Perivascular Coating with Fibrin Glue of Cerebral Arteries in Patients with Aneurysmal Subarachnoid Hemorrhage; Incidence of Chronic Hydrocephalus.

Abstract OBJECTIVE Multislice computed tomographic angiography (CTA) can provide clearer vascular images, even of the peripheral arteries, than conventional CTA. Multislice CTA was compared with digital subtraction angiography (DSA) for the detection of cerebral vasospasm in patients with acute aneurysmal subarachnoid hemorrhage (SAH) to analyze whether multislice CTA can replace DSA in the detection of vasospasm after SAH. METHODS Within 72 hours after the onset of symptoms, multislice CTA and DSA were performed in 20 patients with SAH. Multislice CTA and DSA were repeated on Day 7 to assess cerebral vasospasm. Regions of interest were established in the proximal and distal segments of the anterior and middle cerebral arteries on both multislice CTA and DSA images, and the agreement between the severity of vasospasm on multislice CTA and DSA images was statistically compared. The multislice Aquilon computed tomography system (Toshiba, Inc., Tokyo, Japan) used the following parameters: 1 mm collimation and 3.5 mm per rotation table increment (pitch, 3.5). RESULTS The degree of vasospasm as revealed by multislice CTA correlated significantly with the degree of vasospasm revealed by DSA (P < 0.0001). The agreement between the severity of vasospasm on multislice images obtained via CTA and DSA in the overall, proximal, and distal segments of the cerebral arteries was 91.6, 90.8, and 92.3%, respectively. CONCLUSION Multislice CTA can detect angiographic vasospasm after SAH with accuracy equal to that of DSA.

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Detection of Microemboli by Transcranial Doppler Ultrasonography in Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1097/00006123-200205000-00016 ◽

2002 ◽

Vol 50 (5) ◽

pp. 1026-1031 ◽

Cited By ~ 8

Author(s):

Jose G. Romano ◽

Alejandro M. Forteza ◽

Mauricio Concha ◽

Sebastian Koch ◽

Roberto C. Heros ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Transcranial Doppler ◽

Doppler Ultrasonography ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Statistical Significance ◽

Cerebral Arteries ◽

Transcranial Doppler Ultrasonography ◽

Control Subjects

Abstract OBJECTIVE: To determine the frequency and characteristics of microembolic signals (MES) in subarachnoid hemorrhage (SAH). METHODS: Twenty-three patients with aneurysmal SAH were monitored with transcranial Doppler ultrasonography for the presence of MES and vasospasm. Each middle cerebral artery was monitored for 30 minutes three times each week. Patients were excluded if they had traumatic SAH or cardiac or arterial sources of emboli. Monitoring was initiated 6.3 days (1–16 d) after SAH and lasted 6.6 days (1–13 d). Eleven individuals without SAH or other cerebrovascular diseases who were treated in the same unit served as control subjects. Each patient underwent monitoring of both middle cerebral arteries a mean of three times; therefore, 46 vessels were studied (a total of 138 observations). Control subjects underwent assessment of each middle cerebral artery once, for a total of 22 control vessels. RESULTS: MES were detected for 16 of 23 patients (70%) and 44 of 138 patient vessels (32%) monitored, compared with 2 of 11 control subjects (18%) and 2 of 22 control vessels (9%) (P < 0.05). MES were observed for 83% of patients with clinical vasospasm and 54% of those without clinical vasospasm. Ultrasonographic vasospasm was observed for 71 of 138 vessels monitored; MES were observed for 28% of vessels with vasospasm and 36% of those without vasospasm. Aneurysms proximal to the monitored artery were identified in 38 of 138 vessels, of which 34% exhibited MES, which is similar to the frequency for vessels without proximal aneurysms (31%). Coiled, clipped, and unsecured aneurysms exhibited similar frequencies of MES. CONCLUSION: MES were common in SAH, occurring in 70% of cases of SAH and one-third of all vessels monitored. Although MES were more frequent among patients with clinical vasospasm, this difference did not reach statistical significance. We were unable to demonstrate a relationship between ultrasonographic vasospasm and MES, and the presence of a proximal secured or unsecured aneurysm did not alter the chance of detection of MES. Further studies are required to determine the origin and clinical relevance of MES in SAH.

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A novel score to predict shunt dependency after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2016.12.jns162400 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1273-1279 ◽

Cited By ~ 11

Author(s):

Dominik Diesing ◽

Stefan Wolf ◽

Jenny Sommerfeld ◽

Asita Sarrafzadeh ◽

Peter Vajkoczy ◽

...

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Subarachnoid Hemorrhage ◽

Scoring System ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Receiver Operating Curve ◽

Chronic Hydrocephalus ◽

Predictive Values ◽

Shunt Dependency ◽

Independent Risk Factors

OBJECTIVEFeasible clinical scores for predicting shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) are scarce. The chronic hydrocephalus ensuing from SAH score (CHESS) was introduced in 2015 and has a high predictive value for SDHC. Although this score is easy to calculate, several early clinical and radiological factors are required. The authors designed the retrospective analysis described here for external CHESS validation and determination of predictive values for the radiographic Barrow Neurological Institute (BNI) scoring system and a new simplified combined scoring system.METHODSConsecutive data of 314 patients with aSAH were retrospectively analyzed with respect to CHESS parameters and BNI score. A new score, the shunt dependency in aSAH (SDASH) score, was calculated from independent risk factors identified with multivariate analysis.RESULTSTwo hundred twenty-five patients survived the initial phase after the hemorrhage, and 27.1% of these patients developed SDHC. The SDASH score was developed from results of multivariate analysis, which revealed acute hydrocephalus (aHP), a BNI score of ≥ 3, and a Hunt and Hess (HH) grade of ≥ 4 to be independent risk factors for SDHC (ORs 5.709 [aHP], 6.804 [BNI], and 4.122 [HH]; p < 0.001). All 3 SDHC scores tested (CHESS, BNI, and SDASH) reliably predicted chronic hydrocephalus (ORs 1.533 [CHESS], 2.021 [BNI], and 2.496 [SDASH]; p ≤ 0.001). Areas under the receiver operating curve (AUROC) for CHESS and SDASH were comparable (0.769 vs 0.785, respectively; p = 0.447), but the CHESS and SDASH scores were superior to the BNI grading system for predicting SDHC (BNI AUROC 0.649; p = 0.014 and 0.001, respectively). In contrast to CHESS and BNI scores, an increase in the SDASH score coincided with a monotonous increase in the risk of developing SDHC.CONCLUSIONSThe newly developed SDASH score is a reliable tool for predicting SDHC. It contains fewer factors and is more intuitive than existing scores that were shown to predict SDHC. A prospective score evaluation is needed.

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THE IMPACT OF MICROSURGICAL FENESTRATION OF THE LAMINA TERMINALIS ON SHUNT-DEPENDENT HYDROCEPHALUS AND VASOSPASM AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000311069.48862.c8 ◽

2008 ◽

Vol 62 (1) ◽

pp. 123-134 ◽

Cited By ~ 25

Author(s):

Ricardo J. Komotar ◽

David K. Hahn ◽

Grace H. Kim ◽

Joyce Khandji ◽

J Mocco ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Conversion Rate ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Lamina Terminalis ◽

Chronic Hydrocephalus ◽

Microsurgical Fenestration ◽

Postsurgical Outcomes ◽

Rate Conversion ◽

The Impact

Abstract OBJECTIVE Chronic hydrocephalus requiring shunt placement and cerebral vasospasm are common complications after aneurysmal subarachnoid hemorrhage. Recent publications have investigated the possibility that microsurgical fenestration of the lamina terminalis during aneurysm surgery may reduce the incidence of shunt-dependent hydrocephalus and cerebral vasospasm. We reviewed a single-surgeon series to compare postsurgical outcomes of patients who underwent fenestration of the lamina terminalis against those who did not. METHODS This study is a retrospective review of the medical records of 369 consecutive patients with aneurysmal subarachnoid hemorrhage admitted to Columbia University Medical Center between January 2000 and July 2006. All patients underwent craniotomy and clipping of at least one ruptured cerebral aneurysm by a single neurosurgeon (ESC). The incidences of shunt-dependent hydrocephalus, conversion from acute hydrocephalus on admission to chronic hydrocephalus, and clinical cerebral vasospasm were compared in patients who underwent fenestration of the lamina terminalis with those who did not. The patient cohort was thus divided into three subgroups: 1) patients whose operative records clearly indicated that they underwent fenestration of the lamina terminalis, 2) patients whose operative records clearly indicated that they did not undergo fenestration of the lamina terminalis, and 3) patients whose operative records did not indicate one way or another whether they received fenestration of the lamina terminalis. We performed two separate analyses by comparing the postsurgical outcomes in those patients who were fenestrated versus those who were definitively not fenestrated and comparing the postsurgical outcomes in those patients who were fenestrated versus those who were not plus those whose records did not document fenestration. To further control for any cohort differences, we performed a comparison between patients who were fenestrated and those who were not after matching 1:1 for presenting radiographic and clinical characteristics predictive of hydrocephalus and vasospasm. Outcomes were compared using logistic regression and multivariable analysis. RESULTS In the first model, fenestrated patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 25, 50, and 23%, respectively, versus 20, 27, and 27% in nonfenestrated patients, respectively (P = 0.28, 0.21, and 0.32, respectively). In the second model, the nonfenestrated patients plus nondocumented patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 16, 40, and 20%, respectively (P = 0.19, 0.33, and 0.60, respectively). In the matched cohort, fenestrated patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 29, 67, and 20%, respectively, versus 20, 25, and 25% in nonfenestrated patients, respectively (P = 0.30, 0.24, and 0.20, respectively). CONCLUSION In contrast to other retrospective multisurgeon series, our retrospective single-surgeon series suggests that microsurgical fenestration of the lamina terminalis may not reduce the incidence of shunt-dependent hydrocephalus or cerebral vasospasm after aneurysmal subarachnoid hemorrhage. A prospective multicenter trial is needed to definitively address the use of this maneuver.

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Cilostazol may Inhibit the Development of Chronic Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Surgery for Cerebral Stroke ◽

10.2335/scs.45.14 ◽

2017 ◽

Vol 45 (1) ◽

pp. 14-18

Author(s):

Yoshinari NAKATSUKA ◽

Fumihiro KAWAKITA ◽

Ryuta YASUDA ◽

Yasuyuki UMEDA ◽

Naoki TOMA ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Chronic Hydrocephalus

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Predicting Delayed Ischemic Deficits after Aneurysmal Subarachnoid Hemorrhage Using a Transient Hyperemic Response Test of Cerebral Autoregulation

Neurosurgery ◽

10.1097/00006123-200010000-00004 ◽

2000 ◽

Vol 47 (4) ◽

pp. 819-826 ◽

Cited By ~ 87

Author(s):

Joseph M. K. Lam ◽

Peter Smielewski ◽

Marek Czosnyka ◽

John D. Pickard ◽

Peter J. Kirkpatrick

Keyword(s):

Subarachnoid Hemorrhage ◽

Transcranial Doppler ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Arteries ◽

Neurological Deficits ◽

Fisher Exact Test ◽

Exact Test ◽

Response Test ◽

Baseline Values ◽

Hyperemic Response

Abstract OBJECTIVE To assess whether the development of delayed ischemic deficits (DIDs) after aneurysmal subarachnoid hemorrhage can be predicted using transcranial Doppler ultrasonography and the transient hyperemic response test (THRT). METHODS An increase in the middle cerebral artery peak flow velocity (FV) of more than 9% of baseline values after 5 to 9 seconds of carotid artery compression was defined as a normal THRT result, indicating good autoregulatory reserve. The transcranial Doppler criteria for vasospasm were a FV of more than 120 cm/s and a Lindegaard ratio of more than 3. Twenty patients with no immediate postoperative neurological deficits were studied. The FVs at all of the major cerebral arteries were measured daily after surgery, and the THRT results were assessed bilaterally. RESULTS Five of six patients with abnormal THRT results in the first examination after surgery (primary THRT impairment) developed DIDs; none of the remaining patients developed DIDs (Fisher exact test, P = 0.0004). All five patients with DIDs initially exhibited low FVs but all subsequently developed increases in FVs to values of more than 150 cm/s and four exhibited FVs of more than 200 cm/s. The time of onset of DIDs corresponded to the time of onset of moderate vasospasm (FV > 150 cm/s). None of the patients with initially normal THRT results developed DIDs, although four patients did exhibit late (secondary) THRT impairment, which was associated with FVs of more than 120 cm/s. CONCLUSION When the effects of primarily impaired (after surgery) autoregulation are magnified by vasospasm, the risk of DIDs seems to be very high. Vasospasm alone does not seem to cause DIDs. The development of DIDs could therefore be predicted using the THRT for patients after aneurysm clipping.

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Transcranial Doppler Ultrasounography for Diagnosis of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Mean Blood Flow Velocity Ratio of the Ipsilateral and Contralateral Middle Cerebral Arteries

Journal of Vascular Surgery ◽

10.1016/j.jvs.2012.02.018 ◽

2012 ◽

Vol 55 (4) ◽

pp. 1220 ◽

Cited By ~ 1

Author(s):

R. Nakae ◽

H. Yokota ◽

D. Yoshida

Keyword(s):

Blood Flow ◽

Subarachnoid Hemorrhage ◽

Flow Velocity ◽

Cerebral Vasospasm ◽

Transcranial Doppler ◽

Blood Flow Velocity ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Arteries ◽

Velocity Ratio ◽

Middle Cerebral Arteries

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Abstract P350: Early Transcranial Doppler Velocity Changes as a Predictor for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.52.suppl_1.p350 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Matthew Triano ◽

Maite J Corbin ◽

Sameer Desale ◽

Ai-Hsi Liu ◽

Daniel R Felbaum ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Transcranial Doppler ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Arteries ◽

Delayed Cerebral Ischemia ◽

Multivariate Logistic Regression Analysis ◽

Absolute Velocity ◽

Doppler Velocity ◽

Velocity Change

Introduction: Although transcranial Doppler (TCD) evaluation for vasospasm remains an important study in aneurysmal subarachnoid hemorrhage (aSAH) management, its precise role in predicting delayed cerebral ischemia (DCI) remains unclear. Hypothesis: We evaluated optimal measures for evaluating TCD velocities and hypothesized that TCD velocity change would be the best predictor for DCI in patients with aSAH. Methods: Patients with aSAH over a two-year period were retrospectively analyzed. Baseline characteristics, outcomes, and TCD velocities in bilateral middle cerebral arteries (MCA) for hospital days 2 to14 were recorded. TCD variables, including absolute velocity and change in velocity, were obtained by creating a smoothing curve. A variable representing change in TCD velocity was then created through a linear regression model that confirmed greatest change in velocity associated with DCI occurred at days 2-7. Multivariate logistic regression analysis using DCI as outcome was then completed. Results: 95 patients with aSAH were evaluated. Increased TCD velocity at days 2-7 proved to be a better predictor for DCI than absolute velocity with an optimal cutoff of 8.9 cm/sec/day ( p = 0.019) and AUC 0.651. Multivariate logistic analysis using DCI as the outcome showed that poor admission Hunt-Hess scores (OR 5.02, 95%CI 1.22-22.67, p = 0.028) and increase in TCD velocity during days 2-7 (OR 5.32, 95%CI 1.41-23.33, p = 0.018) were independently associated with DCI. Conclusions: We found that relative increases in TCD velocities in the MCAs during the first 7 days (threshold increase of 8.9 cm/sec/day or 53.4 cm/sec from days 2-7) after aSAH were independently associated with DCI. Our findings suggest that vasospasm should be confirmed and treated aggressively when detected via increased TCD velocities during the first seven days in order to minimize DCI. This association requires independent confirmation.

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Angiotensin-(1-7) Protects against the Development of Aneurysmal Subarachnoid Hemorrhage in Mice

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.2015.30 ◽

2015 ◽

Vol 35 (7) ◽

pp. 1163-1168 ◽

Cited By ~ 23

Author(s):

Kenji Shimada ◽

Hajime Furukawa ◽

Kosuke Wada ◽

Yuan Wei ◽

Yoshiteru Tada ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Protective Effect ◽

Receptor Antagonist ◽

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Arteries ◽

Aneurysm Rupture ◽

Dependent Manner ◽

Aneurysmal Rupture ◽

Mas Receptor

Angiotensin-(1-7) (Ang-(1-7)) can regulate vascular inflammation and remodeling, which are processes that have important roles in the pathophysiology of intracranial aneurysms. In this study, we assessed the effects of Ang-(1-7) in the development of intracranial aneurysm rupture using a mouse model of intracranial aneurysms in which aneurysmal rupture (i.e., aneurysmal subarachnoid hemorrhage) occurs spontaneously and causes neurologic symptoms. Treatment with Ang-(1-7) (0.5 mg/kg/day), Mas receptor antagonist (A779 0.5 mg/kg/day or 2.5 mg/kg/day), or angiotensin II type 2 receptor (AT2R) antagonist (PD 123319, 10 mg/kg/day) was started 6 days after aneurysm induction and continued for 2 weeks. Angiotensin-(1-7) significantly reduced the rupture rate of intracranial aneurysms without affecting the overall incidence of aneurysms. The protective effect of Ang-(1-7) was blocked by the AT2R antagonist, but not by the Mas receptor antagonist. In AT2R knockout mice, the protective effect of Ang-(1-7) was absent. While AT2R mRNA was abundantly expressed in the cerebral arteries and aneurysms, Mas receptor mRNA expression was very scarce in these tissues. Angiotensin-(1-7) reduced the expression of tumor necrosis factor-α and interleukin-1β in cerebral arteries. These findings indicate that Ang-(1-7) can protect against the development of aneurysmal rupture in an AT2R-dependent manner.

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