the daily serum glucose levels was assessed using a multivariate analysis. Results In the univariate analysis, increasing age, increasing Hunt and Hess grade, hypertension, ventriculomegaly on admission computed tomography scan, Caucasian race, and higher mean daily glucose levels were associated with poor (dependent) 2-week outcome after aneurysmal SAH. In the multivariate analysis, older age, the occurrence of symptomatic cerebral vasospasm, increasing admission Hunt and Hess grade, and persistent hyperglycemia were independent predictors of poor (dependent) outcome 2 weeks after aneurysmal SAH. Admission Hunt and Hess grade and persistent hyperglycemia were independent predictors of poor outcome at last follow-up examination a mean 10 ± 3 months after aneurysmal SAH. Isolated hyperglycemic events did not predict poor outcome. Patients with persistent hyperglycemia were 10-fold more likely to have a poor (dependent) 2-week outcome and sevenfold more likely to have a poor outcome a mean 10 months after aneurysmal SAH independent of admission Hunt and Hess grade, occurrence of cerebral vasospasm, or all comorbidities. Conclusions Patients with persistent hyperglycemia were seven times more likely to have a poor outcome at a mean of 10 months after aneurysmal SAH. Isolated hyperglycemic events were not predictive of poor outcome. Serum glucose levels in the acute setting of aneurysmal SAH may help predict outcomes months after surgery.

scholarly journals Evaluation Of Intra-Arterial Nimodipine Therapy In Post-Subarachnoid Hemorrhage Refractory Cerebral Vasospasm

2021 ◽  
Author(s):  
Shrey Jain ◽  
Ajit Kumar Sinha ◽  
Sumit Goyal
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Neurological Assessment ◽  
Minimum Risk ◽  
Operative Morbidity ◽  
Fisher Grade ◽  
Grade 3 ◽  
Triple H

Abstract Background: Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage. Vasospasm is managed with triple H and vasodilators but sometimes, patients do not respond. Intra-arterial vasodilator infusion has been shown to improve outcome in such patients. In this study, we try to evaluate the efficacy of intra-arterial nimodipine therapy in 43 patients of post-aneurysmal subarachnoid hemorrhage refractory cerebral vasospasm. Methods: It is a prospective observational study of a group of 43 patients presenting with refractory cerebral vasospasm as per the inclusion criteria. Pre-procedure neurological assessment and Transcranial Doppler (TCD) monitoring were done. Endovascular spasmolysis was conducted and post-operative morbidity and outcomes were noted. Follow up of the patients was done at the time of discharge and at 6 months according to the Modified Rankin Scale and NCCT head. Results: Most of the patients developing refractory cerebral vasospasm belonged to Hunt and Hess Grade 2 and 3 and Fisher grade 3 and 4. 87.5% of the patients showed clinical recovery following endovascular spasmolysis and 58% of the patients showed complete angiographic recovery. Outcome after 6 months was good in 76%, moderate in 12% and poor in 12% patients. NCCT head showed no infarct in 58%, minor infarct in 28% and major vascular territorial infarct in 14% patients. Conclusions: Intra-arterial nimodipine infusion is a safe and effective therapy with minimum risk of complications if adhered to standard endovascular practice. By timely intervention, major ischemic insult to the brain can be averted, thereby significantly improving the prognosis.

Milrinone as a Rescue Therapy for Symptomatic Refractory Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

2008 ◽  
Vol 11 (2) ◽  
pp. 165-171 ◽  
Author(s):  
C. M. Romero ◽  
D. Morales ◽  
A. Reccius ◽  
F. Mena ◽  
J. Prieto ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Rescue Therapy

scholarly journals Intraventricular hemorrhage clot clearance rate as an outcome predictor in patients with aneurysmal subarachnoid hemorrhage: A retrospective study

2021 ◽  
Author(s):  
Hae Gi Park ◽  
Sunghan Kim ◽  
Joonho Chung ◽  
Chang Ki Jang ◽  
Keun Young Park ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Functional Outcome ◽  
Clearance Rate ◽  
Intraventricular Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Characteristic Curve ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Poor Functional Outcome

Abstract Background The development of intraventricular hemorrhage (IVH) in aneurysmal subarachnoid hemorrhage (aSAH) is linked with higher mortality and poor neurological recovery. Previous studies have investigated the effect of the amount and distribution of the initial IVH on the prognosis of aSAH. However, no studies have assessed the relationship between the changes in IVH over time and the prognosis of aSAH. The aim of this study was to analyze the effect of the clearance rate of IVH, which can be represented by the IVH clot clearance rate (CCR), on the outcomes of aSAH. Methods The IVH CCR was calculated based on the difference between the initial and follow-up modified Graeb scores (mGS), which were assessed by initial and 7-day follow-up brain computed tomography, respectively. Poor functional outcome was defined as a modified Rankin Scale score of 3–6. Univariate and multivariable analyses were performed to assess the relationships between IVH CCR and other risk factors and the prognosis of patients. Receiver operating characteristic curve analysis was performed to identify cut-off values of IVH CCR for predicting poor functional outcome. Results In total, 196 consecutive patients were diagnosed with aSAH between January 2014 and March 2018. According to the inclusion and exclusion criteria, 67 patients were finally included in the study. The univariate analysis revealed that a lower IVH CCR (p < 0.001), higher initial mGS (p < 0.001), older age (p < 0.001), higher initial Hunt and Hess grade (p < 0.001), presence of delayed infarction (p = 0.03), and presence of shunt-dependent hydrocephalus (p = 0.004) were significantly related to poor functional outcome. The multivariable analysis revealed that IVH CCR (odds ratio [OR] 0.941; p = 0.029), initial mGS (OR 1.632; p = 0.043), age (OR 1.561; p = 0.007), initial Hunt and Hess grade (OR 227.296; p = 0.030), and delayed infarction (OR 5310.632; p = 0.023) were independent predictors of poor functional outcome. Optimal cut-off values of IVH CCR and mGS for poor outcome were 36.27%, and 13.5, respectively (all p < 0.001). Conclusions The IVH CCR might have an important predictive value on poor functional outcome in patients with aSAH and IVH, along with initial mGS, age, initial Hunt and Hess grade, and delayed infarction.

scholarly journals E.03 Use of intra-arterial milrinone rescue therapy in patients with refractory and super refractory vasospasm after aneurysmal subarachnoid hemorrhage

2016 ◽  
Vol 43 (S2) ◽  
pp. S16-S17 ◽  
Author(s):  
AS Alamri ◽  
A Alturki ◽  
D Tampeiri ◽  
M Angle ◽  
B Lo ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Rescue Therapy ◽  
Loading Dose ◽  
Single Center ◽  
Single Center Study ◽  
Delayed Ischemic Neurologic Deficit ◽  
Hospital Protocol ◽  
Center Study

Background: Vasospasm causing delayed ischemic neurologic deficit (DIND) remains a leading cause of devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH). Therapy using intravenous milrinone (IVM) and intra-arterial milrinone (IAM) has been described. We report our results using IAM in patients with refractory and super refractory vasospasm (RV and SRV respectively). Methods: Retrospective single center study of all adult patients treated with IAM between 2006 and 2016 inclusively. IAM was used as part of the Montreal Neurological Hospital Protocol when the patients’ symptoms failed to respond to initial and higher IVM doses. We report their clinical outcomes. Results: IAM was used in 19 patients. The median loading dose was 8 mg and average maintenance dose was 0.78 mcg/kg/min. Angiographic improvement was seen in 15 (79%) and clinical improvement - within the first 48 hours - was seen in all patients. The median mRS was 3 at time of discharge and 1 three months later. Five patients lost follow up. Conclusions: IAM appears to be safe and effective in this small retrospective series of RV and SRV complicating aSAH. Angiographic and clinical improvements were observed. Further prospective studies are warranted to confirm these findings.

scholarly journals Assessment of two prophylactic fluid strategies in aneurysmal subarachnoid hemorrhage: A randomized trial

2020 ◽  
Vol 48 (7) ◽  
pp. 030006052092752
Author(s):  
Judit Gál ◽  
Béla Fülesdi ◽  
Dávid Varga ◽  
Babett Fodor ◽  
Eszter Varga ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Mean Arterial Pressure ◽  
Cerebral Vasospasm ◽  
Prophylactic Treatment ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Case Fatality ◽  
Outcome Scores ◽  
Ringer’S Lactate ◽  
Lactate Solution

Objective To compare the effect of two prophylactic euvolemic fluid strategy regimens on the incidence of cerebral vasospasm and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods Ninety-six patients with a basal intravenous intake of 15 mL/kg/day of Ringer’s lactate solution were included, and an additional 15 to 50 mL/kg/day Ringer’s lactate (RL-group) or hydroxyethyl starch 130/0.4 solution (HES-group) was administered to maintain the targeted mean arterial pressure. The primary end point was the occurrence of cerebral vasospasm during the first 14 days. The secondary end points were case fatality, Barthel’s index, and Glasgow Outcome Scores (GOS) at 30 days after SAH. Results Cerebral vasospasm developed in 42 patients (43.7%), and nine of these events were severe. The vasospasm rate among the RL- and HES-based groups was 25/48 and 17/48, respectively. For the secondary endpoint, four patients (4%) died by the end of follow-up (two in each group). Unfavorable outcome cases were not different in the RL and HES groups (9 vs. 14, respectively). There was no difference between the Barthel’s scores at 30 days between the two groups. Conclusions Using starches in a prophylactic treatment strategy in aneurysmal SAH in not supported by the study. The trial was registered at Clinicaltrials.gov under the number NCT02064075

scholarly journals Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

2015 ◽  
Vol 122 (2) ◽  
pp. 414-418 ◽  
Author(s):  
Marianna Pegoli ◽  
Jay Mandrekar ◽  
Alejandro A. Rabinstein ◽  
Giuseppe Lanzino
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Blood Transfusion ◽  
Functional Outcome ◽  
Brain Imaging ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Excellent Outcome ◽  
Symptomatic Vasospasm ◽  
Fisher Grade ◽  
Excellent Functional Outcome

OBJECT Case fatality rates after aneurysmal subarachnoid hemorrhage (aSAH) have decreased over time, and many patients treated with modern paradigms return to a normal life. However, there is little information on predictors of excellent functional outcome after aSAH. In this study, the authors investigated predictors of excellent outcome in a modern consecutive series of patients with aSAH. METHODS A retrospective review was conducted of patients with aSAH admitted between 2001 and 2013. The primary outcome measure was excellent functional outcome, defined as modified Rankin Scale (mRS) score of 0 or 1 at last follow-up within 1 year of aSAH. RESULTS Three hundred seventy-three patients were identified with posthospital follow-up. Excellent outcome was noted in 236 patients (63.3%), including an mRS score of 0 in 122 (32.7%) and an mRS score of 1 in 114 (30.6%). On univariate analysis, the following factors were associated with an excellent outcome: indicators of less severe bleeding, such as better World Federation of Neurosurgical Societies grade at any of the times of assessment, better modified Fisher grade, and absence of intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and symptomatic hydrocephalus; aneurysm treatment with coil embolization; absence of symptomatic vasospasm, delayed cerebral ischemia, and radiological infarction; absence of in-hospital seizures; lack of need for CSF diversion; fewer hours with fever; less severe anemia; and absence of transfusion. On multivariable analysis, the 4 variables that were most strongly associated with excellent outcome were presence of good clinical grade after neurological resuscitation, absence of ICH on initial CT scan, blood transfusion during the hospitalization, and radiological infarctions on final brain imaging. CONCLUSIONS Excellent outcomes (mRS score 0–1) can be achieved in the majority of patients with aSAH. The likelihood of excellent outcome is predicted by good clinical condition after resuscitation, absence of ICH on presentation, no evidence of infarction on brain imaging, and absence of blood transfusion during hospitalization.

Endovascular treatment for cerebral vasospasm following aneurysmal subarachnoid hemorrhage: predictors of outcome and retreatment

2017 ◽  
Vol 10 (4) ◽  
pp. 367-374 ◽  
Author(s):  
Jennifer D Sokolowski ◽  
Ching-Jen Chen ◽  
Dale Ding ◽  
Thomas J Buell ◽  
Daniel M Raper ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Initial Treatment ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Smoking Status ◽  
Functional Independence ◽  
Study Cohort ◽  
Good Outcome ◽  
Symptomatic Vasospasm

ObjectiveAlthough endovascular therapy has been widely adopted for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH), its effect on clinical outcomes remains incompletely understood. The aims of this retrospective cohort study are to evaluate the outcomes of endovascular intervention for post-aSAH vasospasm and identify predictors of functional independence at discharge and repeat endovascular vasospasm treatment.MethodsWe assessed the baseline and outcomes data for patients with aSAH who underwent endovascular vasospasm treatment at our institution, including intra-arterial (IA) vasodilator infusion and angioplasty. Statistical analyses were performed to determine factors associated with good outcome at discharge (modified Rankin Scale 0–2) and repeat endovascular vasospasm treatment.ResultsThe study cohort comprised 159 patients with a mean age of 52 years. Good outcome was achieved in 17% of patients at discharge (26/150 patients), with an in-hospital mortality rate of 22% (33/150 patients). In the multivariate analysis, age (OR 0.895; p=0.009) and positive smoking status (OR 0.206; p=0.040) were negative independent predictors of good outcome. Endovascular retreatment was performed in 34% (53/156 patients). In the multivariate analysis, older age (OR 0.950; p=0.004), symptomatic vasospasm (OR 0.441; p=0.046), initial treatment with angioplasty alone (OR 0.096; p=0.039), and initial treatment with combined IA vasodilator infusion and angioplasty (OR 0.342; p=0.026) were negative independent predictors of retreatment.ConclusionWe found a modest rate of functional independence at discharge in patients with aSAH who underwent endovascular vasospasm treatment. Older patients and smokers had worse functional outcomes at discharge. Initial use of angioplasty appears to decrease the need for subsequent retreatment.

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