scholarly journals Increased blood pressure variability predicts poor outcomes from endovascular treatment for aneurysmal subarachnoid hemorrhage

2021 ◽  
Vol 79 (9) ◽  
pp. 759-765
Author(s):  
Xin-Bo Ge ◽  
Qun-Fu Yang ◽  
Zhen-Bo Liu ◽  
Tao Zhang ◽  
Chao Liang
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Endovascular Treatment ◽  
Blood Pressure Variability ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Significant Risk ◽  
Endovascular Embolization ◽  
Fisher Grade ◽  
Grade 3 ◽  
Poor Outcomes

ABSTRACT Background: Predictors of outcomes following endovascular treatment (ET) for aneurysmal subarachnoid hemorrhage (aSAH) are not well-defined. Identifying them would be beneficial in determining which patients might benefit from ET. Objective: To identify the predictive factors for poor outcomes following ET for aSAH. Methods: 120 patients with ruptured cerebral aneurysms underwent endovascular embolization between January 2017 and December 2018. Blood pressure variability was examined using the standard deviation of the 24-hour systolic blood pressure (24hSSD) and 24-hour diastolic blood pressure (24hDSD). Predictors were identified through univariate and multivariate regression analysis. All patients were followed up for three months. Results: At follow-up, 86 patients (71.7%) had good outcomes and 34 (28.3%) had poor outcomes. Patients with poor outcomes had significantly higher 24hSSD than those with good outcomes (19.3 ± 5.5 vs 14.1 ± 4.8 mmHg; P < 0.001). The 24hDSD did not differ significantly between patients with good outcomes and those with poor outcomes (9.5 ± 2.3 vs 9.9 ± 3.5 mmHg; P = 0.464). The following were significant risk factors for poor outcomes after endovascular embolization: age ≥ 65 years (odds ratio [OR] = 23.0; 95% confidence interval [CI]: 3.0-175.9; P = 0.002); Hunt-Hess grade 3-4 (OR = 6.8; 95% CI: 1.1-33.7; P = 0.039); Fisher grade 3-4 (OR = 47.1; 95% CI: 3.8-586.5; P = 0.003); postoperative complications (OR = 6.1; 95% CI: 1.1-34.8; P = 0.042); and 24hSSD ≥ 15 mmHg (OR = 14.9; 95% CI: 4.0-55.2; P < 0.001). Conclusion: Elevated 24hSSD is a possibly treatable predictive factor for poor outcomes after ET for aSAH.

scholarly journals Evaluation Of Intra-Arterial Nimodipine Therapy In Post-Subarachnoid Hemorrhage Refractory Cerebral Vasospasm

2021 ◽  
Author(s):  
Shrey Jain ◽  
Ajit Kumar Sinha ◽  
Sumit Goyal
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Neurological Assessment ◽  
Minimum Risk ◽  
Operative Morbidity ◽  
Fisher Grade ◽  
Grade 3 ◽  
Triple H

Abstract Background: Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage. Vasospasm is managed with triple H and vasodilators but sometimes, patients do not respond. Intra-arterial vasodilator infusion has been shown to improve outcome in such patients. In this study, we try to evaluate the efficacy of intra-arterial nimodipine therapy in 43 patients of post-aneurysmal subarachnoid hemorrhage refractory cerebral vasospasm. Methods: It is a prospective observational study of a group of 43 patients presenting with refractory cerebral vasospasm as per the inclusion criteria. Pre-procedure neurological assessment and Transcranial Doppler (TCD) monitoring were done. Endovascular spasmolysis was conducted and post-operative morbidity and outcomes were noted. Follow up of the patients was done at the time of discharge and at 6 months according to the Modified Rankin Scale and NCCT head. Results: Most of the patients developing refractory cerebral vasospasm belonged to Hunt and Hess Grade 2 and 3 and Fisher grade 3 and 4. 87.5% of the patients showed clinical recovery following endovascular spasmolysis and 58% of the patients showed complete angiographic recovery. Outcome after 6 months was good in 76%, moderate in 12% and poor in 12% patients. NCCT head showed no infarct in 58%, minor infarct in 28% and major vascular territorial infarct in 14% patients. Conclusions: Intra-arterial nimodipine infusion is a safe and effective therapy with minimum risk of complications if adhered to standard endovascular practice. By timely intervention, major ischemic insult to the brain can be averted, thereby significantly improving the prognosis.

scholarly journals Effect of choice of treatment modality on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

2019 ◽  
Vol 130 (3) ◽  
pp. 949-955 ◽  
Author(s):  
Masaomi Koyanagi ◽  
Hitoshi Fukuda ◽  
Masaaki Saiki ◽  
Yoshihito Tsuji ◽  
Benjamin Lo ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Propensity Score ◽  
Endovascular Treatment ◽  
Treatment Modality ◽  
Propensity Score Analysis ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Endovascular Coiling ◽  
Surgical Clipping ◽  
Propensity Score Model ◽  
Poor Outcomes

OBJECTIVEShunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH.METHODSThe authors’ multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH.RESULTSA total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score–matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2–4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3–6) at discharge (OR 4.3, 95% CI 2.6–7.3; p < 0.001).CONCLUSIONSSDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.

scholarly journals Safety and efficacy of transluminal balloon angioplasty in the prevention of vasospasm in patients with Fisher Grade 3 subarachnoid hemorrhage: a pilot study

1998 ◽  
Vol 5 (4) ◽  
pp. E7 ◽  
Author(s):  
J. Paul Muizelaar ◽  
Marike Zwienenberg ◽  
Nancy A. Mini ◽  
Stephen T. Hecht
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Pilot Study ◽  
Balloon Angioplasty ◽  
Time Window ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Randomized Study ◽  
Pilot Trial ◽  
Safety And Efficacy ◽  
Fisher Grade ◽  
Grade 3

Recent advances in neuroradiology have made it possible to dilate human cerebral arteries that show vasospasm following aneurysmal subarachnoid hemorrhage (SAH), but the time window is short and the success rate for reversal of delayed ischemic neurological deficit (DIND) varies between 31% and 77%. In a canine model of vasospasm, transluminal balloon angioplasty (TBA) performed on Day 0 (the day of aneurysm rupture) has been shown to completely prevent the development of angiographically demonstrated narrowing by Day 7; this effect is better than any pharmacological treatment for vasospasm thus far described. The authors conducted a pilot trial to assess the safety and efficacy of TBA performed within 3 days post-SAH. Twelve patients with a very high probability of developing vasospasm (Fisher Grade 3) were included. Target vessels for prophylactic TBA were the internal carotid artery, A1 segment, M1 segment, and P1 segment bilaterally, the basilar artery, and the vertebral artery. No patient developed DIND or more than mild vasospasm, according to transcranial Doppler criteria. At 3 months, seven patients made a good recovery, two patients were moderately disabled, and three patients died; one patient died because of a vessel rupture during TBA and two older patients died of medical complications associated with an already poor clinical condition at admission. Compared with the results of large series reported in literature of patients with aneurysmal SAH, the results of this pilot study indicate an extremely low incidence of vasospasm and DIND after patients underwent prophylactic TBA. A larger, randomized study, however, is required to determine whether prophylactic TBA is efficacious enough to justify the risks.

Leukocytosis as an independent risk factor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage

2003 ◽  
Vol 98 (6) ◽  
pp. 1222-1226 ◽  
Author(s):  
Matthew J. McGirt ◽  
John C. Mavropoulos ◽  
Laura Y. McGirt ◽  
Michael J. Alexander ◽  
Allan H. Friedman ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Leukocyte Count ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Content Type ◽  
Symptomatic Vasospasm ◽  
Fisher Grade ◽  
Increased Risk ◽  
Grade 3 ◽  
Fine Print

Object. The identification of patients at an increased risk for cerebral vasospasm after subarachnoid hemorrhage (SAH) may allow for more aggressive treatment and improved patient outcomes. Note, however, that blood clot size on admission remains the only factor consistently demonstrated to increase the risk of cerebral vasospasm after SAH. The goal of this study was to assess whether clinical, radiographic, or serological variables could be used to identify patients at an increased risk for cerebral vasospasm. Methods. A retrospective review was conducted in all patients with aneurysmal or spontaneous nonaneurysmal SAH who were admitted to the authors' institution between 1995 and 2001. Underlying vascular diseases (hypertension or chronic diabetes mellitus), Hunt and Hess and Fisher grades, patient age, aneurysm location, craniotomy compared with endovascular aneurysm stabilization, medications on admission, postoperative steroid agent use, and the occurrence of fever, hydrocephalus, or leukocytosis were assessed as predictors of vasospasm. Two hundred twenty-four patients were treated for SAH during the review period. One hundred one patients (45%) developed symptomatic vasospasm. Peak vasospasm occurred 5.8 ± 3 days after SAH. There were four independent predictors of vasospasm: Fisher Grade 3 SAH (odds ratio [OR] 7.5, 95% confidence interval [CI] 3.5–15.8), peak serum leukocyte count (OR 1.09, 95% CI 1.02–1.16), rupture of a posterior cerebral artery (PCA) aneurysm (OR 0.05, 95% CI 0.01–0.41), and spontaneous nonaneurysmal SAH (OR 0.14, 95% CI 0.04–0.45). A serum leukocyte count greater than 15 × 109/L was independently associated with a 3.3-fold increase in the likelihood of developing vasospasm (OR 3.33, 95% CI 1.74–6.38). Conclusions. During this 7-year period, spontaneous nonaneurysmal SAH and ruptured PCA aneurysms decreased the odds of developing vasospasm sevenfold and 20-fold, respectively. The presence of Fisher Grade 3 SAH on admission or a peak leukocyte count greater than 15 × 109/L increased the odds of vasospasm sevenfold and threefold, respectively. Monitoring of the serum leukocyte count may allow for early diagnosis and treatment of vasospasm.

Effect of Clipping, Craniotomy, or Intravascular Coiling on Cerebral Vasospasm and Patient Outcome after Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2004 ◽  
Vol 55 (4) ◽  
pp. 779-789 ◽  
Author(s):  
Brian L. Hoh ◽  
Mehmet A. Topcuoglu ◽  
Aneesh B. Singhal ◽  
Johnny C. Pryor ◽  
James D. Rabinov ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Hospital Mortality ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Poor Grade ◽  
Poor Outcome ◽  
Symptomatic Vasospasm ◽  
Fisher Grade ◽  
Significant Difference ◽  
Good Grade ◽  
Grade 3

Abstract OBJECTIVE: Although several recent studies have suggested that the incidence of vasospasm after aneurysmal subarachnoid hemorrhage is lower in patients undergoing aneurysmal coiling as compared with clipping, other studies have had conflicting results. We reviewed our experience over 8 years and assessed whether clipping, craniotomy, or coiling affects patient outcomes or the risk for vasospasm. METHODS: We included 515 patients with aneurysmal subarachnoid hemorrhage, identified prospectively from November 2000 to February 2003 (243 patients) and retrospectively from November 1995 to October 2000 (272 patients), by using International Classification of Diseases, 9th Revision, codes for subarachnoid hemorrhage. We classified patients as follows: clipping (413 patients), coiling (79 patients), and craniotomy (436 patients, including all 413 patients who underwent clipping plus 23 who underwent coiling as well as craniotomy for various reasons). We studied four outcome measures: total vasospasm, symptomatic vasospasm, poor outcome (modified Rankin score 3–6), and in-hospital mortality. To assess the risk of total vasospasm and symptomatic vasospasm, we performed multivariate regression analyses adjusting for age, Fisher grade, Hunt and Hess grade, aneurysm location (anterior versus posterior circulation), and aneurysm treatment modality. To assess the risk for poor outcome and in-hospital mortality, we adjusted for all the above variables as well as for total and symptomatic vasospasm. RESULTS: In the clipping group there was 63% total vasospasm and 28% symptomatic vasospasm; in the coiling group there was 54% total vasospasm and 33% symptomatic vasospasm; and in the craniotomy group there was 64% total vasospasm and 28% symptomatic vasospasm. In the multivariate analysis, age &lt;50 years (P = 0.0099) and Fisher Grade 3 (P &lt; 0.00001) predicted total vasospasm, and Fisher Grade 3 (P &lt; 0.000001) and Hunt and Hess Grade IV or V (P = 0.018) predicted symptomatic vasospasm. Predictors of poor outcome were age ≥50 years (P &lt; 0.0001), Fisher Grade 3 (P = 0.0072), Hunt and Hess Grade IV or V (P &lt; 0.00001), symptomatic vasospasm (P &lt; 0.0001), and coiling (P = 0.0314 versus clipping and P = 0.045 versus craniotomy). Predictors of in-hospital mortality were age ≥ 50 years (P = 0.0030), Hunt and Hess Grade IV or V (P = 0.0001), symptomatic vasospasm (P &lt; 0.00001), and coiling (P = 0.008 versus clipping and P = 0.0013 versus craniotomy). There was no significant difference in total vasospasm or symptomatic vasospasm when patients who underwent clipping or craniotomy were compared with patients who underwent coiling. In patients with Hunt and Hess Grade I to III (“good grade”), clipping and craniotomy were associated with better outcome and less in-hospital mortality, but there was no difference in total vasospasm or symptomatic vasospasm versus coiling. In patients with Hunt and Hess Grade IV or V (“poor grade”), there was no difference in any outcome measure among the treatment groups. CONCLUSION: In a single-center, retrospective, nonrandomized study, performance of clipping and/or craniotomy had significantly better outcome and lower mortality at discharge than coiling in good-grade patients but had no effect on total vasospasm or symptomatic vasospasm in good- or poor-grade patients.

scholarly journals Preventive effects of cilostazol against the development of shunt-dependent hydrocephalus after subarachnoid hemorrhage

2017 ◽  
Vol 127 (2) ◽  
pp. 319-326 ◽  
Author(s):  
Yoshinari Nakatsuka ◽  
Fumihiro Kawakita ◽  
Ryuta Yasuda ◽  
Yasuyuki Umeda ◽  
Naoki Toma ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Multivariate Analyses ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Matricellular Protein ◽  
Chronic Hydrocephalus ◽  
Multivariate Logistic Regression ◽  
Fisher Grade ◽  
Grade 3 ◽  
Phosphodiesterase Type ◽  
Preventive Effects

OBJECTIVEChronic hydrocephalus develops in association with the induction of tenascin-C (TNC), a matricellular protein, after aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to examine if cilostazol, a selective inhibitor of phosphodiesterase Type III, suppresses the development of chronic hydrocephalus by inhibiting TNC induction in aneurysmal SAH patients.METHODSThe authors retrospectively reviewed the factors influencing the development of chronic shunt-dependent hydrocephalus in 87 patients with Fisher Grade 3 SAH using multivariate logistic regression analyses. Cilostazol (50 or 100 mg administered 2 or 3 times per day) was administered from the day following aneurysmal obliteration according to the preference of the attending neurosurgeon. As a separate study, the effects of different dosages of cilostazol on the serum TNC levels were chronologically examined from Days 1 to 12 in 38 SAH patients with Fisher Grade 3 SAH.RESULTSChronic hydrocephalus occurred in 12 of 36 (33.3%), 5 of 39 (12.8%), and 1 of 12 (8.3%) patients in the 0 mg/day, 100 to 200 mg/day, and 300 mg/day cilostazol groups, respectively. The multivariate analyses showed that older age (OR 1.10, 95% CI 1.13–1.24; p = 0.012), acute hydrocephalus (OR 23.28, 95% CI 1.75–729.83; p = 0.016), and cilostazol (OR 0.23, 95% CI 0.05–0.93; p = 0.038) independently affected the development of chronic hydrocephalus. Higher dosages of cilostazol more effectively suppressed the serum TNC levels through Days 1 to 12 post-SAH.CONCLUSIONSCilostazol may prevent the development of chronic hydrocephalus and reduce shunt surgery, possibly by the inhibition of TNC induction after SAH.

Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms

2017 ◽  
Vol 14 (3) ◽  
pp. 231-235 ◽  
Author(s):  
Roland Roelz ◽  
Christian Scheiwe ◽  
Horst Urbach ◽  
Volker A Coenen ◽  
Peter Reinacher
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Blood Clearance ◽  
Fisher Grade ◽  
Rapid Clearance ◽  
Promising Treatment ◽  
Grade 3 ◽  
Subarachnoid Blood ◽  
The Brain

Abstract BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.

Magnesium Sulfate in the Management of Patients with Fisher Grade 3 Subarachnoid Hemorrhage: A Pilot Study

Neurosurgery ◽  
2000 ◽  
Vol 47 (3) ◽  
pp. 602-607 ◽  
Author(s):  
Ronald Boet ◽  
Edward Mee
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Serum Level ◽  
Magnesium Sulfate ◽  
Glasgow Outcome Scale ◽  
Clinical Evidence ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Constant Infusion ◽  
Baseline Serum ◽  
Fisher Grade ◽  
Grade 3

ABSTRACT OBJECTIVE To evaluate the effect of magnesium sulfate (MgSO4) on the clinical course of patients with severe aneurysmal subarachnoid hemorrhage (SAH). METHODS Ten patients with Fisher Grade 3 aneurysmal SAH were evaluated. The patients were given a bolus as well as a constant infusion of intravenous MgSO4 up to 10 days postictus. Blood magnesium levels were obtained to adjust the daily requirement of MgSO4. The goal was to raise the serum level to 2.0 to 2.5 mmol/L or twice the baseline serum level. Daily transcranial Doppler (TCD) ultrasonography was performed on each patient, insonating both anterior cerebral and middle cerebral arteries. Further management followed standard protocols, including the use of nimodipine and hypervolemic therapy. TCD ultrasonographic findings, as well as clinical evidence of cerebral vasospasm, were documented. All patients had a 3-month assessment using the Glasgow Outcome Scale. RESULTS After administration of a 20 mmol MgSO4 bolus infusion and an average daily continuous infusion of 84.7 mmol, 8 of 10 patients achieved the predetermined serum magnesium levels. No adverse affects were noted during the infusions. Five patients exhibited evidence of vasospasm on TCD ultrasonography; vasospasm was severe in two patients (velocities, &gt;200 cm/s). Three patients, including the two patients in whom TCD ultrasonography demonstrated severe vasospasm, exhibited clinical evidence of vasospasm. Two patients had a Glasgow Outcome Scale score of 3; the remainder had Glasgow Outcome Scale scores of 5. CONCLUSION Administration guidelines for the use of MgSO4 in aneurysmal SAH were established. A prospective double-blind placebo-controlled trial is required to establish the effectiveness of MgSO4 for treating vasospasm in aneurysmal SAH.

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

1997 ◽  
Vol 87 (3) ◽  
pp. 381-384 ◽  
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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