EP05* Early cerebral infarction following aneurysmal subarachnoid hemorrhage is associated with prior circulatory failure and severe intracranial hypertension

Background: Several clinical studies have indicated the efficacy of cilostazol, a selective inhibitor of phosphodiesterase 3, in preventing cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). They were not double-blinded trial resulting in disunited results on assessment of end points among the studies. The randomized, double-blind, placebo-controlled study was performed to assess the effectiveness of cilostazol on cerebral vasospasm. Methods: Patients with aneurysmal SAH admitted within 24 h after the ictus who met the following criteria were enrolled in this study: SAH on CT scan was diffuse thick, diffuse thin, or local thick, Hunt and Hess score was less than 4, administration of cilostazol or placebo could be started within 48 h of SAH. Patients were randomly allocated to placebo or cilostazol after repair of a ruptured saccular aneurysm by aneurysmal neck clipping or endovascular coiling, and the administration of cilostazol or placebo was continued up to 14 days after initiation of treatment. The primary end point was the occurrence of symptomatic vasospasm (sVS), and secondary end points were angiographic vasospasm (aVS) evaluated on digital subtraction angiography, vasospasm-related new cerebral infarction evaluated on CT scan or MRI, and clinical outcome at 3 months of SAH as assessed by Glasgow Outcome Scale, in which poor outcome was defined as severe disability, vegetative state, and death. All end points were evaluated with blinded assessment. Results: One hundred forty eight patients were randomly allocated to the cilostazol group (n = 74) or the control group (n = 74). The occurrence of sVS was significantly lower in the cilostazol group than in the control group (10.8 vs. 24.3%, p = 0.031), and multiple logistic analysis showed that cilostazol use was an independent factor reducing sVS (OR 0.293, 95% CI 0.099-0.568, p = 0.027). The incidence of aVS and vasospasm-related cerebral infarction were not significantly different between the groups. Poor outcome was significantly lower in the cilostazol group than in the control group (5.4 vs. 17.6%, p = 0.011), and multiple logistic analyses demonstrated that cilostazol use was an independent factor that reduced the incidence of poor outcome (OR 0.221, 95% CI 0.054-0.903, p = 0.035). Severe adverse events due to cilostazol administration did not occur during the study period. Conclusions: Cilostazol administration is effective in preventing sVS and improving outcomes without severe adverse events. A larger-scale study including more cases was necessary to confirm this efficacy of cilostazol.

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Vasospasm severity is associated with cerebral infarction after subarachnoid hemorrhage

10.1101/2021.04.20.21255798 ◽

2021 ◽

Author(s):

Samuel B Snider ◽

Ibrahim Migdady ◽

Sarah L LaRose ◽

Morgan E Mckeown ◽

Robert W Regenhardt ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Negative Predictive Value ◽

Predictive Value ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Time Varying ◽

Single Center ◽

Early Screening ◽

Angiographic Vasospasm

AbstractBackgroundThe presence of angiographic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed-cerebral ischemia (DCI)-related cerebral infarction and worsened neurological outcome. Transcranial doppler (TCD) measurements of cerebral blood velocity are commonly used after aSAH to screen for vasospasm. We sought to determine whether time-varying TCD measured vasospasm severity is associated with cerebral infarction and to investigate the performance characteristics of different time/severity cutoffs for predicting cerebral infarction.MethodsWe used a retrospective, single-center cohort of consecutive adult aSAH patients with angiographic vasospasm and at least one TCD study. Our primary outcome was DCI-related cerebral infarction, defined as an infarction developing at least 2 days after any surgical intervention without an alternative cause. Time-varying TCD vasospasm severity was defined ordinally (absent, mild, moderate, severe) by the most abnormal vessel on each post-admission hospital day. Cox proportional-hazards models were used to examine associations between time-varying vasospasm severity and infarction. The optimal TCD-based time/severity thresholds for predicting infarction were then identified using the Youden J statistic.ResultsOf 218 aSAH patients with angiographic vasospasm, 27 (12%) developed DCI-related infarction. As compared to those without infarction, patients with infarction had higher modified Fisher scale (mFS) scores, and an earlier onset of more-severe vasospasm. Adjusted for mFS, vasospasm severity was associated with infarction (aHR 1.9, 95% CI: 1.3-2.6). A threshold of at least mild vasospasm severity on hospital day 4 had a negative predictive value of 92% for the development of infarction, but a positive predictive value of 25%.ConclusionsIn aSAH, TCD-measured vasospasm severity is associated with DCI-related infarction. In a single-center dataset, a TCD-based threshold for predicting infarction had a high negative predictive value, supporting its role as an early screening tool to identify at-risk patients.

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Abstract 194: Cognitive Outcome in Acute Simvastatin Treatment for Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.47.suppl_1.194 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

George Wong ◽

Keyword(s):

Cognitive Impairment ◽

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Primary Outcome Measure ◽

Cognitive Outcomes ◽

Cognitive Outcome ◽

Secondary Outcome ◽

Modified Rankin Scale ◽

Simvastatin Treatment

Objectives: Experimental evidence has indicated the benefit of simvastatin in the treatment of subarachnoid haemorrhage (SAH). Recently, acute simvastatin treatment was not shown to be beneficial in neurological outcome using modified Rankin Scale. Cognitive function is another important dimension of outcome assessment and yet had not been investigated in statin studies for aneurysmal subarachnoid hemorrhage. We therefore explored whether acute simvastatin treatment would improve cognitive outcomes. Methods: The study recruited SAH patients with acute simvastatin treatment enrolled in a randomized controlled double-blinded clinical trial (ClinicalTrials.gov Identifier: NCT01038193). A control cohort of SAH patients without simvastatin treatment was identified with propensity score matching of age and admission grade. Primary outcome measure was Montreal Cognitive Assessment (MoCA). Secondary outcome measures were delayed ischaemic deficit (DID), delayed cerebral infarction, modified Rankin Scale (mRS), and Mini-Mental State Examination( MMSE). Results: Fifty-one SAH patients with acute simvastatin treatment and 51 SAH patients without simvastatin treatment were recruited for analysis. At 3 months, there were no differences in MoCA scores (MoCA: 21+/-6 vs. 21+/-5, p=0.772). MoCA-assessed cognitive impairment (MoCA<26) was not different (75% vs. 80%, OR 0.7, 95%CI 0.3 to 1.8, p=0.477). There were also no differences in DID, delayed cerebral infarction, favorable mRS outcome, and MMSE scores, and MMSE-assessed cognitive impairment between both groups. Conclusions: The current study does not support that acute simvastatin treatment improves cognitive outcome after aneurysmal subarachnoid hemorrhage.

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Abstract 3942: Mild Controlled Hypothermia Induction is Safe and Feasible for the Treatment of Intracranial Hypertension in Patients with Aneurysmal Subarachnoid Hemorrhage.

Stroke ◽

10.1161/str.43.suppl_1.a3942 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Mohammad Ibrahim ◽

Mohammad Moussavi ◽

Elzbieta Wirkowski ◽

Adel Hanna ◽

Cecilia Carlowicz ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Electrolyte Imbalance ◽

Surface Cooling ◽

Conventional Methods ◽

Rebound Increase

Introduction Hypothermia has been increasingly used for cerebral resuscitation in comatose survivors of cardiac arrest. A large number of studies have been undertaken in patients with traumatic brain injury to asses the efficacy of hypothermia for reduction of intracranial hypertension. Hypothermia has also been shown to reduce mortality and increase functional outcome if used for longer duration in patients with severe traumatic brain injury. Due to the risk of rebound cerebral edema during re-warming, medical complications and other factors, hypothermia has not been widely utilized for other neurologic catastrophes. To determine the safety and feasibility of hypothermia to treat intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (SAH), we performed this study. Methods Retrospective analysis was performed on 11 consecutive patients with poor grade (Hunt and Hess IV and V) SAH who had high intracranial pressure that was either non responsive or poorly responsive to conventional methods (head of bed at 30 degrees, sedation, CSF drainage and osmotherapy). All patients had intracranial pressure (ICP) monitoring via an external ventriculostomy drain (EVD) catheter. Hypothermia was induced non-invasively via surface cooling pads (Artic Sun Temperature Management System). Intravenous sedation and paralysis was used via intravenous infusion to control shivering. Hypothermia (target temperature of 32 to 34 degree C) was maintained until ICP normalized. Results Duration of hypothermia ranged from 79 hours to 190 hours. One patient required re-induction due to rebound increase in ICP during re-warming. Modified rankin scale was recorded at 3 month after the ictus. Eight patients (72%) survived with good recovery, one patient (9%) survived with severe disability and two patients (18%) died. The most common side effect was electrolyte imbalance seen in seven patients (63%), thrombocytopenia in three patients (27%), and pneumonia in four patients(36%). All complications were successfully treated and major consequences of complications (bleeding diathesis, septic shock syndrome and death) were not observed in any of these patients. Two patients had decompressive hemicraniectomy prior to hypothermia induction. Out of nine patients who did not undergo hemi-craniectomy, two died and seven did not require surgical intervention after induction of hypothermia. Conclusions Mild hypothermia induction for 72 hours or more for the treatment of intracranial hypertension refractory to other conventional methods in patients with SAH appears safe and feasible. Hypothermia may potentially be an earlier treatment option than currently recommended. This study serves as a template for future efficacy trials.

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Dose-Dependent Inhibitory Effects of Cilostazol on Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Translational Stroke Research ◽

10.1007/s12975-018-0650-y ◽

2018 ◽

Vol 10 (4) ◽

pp. 381-388 ◽

Cited By ~ 8

Author(s):

Hidenori Suzuki ◽

Yoshinari Nakatsuka ◽

Ryuta Yasuda ◽

Masato Shiba ◽

Yoichi Miura ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Inhibitory Effects ◽

Dose Dependent

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Hyperglycemia, excess weight, and history of hypertension as risk factors for poor outcome and cerebral infarction after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2005.102.6.0998 ◽

2005 ◽

Vol 102 (6) ◽

pp. 998-1003 ◽

Cited By ~ 92

Author(s):

Seppo Juvela ◽

Jari Siironen ◽

Johanna Kuhmonen

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Patient Outcomes ◽

Plasma Glucose ◽

Clinical Condition ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Content Type ◽

Poor Outcome ◽

History Of ◽

Fine Print

Object. Stress-induced hyperglycemia has been shown to be associated with poor outcome after aneurysmal subarachnoid hemorrhage (SAH). The authors prospectively tested whether hyperglycemia, independent of other factors, affects patient outcomes and the occurrence of cerebral infarction after SAH. Methods. Previous diseases, health habits, medications, clinical condition, and neuroimaging variables were recorded for 175 patients with SAH who were admitted to the hospital within 48 hours after bleeding. The plasma level of glucose was measured at admission and the fasting value of glucose was measured in the morning after aneurysm occlusion. Factors found to be independently predictive of patient outcomes at 3 months after SAH onset and the appearance of cerebral infarction were tested by performing multiple logistic regression. Plasma glucose values at admission were found to be associated with patient age, body mass index (BMI), history of hypertension, clinical condition, amount of subarachnoid or intraventricular blood, shunt-dependent hydrocephalus, outcome variables, and the appearance of cerebral infarction. When considered independently of age, clinical condition, or amount of subarachnoid, intraventricular, or intracerebral blood, the plasma glucose values at admission predicted poor outcome (per millimole/liter the odds ratio [OR] was 1.24 with a 95% confidence interval [CI] of 1.02–1.51). After an adjustment was made for the amount of subarachnoid blood, the clinical condition, and the duration of temporary artery occlusion during surgery, the BMI was found to be a significant predictor (per kilogram/square meter the OR was 1.15 with a 95% CI of 1.02–1.29) for the finding of cerebral infarction on the follow-up computerized tomography scan. Hypertension (OR 3.11, 95% CI 1.11–8.73)—but not plasma glucose (OR 1.06, 95% CI 0.87–1.29)—also predicted the occurrence of infarction when tested instead of the BMI. Conclusions. Independent of the severity of bleeding, hyperglycemia at admission seems to impair outcome, and excess weight and hypertension appear to elevate the risk of cerebral infarction after SAH.

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Decompressive craniectomy in patients with cerebral infarction due to malignant vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.102598 ◽

2012 ◽

Vol 03 (03) ◽

pp. 251-255 ◽

Cited By ~ 8

Author(s):

Saffet Tuzgen ◽

Baris Kucukyuruk ◽

Seckin Aydin ◽

Fatma Ozlen ◽

Osman Kizilkilic ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Decompressive Craniectomy ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Clinical Results ◽

Cerebral Infarct ◽

World Federation ◽

Life Saving

ABSTRACT Aim: The authors present their experience and the clinical results in decompressive craniectomy (DC) in patients with vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Materials and Methods: Between 2002 and 2010, six patients underwent DC due to cerebral infarct and edema secondary to vasospasm after aneurysmal SAH. Four patients were male, and two were female. The age of patients ranged between 33 and 60 (mean: 47,6 ± 11,4). The follow up period ranged between 12 to 104 months (mean: 47,6 ± 36,6). The SAH grading according World Federation of Neurosurgeons (WFNS) score ranged between 3 to 5. Results: Last documented modified Rankin Score (mRS) ranged between 2 to 6. One patient died in the following year after decompression due to pneumonia and sepsis. Two patients had moderate disability (mRS of 4) and three patients continue their life with minimal deficit and no major dependency (mRS score 2 and 3). Conclusion: DC can be a life-saving procedure which provides a better outcome in patients with cerebral infarction secondary to vasospasm and SAH. However, the small number of the patients in this study is the main limitation of the accuracy of the results, and more studies with larger numbers are required to evaluate the efficiency of DC in this group of patients.

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Mild Controlled Hypothermia Induction Is Safe and Feasible for the Treatment of Intracranial Hypertension in Patients with Aneurysmal Subarachnoid Hemorrhage (P06.258)

Neurology ◽

10.1212/wnl.78.1_meetingabstracts.p06.258 ◽

2012 ◽

Vol 78 (Meeting Abstracts 1) ◽

pp. P06.258-P06.258

Author(s):

M. Ibrahim ◽

D. Turkel-Parrella ◽

A. Hanna ◽

D. Korya ◽

E. Wirkowski ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Hypertension ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Controlled Hypothermia

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Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2012.3.jns11706 ◽

2012 ◽

Vol 117 (1) ◽

pp. 15-19 ◽

Cited By ~ 27

Author(s):

Elias A. Giraldo ◽

Jay N. Mandrekar ◽

Mark N. Rubin ◽

Stefan A. Dupont ◽

Yi Zhang ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Functional Outcome ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Intracerebral Hematoma ◽

Poor Functional Outcome ◽

Poor Outcome ◽

Grade Assessment ◽

Clinical Grading

Object Timing of clinical grading has not been fully studied in patients with aneurysmal subarachnoid hemorrhage (SAH). The primary objective of this study was to identify at which time point clinical assessment using the World Federation of Neurosurgical Societies (WFNS) grading scale and the Glasgow Coma Scale (GCS) is most predictive of poor functional outcome. Methods This study is a retrospective cohort study on the association between poor outcome and clinical grading determined at presentation, nadir, and postresuscitation. Poor functional outcome was defined as a Glasgow Outcome Scale score of 1–3 at 6 months after SAH. Results The authors identified 186 consecutive patients admitted to a teaching hospital between January 2002 and June 2008. The patients' mean age (± SD) was 56.9 ± 13.7 years, and 63% were women. Twenty-four percent had poor functional outcome (the mortality rate was 17%). On univariable logistic regression analyses, GCS score determined at presentation (OR 0.80, p < 0.0001), nadir (OR 0.73, p < 0.0001), and postresuscitation (OR 0.53, p < 0.0001); modified Fisher scale (OR 2.21, p = 0.0013); WFNS grade assessed at presentation (OR 1.92, p < 0.0001), nadir (OR 3.51, < 0.0001), and postresuscitation (OR 3.91, p < 0.0001); intracerebral hematoma on initial CT (OR 4.55, p < 0.0002); acute hydrocephalus (OR 2.29, p = 0.0375); and cerebral infarction (OR 4.84, p < 0.0001) were associated with poor outcome. On multivariable logistic regression analysis, only cerebral infarction (OR 5.80, p = 0.0013) and WFNS grade postresuscitation (OR 3.43, p < 0.0001) were associated with poor outcome. Receiver operating characteristic/area under the curve (AUC) analysis demonstrated that WFNS grade determined postresuscitation had a stronger association with poor outcome (AUC 0.90) than WFNS grade assessed upon admission or at nadir. Conclusions Timing of WFNS grade assessment affects its prognostic value. Outcome after aneurysmal SAH is best predicted by assessing WFNS grade after neurological resuscitation.

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