Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage

ObjectiveTo define the in-hospital course, complications, short- and long-term functional outcomes of patients with angiographically negative subarachnoid hemorrhage (anSAH), particularly those with aneurysmal-pattern anSAH (aanSAH).MethodsRetrospective cohort study of patients with aneurysmal subarachnoid hemorrhage (aSAH), aanSAH, and perimesencephalic-pattern anSAH (panSAH) treated at a single tertiary referral center between January 2006 and April 2018. Ninety-nine patients with anSAH (33 aanSAH and 66 panSAH) and 464 patients with aSAH were included in this study. Outcomes included symptomatic hydrocephalus requiring CSF drainage, need for ventriculoperitoneal shunt, radiographic vasospasm, delayed cerebral ischemia (DCI), radiographic infarction, disability level within 1 year of ictus, and at last clinical follow-up as defined by the modified Rankin Scale.ResultsPatients with aanSAH and panSAH had similar rates of DCI and radiologic infarction, and patients with aanSAH had significantly lower rates compared to aSAH (p ≤ 0.018). Patients with aanSAH were more likely than those with panSAH to require temporary CSF diversion and ventriculoperitoneal shunt (p ≤ 0.03), with similar rates to those seen in aSAH. Only one patient with anSAH died in the hospital. Compared to those with aSAH, patients with aanSAH were significantly less likely to have a poor functional outcome within 1 year of ictus (odds ratio 0.26, 95% confidence interval 0.090–0.75) and at last follow-up (hazard ratio 0.30, 95% confidence interval 0.19–0.49, p = 0.002).ConclusionsDCI is very uncommon in anSAH, but patients with aanSAH have a similar need for short- and long-term CSF diversion to patients with aSAH. Nevertheless, patients with aanSAH have significantly better short- and long-term outcomes.

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Long-term effects of nimodipine on cerebral infarcts and outcome after aneurysmal subarachnoid hemorrhage and surgery

Journal of Neurosurgery ◽

10.3171/jns.1991.74.1.0008 ◽

1991 ◽

Vol 74 (1) ◽

pp. 8-13 ◽

Cited By ~ 66

Author(s):

Juha Öhman ◽

Antti Servo ◽

Olli Heiskanen

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Controlled Trial ◽

Delayed Cerebral Ischemia ◽

Ct Scanning ◽

Long Term Effects ◽

Cerebral Infarcts ◽

Double Blind ◽

Content Type

✓ A total of 213 patients with verified aneurysmal subarachnoid hemorrhage (SAH) of Grades I to III (Hunt and Hess classification) were enrolled in a double-blind placebo-controlled trial to determine the effect of intravenous nimodipine on delayed ischemic deterioration and computerized tomography (CT)-visualized infarcts after SAH and surgery. The administration of the drug or matching placebo was started immediately after the radiological diagnosis of a ruptured aneurysm had been made. Of the 213 patients enrolled in the study, 58 were operated on early (within 72 hours after the bleed: Days 0 to 3), 69 were operated on subacutely (between Days 4 and 7), and 74 had late surgery (on Day 8 or later). Eleven patients died before surgery was undertaken and one was not operated on. A follow-up examination with CT scanning, performed 1 to 3 years after the SAH (mean 1.4 years), revealed no significant differences in the overall outcome between the groups. However, nimodipine treatment was associated with a significantly lower incidence of deaths caused by delayed cerebral ischemia (p = 0.01) and significantly lower occurrence of cerebral infarcts visualized by CT scanning in the whole population (p = 0.05), especially in patients without an associated intracerebral hemorrhage on admission CT scan (p = 0.03).

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Spontaneous subarachnoid hemorrhage of unknown origin: hospital course and long-term clinical and angiographic follow-up

Journal of Neurosurgery ◽

10.3171/2014.10.jns14175 ◽

2015 ◽

Vol 122 (3) ◽

pp. 663-670 ◽

Cited By ~ 39

Author(s):

Ali M. Elhadi ◽

Joseph M. Zabramski ◽

Kaith K. Almefty ◽

George A. C. Mendes ◽

Peter Nakaji ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

External Ventricular Drain ◽

Delayed Cerebral Ischemia ◽

Unknown Origin ◽

Unknown Etiology ◽

Neurological Outcomes ◽

Spontaneous Subarachnoid Hemorrhage

OBJECT Hemorrhagic origin is unidentifiable in 10%–20% of patients presenting with spontaneous subarachnoid hemorrhage (SAH). While the patients in such cases do well clinically, there is a lack of long-term angiographic followup. The authors of the present study evaluated the long-term clinical and angiographic follow-up of a patient cohort with SAH of unknown origin that had been enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). METHODS The BRAT database was searched for patients with SAH of unknown origin despite having undergone two or more angiographic studies as well as MRI of the brain and cervical spine. Follow-up was available at 6 months and 1 and 3 years after treatment. Analysis included demographic details, clinical outcome (Glasgow Outcome Scale, modified Rankin Scale [mRS]), and repeat vascular imaging. RESULTS Subarachnoid hemorrhage of unknown etiology was identified in 57 (11.9%) of the 472 patients enrolled in the BRAT study between March 2003 and January 2007. The mean age for this group was 51 years, and 40 members (70%) of the group were female. Sixteen of 56 patients (28.6%) required placement of an external ventricular drain for hydrocephalus, and 4 of these subsequently required a ventriculoperitoneal shunt. Delayed cerebral ischemia occurred in 4 patients (7%), leading to stroke in one of them. There were no rebleeding events. Eleven patients were lost to followup, and one patient died of unrelated causes. At the 3-year follow-up, 4 (9.1%) of 44 patients had a poor outcome (mRS > 2), and neurovascular imaging, which was available in 33 patients, was negative. CONCLUSIONS Hydrocephalus and delayed cerebral ischemia, while infrequent, do occur in SAH of unknown origin. Long-term neurological outcomes are generally good. A thorough evaluation to rule out an etiology of hemorrhage is necessary; however, imaging beyond 6 weeks from ictus has little utility, and rebleeding is unexpected.

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20-HETE is Associated with Unfavorable Outcomes in Subarachnoid Hemorrhage Patients

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.2015.75 ◽

2015 ◽

Vol 35 (9) ◽

pp. 1515-1522 ◽

Cited By ~ 19

Author(s):

Mark K Donnelly ◽

Elizabeth A Crago ◽

Yvette P Conley ◽

Jeffery R Balzer ◽

Dianxu Ren ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Medical Center ◽

Delayed Cerebral Ischemia ◽

University Of Pittsburgh ◽

Potential Contributor ◽

Csf Levels ◽

Novel Target ◽

Poor Outcomes

Emerging evidence has suggested that patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) develop vascular dysregulation as a potential contributor to poor outcomes. Preclinical studies have implicated the novel microvascular constrictor, 20-hydroxyeicosatetraenoic acid (20-HETE) in aSAH pathogenesis, yet the translational relevance of 20-HETE in patients with aSAH is largely unknown. The goal of this research was to determine the relationship between 20-HETE cerebrospinal fluid (CSF) levels, gene variants in 20-HETE synthesis, and acute/long-term aSAH outcomes. In all, 363 adult patients (age 18 to 75) with aSAH were prospectively recruited from the University of Pittsburgh Medical Center neurovascular Intensive Care Unit. Patients were genotyped for polymorphic variants and cytochrome P450 (CYP)-eicosanoid CSF levels were measured over 14 days. Outcomes included delayed cerebral ischemia (DCI), clinical neurologic deterioration (CND), and modified Rankin Scores (MRS) at 3 and 12 months. Patients with CND and unfavorable 3-month MRS had 2.2- and 2.7-fold higher mean 20-HETE CSF levels, respectively. Patients in high/moderate 20-HETE trajectory groups (35.7%) were 2.5-, 2.1-, 3.1-, 3.3-, and 2.1-fold more likely to have unfavorable MRS at 3 months, unfavorable MRS at 12 months, mortality at 3 months, mortality at 12 months, and CND, respectively. These results showed that 20-HETE is associated with acute and long-term outcomes and suggest that 20-HETE may be a novel target in aSAH.

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Post-treatment Antiplatelet Therapy Reduces Risk for Delayed Cerebral Ischemia due to Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1093/neuros/nyy550 ◽

2018 ◽

Vol 85 (6) ◽

pp. 827-833 ◽

Cited By ~ 16

Author(s):

Marvin Darkwah Oppong ◽

Oliver Gembruch ◽

Daniela Pierscianek ◽

Martin Köhrmann ◽

Christoph Kleinschnitz ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Confidence Interval ◽

Antiplatelet Therapy ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Minor Bleeding ◽

Bleeding Events

ABSTRACT BACKGROUND Delayed cerebral ischemia (DCI) has a strong impact on outcome of patients with aneurysmal subarachnoid hemorrhage (SAH). Positive effect of antiplatelet therapy on DCI rates has been supposed upon smaller SAH series. OBJECTIVE To analyze the benefit/risk profile of antiplatelet use in SAH patients. METHODS This retrospective case–control study was based on institutional observational cohort with 994 SAH patients treated between January 2003 and June 2016. The individuals with postcoiling antiplatelet therapy (aspirin with/without clopidogrel) were compared to a control group without antiplatelet therapy. Occurrence of DCI, major/minor bleeding events in the follow-up computed tomography scans, and favorable outcome at 6 mo after SAH (modified Rankin scale < 3) were compared in both groups. RESULTS Of 580 patients in the final analysis, 329 patients received post-treatment antiplatelet medication. There were no significant differences between the compared groups with regard to basic outcome confounders. Aspirin use was independently associated with reduced DCI risk (P < .001, adjusted odds ratio = 0.41, 95% confidence interval 0.24-0.65) and favorable outcome (P = .02, adjusted odds ratio = 1.78, 95% confidence interval 1.06-2.98). Regarding bleeding complications, aspirin was associated only with minor bleeding events (P = .02 vs P = .51 for major bleeding events). CONCLUSION Regular administration of aspirin might have a positive impact on DCI risk and outcome of SAH patients, without increasing the risk for clinically relevant bleeding events. In our SAH cohort, dual antiplatelet therapy showed no additional benefit on DCI risk, but increased the likelihood of major bleeding events.

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Long-term Neuropsychiatric and Neuropsychological Sequelae of Endovascularly Treated Aneurysmal Subarachnoid Hemorrhage

Acta Médica Portuguesa ◽

10.20344/amp.10894 ◽

2019 ◽

Vol 32 (11) ◽

pp. 706

Author(s):

Lídia Sousa ◽

Ana Antunes ◽

Tiago Mendes ◽

Sofia Reimão ◽

Lia Lucas Neto ◽

...

Keyword(s):

Quality Of Life ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Neuropsychiatric Symptoms ◽

Health Related Quality ◽

Related Quality ◽

Health Related

Introduction: There is limited evidence regarding long-term outcomes of aneurysmal subarachnoid hemorrhage survivors. Most follow-up programs are relatively short and focused on physical functions. Endovascular aneurysmal embolization enables recovery of normal vascular architecture. However, there is growing evidence that neuropsychological and behavior sequelae can significantly impact the lives of these patients, even when treatment is successful. In this study, we reviewed cognition, psychiatric and neuropsychological symptoms, global functionality, and health-related quality of life 10 to 12 years after an aneurysmal subarachnoid hemorrhage.Material and Methods: A cross-sectional observational study was carried out in a university hospital. All cases of aneurysmal subarachnoid hemorrhage admitted between January 2004 and December 2006 and endovascularly treated were reviewed. Participants underwent a neuropsychological evaluation and a clinical interview with a psychiatrist.Results: Fourteen patients participated in the study. Almost 70% (n = 10) showed cognitive impairment; in more than 40% (n = 6) of the subjects, significant symptoms of anxiety were identified, and 35% (n = 5) were classified as having clinical depression. Relevant posttraumatic symptoms were reported by more than 70% (n = 10) of patients, and almost 30% (n = 4) showed other moderate neuropsychiatric symptoms. Overall, health-related quality of life was impaired, and personality changes were frequently reported by the participants and their relatives.Discussion: A significant prevalence of ongoing deficits in high-level functioning and reduced health-related quality of life were observed in a sample of young and professionally active individuals that were successfully treated and discharged from follow-up consultations.Conclusion: There is a need for better follow-up strategies, targeting more subtle deficits and psychological symptoms after aneurysmal subarachnoid hemorrhage.

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THE STOCKHOLM 20-YEAR FOLLOW-UP OF ANEURYSMAL SUBARACHNOID HEMORRHAGE OUTCOME

Neurosurgery ◽

10.1227/01.neu.0000255458.07140.e6 ◽

2007 ◽

Vol 60 (6) ◽

pp. 1017-1024 ◽

Cited By ~ 22

Author(s):

Göran Edner ◽

Håkan Almqvist

Keyword(s):

Subarachnoid Hemorrhage ◽

De Novo ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Hospital Records ◽

Long Term Outcome ◽

Aneurysm Formation ◽

Long Term Follow Up ◽

De Novo Aneurysm

Abstract OBJECTIVE To assess the clinical and radiological long-term outcome after aneurysmal subarachnoid hemorrhage (SAH) in a defined referral area regarding recurrent SAH and de novo aneurysm formation. METHODS One hundred and two 1-year survivors after aneurysmal SAH, who were treated at the Neurosurgical Clinic, South Hospital, Stockholm, Sweden, between 1983 and 1985, were followed for 20 years. Forty-nine surviving patients were reevaluated. Hospital records and death certificates were scrutinized for all 53 nonsurviving patients. Clinical history penetration, Mini Mental Status, Rankin Disability Score, and Barthel Index were used to evaluate the outcome. Computed tomographic angiography was used to investigate the cerebral arteries. RESULTS One hundred and two patients were traced. Fifty-three patients were deceased. One patient had a hospital record of sustaining an aneurysmal SAH from a known but not clipped aneurysm. Three patients had nonaneurysmal intracerebral hemorrhage and two sustained traumatic SAH. There were 49 surviving patients. Six refused follow-up. None of these patients had hospital records of intracranial disease. Three of the 43 remaining patients could not be tested. None of the survivors had experienced a new SAH. Aneurysm base remnants were observed in 1% (eight patients, 790 person-years of follow-up) and de novo aneurysms were observed in 0.9% (seven patients, 790 person-years of follow-up). CONCLUSION From this epidemiological survey of patients with aneurysmal SAH, it was found that none of the patients experienced a recurrent subarachnoid bleed from the treated aneurysm during a 20-year follow-up period. Thus, a routine extreme long-term follow-up period is not necessary. De novo aneurysm formation and possible enlargements of aneurysm base remnants were observed in almost 2% of patients per person year and should, therefore, be subject of a routine, long-term follow-up.

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Short and long-term outcomes of medical management of patients with a first episode of arrhythmic storm

European Heart Journal ◽

10.1093/ehjci/ehaa946.0357 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

C.M Gonzalez De La Portilla-Concha ◽

J Acosta Martinez ◽

J.L Dominguez Cano ◽

M.R Caballero Valderrama ◽

A Abril Molina ◽

...

Keyword(s):

Catheter Ablation ◽

Confidence Interval ◽

Medical Management ◽

High Rate ◽

First Episode ◽

Long Term Outcomes ◽

All Cause Mortality ◽

Short And Long Term

Abstract Introduction There is few data about long-term outcomes of conservative management (without catheter ablation) of patients with a first episode of arrhythmic storm (AS) in the current context. This study analyzes the short and long-term outcomes of implantable cardioverter defibrillator (ICD) patients with a first episode of AS receiving non-interventional management. Methods Consecutive patients admitted with a first episode of AS between January 2008 and June 2019 receiving medical management without catheter ablation were included. AS was defined as 3 or more appropriate ICD therapies occurring during a 24 h span. Medical management included: correction of triggers, sedation/mechanical ventilation, antiarrhythmic drugs, ICD reprogramming and neuraxial modulation. Baseline clinical characteristics and follow-up data were recorded. All patients were followed every 6 months at the ICD office. The primary end-point was all-cause mortality. Results 60 patients (81% male, 62.8±16.2 years, 43% ischaemic, LVEF 35.4±14%) with a first episode of AS treated conservatively were included. Thirty-day survival was 96.5% and 1-year survival was 82%. During a median (interquartilic range) follow-up of 31 (6–69) months, 31 (51.7%) patients died (51.6% due to cardiovascular aetiology) and 35 (58.3%) patients were readmitted (48.5% due to recurrent arrhythmic events and 45.7% due to heart failure). Age [HR 1.05 (95% confidence interval: 1.01–1.08)] and end-diastolic diameter [HR 1.05 (95% confidence interval: 1–2)] were the strongest independent predictors of all-cause mortality. Conclusion Despite the severity of this entity, medical management (without catheter ablation) of a first episode of AS is reasonable given its good 30-day and 1-year survival. However, a high rate of AS recurrence and readmissions are observed during long-term follow-up. Efforts are needed in order to identify those patients with a first episode of AS that could benefit from an early catheter ablation strategy. Funding Acknowledgement Type of funding source: None

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Early permanent cerebrospinal fluid diversion lowers the rate of nosocomial meningitis in aneurysmal subarachnoid hemorrhage

10.21203/rs.2.21401/v1 ◽

2020 ◽

Author(s):

Davide Marco Croci ◽

Martina Dalolio ◽

Soheila Aghlmandi ◽

Ethan Taub ◽

Daniel Zumofen ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Blood Clot ◽

Delayed Cerebral Ischemia ◽

Infectious Complications ◽

Detectable Effect ◽

Catheter Colonization ◽

Delayed Cerebral Vasospasm ◽

Csf Diversion

Abstract Background: Early permanent cerebrospinal fluid (CSF) diversion for hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) might shorten the duration of external ventricular drainage (EVD) and thereby reduce infectious complications. The potential effect on the rate of delayed cerebral vasospasm (DCVS) and associated morbidity has not been studied to date. The objective of this study was to detect any association with EVD-associated infections (EVDAI), symptomatic DCVS, or delayed cerebral ischemia (DCI) by the time of hospital discharge. Methods: A single-center dataset of aSAH patients who received a permanent CSF diversion procedure between 2009 and 2018 was used for the evaluation. The subjects were divided into an “early group” if such a procedure was performed up to 14 days after the ictus, and a “late group” if it was performed from the 15 th day onward. The statistical analysis employed univariable and multivariable logistic regression models. Results: Among 274 consecutive aSAH patients, 39 (14.2 %) had a permanent CSF diversion procedure. While the blood clot burden was similarly distributed, patients with early permanent CSF diversion (20 out of 39, 51.2%) had higher levels of consciousness on admission. Early permanent CSF diversion was associated with a shorter duration of EVD (OR 0.73, 95%CI 0.58-0.92 per day). Higher catheter colonization to EVDAI ratio (1/7 out of 20 vs. 7/7 out of 19) and a markedly lower frequency of EVDAI (OR 0.08, 95 %CI 0.01-0.80) were detected. The prevalence (5 vs. 37) and the cumulative incidence (3 vs. 18) of EVDAI were remarkably lower in patients receiving early permanent CSF diversion. The occurrence of CSF-diversion device obstruction, the rate of symptomatic DCVS (OR 0.61, 95 %CI 0.16-2.27) or detected DCI on computed tomography (OR 0.35, 95 %CI 0.08-1.47), and the likelihood of a poor outcome at discharge did not differ between the two groups (OR 0.88, 95%CI 0.24-3.22). Conclusions: Early permanent CSF diversion in good grade aSAH patients is associated with a shorter duration of EVD, lower catheter colonization rates, and fewer infectious complications. The timing of permanent CSF diversion had no detectable effect on DCVS-related morbidity. These findings need to be confirmed in larger cohorts.

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Abstract TP456: Coated-platelets Levels After Subarachnoid Hemorrhage Predict Post-discharge Short-term Cognitive Outcome

Stroke ◽

10.1161/str.47.suppl_1.tp456 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Bappaditya Ray ◽

Vijay M Pandav ◽

Eleanor A Mathews ◽

David M Thompson ◽

Aminata A Traore ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Acute Phase ◽

Delayed Cerebral Ischemia ◽

Cognitive Outcome ◽

Short Term ◽

Post Discharge ◽

Acute Hospitalization ◽

Symptomatic Vasospasm

Introduction: Delayed cerebral ischemia (DCI) is a determinant of short-term and long-term morbidity after subarachnoid hemorrhage (SAH). DCI is likely due to neurohumoral activation and inflammation-thrombosis cross-talk during the acute phase. Coated-platelets (CP), a subset of procoagulant platelets, contribute to systemic thrombogenicity and are associated with recurrent ischemic stroke. Hypothesis: We hypothesized that high CP levels during first 3 weeks of SAH (acute hospitalization) would be associated with worse short-term clinical outcome. Methods: A prospective cohort of 28 patients with post-discharge clinical follow-up (average 12 weeks) was studied. Outcomes were assessed using modified Rankin Scale (mRS) and Montreal Cognitive Outcome Assessment (MOCA). Blood samples to measure CP levels were performed - 1) during acute hospitalization and 2) at follow-up visit (defined as patient’s baseline). Trend of CP during acute hospitalization was analyzed against weighted mean baseline CP level to test hypothesis. Results: Average age of cohort was 52.6±12.2 years with 71.5% women. During acute phase 9 (32.1%) patients developed symptomatic vasospasm and 14 (50%) had DCI on imaging. Baseline CP levels did not differ (p=0.118) between patients with MOCA ≥26 (41.3%, n=13) and MOCA <26 (29.5%, n=15). However, patients with MOCA <26 had significantly higher CP levels during first 5 days than baseline (50.4% vs 29.5%, p=0.0004). These levels decreased by 1.77%/day from 6-21 days as compared to 1.55%/day for patients with MOCA ≥26 (p=0.723). In contrast, 20 (71.4%) patients with mRS 0-2 had average baseline CP levels of 37.3% vs 8 (28.6%) with mRS 3-6 having CP levels of 31.7%. For patients with mRS 0-2 and mRS 3-6, CP levels increased from baseline during first 5 days after SAH by 10.3% and 16.5% respectively (not statistically significant). Rate of CP decrease during 6-21 days was 1.43%/day and 2.02%/day (p=0.259) for mRS 0-2 and mRS 3-6 respectively. Conclusion: Elevated CP levels during the acute phase of SAH are strongly associated with lower MOCA scores at 12 weeks but not with higher mRS assessment. These results suggest that increased thrombogenicity after SAH leads to cognitive impairment despite good physical outcomes.

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