scholarly journals Multivariable and Bayesian Network Analysis of Outcome Predictors in Acute Aneurysmal Subarachnoid Hemorrhage: Review of a Pure Surgical Series in the Post-International Subarachnoid Aneurysm Trial Era

2017 ◽  
Vol 14 (6) ◽  
pp. 603-610 ◽  
Author(s):  
Zsolt Zador ◽  
Wendy Huang ◽  
Matthew Sperrin ◽  
Michael T Lawton
Keyword(s):  
Machine Learning ◽  
Subarachnoid Hemorrhage ◽  
Bayesian Networks ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Case Series ◽  
Variable Importance ◽  
Outcome Predictors ◽  
Surgical Clipping ◽  
International Subarachnoid Aneurysm Trial ◽  
Importance Ranking

AbstractBACKGROUNDFollowing the International Subarachnoid Aneurysm Trial (ISAT), evolving treatment modalities for acute aneurysmal subarachnoid hemorrhage (aSAH) has changed the case mix of patients undergoing urgent surgical clipping.OBJECTIVETo update our knowledge on outcome predictors by analyzing admission parameters in a pure surgical series using variable importance ranking and machine learning.METHODSWe reviewed a single surgeon's case series of 226 patients suffering from aSAH treated with urgent surgical clipping. Predictions were made using logistic regression models, and predictive performance was assessed using areas under the receiver operating curve (AUC). We established variable importance ranking using partial Nagelkerke R2 scores. Probabilistic associations between variables were depicted using Bayesian networks, a method of machine learning.RESULTSImportance ranking showed that World Federation of Neurosurgical Societies (WFNS) grade and age were the most influential outcome prognosticators. Inclusion of only these 2 predictors was sufficient to maintain model performance compared to when all variables were considered (AUC = 0.8222, 95% confidence interval (CI): 0.7646-0.88 vs 0.8218, 95% CI: 0.7616-0.8821, respectively, DeLong's P = .992). Bayesian networks showed that age and WFNS grade were associated with several variables such as laboratory results and cardiorespiratory parameters.CONCLUSIONOur study is the first to report early outcomes and formal predictor importance ranking following aSAH in a post-ISAT surgical case series. Models showed good predictive power with fewer relevant predictors than in similar size series. Bayesian networks proved to be a powerful tool in visualizing the widespread association of the 2 key predictors with admission variables, explaining their importance and demonstrating the potential for hypothesis generation.

Invasive Multimodal Neuromonitoring in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review

Stroke ◽  
2021 ◽  
Author(s):  
Michael Veldeman ◽  
Walid Albanna ◽  
Miriam Weiss ◽  
Soojin Park ◽  
Anke Hoellig ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Trend Analysis ◽  
Oxygen Tension ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
Case Series ◽  
Diagnostic Value ◽  
Cerebral Microdialysis ◽  
Treatment Support ◽  
Patients At Risk

Background and Purpose: Aneurysmal subarachnoid hemorrhage is a devastating disease leaving surviving patients often severely disabled. Delayed cerebral ischemia (DCI) has been identified as one of the main contributors to poor clinical outcome after subarachnoid hemorrhage. The objective of this review is to summarize existing clinical evidence assessing the diagnostic value of invasive neuromonitoring (INM) in detecting DCI and provide an update of evidence since the 2014 consensus statement on multimodality monitoring in neurocritical care. Methods: Three invasive monitoring techniques were targeted in the data collection process: brain tissue oxygen tension (p ti O 2 ), cerebral microdialysis, and electrocorticography. Prospective and retrospective studies as well as case series (≥10 patients) were included as long as monitoring was used to detect DCI or guide DCI treatment. Results: Forty-seven studies reporting INM in the context of DCI were included (p ti O 2 : N=21; cerebral microdialysis: N=22; electrocorticography: N=4). Changes in brain oxygen tension are associated with angiographic vasospasm or reduction in regional cerebral blood flow. Metabolic monitoring with trend analysis of the lactate to pyruvate ratio using cerebral microdialysis, identifies patients at risk for DCI. Clusters of cortical spreading depolarizations are associated with clinical neurological worsening and cerebral infarction in selected patients receiving electrocorticography monitoring. Conclusions: Data supports the use of INM for the detection of DCI in selected patients. Generalizability to all subarachnoid hemorrhage patients is limited by design bias of available studies and lack of randomized trials. Continuous data recording with trend analysis and the combination of INM modalities can provide tailored treatment support in patients at high risk for DCI. Future trials should test interventions triggered by INM in relation to cerebral infarctions.

Abstract W P307: Novel Application of Reversible Parental Anti-platelets in Patients with Aneurysmal Subarachnoid Hemorrhage

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Siddhart Mehta ◽  
Mohammed Hussain ◽  
Jaskiran Brar ◽  
Daniel Korya ◽  
Harina Chahal ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Coil Embolization ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Antiplatelet Agents ◽  
Endovascular Coiling ◽  
International Subarachnoid Aneurysm Trial ◽  
Procedural Complications ◽  
Acute Subarachnoid Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and Objective: The International Subarachnoid Aneurysm Trial (ISAT) showed a greater likelihood of survival free 1 year disability in patients undergoing endovascular coiling who were started on antiplatelet agents after SAH compared to ones undergoing neurosurgical clipping. However, data on safety of acute parental antiplatelet agents after aneurysmal coiling is lacking. We report on the safety of IV Eptifibatide (rapidly reversible Glyprotein IIbIIIa inhibitor) on patients presenting with acute subarachnoid hemorrhage undergoing endovascular coiling for aneurysmal embolization. Methods: All the patients from 2009-13 who presented to our university affiliated comprehensive stroke center with aneurysmal subarachnoid hemorrhage and underwent endovascular coiling were included for the study. Patients that received IV Eptifibatide for various reasons including acute need for stent assist coiling after securing the ruptured aneurysm with endovascular coiling were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic intra- and extra-cranial hemorrhages, groin hematomas, epistaxis and gross hematuria. Results: Of the total of 93 patients treated with coil embolization during this period, 5 patients (mean age 56 years, 20% male [n=1]) received acute intra-procedural Eptifibatide followed by IV infusion for a mean duration of 77 hours (range 20-130 hours). Various reasons for use of Eptifibatide included: stent assist coiling [n=2], multiple stents for flow diversion [n=1], partial coil prolapse [n=1] and vascular lumen flow compromise [n=1]. None of the patients demonstrated symptomatic/asymptomatic hemorrhage, groin hematoma, epistaxis or hematuria. Conclusion: Our results may highlight safety of administering IV Eptifibatide to prevent thrombotic complications after endovascular coil embolization in select patients with aneurysmal subarachnoid hemorrhage. Multicenter prospective trials are warranted to corroborate our findings.

Abstract TP457: Intraventricular and Intravenous Milrinone for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Meghan Purohit ◽  
Naresh Mullaguri ◽  
Christine Ahrens ◽  
Christopher Newey ◽  
Dani Dhimant ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Demographic Data ◽  
Case Series ◽  
Standard Of Care ◽  
Mean Flow ◽  
First Case ◽  
Fisher Grade ◽  
Tertiary Center

Introduction: Cerebral vasospasm (CVS) is a complication of aneurysmal subarachnoid hemorrhage (aSAH). Intraventricular milrinone (IVtM) and intravenous milrinone (IVM) have been studied for treatment of CVS. We aimed to determine the effect of milrinone therapy on clinical and transcranial Doppler (TCD) measures of CVS. Methods: We performed a retrospective analysis of patients with aSAH treated with IVtM at a single tertiary center between 2016 and 2018. Patients were treated with IVtM if they had symptomatic CVS or TCD suggestive of critical CVS that persisted despite blood pressure augmentation or endovascular therapies. Nimodipine was given as standard of care. A subset of patients were also treated with IVM, which was dosed in a standard fashion based on Montreal Neurological Institute protocol. We collected demographic data, TCD mean flow velocity and pulsatility index, angiographic data, as well as utilization and frequency of IVtM and IVM. Results: Twenty-eight patients in our cohort had modified Fisher grade 4 (57%) or grade 3 (25%) and median Hunt-Hess score of 3 (IQR 2, 4). Twenty-one of 28 patients were treated with IVtM+IVM. Seven (25%) who received IVtM alone had no significant improvement in TCD velocities or reduction in symptomatic CVS (p=0.611). Patients received between 1 and 30 doses of IVtM. There was no significant improvement with time or with number of IVtM doses IVtM. There was also no significant improvement in TCD velocities of CVS patients nor reduction in symptomatic CVS with IVtM+IVM (p=0.69). The number of IVtM doses correlated with an increased discharge mRS (p=0.05). There were no direct complications due to IVtM or IVM. Conclusion: Neither IVtM+IVM nor IVtM alone appear to be effective treatment of CVS in aSAH. Our data represent one of the first case series reporting IVtM and IVtM+IVM utilization for the treatment of CVS.

Vasopressin-Induced Hyponatremia in Patients With Aneurysmal Subarachnoid Hemorrhage: A Case Series and Literature Review

2021 ◽  
pp. 089719002110534
Author(s):  
Hilamber Subba ◽  
Richard R. Riker ◽  
Susan Dunn ◽  
David J. Gagnon
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Scale Score ◽  
Serum Sodium ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Medical Center ◽  
Case Series ◽  
Fixed Dose ◽  
Endovascular Coiling ◽  
Convenience Sample ◽  
Maine Medical

Objective Vasopressin may be administered to treat vasospasm following aneurysmal subarachnoid hemorrhage (aSAH). The objectives of this study were to describe five cases of suspected vasopressin-induced hyponatremia after aSAH and to review the literature. Design Single-center, observational case series of intensive care unit (ICU) patients Settings Ten-bed neurological ICU at Maine Medical Center in Portland, Maine Patients Convenience sample of patients with aSAH treated with a vasopressin for symptomatic, radiologically confirmed vasospasm Results A total of five patients were included in the case series with a median age of 57 (51, 65) years and all were women. The median Glasgow coma scale score was 15 (11, 15) on admission, and the Hunt and Hess scale score was 3, (3, 4). All patients were treated with endovascular coiling of their aneurysm. Vasopressin was administered to treat symptomatic, radiographically confirmed vasospasm on median post-bleed day (PBD) 10 (10, 15) at a fixed-dose of .03 units/min. Serum sodium at baseline was 140 (140, 144) mEq/L and decreased to 129 (126, 129) mEq/L within 26 (17, 83) hours of vasopressin initiation for a median change of −16 (−10, −16) mEq/L. Serum sodium returned to baseline within 18 (14, 22) hours of stopping the infusion. Conclusions Vasopressin use in vasospasm after aSAH may be associated with clinically significant hyponatremia within 24 hours of starting the infusion. Hyponatremia appears to resolve within 24 hours of stopping the infusion. Additional study in a larger sample size is needed to determine if a causal relationship exist.

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