Abstract MP12: Drivers of Rescue Therapy Efficacy for Vasospasm Following Aneurysmal Subarachnoid Hemorrhage: A Propensity-Score Matched Analysis With Machine Learning

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michael L Martini ◽  
Sean Neifert ◽  
William Shuman ◽  
Emily Chapman ◽  
Alexander Schupper ◽  
...  
Keyword(s):  
Machine Learning ◽  
Subarachnoid Hemorrhage ◽  
Propensity Score ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Rescue Therapy ◽  
Patient Characteristics ◽  
Therapeutic Interventions ◽  
Gradient Boosting ◽  
Symptomatic Vasospasm ◽  
Patient Selection Criteria

Introduction: One of the foremost challenges in subarachnoid hemorrhage (SAH) management is understanding which patient characteristics and treatment decisions lead to good outcomes. This study uses novel game theory-based methods in explainable machine learning (ML) and propensity-score matching to elucidate the clinical factors driving outcomes following rescue therapy for post-SAH vasospasm. Methods: Data for patients with post-SAH angiographic or symptomatic vasospasm were obtained from six clinical trials and observational studies in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and 3-month Glasgow Outcome Scale (GOS) scores. Shapley Additive Explanation (SHAP) values were calculated to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. Results: A total of 1,532 patients were included. SAH characteristics and neurological sequelae, but not admission neurological scores, heavily influenced the probability of receiving rescue therapy. Comparing feature importances showed cerebral ischemia/infarction was invariably linked to poor outcome, while other important predictors of outcome varied by rescue type. Higher blood pressures and fewer postoperative days until vasospasm treatment were more important for predicting worse outcome following interventional rescue, while high admission WFNS grade and pneumonia were important predictors of worse outcome for non-interventional rescue. Finally, in a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS of 4-5 (odds ratio: 1.63; 95%CI 1.22-2.17; p=0.001). Conclusion: Rescue therapy for vasospasm was associated with good functional outcomes. Future randomized trials focusing on preventative or therapeutic interventions may be able to demonstrate improvements in clinical outcomes. Insights from these models may help improve patient selection criteria and trial designs for rescue therapy.

Early identification of patients at risk for symptomatic vasospasm after aneurysmal subarachnoid hemorrhage

2000 ◽  
Vol 28 (4) ◽  
pp. 984-990 ◽  
Author(s):  
Adnan I. Qureshi ◽  
Gene Y. Sung ◽  
Alexander Y. Razumovsky ◽  
Karen Lane ◽  
Robert N. Straw ◽  
...  
Keyword(s):  
At Risk ◽  
Subarachnoid Hemorrhage ◽  
Early Identification ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Symptomatic Vasospasm ◽  
Patients At Risk

A review of current and future medical therapies for cerebral vasospasm following aneurysmal subarachnoid hemorrhage

2006 ◽  
Vol 21 (3) ◽  
pp. 1-7 ◽  
Author(s):  
J Mocco ◽  
Brad E. Zacharia ◽  
Ricardo J. Komotar ◽  
E. Sander Connolly
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Relevant Literature ◽  
Therapeutic Interventions ◽  
Common Complication ◽  
Current State ◽  
Threefold Increase ◽  
Poor Understanding ◽  
Medical Therapies

✓In an effort to help clarify the current state of medical therapy for cerebral vasospasm, the authors reviewed the relevant literature on the established medical therapies used for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH), and they discuss burgeoning areas of investigation. Despite advances in the treatment of aneurysmal SAH, cerebral vasospasm remains a common complication and has been correlated with a 1.5- to threefold increase in death during the first 2 weeks after hemorrhage. A number of medical, pharmacological, and surgical therapies are currently in use or being investigated in an attempt to reverse cerebral vasospasm, but only a few have proven to be useful. Although much has been elucidated regarding its pathophysiology, the treatment of cerebral vasospasm remains a dilemma. Although a poor understanding of SAH-induced cerebral vasospasm pathophysiology has, to date, hampered the development of therapeutic interventions, current research efforts promise the eventual production of new medical therapies.

Abstract P823: Evaluating Time-To-Aneurysm Repair as a Performance Measure in Aneurysmal Subarachnoid Hemorrhage

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Tiffany O Sheehan ◽  
Nicolle W Davis ◽  
Yi Guo ◽  
Debra Lynch Kelly ◽  
Saun-joo Yoon ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Performance Metrics ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Patient Characteristics ◽  
Performance Measure ◽  
Hospital Death ◽  
Discharge Data ◽  
Stroke Center ◽  
Aneurysm Repair ◽  
The Relationship

Background: Implementation of evidence-based performance metrics drive standardized care and improve patient outcomes. Limited performance metrics have been developed for implementation in the aneurysmal subarachnoid hemorrhage (aSAH) population. Timely aneurysm repair following an aSAH is associated with rebleeding prevention and mortality. The purpose of this study was to evaluate time to aneurysm repair as a candidate performance metric by testing a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, with time to aneurysm repair as a potential influence on these relationships in aSAH. Methods: A retrospective, cross-sectional analysis of patient discharge data from 2014 in the state of Florida was conducted. Data were derived from The Agency for Healthcare Research and Quality, HealthCare Utilization Project, State Inpatient Dataset, and the American Hospital Association Annual Survey. Patients with a primary ICD-9 diagnosis of aSAH and principle procedure of clipping or coiling were included (n=387). The study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. Results: Patients who underwent endovascular repair of an aneurysm were more likely to be treated in <24 hours compared to those undergoing aneurysm clipping (OR = 0.54, CI = .35-.84, p =0.01). Patients treated at a comprehensive stroke center (CSC) had a 72% reduction in odds of death compared to those treated at primary stroke centers (OR =0.28, CI = 0.10-0.77, p =0.01), controlling for disease severity and comorbidity. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. Conclusions: Treatment at a certified CSC was the only significant predictor of surviving aSAH. Time to aneurysm repair did not influence the relationship between hospital and patient characteristics associated with mortality. Further research is needed to identify appropriate measures and to define what should be tracked for performance in the aSAH population.

STATIN USE WAS NOT ASSOCIATED WITH LESS VASOSPASM OR IMPROVED OUTCOME AFTER SUBARACHNOID HEMORRHAGE

Neurosurgery ◽  
2008 ◽  
Vol 62 (2) ◽  
pp. 422-430 ◽  
Author(s):  
Andreas H. Kramer ◽  
Matthew J. Gurka ◽  
Bart Nathan ◽  
Aaron S. Dumont ◽  
Neal F. Kassell ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Vegetative State ◽  
Treatment Protocol ◽  
Poor Outcome ◽  
Reductase Inhibitors ◽  
Symptomatic Vasospasm ◽  
Endovascular Coil Embolization ◽  
Baseline Characteristics ◽  
Statin Use

Abstract OBJECTIVE The development of delayed ischemia caused by cerebral vasospasm remains a common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Preliminary studies suggest that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) may decrease the risk of vasospasm, but additional study is required. METHODS Beginning in May 2006, our treatment protocol for patients presenting with subarachnoid hemorrhage was altered to routinely include the use of 80 mg of simvastatin per day for 14 days. Before this time, only patients with other indications for statins were treated. The charts of 203 consecutive patients over a period of 27 months were retrospectively reviewed, and 150 patients were included in the analysis, of whom 71 patients received statins. These patients were compared with 79 untreated patients to determine whether or not the use of statins was associated with a reduction in the occurrence of vasospasm, delayed infarction, or poor outcome (death, vegetative state, or severe disability). RESULTS Patients who were treated with statins and those who were not had similar baseline characteristics, although more patients in the former group were managed with endovascular coil embolization. There were no statistically significant differences in the proportion of patients developing at least moderate radiographic vasospasm (41% with statins versus 42% without, P = 0.91), symptomatic vasospasm (32% with statins versus 25% without, P = 0.34), delayed infarction (23% with statins versus 28% without, P = 0.46), or poor outcome (39% with statins versus 35% without, P = 0.61). After adjustment for differences in baseline characteristics, including the method of aneurysm treatment, statins were still not significantly protective. CONCLUSION The addition of statins to standard care was not associated with any reduction in the development of vasospasm or improvement in outcomes after aneurysmal subarachnoid hemorrhage. If there is a benefit to statin use, it may be smaller than suggested by previous studies. However, further randomized controlled trials are awaited.

scholarly journals Increased levels of lipid peroxides as predictive of symptomatic vasospasm and poor outcome after aneurysmal subarachnoid hemorrhage

2002 ◽  
Vol 97 (6) ◽  
pp. 1302-1305 ◽  
Author(s):  
Takao Kamezaki ◽  
Kiyoyuki Yanaka ◽  
Sohji Nagase ◽  
Keishi Fujita ◽  
Noriyuki Kato ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Lipid Peroxides ◽  
Medical Complication ◽  
Content Type ◽  
Poor Outcome ◽  
Symptomatic Vasospasm ◽  
Delayed Cerebral Vasospasm ◽  
Fine Print

Object. Cerebral vasospasm remains a devastating medical complication of aneurysmal subarachnoid hemorrhage (SAH). Reactive oxygen species and subsequent lipid peroxidation are reported to participate in the causes of cerebral vasospasm. This clinical study was performed to investigate the relationships between levels of lipid peroxides in cerebrospinal fluid (CSF) and both delayed cerebral vasospasm and clinical outcome after SAH. Methods. Levels of phosphatidylcholine hydroperoxide (PCOOH) and cholesteryl ester hydroperoxide (CEOOH) in the CSF were measured in 20 patients with aneurysmal SAH. The patients' CSF was collected within 48 hours of hemorrhage onset and on Day 6 or 7 post-SAH. On Day 7, angiography was performed to verify the degree and extent of the vasospasm. The relationship between the patients' clinical profiles and the levels of lipid peroxides in the CSF were investigated. Both PCOOH and CEOOH were detectable in CSF, and their levels decreased within 7 days after onset of SAH. The levels of CEOOH within 48 hours after onset of hemorrhage were significantly higher in patients in whom symptomatic vasospasm later developed than in patients in whom symptomatic vasospasm did not develop (p = 0.002). Levels of PCOOH measured within 48 hours after onset of hemorrhage were significantly higher in patients with poor outcomes than in patients with good outcomes (p = 0.043). Conclusions. Increased levels of lipid peroxides measured in the CSF during the acute stage of SAH were predictive of both symptomatic vasospasm and poor outcome. Measurements of lipid peroxides in the CSF may be useful prognostically for patient outcomes as well as for predicting symptomatic vasospasm.

scholarly journals Intra-Arterial Nimodipine Infusion for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage

2011 ◽  
Vol 17 (2) ◽  
pp. 169-178 ◽  
Author(s):  
W-S. Cho ◽  
H-S. Kang ◽  
J.E. Kim ◽  
O-K. Kwon ◽  
C.W. Oh ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Clinical Response ◽  
Clinical Improvement ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Related Complication ◽  
Improvement Rate ◽  
Deterioration Rate ◽  
Symptomatic Vasospasm ◽  
Favorable Clinical Outcome

This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.

scholarly journals Identification of Early Markers for Symptomatic Vasospasm in Human Cerebral Microdialysate after Subarachnoid Hemorrhage: Preliminary Results of a Proteome-Wide Screening

2007 ◽  
Vol 27 (10) ◽  
pp. 1675-1683 ◽  
Author(s):  
Martin H Maurer ◽  
Daniel Haux ◽  
Oliver W Sakowitz ◽  
Andreas W Unterberg ◽  
Wolfgang Kuschinsky
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Expression Profiles ◽  
Major Complication ◽  
High Risk Group ◽  
Individual Risk ◽  
Two Dimensional Gel Electrophoresis ◽  
Symptomatic Vasospasm ◽  
Early Markers ◽  
The Individual

A major complication of aneurysmal subarachnoid hemorrhage (SAH) is symptomatic vasospasm, a complex syndrome consisting of neurological deterioration and exclusion of other sources of ischemia. Approximately 30% of SAH patients are affected. Although symptomatic vasospasm is associated with high mortality and poor clinical outcome, it is not possible to identify the individual risk on a molecular level for patients before symptoms have developed. In this study, we hypothesize that protein changes occur in the cerebral microdialysate of patients who later develop symptomatic vasospasm which are not found in matched-pairs control subjects. We searched for changes in protein concentrations in microdialysate sampled from the fronto-temporal brain tissue of five vasospastic and five nonvasospastic SAH patients using proteomics technology based on two-dimensional gel electrophoresis and mass spectrometry. Microdialysate samples were taken at least 1.5 days before the onset of symptomatic vasospasm. Comparing protein expression profiles, we found that the protein concentrations of several isoforms of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) were 1.79-fold ± 1.29 ( N = 5, P < 0.05) higher in the group which later developed symptomatic vasospasm, whereas heat—shock cognate 71 kDa protein (HSP7C) isoforms were decreased to 0.50-fold ± 0.19 ( N = 5, P < 0.05; all expression data means ± s.d.). The changes in protein concentrations were detected 3.8 ± 1.7 days ( N = 5, P < 0.05) before symptomatic vasospasm developed. We conclude that GAPDH and HSP7C may be used as early markers indicating the later development of symptomatic vasospasm after SAH, enabling selective early therapeutic intervention in this high-risk group of patients.

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