scholarly journals Management of aneurysmal subarachnoid haemorrhage with intracerebral hematoma: Is there an indication for coiling first? Study of 44 cases

2015 ◽  
Vol 22 (1) ◽  
pp. 5-11
Author(s):  
Céline Salaud ◽  
Olivier Hamel ◽  
Tanguy Riem ◽  
Hubert Desal ◽  
Kevin Buffenoir
Keyword(s):  
Subarachnoid Haemorrhage ◽  
Poor Prognosis ◽  
Intracerebral Hematoma ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Aneurysm Clipping ◽  
Good Outcome ◽  
A Prospective Study ◽  
Aneurysm Coiling ◽  
Radiologic Characteristics

Background Aneurysmal subarachnoid haemorrhage (ASH) with intracerebral hematoma (ICH) has a poor prognosis. The treatment is to secure the aneurysm and do an ICH evacuation. Objective The aim of the study was to determine if aneurysm coiling followed by ICH evacuation is a viable alternative treatment compared to exclusive surgery, regardless of the clinical or paraclinical presentations. Methods A retrospective study was conducted between 2004 and 2014, which included 44 patients. The patients were divided up in four groups. Two were principal groups: The clipped group (aneurysm clipping with ICH evacuation) and the coiled group (aneurysm coiling, followed by ICH evacuation); and two were subgroups of the latter: Aneurysm coiling with ICH evacuation after 24 hours and ICH evacuation followed by aneurysm coiling. We studied the demographic and radiologic characteristics, and the 3-month outcome. Results We included 17 patients in the coiled group: The outcome was better for the patients with World Federation of Neurosurgery (WFNS) scores of 1, 2 and 3; compared to the patients with WFNS scores 4 and 5. We included 16 patients in the clipped group: The outcome was better, compared the coiled group, for those patients with WFNS scores 4 and 5. Six patients were treated with aneurysm coiling, followed by ICH evacuation after 24 hours: 33% had a good outcome. Five patients were treated by ICH evacuation, followed by aneurysm coiling: None had a good outcome. Conclusions It was necessary to realise a prospective study to compare the outcomes of patients with WFNS scores of 1, 2 or 3; between those with aneurysm coiling followed by ICH evacuation and aneurysm clipping with ICH evacuation, to determine the potential of using the coiling first, for these patients.

Visualisation of the non-linear correlation between age and poor outcome in patients with aneurysmal subarachnoid haemorrhage

2021 ◽  
pp. jnnp-2020-325306
Author(s):  
Fusao Ikawa ◽  
Nao Ichihara ◽  
Masaaki Uno ◽  
Yoshiaki Shiokawa ◽  
Kazunori Toyoda ◽  
...  
Keyword(s):  
Subarachnoid Haemorrhage ◽  
Linear Correlation ◽  
Clinical Decision Making ◽  
Variable Importance ◽  
Additive Models ◽  
Endovascular Coiling ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Poor Outcome ◽  
Non Linear

ObjectiveTo visualise the non-linear correlation between age and poor outcome at discharge in patients with aneurysmal subarachnoid haemorrhage (SAH) while adjusting for covariates, and to address the heterogeneity of this correlation depending on disease severity by a registry-based design.MethodsWe extracted data from the Japanese Stroke Databank registry for patients with SAH treated via surgical clipping or endovascular coiling within 3 days of SAH onset between 2000 and 2017. Poor outcome was defined as a modified Rankin Scale Score ≥3 at discharge. Variable importance was calculated using machine learning (random forest) model. Correlations between age and poor outcome while adjusting for covariates were determined using generalised additive models in which spline-transformed age was fit to each neurological grade of World Federation of Neurological Societies (WFNS) and treatment.ResultsIn total, 4149 patients were included in the analysis. WFNS grade and age had the largest and second largest variable importance in predicting the outcome. The non-linear correlation between age and poor outcome was visualised after adjusting for other covariates. For grades I–III, the risk slope for unit age was relatively smaller at younger ages and larger at older ages; for grade IV, the slope was steep even in younger ages; while for grade V, it was relatively smooth, but with high risk even at younger ages.ConclusionsThe clear visualisation of the non-linear correlation between age and poor outcome in this study can aid clinical decision making and help inform patients with aneurysmal SAH and their families better.

scholarly journals CSF proteomics of patients with hydrocephalus and subarachnoid haemorrhage

2019 ◽  
Vol 10 (1) ◽  
pp. 244-253
Author(s):  
Bartosz Sokół ◽  
Bartosz Urbaniak ◽  
Bartosz Zaremba ◽  
Norbert Wąsik ◽  
Zenon J. Kokot ◽  
...  
Keyword(s):  
Mass Spectrometry ◽  
Subarachnoid Haemorrhage ◽  
Aneurysm Rupture ◽  
Control Group ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Time Intervals ◽  
Ionization Time ◽  
Good Outcome ◽  
Poor Outcome ◽  
Maldi Tof

Abstract Background The pathophysiology of brain injury following aneurysmal subarachnoid haemorrhage (SAH) is associated with numerous mediators. The aim of the study is to analyse protein changes after SAH in cerebrospinal fluid (CSF) using mass spectrometry (MS). Methods CSF samples were obtained from forty-four control subjects, seven good outcome and ten poor outcome SAH patients. CSF samples were collected at specific time intervals after SAH (days 1, 5 and 10). MALDI-TOF (Matrix Assisted Laser Desorption/Ionization Time-of-Flight) and ClinProTools software were utilised for MS, MS/MS (Mass Spectrometry) spectra collection and analysis. Selected masses were identified. The MALDI-TOF profiling experiments allowed for the targeted selection of potential markers in SAH. The study was performed in three steps by comparison of CSF samples: (1) from the control group and SAH patients (both good and poor outcome groups); (2) collected on days 1, 5 and 10 within the groups of poor SAH and good SAH patients, respectively; (3) from poor outcome SAH and good outcome patients at days 1, 5 and 10. Results 15 new proteins whose CSF level is alternated by SAH presence, SAH treatment outcome and time passed since aneurysm rupture were identified. Conclusions We demonstrated new proteins which might play a role in different stages of subarachnoid haemorrhage and could be a new target for further investigation.

scholarly journals Pipeline shield with single antiplatelet therapy in aneurysmal subarachnoid haemorrhage: multicentre experience

2018 ◽  
Vol 11 (7) ◽  
pp. 694-698 ◽  
Author(s):  
Nathan W Manning ◽  
Andrew Cheung ◽  
Timothy J Phillips ◽  
Jason D Wenderoth
Keyword(s):  
Subarachnoid Haemorrhage ◽  
Antiplatelet Therapy ◽  
Acute Treatment ◽  
Intracranial Aneurysms ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Anterior Circulation ◽  
Heparin Infusion ◽  
Poor Grade ◽  
Ruptured Intracranial Aneurysms

BackgroundThe Pipeline Embolisation Device with Shield technology (PED-Shield) is suggested to have reduced thrombogenicity. This reduced thrombogenicity may make it possible to use safely in the acute treatment of aneurysmal subarachnoid haemorrhage (aSAH) on single antiplatelet therapy (SAPT).ObjectiveTo evaluate the safety and efficacy of the off-label use of PED-Shield with SAPT for the acute treatment of aSAH.MethodsPatients who underwent acute treatment of ruptured intracranial aneurysms with the PED-Shield with SAPT were retrospectively identified from prospectively maintained databases at three Australian neurointerventional centres. Patient demographics, aneurysm characteristics, clinical and imaging outcomes were reviewed.ResultsFourteen patients were identified (12 women), median age 64 (IQR 21.5) years. Aneurysm morphology was saccular in seven, fusiform in five, and blister in two. Aneurysms arose from the anterior circulation in eight patients (57.1%). Six (42.9%) patients were poor grade (World Federation of Neurological Societies grade ≥IV) SAH. Median time to treatment was 1 (IQR 0.5) day. Complete or near complete aneurysm occlusion (Raymond-Roy <3) was achieved in 12 (85.7%) patients at the end of early-acute follow-up (median day 7 after SAH). Permanent, treatment-related morbidity occurred in one (7.1%) patient and one (7.1%) treatment-related death occurred. The use of a postoperative heparin infusion (n=5) was associated with a higher rate of all complications (80.0% vs 11.1%, p=0.023) and symptomatic complications (60% vs 0.0%, p=0.028). No symptomatic ischaemic or haemorrhagic complications were observed in the patients who did not receive a post-operative heparin infusion. Nine (64.3%) patients were functionally independent on discharge from the treatment centre.ConclusionThe PED-Shield may be safe to use in the acute treatment of ruptured intracranial aneurysms with SAPT. Further investigation with a formal treatment registry is needed.

scholarly journals Relevance of Presenting Risks of Frailty, Sarcopaenia and Osteopaenia to Outcomes From Aneurysmal Subarachnoid Haemorrhage

2021 ◽  
Author(s):  
Jia Xu Lim ◽  
Yuan Guang Lim ◽  
A Aravin Kumar ◽  
Tien Meng Cheong ◽  
Julian Xinguang Han ◽  
...  
Keyword(s):  
Brain Injury ◽  
Subarachnoid Haemorrhage ◽  
Frailty Index ◽  
Acute Brain Injury ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Improvement Program ◽  
Modified Frailty Index ◽  
Neurological Surgery

Abstract IntroductionAneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. In the context of acute brain injury, frailty, sarcopaenia and osteopaenia have become increasing concerns. Multiple indices have been devised in various surgical specialties to predict outcome and guide management. In this study, we examined whether such markers have relevance towards outcomes from acute brain conditions, such as aSAH. MethodsAn observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]), temporalis (TMT) and zygoma thickness (markers of sarcopaenia and osteopaenia), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. ResultsTMT was the best performing marker in our cohort with an AUC of 0.82, Somers’ D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69, Somer’s D 0.40, Tau 0.16), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68, Somer’s D 0.43, Tau 0.17). After multivariate analysis, patients with TMT ≥5.5mm (defined as non-frail), were less likely to experience complications (OR 0.20 [0.06 – 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes. ConclusionTMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes Trial registrationNot applicable

Abstract P37: Impact of Onset-To-Treatment Time on Hospital Discharge Destination After Aneurysmal Subarachnoid Haemorrhage - The REDDISH Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Marie-Jeanne BUSCOT ◽  
Ronil V Chandra ◽  
Linda Nichols ◽  
Leigh Blizzard ◽  
Christine Stirling ◽  
...  
Keyword(s):  
Subarachnoid Haemorrhage ◽  
Hospital Discharge ◽  
Treatment Time ◽  
Optimal Time ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Discharge Destination ◽  
Linear Effect ◽  
Treatment Type ◽  
Non Linear

Background and aims: Rapid access to specialised care improves outcomes after aneurysmal subarachnoid haemorrhage (aSAH) but there is limited evidence on the optimal time-to-treatment. We investigated onset-to-treatment time and hospital discharge destination in aSAH. Methods: Consecutive first-ever aSAH patients were retrospectively identified from multiple overlapping sources in two comprehensive cerebrovascular referral centres between 2010-2016. Onset-to-treatment time (hours from onset of symptoms to treatment to secure aneurysm), clinical characteristics, and neurological complications (NINDS classifications) were extracted by clinical data collectors from medical records. Among survivors, we estimated the effect of continuous onset-to-treatment on hospital discharge destination (i.e. home vs. rehabilitation/other hospital as proxy for functional recovery) using logistic regression with adjustment for gender, treatment type (clipping or coiling), hospital presentation (direct admission or transfer), and severity (World Federation of Neurosurgical Societies scale, modified Fisher scale). Non-linear effects were investigated using natural cubic splines. Results: Among 402 survivors at discharge, there was a strong non-linear effect of onset-to-treatment time on odds of being discharged home compared to discharge to rehabilitation independent of severity, gender, treatment type and transfer (see Figure). The greatest benefit to discharge home was evident with treatment at up to 12.5 hours but the benefit remained at up to 20 hours post-onset. Conclusions: aSAH Treatment occurring within 12.5 hours led to greater discharge to home. Our use of continuous modelling provides clarity around optimal treatment times for aSAH to guide clinical practice.

scholarly journals Early brain injury and cognitive impairment after aneurysmal subarachnoid haemorrhage

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Matthew J. Rowland ◽  
Payashi Garry ◽  
Martyn Ezra ◽  
Rufus Corkill ◽  
Ian Baker ◽  
...  
Keyword(s):  
Cognitive Impairment ◽  
Brain Injury ◽  
Subarachnoid Haemorrhage ◽  
Acute Phase ◽  
Early Brain Injury ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Healthy Controls ◽  
Good Grade ◽  
The Impact

AbstractThe first 72 h following aneurysm rupture play a key role in determining clinical and cognitive outcomes after subarachnoid haemorrhage (SAH). Yet, very little is known about the impact of so called “early brain injury” on patents with clinically good grade SAH (as defined as World Federation of Neurosurgeons Grade 1 and 2). 27 patients with good grade SAH underwent MRI scanning were prospectively recruited at three time-points after SAH: within the first 72 h (acute phase), at 5–10 days and at 3 months. Patients underwent additional, comprehensive cognitive assessment 3 months post-SAH. 27 paired healthy controls were also recruited for comparison. In the first 72 h post-SAH, patients had significantly higher global and regional brain volume than controls. This change was accompanied by restricted water diffusion in patients. Persisting abnormalities in the volume of the posterior cerebellum at 3 months post-SAH were present to those patients with worse cognitive outcome. When using this residual abnormal brain area as a region of interest in the acute-phase scans, we could predict with an accuracy of 84% (sensitivity 82%, specificity 86%) which patients would develop cognitive impairment 3 months later, despite initially appearing clinically indistinguishable from those making full recovery. In an exploratory sample of good clinical grade SAH patients compared to healthy controls, we identified a region of the posterior cerebellum for which acute changes on MRI were associated with cognitive impairment. Whilst further investigation will be required to confirm causality, use of this finding as a risk stratification biomarker is promising.

scholarly journals Emergent aneurysm treatment compared with treatment on neurological improvement in patients with ruptured poor-grade aneurysmal subarachnoid haemorrhage: the TOPSAT2 RCT

2021 ◽  
Vol 8 (8) ◽  
pp. 1-54
Author(s):  
Philip White ◽  
Barbara Gregson ◽  
Elaine McColl ◽  
Paul Brennan ◽  
Alison Steel ◽  
...  
Keyword(s):  
Subarachnoid Haemorrhage ◽  
Functional Outcome ◽  
Early Treatment ◽  
Randomised Trial ◽  
World Federation ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Modified Rankin Scale ◽  
Poor Grade ◽  
Neurological Improvement ◽  
Future Work

Background Aneurysmal subarachnoid haemorrhage is a major cause of haemorrhagic stroke. The incidence is ≈ 80 per million population per year; it peaks in the 40–60 years age range and often has a poor prognosis with the outcome linked to severity of the initial haemorrhage. Aneurysmal subarachnoid haemorrhage accounts for 5% of strokes, but 20% of quality-adjusted life-years are lost to stroke and much of that loss is concentrated in World Federation of Neurosurgical Societies grade 4–5 (or poor-grade) aneurysmal subarachnoid haemorrhage patients. Before endovascular coiling was available, the conventional management strategy for poor-grade aneurysmal subarachnoid haemorrhage patients was to treat the ruptured aneurysm on neurological improvement. That incurs a risk of aneurysm rebleeding, which is highest soon after the first bleed; if rebleed occurs prior to aneurysm treatment, prognosis is dismal. Reducing rebleeding with early treatment might improve outcome. Therefore, an early coiling strategy in grade 4–5 patients is appealing, but not robustly evidenced. Early treatment in all grade 4–5 patients might prevent death from rebleeding but possibly at the expense of creating severely disabled survivors, with attendant societal costs. Many neuroclinicians have expressed genuine uncertainty regarding whether or not to treat all grade 4–5 aneurysmal subarachnoid haemorrhage patients emergently (as soon as possible regardless of neurological status). A pilot trial, the treatment of poor-grade subarachnoid haemorrhage trial 1 (TOPSAT1), indicated that recruitment to a randomised trial to address this uncertainty was feasible. Methods We investigated a management policy in aneurysmal subarachnoid haemorrhage World Federation of Neurosurgical Societies grades 4 or 5 of securing the ruptured aneurysm emergently (within 24 hours of randomisation) compared with the strategy to treat the aneurysm on neurological improvement (to World Federation of Neurosurgical Societies grades 1–3), irrespective of when that improvement occurred. The treatment of poor-grade subarachnoid haemorrhage trial 2 (TOPSAT2) was a pragmatic, randomised, open-blinded, end-point design trial aiming to recruit 346 adult patients (aged 18–80 years) in 30 UK and European neuroscience centres. Randomisation was web based, with minimisation criteria relating to age, grade, presence of hydrocephalus and UK location (vs. non-UK). Fifteen sites were opened to recruitment, 12 of which were in the UK. Standard institutional procedures for securing aneurysms were followed. An exploratory magnetic resonance biomarker substudy of 100 UK participants was planned but not opened. The primary end point was functional outcome at 12 months, determined by analysis of the modified Rankin Scale score. The secondary end points relating to safety were assessed. Results Of the 305 World Federation of Neurosurgical Societies grade 4–5 patients screened, 23 were randomised: 11 to the emergent treatment arm and 12 to the treatment on neurological improvement (control) arm. Trial recruitment was suspended when it was judged to have failed a feasibility assessment. The median time from ictus to treatment (where aneurysm was treated) was 26 hours in the emergent treatment arm and 163 hours in the treatment on neurological improvement arm. There were no statistically significant differences between arms in mortality (p = 0.4) or functional outcome at 365 days [modified Rankin Scale score 0–3 vs. 4–6 (p = 0.32)]. Sensitivity analysis was performed to examine the effect of missing data but differences remained non-significant. Limitations A limitation was the failure to recruit to time/target. Conclusions The randomised trial approach to investigating whether poor-grade aneurysmal subarachnoid haemorrhage patients should receive emergent treatment or be treated on neurological improvement proved unfeasible. No statistically significant differences were identified between the trial arms in mortality or functional outcome, but the small number of patients enrolled limits drawing firm conclusions. Future work No future work is currently planned. Trial registration Current Controlled Trials ISRCTN15960635. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 8. See the NIHR Journals Library website for further project information.

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