Neurocritical care complications and interventions influence the outcome in aneurysmal subarachnoid hemorrhage

Abstract Background This observational study was performed to show the impact of complications and interventions during neurocritical care on the outcome after aneurysmal subarachnoid hemorrhage (SAH). Methods We analyzed 203 cases treated for ruptured intracranial aneurysms, which were classified regarding clinical outcome after one year according to the modified Rankin Scale (mRS). We reviewed the data with reference to the occurrence of typical complications and interventions in neurocritical care units. Results Decompressive craniectomy (odds ratio 21.77 / 6.17 ; p < 0.0001 / p = 0.013), sepsis (odds ratio 14.67 / 6.08 ; p = 0.037 / 0.033) and hydrocephalus (odds ratio 3.71 / 6.46 ; p = 0.010 / 0.00095) were significant predictors for poor outcome and death after one year beside “World Federation of Neurosurgical Societies” (WFNS) grade (odds ratio 3.86 / 4.67 ; p < 0.0001 / p < 0.0001) and age (odds ratio 1.06 / 1.10 ; p = 0.0030 / p < 0.0001) in our multivariate analysis (binary logistic regression model). Conclusions In summary, decompressive craniectomy, sepsis and hydrocephalus significantly influence the outcome and occurrence of death after aneurysmal 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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Increased risk of delayed cerebral ischemia in subarachnoid hemorrhage patients with additional intracerebral hematoma

Journal of Neurosurgery ◽

10.3171/2015.12.jns151563 ◽

2017 ◽

Vol 126 (2) ◽

pp. 504-510 ◽

Cited By ~ 17

Author(s):

Johannes Platz ◽

Erdem Güresir ◽

Marlies Wagner ◽

Volker Seifert ◽

Juergen Konczalla

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Intracerebral Hematoma ◽

World Federation ◽

Single Center ◽

New Classification ◽

Increased Risk ◽

The Impact

OBJECTIVE Delayed cerebral ischemia (DCI) has a major impact on the outcome of patients suffering from aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to assess the influence of an additional intracerebral hematoma (ICH) on the occurrence of DCI. METHODS The authors conducted a single-center retrospective analysis of cases of SAH involving patients treated between 2006 and 2011. Patients who died or were transferred to another institution within 10 days after SAH without the occurrence of DCI were excluded from the analysis. RESULTS Additional ICH was present in 123 (24.4%) of 504 included patients (66.7% female). ICH was classified as frontal in 72 patients, temporal in 24, and perisylvian in 27. DCI occurred in 183 patients (36.3%). A total of 59 (32.2%) of these 183 patients presented with additional ICH, compared with 64 (19.9%) of the 321 without DCI (p = 0.002). In addition, DCI was detected significantly more frequently in patients with higher World Federation of Neurosurgical Societies (WFNS) grades. The authors compared the original and modified Fisher Scales with respect to the occurrence of DCI. The modified Fisher Scale (mFS) was superior to the original Fisher Scale (oFS) in predicting DCI. Furthermore, they suggest a new classification based on the mFS, which demonstrates the impact of additional ICH on the occurrence of DCI. After the different scales were corrected for age, sex, WFNS score, and aneurysm site, the oFS no longer was predictive for the occurrence of DCI, while the new scale demonstrated a superior capacity for prediction as compared with the mFS. CONCLUSIONS Additional ICH was associated with an increased risk of DCI in this study. Furthermore, adding the presence or absence of ICH to the mFS improved the identification of patients at the highest risk for the development of DCI. Thus, a simple adjustment of the mFS might help to identify patients at high risk for DCI.

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PREDICTORS OF CEREBRAL INFARCTION IN PATIENTS WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000255396.23280.31 ◽

2007 ◽

Vol 60 (4) ◽

pp. 658-667 ◽

Cited By ~ 175

Author(s):

Sherise Ferguson ◽

R. Loch Macdonald

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Odds Ratio ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multivariable Analysis ◽

Double Blind ◽

Poor Outcome ◽

Symptomatic Vasospasm ◽

Explained Variance ◽

The Impact

Abstract OBJECTIVE Cerebral infarction would be expected to be associated with poor outcome after aneurysmal subarachnoid hemorrhage (SAH), although there are few data on which to base this assumption. The goals of this study were to determine the impact of cerebral infarction on outcome and to examine predictors of infarction in these patients. METHODS Univariate and multivariable statistical methods were used to examine the impact of cerebral infarction on the Glasgow Outcome Scale score 3 months after SAH among 3567 patients entered into four prospective, randomized, double-blind, placebo-controlled trials of tirilazad conducted in neurosurgical centers around the world between 1991 and 1997. Patient demographics, clinical variables, radiographic characteristics, and treatment variables associated with cerebral infarction were also determined by the same methods. RESULTS Seven hundred and seven (26%) out of 2741 patients with complete data had cerebral infarction on computed tomographic scans 6 weeks after SAH. Multivariable logistic regression showed that cerebral infarction increased the odds of unfavorable outcome by a factor of 5.4 (adjusted odds ratio, 5.4; 95% confidence interval, 4.2–6.8; P < 0.0001), which was a higher odds ratio than all other factors associated with outcome. The proportion of explained variance in outcome was also highest for cerebral infarction and accounted for 39% of the explained variance. Multivariable analysis found that cerebral infarction was significantly associated with increasing patient age, worse neurological grade on admission, history of hypertension or diabetes mellitus, larger aneurysm, use of prophylactically or therapeutically induced hypertension, temperature more than 38°C 8 days after SAH, and symptomatic vasospasm. CONCLUSION Cerebral infarction was strongly associated with poor outcome after aneurysmal SAH. The most important potentially treatable factor associated with infarction was symptomatic vasospasm.

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Reactive Thrombocytosis in Non-aneurysmal Subarachnoid Hemorrhage

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0040-1709167 ◽

2020 ◽

Vol 81 (05) ◽

pp. 412-417

Author(s):

Daniel Dubinski ◽

Sae-Yeon Won ◽

Bedjan Behmanesh ◽

Nina Brawanski ◽

Volker Seifert ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

World Federation ◽

Reactive Thrombocytosis ◽

Vp Shunt ◽

Fisher Grade ◽

The Impact

Abstract Background The role of reactive thrombocytosis in non-aneurysmal subarachnoid hemorrhage (NA-SAH) is largely unexplored to date. Therefore, the impact of a quantitative thrombocyte dynamic in patients with NA-SAH and its clinical relevance were analyzed in the present study. Methods In this retrospective analysis, 113 patients with nontraumatic and NA-SAH treated between 2003 and 2015 at our institution were included. World Federation of Neurosurgical Societies admission status, cerebral vasospasm, delayed infarction, hydrocephalus, need for ventriculoperitoneal (VP) shunt, and Fisher grade were analyzed for their association with reactive thrombocytosis. Results Reactive thrombocytosis was not associated with hydrocephalus (p ≥ 0.05), need for VP shunt implantation (p ≥ 0.05), cerebral vasospasm (p ≥ 0.05), or delayed cerebral ischemia (p ≥ 0.05). Conclusion Our study is the first to investigate the role of thrombocyte dynamics, reactive thrombocytosis, and the clinical course of NA-SAH patients. Our analysis showed no significant impact of thrombocyte count on NA-SAH sequelae.

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Cigarette smoking—induced increase in the risk of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1997.87.3.0381 ◽

1997 ◽

Vol 87 (3) ◽

pp. 381-384 ◽

Cited By ~ 83

Author(s):

Todd M. Lasner ◽

Robert J. Weil ◽

Howard A. Riina ◽

Joseph T. King ◽

Eric L. Zager ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Alcohol Abuse ◽

Cigarette Smoking ◽

Cerebral Vasospasm ◽

Odds Ratio ◽

Aneurysmal Subarachnoid Hemorrhage ◽

World Federation ◽

Symptomatic Vasospasm ◽

Fisher Grade ◽

Grade 3

✓ Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is correlated with the thickness of blood within the basal cisterns on the initial computerized tomography (CT) scan. To identify additional risk factors for symptomatic vasospasm, the authors performed a prospective analysis of 75 consecutively admitted patients who were treated for aneurysmal SAH. Five patients who died before treatment or were comatose postoperatively were excluded from the study. Of the remaining 70 patients, demographic (age, gender, and race) and clinical (hypertension, diabetes, coronary artery disease, smoking, alcohol abuse, illicit drug use, sentinel headache, Fisher grade, Hunt and Hess grade, World Federation of Neurological Surgeons grade, and ruptured aneurysm location) parameters were evaluated using multivariate logistic regression to determine factors independently associated with cerebral vasospasm. All patients were treated with hypervolemic therapy and administration of nimodipine as prophylaxis for vasospasm. Cerebral vasospasm was suspected in cases that exhibited (by elevation of transcranial Doppler velocities) neurological deterioration 3 to 14 days after SAH with no other explanation and was confirmed either by clinical improvement in response to induced hypertension or by cerebral angiography. The mean age of the patients was 50 years. Sixty-three percent of the patients were women, 74% were white, 64% were cigarette smokers, and 46% were hypertensive. Ten percent of the patients suffered from alcohol abuse, 19% from sentinel bleed, and 49% had a Fisher Grade 3 SAH. Twenty-nine percent of the patients developed symptomatic vasospasm. Multivariate analysis demonstrated that cigarette smoking (p = 0.033; odds ratio 4.7, 95% confidence interval [CI] 2.4–8.9) and Fisher Grade 3, that is, thick subarachnoid clot (p = 0.008; odds ratio 5.1, 95% CI 2–13.1), were independent predictors of symptomatic vasospasm. The authors make the novel observation that cigarette smoking increases the risk of symptomatic vasospasm after aneurysmal SAH, independent of Fisher grade.

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Long-term Excess Mortality of 244 Familial and 1502 Sporadic One-Year Survivors of Aneurysmal Subarachnoid Hemorrhage Compared With a Matched Eastern Finnish Catchment Population

Neurosurgery ◽

10.1227/neu.0b013e3181ff33ca ◽

2011 ◽

Vol 68 (1) ◽

pp. 20-27 ◽

Cited By ~ 25

Author(s):

Terhi. Huttunen ◽

Mikael. von und zu Fraunberg ◽

Timo. Koivisto ◽

Antti. Ronkainen ◽

Jaakko. Rinne ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Glasgow Outcome Scale ◽

Excess Mortality ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Relative Survival ◽

Survival Ratio ◽

Catchment Population ◽

One Year ◽

The Impact

Abstract BACKGROUND: Saccular intracranial aneurysms (sIAs) develop in 2% of the population. Rupture of the sIA wall causes almost all cases of aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: We analyzed the long-term excess mortality of 244 familial and 1502 sporadic 1-year survivors of aSAH from sIA compared with a matched Eastern Finnish catchment population. METHODS: The Kuopio Neurosurgery Database contains 1746 one-year survivors of aSAH (1980–2007) from a defined population. The median follow-up time, until death (n = 494) or the end of 2008, was 12 years. Relative survival ratios were calculated compared with the matched (sex, age, calendar time) catchment population. Relative excess risk of death (RER) was estimated for variables known on admission for aSAH as well as Glasgow Outcome Scale score at 12 months. RESULTS: There was 12% excess mortality at 15 years (cumulative relative survival ratio: 0.88; 95% confidence interval: 0.85-0.91). Independent risk factors were male sex (RER: 1.6), age older than 64 years (RER: 2.9), ruptured basilar tip sIA (RER: 4.5), severe hydrocephalus on admission (RER: 3.6), no occlusive therapy (RER: 6.0), and Glasgow Outcome Scale scores of 2, 3, or 4 at 12 months (RER: 23, 4.1, 2.1, respectively), but not familial sIA disease. There were lethal rebleeds from 13 of the 1440 clipped sIAs, 2 of the 265 coiled sIAs, and 2 from the 17 nonoccluded sIAs, and 14 new lethal bleeds from other sIAs. CONCLUSION: The impact of both sporadic and familial aSAH and their sequelae in the central nervous and cardiovascular systems may cause long-term morbidity and mortality. The complex sIA disease may predispose to other vascular events later in life. The causes of the long-term excess mortality are heterogeneous, and more detailed analyses are required.

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Nimodipine pharmacokinetics after intraventricular injection of sustained-release nimodipine for subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.9.jns191366 ◽

2021 ◽

Vol 134 (1) ◽

pp. 95-101 ◽

Cited By ~ 2

Author(s):

R. Loch Macdonald ◽

Daniel Hänggi ◽

Poul Strange ◽

Hans Jakob Steiger ◽

J Mocco ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Sustained Release ◽

Aneurysmal Subarachnoid Hemorrhage ◽

External Ventricular Drain ◽

Plasma Concentrations ◽

Intraventricular Injection ◽

World Federation ◽

Maximum Plasma ◽

Clinical Trial Registration ◽

Sustained Release Formulation

OBJECTIVEThe objective of this study was to measure the concentration of nimodipine in CSF and plasma after intraventricular injection of a sustained-release formulation of nimodipine (EG-1962) in patients with aneurysmal subarachnoid hemorrhage (SAH).METHODSPatients with SAH repaired by clip placement or coil embolization were randomized to EG-1962 or oral nimodipine. Patients were classified as grade 2–4 on the World Federation of Neurosurgical Societies grading scale for SAH and had an external ventricular drain inserted as part of their standard of care. Cohorts of 12 patients received 100–1200 mg of EG-1962 as a single intraventricular injection (9 per cohort) or they remained on oral nimodipine (3 per cohort). Plasma and CSF were collected from each patient for measurement of nimodipine concentrations and calculation of maximum plasma and CSF concentration, area under the concentration-time curve from day 0 to 14, and steady-state concentration.RESULTSFifty-four patients in North America were randomized to EG-1962 and 18 to oral nimodipine. Plasma concentrations increased with escalating doses of EG-1962, remained stable for 14 to 21 days, and were detectable at day 30. Plasma concentrations in the oral nimodipine group were more variable than for EG-1962 and were approximately equal to those occurring at the EG-1962 800-mg dose. CSF concentrations of nimodipine in the EG-1962 groups were 2–3 orders of magnitude higher than in the oral nimodipine group, in which nimodipine was only detected at low concentrations in 10% (21/213) of samples. In the EG-1962 groups, CSF nimodipine concentrations were 1000 times higher than plasma concentrations.CONCLUSIONSPlasma concentrations of nimodipine similar to those achieved with oral nimodipine and lasting for 21 days could be achieved after a single intraventricular injection of EG-1962. The CSF concentrations from EG-1962, however, were at least 2 orders of magnitude higher than those with oral nimodipine. These results supported a phase 3 study that demonstrated a favorable safety profile for EG-1962 but yielded inconclusive efficacy results due to notable differences in clinical outcome based on baseline disease severity.Clinical trial registration no.: NCT01893190 (ClinicalTrials.gov).

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