Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

Object The purpose of this study was to identify predictors of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH). Methods The authors evaluated the incidence of shunt-dependent hydrocephalus in a consecutive cohort of 580 patients with SAH who were admitted to the Neurological Intensive Care Unit of Columbia University Medical Center between July 1996 and September 2002. Patient demographics, 24-hour admission variables, initial CT scan characteristics, daily transcranial Doppler variables, and development of in-hospital complications were analyzed. Odds ratios and 95% CIs for candidate predictors were calculated using multivariate nominal logistic regression. Results Admission glucose of at least 126 mg/dl (adjusted OR 1.6; 95% CI 1.0–2.6), admission brain CT scan with a bicaudate index of at least 0.20 (adjusted OR 1.43; 95% CI 1.0–2.0), Fisher Grade 4 (adjusted OR 2.71; 95% CI 1.2–5.7), fourth ventricle hemorrhage (adjusted OR 1.78; 95% CI 1.1–2.7), and development of nosocomial meningitis (adjusted OR 2.2; 95% CI 1.4–3.7) were independently associated with shunt dependency. Conclusions These data suggest that permanent CSF diversion after aneurysmal SAH may be independently predicted by hyperglycemia at admission, findings on the admission CT scan (Fisher Grade 4, fourth ventricle intraventricular hemorrhage, and bicaudate index ≥ 0.20), and development of nosocomial meningitis. Future research is needed to assess if tight glycemic control, reduction of fourth ventricle clot burden, and prevention of nosocomial meningitis may reduce the need for permanent CSF diversion after aneurysmal SAH.

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Risk factors for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage

Open Medicine ◽

10.1515/med-2020-0169 ◽

2020 ◽

Vol 15 (1) ◽

pp. 598-604

Author(s):

Valentina Opancina ◽

Snezana Lukic ◽

Slobodan Jankovic ◽

Radisa Vojinovic ◽

Milan Mijailovic

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Medical Center ◽

White Blood Cells ◽

Cerebral Aneurysms ◽

International Normalized Ratio ◽

Cross Sectional Study ◽

Cross Sectional

AbstractIntroductionAneurysmal subarachnoid hemorrhage is a type of spontaneous hemorrhagic stroke, which is caused by a ruptured cerebral aneurysm. Cerebral vasospasm (CVS) is the most grievous complication of subarachnoid hemorrhage (SAH). The aim of this study was to examine the risk factors that influence the onset of CVS that develops after endovascular coil embolization of a ruptured aneurysm.Materials and methodsThe study was designed as a cross-sectional study. The patients included in the study were 18 or more years of age, admitted within a period of 24 h of symptom onset, diagnosed and treated at a university medical center in Serbia during a 5-year period.ResultsOur study showed that the maximum recorded international normalized ratio (INR) values in patients who were not receiving anticoagulant therapy and the maximum recorded white blood cells (WBCs) were strongly associated with cerebrovascular spasm, increasing its chances 4.4 and 8.4 times with an increase of each integer of the INR value and 1,000 WBCs, respectively.ConclusionsSAH after the rupture of cerebral aneurysms creates an endocranial inflammatory state whose intensity is probably directly related to the occurrence of vasospasm and its adverse consequences.

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Abstract 2792: Cardiac Complications After Aneurysmal Subarachnoid Hemorrhage Are Associated With Outcome: A Meta-analysis

Circulation ◽

10.1161/circ.116.suppl_16.ii_620-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Ivo A van der Bilt ◽

Djo Hasan ◽

W. P Vandertop ◽

Arthur A Wilde ◽

Ale Algra ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Meta Analysis ◽

Prognostic Significance ◽

Delayed Cerebral Ischemia ◽

Myocardial Damage ◽

Future Research ◽

Cardiac Complications ◽

Pathophysiological Mechanism ◽

Cardiac Abnormalities

Cardiac complications after subarachnoid hemorrhage (SAH) occur frequently, but their prognostic significance remains unclear. We performed a meta-analysis to assess whether echocardiographic wall motion abnormalities (WMA), electrocardiographic (ECG) changes, or elevated markers for myocardial damage are related to the occurrence of delayed cerebral ischemia (DCI) or death. Methods All articles that reported on cardiac abnormalities after aneurysmal SAH, that met predefined criteria, and were published between 1960 and 2007 were assessed. Data were extracted on predefined methodological criteria, patient characteristics, prevalence of cardiac abnormalities, and DCI or death. We calculated pooled relative risks (RR) with corresponding 95% confidence intervals (CI) for the separate cardiac abnormalities and outcome. Results We included 25 studies (16 prospective), comprising 2690 patients (mean age 53 years; 35% was male). The figure shows the univariable RRs of the determinants for death. For DCI we found a significant association with WMA (RR 2.10 [CI 1.17, 3.78]); Troponin RR 3.15 [CI 2.27, 4.38]; CK-MB RR: 2.90 [CI 1.86, 4.52]; BNP RR: 4.52 [CI 1.79, 11.39]; and ST depression RR: 2.40 [CI 1.2, 4.9]. No significant associations were found for DCI and ST elevation RR: 2.1 [CI 0.7, 5.7]; T wave abnormality RR: 0.9 [CI 0.5, 1.7]; U wave RR: 0.7 [CI 0.4, 1.3] or prolonged QT RR: 1.0 [CI 0.5, 2.3]. Conclusion Cardiac abnormalities increase the risk of DCI and death after SAH. Future research should be directed towards elucidating the multivariable relationship between the cardiac prognosticators, the pathophysiological mechanism and potential treatment options.

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Variation of patient characteristics, management, and outcome with timing of surgery for aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2010.11.jns10795 ◽

2011 ◽

Vol 114 (4) ◽

pp. 1045-1053 ◽

Cited By ~ 13

Author(s):

Kelly B. Mahaney ◽

Michael M. Todd ◽

James C. Torner

Keyword(s):

Subarachnoid Hemorrhage ◽

Management Practices ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Timing Of Surgery ◽

Early Surgery ◽

Outcome Variable ◽

Optimal Time ◽

World Federation ◽

Time Interval ◽

Fisher Grade

ObjectThe past 30 years have seen a shift in the timing of surgery for aneurysmal subarachnoid hemorrhage (SAH). Earlier practices of delayed surgery that were intended to avoid less favorable surgical conditions have been replaced by a trend toward early surgery to minimize the risks associated with rebleeding and vasospasm. Yet, a consensus as to the optimal timing of surgery has not been reached. The authors hypothesized that earlier surgery, performed using contemporary neurosurgical and neuroanesthesia techniques, would be associated with better outcomes when using contemporary management practices, and sought to define the optimal time interval between SAH and surgery.MethodsData collected as part of the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) were analyzed to investigate the relationship between timing of surgery and outcome at 3 months post-SAH. The IHAST enrolled 1001 patients in 30 neurosurgical centers between February 2000 and April 2003. All patients had a radiographically confirmed SAH, were World Federation of Neurosurgical Societies Grades I–III at the time of surgery, and underwent surgical clipping of the presumed culprit aneurysm within 14 days of the date of hemorrhage. Patients were seen at 90-day follow-up visits. The primary outcome variable was a Glasgow Outcome Scale score of 1 (good outcome). Intergroup differences in baseline, intraoperative, and postoperative variables were compared using the Fisher exact tests. Variables reported as means were compared with ANOVA. Multiple logistic regression was used for multivariate analysis, adjusting for covariates. A p value of less than 0.05 was considered to be significant.ResultsPatients who underwent surgery on Days 1 or 2 (early) or Days 7–14 (late) (Day 0 = date of SAH) fared better than patients who underwent surgery on Days 3–6 (intermediate). Specifically, the worst outcomes were observed in patients who underwent surgery on Days 3 and 4. Patients who had hydrocephalus or Fisher Grade 3 or 4 on admission head CT scans had better outcomes with early surgery than with intermediate or late surgery.ConclusionsEarly surgery, in good-grade patients within 48 hours of SAH, is associated with better outcomes than surgery performed in the 3- to 6-day posthemorrhage interval. Surgical treatment for aneurysmal SAH may be more hazardous during the 3- to 6-day interval, but this should be weighed against the risk of rebleeding.

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Elevated Baseline C-Reactive Protein as a Predictor of Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/neu.0000000000000963 ◽

2015 ◽

Vol 77 (5) ◽

pp. 786-793 ◽

Cited By ~ 22

Author(s):

◽

Carole L. Turner ◽

Karol Budohoski ◽

Christopher Smith ◽

Peter J. Hutchinson ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

White Blood Cells ◽

Cerebral Injury ◽

World Federation ◽

C Reactive Protein ◽

Reactive Protein ◽

Poor Outcome ◽

Fisher Grade ◽

Good Grade

Abstract BACKGROUND: There remains a proportion of patients with unfavorable outcomes after aneurysmal subarachnoid hemorrhage, of particular relevance in those who present with a good clinical grade. A forewarning of those at risk provides an opportunity towards more intensive monitoring, investigation, and prophylactic treatment prior to the clinical manifestation of advancing cerebral injury. OBJECTIVE: To assess whether biochemical markers sampled in the first days after the initial hemorrhage can predict poor outcome. METHODS: All patients recruited to the multicenter Simvastatin in Aneurysmal Hemorrhage Trial (STASH) were included. Baseline biochemical profiles were taken between time of ictus and day 4 post ictus. The t-test compared outcomes, and a backwards stepwise binary logistic regression was used to determine the factors providing independent prediction of an unfavorable outcome. RESULTS: Baseline biochemical data were obtained in approximately 91% of cases from 803 patients. On admission, 73% of patients were good grade (World Federation of Neurological Surgeons grades 1 or 2); however, 84% had a Fisher grade 3 or 4 on computed tomographic scan. For patients presenting with good grade on admission, higher levels of C-reactive protein, glucose, and white blood cells and lower levels of hematocrit, albumin, and hemoglobin were associated with poor outcome at discharge. C-reactive protein was found to be an independent predictor of outcome for patients presenting in good grade. CONCLUSION: Early recording of C-reactive protein may prove useful in detecting those good grade patients who are at greater risk of clinical deterioration and poor outcome.

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Clot volume and clearance rate as independent predictors of vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2004.101.2.0255 ◽

2004 ◽

Vol 101 (2) ◽

pp. 255-261 ◽

Cited By ~ 118

Author(s):

Christopher Reilly ◽

Chris Amidei ◽

Jocelyn Tolentino ◽

Babak S. Jahromi ◽

R. Loch Macdonald

Keyword(s):

Subarachnoid Hemorrhage ◽

Clearance Rate ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Quantitative Imaging ◽

Univariate Analysis ◽

Ct Scans ◽

Focal Neurological Deficit ◽

Content Type ◽

Fisher Grade ◽

Fine Print

Object. This study was conducted for two purposes. The first was to determine whether a combination of measurements of subarachnoid clot volume, clearance rate, and density could improve prediction of which patients experience vasospasm. The second was to determine if each of these three measures could be used independently to predict vasospasm. Methods. Digital files of the cranial computerized tomography (CT) scans obtained in 75 consecutive patients admitted within 24 hours of subarachnoid hemorrhage (SAH) were analyzed in a blinded fashion by an observer who used quantitative imaging software to measure the volume of SAH and its density. Clot clearance rates were measured by quantifying SAH volume on subsequent CT scans. Vasospasm was defined as new onset of a focal neurological deficit or altered consciousness 5 to 12 days after SAH in the absence of other causes of deterioration, diagnosed with the aid of or exclusively by confirmatory transcranial Doppler ultrasonography and/or cerebral angiography. Univariate analysis showed that vasospasm was significantly associated with the SAH grade as classified on the Fisher scale, the initial clot volume, initial clot density, and percentage of clot cleared per day (p < 0.05). In multivariate analysis, initial clot volume and percentage of clot cleared per day were significant predictors of vasospasm (p < 0.05), whereas Fisher grade and initial clot density were not. Conclusions. Quantitative analysis of subarachnoid clot shows that vasospasm is best predicted by initial subarachnoid clot volume and the percentage of clot cleared per day.

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Length of hospital stay in aneurysmal subarachnoid hemorrhage patients without vasospasm on angiography: potential for a fast-track discharge cohort

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017424 ◽

2021 ◽

pp. neurintsurg-2021-017424

Author(s):

Joshua S Catapano ◽

Visish M Srinivasan ◽

Kavelin Rumalla ◽

Mohamed A Labib ◽

Candice L Nguyen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Length Of Stay ◽

Hospital Stay ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Length Of Hospital Stay ◽

Hospital Length Of Stay ◽

Neurologic Outcome ◽

Angiographic Vasospasm ◽

Fisher Grade ◽

Tertiary Center

BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) frequently suffer from vasospasm. We analyzed the association between absence of early angiographic vasospasm and early discharge.MethodsAll aSAH patients treated from August 1, 2007, to July 31, 2019, at a single tertiary center were reviewed. Patients undergoing diagnostic digital subtraction angiography (DSA) on post-aSAH days 5 to 7 were analyzed; cohorts with and without angiographic vasospasm (angiographic reports by attending neurovascular surgeons) were compared. Primary outcome was hospital length of stay; secondary outcomes were intensive care unit length of stay, 30 day return to the emergency department (ED), and poor neurologic outcome, defined as a modified Rankin Scale (mRS) score >2.ResultsA total of 298 patients underwent DSA on post-aSAH day 5, 6, or 7. Most patients (n=188, 63%) had angiographic vasospasm; 110 patients (37%) did not. Patients without vasospasm had a significantly lower mean length of hospital stay than vasospasm patients (18.0±7.1 days vs 22.4±8.6 days; p<0.001). The two cohorts did not differ significantly in the proportion of patients with mRS scores >2 at last follow-up or those returning to the ED before 30 days. After adjustment for Hunt and Hess scores, Fisher grade, admission Glasgow Coma Scale score, and age, logistic regression analysis showed that the absence of vasospasm on post-aSAH days 5–7 predicted discharge on or before hospital day 14 (OR 3.4, 95% CI 1.8 to 6.4, p<0.001).ConclusionLack of angiographic vasospasm 5 to 7 days after aSAH is associated with shorter hospitalization, with no increase in 30 day ED visits or poor neurologic outcome.

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Abstract W MP37: Novel Prognostic Scores for Early Prediction of Outcome Following Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.46.suppl_1.wmp37 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Blessing Jaja ◽

Hester Lingsma ◽

Ewout Steyerberg ◽

R. Loch Macdonald ◽

Keyword(s):

Subarachnoid Hemorrhage ◽

Cross Validation ◽

Prediction Models ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Model Performance ◽

Predictor Variable ◽

Predictive Ability ◽

Prognostic Scores ◽

Operating Characteristics ◽

Fisher Grade

Background: Aneurysmal subarachnoid hemorrhage (SAH) is a cerebrovascular emergency. Currently, clinicians have limited tools to estimate outcomes early after hospitalization. We aimed to develop novel prognostic scores using large cohorts of patients reflecting experience from different settings. Methods: Logistic regression analysis was used to develop prediction models for mortality and unfavorable outcomes according to 3-month Glasgow outcome score after SAH based on readily obtained parameters at hospital admission. The development cohort was derived from 10 prospective studies involving 10936 patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository. Model performance was assessed by bootstrap internal validation and by cross validation by omission of each of the 10 studies, using R2 statistic, Area under the receiver operating characteristics curve (AUC), and calibration plots. Prognostic scores were developed from the regression coefficients. Results: Predictor variable with the strongest prognostic strength was neurologic status (partial R2 = 12.03%), followed by age (1.91%), treatment modality (1.25%), Fisher grade of CT clot burden (0.65%), history of hypertension (0.37%), aneurysm size (0.12%) and aneurysm location (0.06%). These predictors were combined to develop 3 sets of hierarchical scores based on the coefficients of the regression models. The AUC at bootstrap validation was 0.79-0.80, and at cross validation was 0.64-0.85. Calibration plots demonstrated satisfactory agreement between predicted and observed probabilities of the outcomes. Conclusions: The novel prognostic scores have good predictive ability and potential for broad application as they have been developed from prospective cohorts reflecting experience from different centers globally.

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Assessment of the Subarachnoid Hemorrhage International Trialists (SAHIT) Models for Dichotomized Long-Term Functional Outcome Prediction After Aneurysmal Subarachnoid Hemorrhage in a United Kingdom Multicenter Cohort Study

Neurosurgery ◽

10.1093/neuros/nyaa299 ◽

2020 ◽

Author(s):

Isabel C Hostettler ◽

Menelaos Pavlou ◽

Gareth Ambler ◽

Varinder S Alg ◽

Stephen Bonner ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Functional Outcome ◽

Outcome Prediction ◽

Prediction Models ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Predictive Performance ◽

Term Outcome ◽

Long Term Outcome ◽

Fisher Grade

Abstract BACKGROUND Long-term outcome after subarachnoid hemorrhage, beyond the first few months, is difficult to predict, but has critical relevance to patients, their families, and carers. OBJECTIVE To assess the performance of the Subarachnoid Hemorrhage International Trialists (SAHIT) prediction models, which were initially designed to predict short-term (90 d) outcome, as predictors of long-term (2 yr) functional outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We included 1545 patients with angiographically-proven aSAH from the Genetic and Observational Subarachnoid Haemorrhage (GOSH) study recruited at 22 hospitals between 2011 and 2014. We collected data on age, WNFS grade on admission, history of hypertension, Fisher grade, aneurysm size and location, as well as treatment modality. Functional outcome was measured by the Glasgow Outcome Scale (GOS) with GOS 1 to 3 corresponding to unfavorable and 4 to 5 to favorable functional outcome, according to the SAHIT models. The SAHIT models were assessed for long-term outcome prediction by estimating measures of calibration (calibration slope) and discrimination (area under the receiver-operating characteristic curve [AUC]) in relation to poor clinical outcome. RESULTS Follow-up was standardized to 2 yr using imputation methods. All 3 SAHIT models demonstrated acceptable predictive performance for long-term functional outcome. The estimated AUC was 0.71 (95% CI: 0.65-0.76), 0.73 (95% CI: 0.68-0.77), and 0.74 (95% CI: 0.69-0.79) for the core, neuroimaging, and full models, respectively; the calibration slopes were 0.86, 0.84, and 0.89, indicating good calibration. CONCLUSION The SAHIT prediction models, incorporating simple factors available on hospital admission, show good predictive performance for long-term functional outcome after aSAH.

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Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage

Neurology ◽

10.1212/wnl.0000000000007501 ◽

2019 ◽

Vol 92 (20) ◽

pp. e2385-e2394 ◽

Cited By ~ 2

Author(s):

Cody L. Nesvick ◽

Soliman Oushy ◽

Lorenzo Rinaldo ◽

Eelco F. Wijdicks ◽

Giuseppe Lanzino ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Confidence Interval ◽

Ventriculoperitoneal Shunt ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Tertiary Referral Center ◽

Short And Long Term ◽

Csf Diversion

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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