806: USE OF AN OPIOID-SPARING HEADACHE PROTOCOL FOR TREATING LOW-GRADE SUBARACHNOID HEMORRHAGE PATIENTS

Introduction: Cerebral vasospasm leading to delayed cerebral ischemia (DCI) is one of the most significant factors impacting functional outcome in patients diagnosed with non-traumatic subarachnoid hemorrhage (SAH). Effective treatment in this setting is lacking. We now report a single center retrospective cohort experience with intrathecal (IT) Nicardipine for this indication. Methods: All patients discharged between 2013-2017 diagnosed with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Demographics, risk factors, clinical courses, radiological DCI, and functional outcomes were analyzed. Results: 1,085 patients were admitted with aneurysmal (n=796) or idiopathic (n=289) SAH. The mean age was 54.5±14.1 and 67.7% were women. Low grade hemorrhage (WFNS 1) was found in 42.4%, medium (WFNS 2-3) in 26.9%, and high grade (WFNS 4-5) in 30.7%. Cerebral vasospasm was diagnosed in 36.6% of the patients, and 85.4% of those received IT Nicardipine (n=339). Only 8.4% of all patients required angiography to treat vasospasm. TCD data was available for 159 patients who received IT Nicardipine. Treatment reduced mean velocities in all arteries within one day by 15.4% on average (p<0.01). This reduction was sustained for the duration of treatment. Nineteen patients (1.8%) suffered from bacterial ventriculitis, and no statistically significant correlation was noted between IT treatment and infection (OR 1.06 95%CI[0.42-2.7]). The incidence of radiological DCI, identified by blinded assement of imaging, was 9.4% and clinical DCI was 5.7%. In this cohort, 65.5% had a favorable functional outcome (mRS≤2) at 90 days. Conclusions: In a retrospective analysis, off-label IT Nicardipine is a safe and potentially effective treatment for cerebral vasospasm and prevention of the subsequent cerebral ischemia. Being the largest of its kind, this cohort could serve as a baseline for future clinical trial designs assessing IT Nicardipine safety and efficacy in a prospective, controlled fashion.

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Poor-grade aneurysmal subarachnoid hemorrhage: relationship of cerebral metabolism to outcome

Journal of Neurosurgery ◽

10.3171/jns.2004.100.3.0400 ◽

2004 ◽

Vol 100 (3) ◽

pp. 400-406 ◽

Cited By ~ 96

Author(s):

Asita Sarrafzadeh ◽

Daniel Haux ◽

Ingeborg Küchler ◽

Wolfgang R. Lanksch ◽

Andreas W. Unterberg

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Metabolism ◽

Univariate Analysis ◽

High Morbidity ◽

Low Grade ◽

High Grade ◽

Content Type ◽

Poor Grade ◽

Fisher Grade ◽

Fine Print

Object. The majority of patients with poor-grade subarachnoid hemorrhage (SAH), that is, World Federation of Neurosurgical Societies (WFNS) Grades IV and V, have high morbidity and mortality rates. The objective of this study was to investigate cerebral metabolism in patients with low-compared with high-grade SAH by using bedside microdialysis and to evaluate whether microdialysis parameters are of prognostic value for outcome in SAH. Methods. A prospective investigation was conducted in 149 patients with SAH (mean age 50.9 ± 12.9 years); these patients were studied for 162 ± 84 hours (mean ± standard deviation). Lesions were classified as low-grade SAH (WFNS Grades I–III, 89 patients) and high-grade SAH (WFNS Grade IV or V, 60 patients). After approval by the local ethics committee and consent from the patient or next of kin, a microdialysis catheter was inserted into the vascular territory of the aneurysm after clip placement. The microdialysates were analyzed hourly for extracellular glucose, lactate, lactate/pyruvate (L/P) ratio, glutamate, and glycerol. The 6- and 12-month outcomes according to the Glasgow Outcome Scale and functional disability according to the modified Rankin Scale were assessed. In patients with high-grade SAH, cerebral metabolism was severely deranged compared with those who suffered low-grade SAH, with high levels (p < 0.05) of lactate, a high L/P ratio, high levels of glycerol, and, although not significant, of glutamate. Univariate analysis revealed a relationship among hyperglycemia on admission, Fisher grade, and 12-month outcome (p < 0.005). In a multivariate regression analysis performed in 131 patients, the authors identified four independent predictors of poor outcome at 12 months, in the following order of significance: WFNS grade, patient age, L/P ratio, and glutamate (p < 0.03). Conclusions. Microdialysis parameters reflected the severity of SAH. The L/P ratio was the best metabolic independent prognostic marker of 12-month outcome. A better understanding of the causes of deranged cerebral metabolism may allow the discovery of therapeutic options to improve the prognosis, especially in patients with high-grade SAH, in the future.

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Risk of fatal sinus arrest induced by low-grade subarachnoid hemorrhage: A case of a young patient with obstructive sleep apnea

Surgical Neurology International ◽

10.25259/sni_66_2020 ◽

2020 ◽

Vol 11 ◽

pp. 156

Author(s):

Naoki Wakuta ◽

Satoshi Yamamoto

Keyword(s):

Subarachnoid Hemorrhage ◽

Sleep Apnea ◽

Nervous Activity ◽

Sleep Apnea Syndrome ◽

Sympathetic Nervous Activity ◽

Low Grade ◽

Sinus Arrest ◽

Obstructive Sleep ◽

Increased Risk ◽

Temporary Pacemaker

Background: Sleep apnea syndrome (SAS) and subarachnoid hemorrhage (SAH) are both considered possible causes of secondary arrhythmias. However, there are limited reports on the increased risk of bradyarrhythmia for arrhythmia-free SAS patients with SAH. Case Description: A 31-year-old woman with SAS developed low-grade SAH and underwent coil embolization on postbleed day 1. Following a coiling procedure, she experienced worsening episodes of sinus arrest lasting up to 12 s and required a temporary pacemaker. Frequent episodes of sinus arrest were detected for the next 4 days. Thereafter, all types of arrhythmias gradually decreased, and she eventually recovered to be arrhythmia free. Conclusion: Acceleration of sympathetic nervous activity caused by acute SAH may predispose patients to bradyarrhythmia with SAS and elicit asystole. The coexistence of SAS and SAH should be recognized as a cause of life-threatening sinus arrest, even if the severity of SAH is low grade.

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Predictors of Adverse Outcome in Patients Treated for Low-Grade Aneurysmal Subarachnoid Hemorrhage: A Cohort Study

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0034-1383754 ◽

2014 ◽

Vol 75 (S 02) ◽

Author(s):

K. Al-Taha ◽

D. Bervini ◽

M. Messerer ◽

P. Mosimann ◽

J.-B. Zerlauth ◽

...

Keyword(s):

Cohort Study ◽

Subarachnoid Hemorrhage ◽

Adverse Outcome ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Low Grade

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Xanthochromia: yellow color is a red flag

QJM ◽

10.1093/qjmed/hcab052 ◽

2021 ◽

Author(s):

Takuhiro Hashiyama ◽

Nobuaki Mori ◽

Yu Tsuruyama

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Artery Aneurysm ◽

World Federation ◽

Anterior Communicating Artery ◽

Low Grade ◽

Presenting Symptoms ◽

Csf Analysis ◽

Yellow Color ◽

Fisher Grade

Abstract A 72-year-old previously healthy man consulted in our hospital for persistent moderate headache, accompanied by flexor pain of both thighs and low-grade fever for five days. Although the symptoms were worsened by motion, he noticed the flexor pain was most severe when taking a bow. On physical examination, he was fully alert and oriented to person, place, and time. His body temperature, blood pressure, pulse, and respiratory rate were 37.6 °C, 126/81 mmHg, 67 beats/min, and 16 breaths/min, respectively. His neck was supple. Kernig’s and Brudzinski’s signs were negative. There was a positive jolt accentuation test. No other neurologic findings were remarkable. Head computed tomography (CT) was normal; therefore, a lumbar puncture was performed, following suspicion of meningitis. Cerebrospinal fluid (CSF) analysis revealed 14 cells per microliter (mononucleosis was dominant), protein 185 mg/dL, and glucose 34 mg/dL. The opening pressure was 13 cmH2O. The CSF had an orange-yellow appearance (Figure 1a). This was suggestive of xanthochromia. Contrast-enhanced head CT and head magnetic resonance imaging were performed, and a ruptured anterior communicating artery aneurysm was detected (Figure 1 b). He was diagnosed with aneurysmal subarachnoid hemorrhage (SAH), which was classified as Grade 1 and Group 1, according to the World Federation of Neurological Surgeons subarachnoid hemorrhage grading scale and Fisher grade of cerebral vasospasm risk, respectively. Regarding the presenting symptoms, thigh flexor pain and low-grade fever were symptoms of breakdown of blood products within the CSF, which led to aseptic meningitis, also called meningismus. He was admitted to the intensive care unit for neurological and hemodynamic monitoring. Aneurysm repair with surgical clipping was performed, and after 4 weeks of rehabilitation, he was discharged ambulatory.

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Post-operative changes of cerebral circulation and metabolism in the acute stage of low-grade aneurysmal subarachnoid hemorrhage

Neurological Research ◽

10.1179/174313208x291676 ◽

2008 ◽

Vol 30 (7) ◽

pp. 678-683 ◽

Cited By ~ 6

Author(s):

Toshiaki Hayashi ◽

Akifumi Suzuki ◽

Jun Hatazawa ◽

Hiromu Hadeishi ◽

Reizo Shirane ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Circulation ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Acute Stage ◽

Low Grade

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Comparison of Magnetic Resonance Imaging Sequences With Computed Tomography to Detect Low-Grade Subarachnoid Hemorrhage

Journal of Computer Assisted Tomography ◽

10.1097/00004728-200603000-00025 ◽

2006 ◽

Vol 30 (2) ◽

pp. 295-303 ◽

Cited By ~ 41

Author(s):

Ant??nio Jos?? da Rocha ◽

Carlos Jorge da Silva ◽

Hugo Pereira Pinto Gama ◽

Carlos Eduardo Baccin ◽

Fl??vio T??lio Braga ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Magnetic Resonance ◽

Low Grade ◽

Resonance Imaging

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Low grade glioma presenting as subarachnoid hemorrhage

Neurosurgery ◽

10.1097/00006123-198405000-00010 ◽

1984 ◽

Vol 14 (5) ◽

pp. 574???7 ◽

Cited By ~ 1

Author(s):

M Y Memon ◽

A Neal ◽

R Imami ◽

N Villareal

Keyword(s):

Subarachnoid Hemorrhage ◽

Low Grade Glioma ◽

Low Grade

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Predictors of hospital-associated complications prolonging ICU stay in patients with low-grade aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.1.jns182394 ◽

2020 ◽

Vol 132 (6) ◽

pp. 1829-1835 ◽

Cited By ~ 1

Author(s):

Nikolaos Mouchtouris ◽

Michael J. Lang ◽

Kaitlyn Barkley ◽

Guilherme Barros ◽

Justin Turpin ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

External Ventricular Drain ◽

Significant Risk ◽

Early Discharge ◽

Neurological Complications ◽

Medical Complications ◽

Low Grade ◽

Icu Stay

OBJECTIVEThe authors sought to determine the predictors of late neurological and hospital-acquired medical complications (HACs) in patients with low-grade aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe authors conducted a retrospective study of 424 patients with low-grade aSAH admitted to their institution from 2008 to 2015. Data collected included patient comorbidities, Hunt and Hess (HH) grade, ICU length of stay (LOS), and complications. A logistic regression analysis was performed to determine the predictors for neurological and hospital-associated complications.RESULTSOut of 424 patients, 50 (11.8%) developed neurological complications after the first week, with a mean ICU stay of 16.3 ± 6.5 days. Of the remaining 374 patients without late neurological complications, 83 (22.2%) developed late HACs with a mean LOS of 15.1 ± 7.6 days, while those without medical complications stayed 11.8 ± 6.2 days (p = 0.001). Of the 83 patients, 55 (66.3%) did not have any HACs in the first week. Smoking (p = 0.062), history of cardiac disease (p = 0.043), HH grade III (p = 0.012), intraventricular hemorrhage (IVH) (p = 0.012), external ventricular drain (EVD) placement (p = 0.002), and early pneumonia/urinary tract infection (UTI)/deep vein thrombosis (DVT) (p = 0.001) were independently associated with late HACs. Logistic regression showed early pneumonia/UTI/DVT (p = 0.026) and increased HH grade (p = 0.057) to be significant risk factors for late medical complications.CONCLUSIONSWhile an extended ICU admission allows closer monitoring, low-grade aSAH patients develop HACs despite being at low risk for neurological complications. The characteristics of low-grade aSAH patients who would benefit from early discharge are reported in detail.

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Low Grade Glioma Presenting as Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/00006123-198405000-00010 ◽

1984 ◽

Vol 14 (5) ◽

pp. 574-577 ◽

Cited By ~ 7

Author(s):

Muhammed Yacob Memon ◽

A. Neal ◽

R. Imami ◽

N. Villareal

Keyword(s):

Cerebrospinal Fluid ◽

Brain Tumor ◽

Subarachnoid Hemorrhage ◽

Intracranial Hemorrhage ◽

Intraventricular Hemorrhage ◽

Low Grade Glioma ◽

Low Grade ◽

Neurological Sequelae

Abstract During the last 2 years, we treated three cases of brain tumor that presented with intracranial hemorrhage. Two of the three tumors were metastatic. They presented with hemorrhage into the tumor, but no blood in the cerebrospinal fluid. One tumor was a low grade astrocytoma that presented as subarachnoid and intraventricular hemorrhage in a 15-year-old child. It was removed with no neurological sequelae.

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