scholarly journals Predictors of poor outcome from aneurysmal subarachnoid hemorrhage and an exploratory analysis into the causes of delayed neurosurgical clipping at a major public hospital in the Philippines

2021 ◽  
Author(s):  
Kevin Paul Ferraris ◽  
Jared Paul Golidtum ◽  
Eric Paolo M. Palabyab ◽  
Alain James Salloman ◽  
Jose Carlos Alcazaren ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
The Philippines ◽  
Unfavorable Outcome ◽  
Middle Income ◽  
Low Resource ◽  
Resource Setting ◽  
Neurosurgical Treatment ◽  
Intraoperative Rupture

Abstract Objective:The provision of neurosurgical care for patients with aneurysmal subarachnoid hemorrhage (SAH) is beset with particular challenges in low- to middle-income countries (LMICs) like the Philippines. In this study located in a low-resource setting, we identify the factors that contribute to unfavorable outcomes of dependency and death. Methods:The authors retrospectively reviewed 106 patients who underwent surgery for aneurysmal subarachnoid hemorrhage in a single institution from January 2016 to September 2018. Data were obtained on exposure variables comprising patient demographics, clinical features, perioperative management, and complications and other interventions; while outcomes on discharge were investigated using the modified Rankin scale (mRS). Descriptive statistics and multivariate logistic regression analyses were done. Root cause analysis was done to identify the causes of delay.Results:The percentage of patients who had unfavorable outcome (mRS ≥ 3) was 29.2%. The timing of surgery—whether early (<3 days), intermediate (3-10 days), or late (>10 days)—was not found to be significantly associated with dependency or mortality. On multiple logistic regression, the factors associated with unfavorable outcome were: intraoperative rupture (OR 23.98, 95%CI 3.56–161.33, p=0.001), vasospasm (OR 12.47, 95%CI 3.01–51.57, p<0.001), and a high Hunt & Hess grade (OR 5.96, 95%CI 1.47–24.18, p=0.012). Intraoperative rupture and vasospasm were further found to be independent predictors of mortality. Many causes of delay were identified in terms of patient-, provider-, and health system-levels. These constitute as barriers to timely care and also contribute to the gap in quality and efficiency of neurosurgical treatment situated in low-resource settings in LMICs.Conclusion:The identified predictors of poor outcomes, as well as the causes delays in neurosurgical treatment, pose as significant challenges to the care of socioeconomically-disadvantaged SAH patients. When considering the solutions to these challenges, the broader environment of practice ought to be taken into account.

scholarly journals Systemic Immune-Inflammation Index Predicts the Outcome After Aneurysmal Subarachnoid Hemorrhage

2021 ◽  
Author(s):  
Fushu Luo ◽  
Yuanyou Li ◽  
Yutong Zhao ◽  
Mingjiang Sun ◽  
Qiuguang He ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Inflammatory Response ◽  
Early Stage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Area Under The Curve ◽  
Systemic Inflammatory Response ◽  
Unfavorable Outcome ◽  
Operating Characteristics ◽  
Immune Inflammation

Abstract Objectives: Systemic inflammatory response is closely related to the pathogenesis and prognosis in critical patients. Recently, systemic immune-inflammation index (SII), an indicator of systemic inflammatory response, was proved to predict the outcome in cancerous and non-cancerous diseases. The aim of this study is to evaluate the relationship between SII on admission and 6-month outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH).Methods: The clinical data and prognosis of 76 patients with aSAH was analyzed. Patients were divided into high SII group and low SII group. The 6-month outcome was assessed by the modified Rankin scale (mRS).The unfavorable outcome was defined as mRS score ≥3. Receiver operating characteristics (ROC), area under the curve (AUC) and logistic regression were used to examine the relations between SII levels and 6-month clinical outcomes.Results: Thirty-six patients (47.4%) in our study had a unfavorable outcome (mRS ≥3) at 6 months, and twenty-four (66.7%) of them had high SII. Spearman correlation analysis showed that the SII was correlated with mRS (r=0.418, P＜0.05). Binary logistic regression showed that there was an independent association between SII on admission and 6-month clinical outcome (OR=4.271, 95%CI: 1.047-17.422, P＜0.05). The AUC of the SII for predicting unfavorable outcome was 0.692(95% CI:0.571–0.814, P＜0.05).Conclusion: Systemic immune-inflammation index (SII) could be a novel independent prognostic factor for aSAH patients at the early stage of the disease.

Evidence for a conditioning effect of inhalational anesthetics on angiographic vasospasm after aneurysmal subarachnoid hemorrhage

2020 ◽  
Vol 133 (1) ◽  
pp. 152-158 ◽  
Author(s):  
Umeshkumar Athiraman ◽  
Diane Aum ◽  
Ananth K. Vellimana ◽  
Joshua W. Osbun ◽  
Rajat Dhar ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Brain Injury ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Multivariate Logistic Regression Analysis ◽  
Secondary Brain Injury ◽  
Large Artery ◽  
Inhalational Anesthetics ◽  
Angiographic Vasospasm ◽  
Inhalational Anesthetic

OBJECTIVEDelayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is characterized by large-artery vasospasm, distal autoregulatory dysfunction, cortical spreading depression, and microvessel thrombi. Large-artery vasospasm has been identified as an independent predictor of poor outcome in numerous studies. Recently, several animal studies have identified a strong protective role for inhalational anesthetics against secondary brain injury after SAH including DCI—a phenomenon referred to as anesthetic conditioning. The aim of the present study was to assess the potential role of inhalational anesthetics against cerebral vasospasm and DCI in patients suffering from an SAH.METHODSAfter IRB approval, data were collected retrospectively for all SAH patients admitted to the authors’ hospital between January 1, 2010, and December 31, 2013, who received general anesthesia with either inhalational anesthetics only (sevoflurane or desflurane) or combined inhalational (sevoflurane or desflurane) and intravenous (propofol) anesthetics during aneurysm treatment. The primary outcomes were development of angiographic vasospasm and development of DCI during hospitalization. Univariate and logistic regression analyses were performed to identify independent predictors of these endpoints.RESULTSThe cohort included 157 SAH patients whose mean age was 56 ± 14 (± SD). An inhalational anesthetic–only technique was employed in 119 patients (76%), while a combination of inhalational and intravenous anesthetics was employed in 34 patients (22%). As expected, patients in the inhalational anesthetic–only group were exposed to significantly more inhalational agent than patients in the combination anesthetic group (p < 0.05). Multivariate logistic regression analysis identified inhalational anesthetic–only technique (OR 0.35, 95% CI 0.14–0.89), Hunt and Hess grade (OR 1.51, 95% CI 1.03–2.22), and diabetes (OR 0.19, 95% CI 0.06–0.55) as significant predictors of angiographic vasospasm. In contradistinction, the inhalational anesthetic–only technique had no significant impact on the incidence of DCI or functional outcome at discharge, though greater exposure to desflurane (as measured by end-tidal concentration) was associated with a lower incidence of DCI.CONCLUSIONSThese data represent the first evidence in humans that inhalational anesthetics may exert a conditioning protective effect against angiographic vasospasm in SAH patients. Future studies will be needed to determine whether optimized inhalational anesthetic paradigms produce definitive protection against angiographic vasospasm; whether they protect against other events leading to secondary brain injury after SAH, including microvascular thrombi, autoregulatory dysfunction, blood-brain barrier breakdown, neuroinflammation, and neuronal cell death; and, if so, whether this protection ultimately improves patient outcome.

Interaction of neurovascular protection of erythropoietin with age, sepsis, and statin therapy following aneurysmal subarachnoid hemorrhage

2010 ◽  
Vol 112 (6) ◽  
pp. 1235-1239 ◽  
Author(s):  
Ming-Yuan Tseng ◽  
Peter J. Hutchinson ◽  
Peter J. Kirkpatrick
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Statin Therapy ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Controlled Trial ◽  
Potential Interaction ◽  
Repeated Measurements ◽  
Unfavorable Outcome ◽  
Phase Iii ◽  
Neurovascular Protection ◽  
Phase Iii Trials

Object In a previous randomized controlled trial, the authors demonstrated that acute erythropoietin (EPO) therapy reduced severe vasospasm and delayed ischemic deficits (DIDs) following aneurysmal subarachnoid hemorrhage. In this study, the authors aimed to investigate the potential interaction of neurovascular protection by EPO with age, sepsis, and concurrent statin therapy. Methods The clinical events of 80 adults older than 18 years and with < 72 hours of aneurysmal subarachnoid hemorrhage, who were randomized to receive 30,000 U of intravenous EPO-β or placebo every 48 hours for a total of 3 doses, were analyzed by stratification according to age (< or ≥ 60 years), sepsis, or concomitant statin therapy. End points in the trial included cerebral vasospasm and impaired autoregulation on transcranial Doppler ultrasonography, DIDs, and unfavorable outcome at discharge and at 6 months measured with the modified Rankin Scale and Glasgow Outcome Scale. Analyses were performed using the t-test and/or ANOVA for repeated measurements. Results Younger patients (< 60 years old) or those without sepsis obtained benefits from EPO by a reduction in vasospasm, impaired autoregulation, and unfavorable outcome at discharge. Compared with nonseptic patients taking EPO, those with sepsis taking EPO had a lower absolute reticulocyte count (nonsepsis vs sepsis, 143.5 vs. 105.8 × 109/L on Day 6; p = 0.01), suggesting sepsis impaired both hematopoiesis and neurovascular protection by EPO. In the EPO group, none of the statin users suffered DIDs (p = 0.078), implying statins may potentiate neuroprotection by EPO. Conclusions Erythropoietin-related neurovascular protection appears to be attenuated by old age and sepsis and enhanced by statins, an important finding for designing Phase III trials.

Abstract TMP105: Endovascular Treatment of Severe and Refractory Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Improves Outcome: A Systematic Review and Meta-analysis of Different Treatment Options Evaluated Since 2006 for Cerebral Vasospasm

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Gregoire Boulouis ◽  
Marc-Antoine Labeyrie ◽  
Jean Raymond ◽  
Christine Rodriguez-Regent ◽  
Anne-Claire Lukaszewicz ◽  
...  
Keyword(s):  
Systematic Review ◽  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Endovascular Treatment ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Route Of Administration ◽  
Unfavorable Outcome ◽  
Q Value

Introduction: To report clinical outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS) targeted treatments in a systematic review and meta-analysis and compare the efficacy of endovascular and non-endovascular treatments in severe / refractory vasospasm patients. Methods: The literature was searched using PubMed, EMBASE, and The Cochrane Library database. Eligibility criteria were (1) Rated clinical outcome; (2) at least 10 patients; (3) aSAH; (4) study published in English or French (January 2006 - October 2014); and (5) methodological quality score > 10, according to STROBE criteria. Endpoint included unfavorable outcome rate, defined as mRS 3-6, GOS 1-3 or GOSE 1-4 at latest follow-up. Analyses included stratification per route of administration (oral, i.v., intra-arterial or cisternoventricular) and per study inclusion criteria (severe, CVS, refractory CVS or high risk for CVS). Univariate and multivariate subgroup analyses were performed to identify interventions associated with a better outcome. Results: Sixty-two studies, including 26 randomized controlled trials, were included (8976 patients). Overall 2490 patients had unfavorable outcome including death (random-effect weighted average: 33.7%, 99%CI, 28.1-39.7%; Q-value: 806.0, I 2 =92.7%). Clinical outcome was significantly better in severe or refractory patients for whom, on top of best medical treatment, endovascular intervention was performed (RR=0.76, IC95% [0.66-0.89], p <0.00001) whereas other route of administration didn’t show significant differences. RR of unfavorable outcome was significantly lower, vs control groups, in patients treated with Cilostazol (RR=0.46 (IC99% [0.25-0.85], P = 0.001, Q value 1.5, I 2 = 0). Conclusion: In case of CVS following aSAH, endovascular treatment in severe / refractory vasospasm patients. including intra-arterial injection of pharmacological agents or balloon angioplasty, improves outcome as compared to other route of administration.

scholarly journals A sustained systemic inflammatory response syndrome is associated with shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

2019 ◽  
Vol 130 (6) ◽  
pp. 1984-1991 ◽  
Author(s):  
Aaron P. Wessell ◽  
Matthew J. Kole ◽  
Gregory Cannarsa ◽  
Jeffrey Oliver ◽  
Gaurav Jindal ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Systemic Inflammatory Response Syndrome ◽  
Inflammatory Response ◽  
Regression Model ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Systemic Inflammatory Response ◽  
Multivariate Logistic Regression ◽  
Shunt Placement ◽  
Shunt Dependence

OBJECTIVEThe authors sought to evaluate whether a sustained systemic inflammatory response was associated with shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage.METHODSA retrospective analysis of 193 consecutive patients with aneurysmal subarachnoid hemorrhage was performed. Management of hydrocephalus followed a stepwise algorithm to determine the need for external CSF drainage and subsequent shunt placement. Systemic inflammatory response syndrome (SIRS) data were collected for all patients during the first 7 days of hospitalization. Patients who met the SIRS criteria every day for the first 7 days of hospitalization were considered as having a sustained SIRS. Univariate and multivariate regression analyses were used to determine predictors of shunt dependence.RESULTSSixteen percent of patients required shunt placement. Sustained SIRS was observed in 35% of shunt-dependent patients compared to 14% in non–shunt-dependent patients (p = 0.004). On multivariate logistic regression, female sex (OR 0.35, 95% CI 0.142–0.885), moderate to severe vasospasm (OR 3.78, 95% CI 1.333–10.745), acute hydrocephalus (OR 21.39, 95% CI 2.260–202.417), and sustained SIRS (OR 2.94, 95% CI 1.125–7.689) were significantly associated with shunt dependence after aneurysmal subarachnoid hemorrhage. Receiver operating characteristic analysis revealed an area under the curve of 0.83 for the final regression model.CONCLUSIONSSustained SIRS was a predictor of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage even after adjustment for potential confounding variables in a multivariate logistic regression model.

Correlation Among Systemic Inflammatory Parameter, Occurrence of Delayed Neurological Deficits, and Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2012 ◽  
Vol 72 (3) ◽  
pp. 367-375 ◽  
Author(s):  
Carl Muroi ◽  
Michael Hugelshofer ◽  
Martin Seule ◽  
Ilhan Tastan ◽  
Masayuki Fujioka ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Confidence Interval ◽  
Early Phase ◽  
Odds Ratio ◽  
Time Course ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Unfavorable Outcome ◽  
Neurological Deficits ◽  
Inflammatory Parameters ◽  
Leukocyte Counts

Abstract BACKGROUND: The role and impact of systemic inflammatory response after aneurysmal subarachnoid hemorrhage remain to be elucidated. OBJECTIVE: To assess the time course and correlation of systemic inflammatory parameters with outcome and the occurrence of delayed ischemic neurological deficits (DINDs) after subarachnoid hemorrhage. METHODS: Besides the baseline characteristics, daily interleukin-6 (IL-6), procalcitonin, C-reactive protein levels, and leukocyte counts were prospectively measured until day 14 after subarachnoid hemorrhage. Occurrence of infectious complications and application of therapeutic hypothermia were assessed as confounding factors. The primary end point was outcome after 3 months, assessed by Glasgow Outcome Scale; the secondary end point was the occurrence of DINDs. RESULTS: During a 3-year period, a total of 138 patients were included. All inflammatory parameters measured were higher in patients with unfavorable outcome (Glasgow Outcome Scale score, 1-3). After adjustment for confounding factors, elevated IL-6 and leukocyte counts remained significant risk factors for unfavorable outcome. The odds ratio for log IL-6 was 4.07 (95% confidence interval, 1.18 to 14.03; P = .03) and for leukocyte counts was 1.24 (95% confidence interval, 1.06-1.46, P = .008). The analysis of the time course established that IL-6 was the only significantly elevated parameter in the early phase in patients with unfavorable outcome. Higher IL-6 levels in the early phase (days 3-7) were associated with the occurrence of DINDs. The adjusted odds ratio for log IL-6 was 4.03 (95% confidence interval, 1.21-13.40; P = .02). CONCLUSION: Higher IL-6 levels are associated with worse clinical outcome and the occurrence of DINDs. Because IL-6 levels were significantly elevated in the early phase, they might be a useful parameter to monitor.

Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorrhage

2012 ◽  
Vol 117 (1) ◽  
pp. 15-19 ◽  
Author(s):  
Elias A. Giraldo ◽  
Jay N. Mandrekar ◽  
Mark N. Rubin ◽  
Stefan A. Dupont ◽  
Yi Zhang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Infarction ◽  
Functional Outcome ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Intracerebral Hematoma ◽  
Poor Functional Outcome ◽  
Poor Outcome ◽  
Grade Assessment ◽  
Clinical Grading

Object Timing of clinical grading has not been fully studied in patients with aneurysmal subarachnoid hemorrhage (SAH). The primary objective of this study was to identify at which time point clinical assessment using the World Federation of Neurosurgical Societies (WFNS) grading scale and the Glasgow Coma Scale (GCS) is most predictive of poor functional outcome. Methods This study is a retrospective cohort study on the association between poor outcome and clinical grading determined at presentation, nadir, and postresuscitation. Poor functional outcome was defined as a Glasgow Outcome Scale score of 1–3 at 6 months after SAH. Results The authors identified 186 consecutive patients admitted to a teaching hospital between January 2002 and June 2008. The patients' mean age (± SD) was 56.9 ± 13.7 years, and 63% were women. Twenty-four percent had poor functional outcome (the mortality rate was 17%). On univariable logistic regression analyses, GCS score determined at presentation (OR 0.80, p < 0.0001), nadir (OR 0.73, p < 0.0001), and postresuscitation (OR 0.53, p < 0.0001); modified Fisher scale (OR 2.21, p = 0.0013); WFNS grade assessed at presentation (OR 1.92, p < 0.0001), nadir (OR 3.51, < 0.0001), and postresuscitation (OR 3.91, p < 0.0001); intracerebral hematoma on initial CT (OR 4.55, p < 0.0002); acute hydrocephalus (OR 2.29, p = 0.0375); and cerebral infarction (OR 4.84, p < 0.0001) were associated with poor outcome. On multivariable logistic regression analysis, only cerebral infarction (OR 5.80, p = 0.0013) and WFNS grade postresuscitation (OR 3.43, p < 0.0001) were associated with poor outcome. Receiver operating characteristic/area under the curve (AUC) analysis demonstrated that WFNS grade determined postresuscitation had a stronger association with poor outcome (AUC 0.90) than WFNS grade assessed upon admission or at nadir. Conclusions Timing of WFNS grade assessment affects its prognostic value. Outcome after aneurysmal SAH is best predicted by assessing WFNS grade after neurological resuscitation.

167 High Throughput Metabolite Profiling Identifies Plasma Anandamide as a Biomarker of Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 242-243
Author(s):  
Christopher J Stapleton ◽  
Hannah Irvine ◽  
Zoe Wolcott ◽  
Aman B Patel ◽  
Jonathan Rosand ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Functional Outcome ◽  
High Throughput ◽  
Metabolite Profiling ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Plasma Samples ◽  
Symptomatic Vasospasm ◽  
Good Functional Outcome ◽  
Fisher Grade

Abstract INTRODUCTION The quantification of metabolites in plasma samples in patients with aneurysmal subarachnoid hemorrhage (aSAH) can highlight important alterations in critical metabolic pathways. As metabolites reflect changes associated with disease conditions, metabolite profiling (metabolomics) can identify candidate biomarkers for disease and potentially uncover pathways for intervention. METHODS We performed high throughput metabolite profiling across a broad spectrum of chemical classes (173 metabolites) on plasma samples taken from 119 patients with aSAH. Samples were drawn at 3 time points following ictus: 2–4, 7–10, and 12–14 days. Univariate and logistic regression analyses were performed to examine the relation of each metabolite with multiple outcome variables, including short- and long-term functional outcome (modified Rankin Scale, mRS). RESULTS >A good functional outcome (mRS 0–2) was found in 63.1% and 66.7% of patients at 30 and 90 days, respectively, following aSAH. Plasma concentrations of the endogenous cannabinoid anandamide during days 2–4 after aneurysmal SAH were decreased by 48.1% (P < 0.0001) and 57.6% (P <0.0001) in patients with mRS 0–2 at 30 and 90 days, respectively. A similar statistical result was noted with plasma anandamide concentrations averaged across all time periods. Logistic regression further demonstrated that anandamide remained an independent predictor of functional outcome (30 days: P = 0.04; 90 days: P = 0.03), even after adjusting for other factors that influence outcome, including age, World Federation of Neurological Surgeons grade (WFNS), Fisher grade, and symptomatic vasospasm. CONCLUSION Decreased plasma anandamide following aSAH predicts a good functional outcome at 30 and 90 days. While a role for anandamide in aneurysmal SAH has not been previously reported, elevated anandamide levels have been implicated in neuronal apoptosis and cerebral edema in the acutely injured brain. These data highlight the increasing capability of metabolomics techniques in profiling large-sized cohorts to illuminate novel markers of disease and potential metabolic regulators.

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