Delayed hospital admission of patients with aneurysmal subarachnoid hemorrhage: clinical presentation, treatment strategies, and outcome

OBJECTIVETimely aneurysm occlusion and neurointensive care treatment are key principles in the management of aneurysmal subarachnoid hemorrhage (aSAH) to prevent secondary brain injury. Patients with early (EHA) and delayed hospital admission (DHA) were compared in terms of clinical presentation, treatment strategies, aSAH-related complications, and outcome.METHODSIn this retrospective study, consecutive aSAH patients were treated at a single neurovascular center between 2009 and 2019. Propensity score matching was performed to account for divergent baseline characteristics.RESULTSAmong 509 included patients, 55 were admitted more than 48 hours after ictus (DHA group). DHA patients were significantly younger (52 ± 11 vs 56 ± 14 years, p = 0.03) and had lower World Federation of Neurosurgical Societies scores (p < 0.01) than EHA patients. In 54.5% of the cases, DHA patients presented with neurological deterioration or aggravated symptoms. Propensity score matching revealed a higher vasospastic infarction rate in the DHA group (41.5%) than in the EHA group (22.6%) (p = 0.04). A similar portion of patients in both groups achieved favorable outcome at midterm follow-up (77.3% vs 73.6%, p = 0.87). DHA patients (62.3%) received conventional coiling more often than EHA patients (41.5%) (p = 0.03).CONCLUSIONSDHA patients are at an increased risk of cerebral infarction. Nevertheless, state-of-the-art neurointensive care treatment can result in a good clinical outcome.

Download Full-text

Impact of Chronic Obstructive Pulmonary Disease on In-hospital Mortality in Patients with Aneurysmal Subarachnoid Hemorrhage: An Observational Cohort Study with Propensity Score Matching

10.21203/rs.3.rs-93436/v1 ◽

2020 ◽

Author(s):

Yu Zhang ◽

Linjie Li ◽

Wei Yao ◽

Xing Wang ◽

Liyuan Peng ◽

...

Keyword(s):

Chronic Obstructive Pulmonary Disease ◽

Cohort Study ◽

Subarachnoid Hemorrhage ◽

Propensity Score ◽

Hospital Mortality ◽

Propensity Score Matching ◽

Pulmonary Disease ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease

Abstract Objective: Chronic obstructive pulmonary disease (COPD) has been associated with several complications and mortality in acutely ill patients. For patients with aneurysmal subarachnoid hemorrhage (aSAH), the association between COPD and clinical outcomes remains unclear. Methods: In this retrospective cohort study, we analyzed consecutive aSAH patients admitted to the West China Hospital between 2009 and 2019. Propensity score matching was performed to obtain the adjusted odds ratios (ORs) with 95% CI. The primary outcome was in hospital mortality.Results: Using a ten-year clinical database from a large university medical center, 5643 patients with aSAH were identified, of whom 377 (7.9%) also had COPD. After matching, 289 patients were included in COPD group and 1156 in non-COPD groups. COPD was associated with increased in-hospital mortality (OR 1.63, 95% CI 1.02-2.62) and poor functional outcome at discharge (OR 1.37, 95% CI 1.04-1.80). Similarly, patients with COPD had significantly longer length of hospital stay, higher odds of seizure (OR 2.05, 95% CI 1.04-4.04), pneumonia (OR 3.10, 95% CI 2.38-4.04), intracranial infection (OR 1.62, 95% CI 1.14-2.29), urinary tract infection (OR 1.59, 95% CI 1.16-2.20) and bloodstream infection(OR 3.27, 95% CI 1.74-6.15). Conclusions: Among aSAH patients, COPD is associated with increased mortality. COPD represents a significant risk factor for pneumonia and seizure.

Download Full-text

Neutrophil Counts as Promising Marker for Predicting In-Hospital Mortality in Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/strokeaha.120.034024 ◽

2021 ◽

Author(s):

Yu Zhang ◽

Linjie Li ◽

Lu Jia ◽

Tiangui Li ◽

Yuanyuan Di ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Propensity Score ◽

Hospital Mortality ◽

Propensity Score Matching ◽

Odds Ratio ◽

Prognostic Value ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Inflammatory Factors ◽

Hospital Acquired Infections ◽

Hospital Acquired

Background and Purpose: Systemic inflammation is recognized as a hallmark of stroke. We aimed to evaluate the prognostic value of various inflammatory factors using blood at admission in patients with aneurysmal subarachnoid hemorrhage. Methods: In a multicenter observational study of patients with aneurysmal subarachnoid hemorrhage, the counts of neutrophil, platelet, and lymphocyte were collected on admission. Patients were stratified based on neutrophil counts with propensity score matching to minimize confounding. We calculated the adjusted odds ratios with 95% CIs for the primary outcome of in-hospital mortality and hospital-acquired infections. Results: A total of 6041 patients were included in this study and 344(5.7%) of them died in hospital. Propensity score matching analyses indicated that compared with the lower neutrophil counts, higher neutrophil counts were associated with increased risk of in-hospital mortality (odds ratio, 1.53 [95% CI, 1.14–2.06]), hospital-acquired infections (odds ratio, 1.61 [95% CI, 1.38–1.79]), and delayed neurological ischemic deficits (odds ratio, 1.52 [95% CI, 1.09–1.97]). Moreover, out of all the inflammatory factors studied, neutrophil counts demonstrated the highest correlation with in-hospital mortality and hospital-acquired infections. Conclusions: Among patients with aneurysmal subarachnoid hemorrhage, high neutrophil counts at admission were associated with increased mortality and hospital-acquired infections. The neutrophil count is a simple, useful marker with prognostic value in patients with aneurysmal subarachnoid hemorrhage.

Download Full-text

P.093 Hemoglobin values, fluctuations from baseline, and transfusion as predictors of outcome following aneurysmal subarachnoid hemorrhage

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2018.195 ◽

2018 ◽

Vol 45 (s2) ◽

pp. S41-S41

Author(s):

ME Eagles ◽

MK Tso ◽

RL Macdonald

Keyword(s):

Subarachnoid Hemorrhage ◽

Propensity Score ◽

Propensity Score Matching ◽

Roc Curve ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Youden Index ◽

Predictors Of Outcome ◽

Roc Curve Analysis ◽

Transfusion Threshold ◽

Poor Outcome

Background: Anemia following aneurysmal subarachnoid hemorrhage (aSAH) has been associated with poor outcome, but complications from transfusion have limited aggressive management of anemic patients. This study examined the relationship between hemoglobin levels, transfusion and outcome following aSAH. Methods: We performed a post-hoc analysis of the CONSCIOUS-1 trial. Poor outcome was defined as a 3-month modified Rankin Scale > 2. Minimum hemoglobin levels were evaluated as predictors of outcome using logistic regression analysis, ROC curve analysis, and LOWESS curves. Propensity score matching was used to assess the effect of transfusion on poor outcome in patients with minimum hemoglobin levels between 70-90 and 80-100 g/L. Results: Lower minimum hemoglobin levels were associated with poor outcome on both univariate (p<0.001) and multivariate (p=0.012) analysis. Area under the ROC curve for minimum hemoglobin was 0.673. Youden index analysis found a minimum hemoglobin threshold of 91.5 g/L maximally predictive for good functional outcome. Propensity score matching showed a trend towards poor outcome in transfused patients with minimum hemoglobin levels between 70-90 and 80-100 g/L (p=0.052 and 0.09). Conclusions: This work suggests that decreasing hemoglobin is an independent predictor of poor outcome following aSAH. However, there was a trend towards poor outcome in transfused patients. The optimal transfusion threshold should be evaluated by prospective trials.

Download Full-text

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

Journal of Neurosurgery ◽

10.3171/2019.3.jns183512 ◽

2020 ◽

Vol 133 (1) ◽

pp. 152-158 ◽

Cited By ~ 1

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.

Download Full-text

Clinical condition of 120 patients alive at 3 years after poor-grade aneurysmal subarachnoid hemorrhage

Acta Neurochirurgica ◽

10.1007/s00701-021-04725-2 ◽

2021 ◽

Author(s):

Anniina H. Autio ◽

Juho Paavola ◽

Joona Tervonen ◽

Maarit Lång ◽

Terhi J. Huuskonen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Condition ◽

Hospice Care ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Blood Clot ◽

Neurointensive Care ◽

Intracerebral Hematoma ◽

Poor Grade ◽

Final Study ◽

Study Population

Abstract Background To study the clinical condition of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients alive at 3 years after neurointensive care. Methods Of the 769 consecutive aSAH patients from a defined population (2005–2015), 269 (35%) were in poor condition on admission: 145 (54%) with H&H 4 and 124 (46%) with H&H 5. Their clinical lifelines were re-constructed from the Kuopio Intracranial Aneurysm Database and Finnish nationwide registries. Of the 269 patients, 155 (58%) were alive at 14 days, 125 (46%) at 12 months, and 120 (45%) at 3 years. Results The 120 H&H 4–5 patients alive at 3 years form the final study population. On admission, 73% had H&H 4 but only 27% H&H 5, 59% intracerebral hematoma (ICH; median 22 cm3), and 26% intraventricular blood clot (IVH). The outcome was favorable (mRS 0–1) in 45% (54 patients: ICH 44%; IVH clot 31%; shunt 46%), moderate (mRS 2–3) in 30% (36 patients: ICH 64%; IVH clot 19%; shunt 42%), and unfavorable (mRS 4–5) in 25% (30 patients: ICH 80%; IVH clot 23%; shunt 50%). A total of 46% carried a ventriculoperitoneal shunt. ICH volume was a significant predictor of mRS at 3 years. Conclusions Of poor-grade aSAH patients, 45% were alive at 3 years, even 27% of those extending to pain (H&H 5). Of the survivors, 75% were at least in moderate condition, while only 2.6% ended in hospice care. Consequently, we propose non-selected admission to neurointensive care (1) for a possibility of moderate outcome, and (2), in case of brain death, possibly improved organ donation rates.

Download Full-text

Stereotactic cisternal lavage in patients with aneurysmal subarachnoid hemorrhage with urokinase and nimodipine for the prevention of secondary brain injury (SPLASH): study protocol for a randomized controlled trial

Trials ◽

10.1186/s13063-021-05208-6 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Roland Roelz ◽

Fabian Schubach ◽

Volker A. Coenen ◽

Carolin Jenkner ◽

Christian Scheiwe ◽

...

Keyword(s):

Clinical Trials ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Neurological Outcome ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Standard Of Care ◽

Secondary Brain Injury ◽

Ringer’S Solution ◽

Randomized Controlled ◽

Therapy Protocol

Abstract Background Delayed cerebral infarction (DCI) is a major cause of death and poor neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Direct intrathecal therapies with fibrinolytic and spasmolytic drugs have appeared promising in clinical trials. However, access to the subarachnoid space for intrathecal drug administration is an unsolved problem so far, especially in patients with endovascular aneurysm securing. We investigate a therapy protocol based on stereotactic catheter ventriculocisternostomy (STX-VCS), a new approach to overcome this problem. The primary objective of this study is to assess whether cisternal lavage with urokinase, nimodipine, and Ringer’s solution administered via a stereotactically implanted catheter into the basal cisterns (= investigational treatment (IT)) is safe and improves neurological outcome in patients with aSAH. Methods This is a randomized, controlled, parallel-group, open-label phase II trial. Fifty-four patients with severe aSAH (WFNS grade ≥ 3) will be enrolled at one academic tertiary care center in Southern Germany. Patients will be randomized at a ratio of 1:1 to receive either standard of care only or standard of care plus the IT. The primary endpoint is the proportion of subjects with a favorable outcome on the Modified Rankin Scale (defined as mRS 0–3) at 6 months after aSAH. Further clinical and surrogate outcome parameters are defined as secondary endpoints. Discussion New approaches for the prevention and therapy of secondary brain injury in patients with aSAH are urgently needed. We propose this RCT to assess the clinical safety and efficacy of a novel therapy protocol for intrathecal administration of urokinase, nimodipine, and Ringer’s solution. Trial registration Deutsches Register Klinischer Studien (German Clinical Trials Register), DRKS00015645. Registered on 8 May 2019

Download Full-text

Hyponatremia in the Neurologically Ill Patient: A Review

The Neurohospitalist ◽

10.1177/1941874419895124 ◽

2020 ◽

Vol 10 (3) ◽

pp. 208-216

Author(s):

David P. Lerner ◽

Starane A. Shepherd ◽

Ayush Batra

Keyword(s):

Traumatic Brain Injury ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Early Diagnosis ◽

Neurological Disorders ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Treatment Strategies ◽

Diagnosis And Treatment ◽

Systemic Complications ◽

Acute Presentation

Hyponatremia is a well-known disorder commonly faced by clinicians managing neurologically ill patients. Neurological disorders are often associated with hyponatremia during their acute presentation and can be associated with specific neurologic etiologies and symptoms. Patients may present with hyponatremia with traumatic brain injury, develop hyponatremia subacutely following aneurysmal subarachnoid hemorrhage, or may manifest with seizures due to hyponatremia itself. Clinicians caring for the neurologically ill patient should be well versed in identifying these early signs, symptoms, and etiologies of hyponatremia. Early diagnosis and treatment can potentially avoid neurologic and systemic complications in these patients and improve outcomes. This review focuses on the causes and findings of hyponatremia in the neurologically ill patient and discusses the pathophysiology, diagnoses, and treatment strategies for commonly encountered etiologies.

Download Full-text

Effect of heparin on secondary brain injury in patients with subarachnoid hemorrhage: an additional ‘H’ therapy in vasospasm treatment

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012925 ◽

2017 ◽

Vol 9 (7) ◽

pp. 659-663 ◽

Cited By ~ 8

Author(s):

Markus Bruder ◽

Sae-Yeon Won ◽

Sepide Kashefiolasl ◽

Marlies Wagner ◽

Nina Brawanski ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Favorable Outcome ◽

Matched Pair ◽

Control Group ◽

High Morbidity ◽

Secondary Brain Injury ◽

Heparin Group ◽

Vasomotor Function

ObjectiveSecondary brain injury leads to high morbidity and mortality rates in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, evidence-based treatment strategies are sparse. Since heparin has various effects on neuroinflammation, microthromboembolism and vasomotor function, our objective was to determine whether heparin can be used as a multitarget prophylactic agent to ameliorate morbidity in SAH.MethodsBetween June 1999 and December 2014, 718 patients received endovascular treatment after rupture of an intracranial aneurysm at our institution; 197 of them were treated with continuous unfractionated heparin in therapeutic dosages after the endovascular procedure. We performed a matched pair analysis to evaluate the effect of heparin on cerebral vasospasm (CVS), cerebral infarction (CI), and outcome.ResultsThe rate of severe CVS was significantly reduced in the heparin group compared with the control group (14.2% vs 25.4%; p=0.005). CI and multiple ischemic lesions were less often present in patients with heparin treatment. These effects were enhanced if patients were treated with heparin for >48 hours, but the difference was not significant. Favorable outcome at 6-month follow-up was achieved in 69% in the heparin group and in 65% in the control group.ConclusionsPatients receiving unfractionated continuous heparin after endovascular aneurysm occlusion have a significant reduction in the rate of severe CVS, have CI less often, and tend to have a favorable outcome more often. Our findings support the potential beneficial effects of heparin as a multitarget therapy in patients with SAH, resulting in an additional ‘H’ therapy in vasospasm treatment.

Download Full-text

Thunderclap Headache

10.1093/med/9780190495541.003.0024 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Presentation ◽

Clinical Symptoms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Thunderclap Headache ◽

Reversible Cerebral Vasoconstriction Syndrome ◽

Cerebral Vasoconstriction ◽

Vasoactive Medication ◽

Angiographic Findings

Reversible cerebral vasoconstriction syndrome can cause thunderclap headache, subarachnoid hemorrhage, and stroke. The clinical presentation can be similar to aneurysmal subarachnoid hemorrhage and therefore requires rapid angiography. Angiographic findings of vasculopathy and resolution of clinical symptoms and imaging abnormalities support this diagnosis. This syndrome is most often incited following pregnancy or the ingestion of a vasoactive medication.

Download Full-text

Twelve-year single critical care center experience of nicardipine prolonged-release implants in patients with subarachnoid hemorrhage: a propensity score matching analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015664 ◽

2020 ◽

Vol 12 (8) ◽

pp. 774-776 ◽

Cited By ~ 2

Author(s):

Yasuhiro Kuroi ◽

Hidenori Ohbuchi ◽

Naoyuki Arai ◽

Yuichi Takahashi ◽

Shinji Hagiwara ◽

...

Keyword(s):

Critical Care ◽

Subarachnoid Hemorrhage ◽

Side Effects ◽

Propensity Score ◽

Cerebral Infarction ◽

Propensity Score Matching ◽

Cerebral Vasospasm ◽

Care Center ◽

Prolonged Release ◽

Significant Difference

ObjectiveTo develop a nicardipine prolonged-release implant (NPRI) to prevent cerebral vasospasm in patients with subarachnoid hemorrhage in 1999, which may be used during craniotomy, and report the results of our recent 12-year single critical care center experience.MethodsOf 432 patients with aneurysmal subarachnoid hemorrhage treated between 2007 and 2019, 291 were enrolled. 97 Patients were aged >70 years (33%), 194 were female (67%), 138 were World Federation of Neurological Societies grades 1, 2, and 3 (47%), 218 were Fisher group 3 (75%), and 243 had an anterior circulation aneurysm (84%). Using a propensity score matching method for these five factors, the severity of cerebral vasospasm, occurrence of delayed cerebral infarction, and modified Rankin Scale (mRS) score at discharge were analyzed.ResultsOne hundred patients each with or without NPRI were selected, and the ratios of coil/clip were 0/100 and 88/12, respectively. Cerebral vasospasm and delayed cerebral infarction were both significantly less common in the NPRI group (p=0.004, OR=0.412 (95% CI 0.223 to 0.760) and p=0.005, OR=0.272 (95% CI 0.103 to 0.714, respectively); a significant difference was seen in the mRS score at discharge by Fisher’s exact test (p=0.0025). A mRS score of 6 (dead) was less common in the group with NPRI, and mRS scores of 0 and 1 were also less common. No side effects were seen.ConclusionsNPRIs significantly reduced the occurrence of cerebral vasospasm and delayed cerebral infraction without any side effects. The NPRI and non-NPRI groups showed different patterns of short-term outcomes in the single critical care center, which might have been due to selection bias and patient characteristics. Differences in outcomes may become clear in comparisons with patients treated by craniotomy.

Download Full-text