Prevalence and predictors of fatigue after aneurysmal subarachnoid hemorrhage

Background Fatigue is a common and disabling sequel after aneurysmal subarachnoid hemorrhage (aSAH). At present, prevalence estimates of post-aSAH fatigue in the chronic phase are scarce and vary greatly. Factors from the acute phase of aSAH have hitherto barely been associated with post-aSAH fatigue in the chronic phase. Methods Prospective study assessing prevalence of fatigue using the Fatigue Severity Scale (FSS) in patients who were living independently 1 to 7 years after aSAH. We compared demographic, medical, and radiological variables from the acute phase of aSAH between patients with and without fatigue (FSS ≥ 4 versus < 4) and searched for predictors of fatigue among these variables applying univariable and multivariable regression analyses. Results Of 726 patients treated for aSAH in the period between January 2012 and December 2017, 356 patients completed the assessment. The mean FSS score was 4.7 ± 1.7, and fatigue was present in 69.7%. The frequency of patients with fatigue did not decline significantly over time. Univariable analysis identified nicotine use, loss of consciousness at ictus (LOCi), rebleed prior to aneurysm repair, reduced consciousness to Glasgow Coma Scale (GCS) < 14, large amounts of subarachnoid blood, the presence of acute hydrocephalus, and severe vasospasm as factors that were significantly associated with fatigue. In multivariable analysis, nicotine use, reduced GCS, and severe vasospasm were independent predictors that all more than doubled the risk to develop post-aSAH fatigue. Conclusions Fatigue is a frequent sequel persisting several years after aSAH. Nicotine use, reduced consciousness at admission, and severe vasospasm are independent predictors of fatigue from the acute phase of aSAH. We propose inflammatory cytokines causing dopamine imbalance to be a common denominator for post-aSAH fatigue and the presently identified predictors.

Impact of smoking on course and outcome of aneurysmal subarachnoid hemorrhage

Background While the smoking-related risk of experiencing an aneurysmal subarachnoid hemorrhage (aSAH) is well established, it remains unclear whether smoking has an unexpected “protective effect” in aSAH, or if smokers are more at risk for complications and poor outcomes. Methods Prospective, observational study investigating the course and outcome of aSAH in patients admitted during the years 2011 and 2012. Smoking status at admittance, demographic, medical, and radiological variables were registered along with management, complications, and outcome at 1 year in terms of mortality, modified Rankin score, and Glasgow outcome score extended. We compared current smokers with nonsmokers on group level and by paired analysis matched by aSAH severity, age, and severity of vasospasm. Results We included 237 patients, thereof 138 current smokers (58.2%). Seventy-four smoker/nonsmoker pairs were matched. Smokers presented more often in poor clinical grade, had less subarachnoid blood, and were younger than nonsmokers. Ruptured aneurysms were larger, and multiple aneurysms more common in smokers. Severe multi-vessel vasospasm was less frequent in smokers, whereas all other complications occurred at similar rates. Mortality at 30 days was lower in smokers and functional outcome was similar in smokers and nonsmokers. Poor clinical grade, age, cerebral infarction, and vertebrobasilar aneurysms were independent predictors of 1-year mortality and of poor functional outcome. Serious comorbidity was a predictor of 1-year mortality. Smoking did not predict mortality or poor functional outcome. Conclusions Notwithstanding clinically more severe aSAH, smokers developed less frequently severe vasospasm and had better outcome than expected. The risk for complications after aSAH is not increased in smokers.

Grief-induced reversible cerebral vasoconstriction syndrome (RCVS)

Stress is under-recognised as a potential causative factor for reversible cerebral vasoconstriction syndrome (RCVS). Here we present a case of RCVS occurring during a time of extreme emotional duress. A 46-year-old female patient with medical history of bipolar disorder developed a severe headache during her father’s funeral. The following day she was discovered to have bilateral hemiparesis, aphasia, encephalopathy and was brought emergently to the hospital. Neuroimaging revealed a 33 mL left fronto-parietal haematoma with subarachnoid blood near the vertex bilaterally. She underwent craniotomy, haematoma evacuation and external ventricular drain placement. The patient received two cerebral angiograms, the first showing multifocal cerebral vasoconstriction and the second showing resolution of these changes. She improved significantly over the course of her 3-week hospitalisation and eventually made a full recovery, including the ability to speak fluently in six languages with no significant deficits other than hypersomnia; she now requires 10 hours of sleep each night as compared with 7 hours prior to her brain injury.

Subarachnoid haemorrhage due to intracranial vertebral artery dissection presenting with atypical cauda equina syndrome features: case report

Background Failing to recognise the signs and symptoms of subarachnoid haemorrhage (SAH) causes diagnostic delay and may result in poorer outcomes. We report a rare case of SAH secondary to a vertebral artery dissection (VAD) that initially presented with cauda equina-like features, followed by symptoms more typical of SAH. Case presentation A 55-year-old man developed severe lower back pain after sudden movement. Over the next 5 days he developed paraesthesiaes in the feet, progressing to the torso gradually, and reported constipation and reduced sensation when passing urine. On day six he developed left facial palsy, and later gradual-onset headache and intermittent confusion. Magnetic resonance imaging of the brain showed diffuse subarachnoid FLAIR hyperintensity, concerning for blood, including a focus of cortical/subcortical high signal in the left superior parietal lobule, which was confirmed by computed tomography. Digital subtraction angiography demonstrated a left VAD with a fusiform aneurysm. Conclusion We present a very rare case of intracranial VAD with SAH initially presenting with spinal symptoms. The majority of subsequent clinical features were consistent with a parietal focus of cortical subarachnoid blood, as observed on neuroimaging.

PL01: Multicentre before-after implementation study of the Ottawa subarachnoid hemorrhage strategy

Introduction: The Ottawa SAH Rule was developed to identify patients at high-risk for subarachnoid hemorrhage (SAH) who require investigations and the 6-Hour CT Rule found that computed tomography (CT) was 100% sensitive for SAH 6 hours of headache onset. Together, they form the Ottawa SAH Strategy. Our objectives were to assess: 1) Safety of the Ottawa SAH Strategy and its 2) Impact on: a) CTs, b) LPs, c) ED length of stay, and d) CT angiography (CTA). Methods: We conducted a multicentre prospective before/after study at 6 tertiary-care EDs January 2010 to December 2016 (implementation July 2013). Consecutive alert, neurologically intact adults with a headache peaking within one hour were included. SAH was defined by subarachnoid blood on head CT (radiologists final report); xanthochromia in the cerebrospinal fluid (CSF); >1x106/L red blood cells in the final tube of CSF with an aneurysm on CTA. Results: We enrolled 3,669 patients, 1,743 before and 1,926 after implementation, including 185 with SAH. The investigation rate before implementation was 89.0% (range 82.9 to 95.6%) versus 88.4% (range 85.2 to 92.3%) after implementation. The proportion who had CT remained stable (88.0% versus 87.4%; p=0.60), while the proportion who had LP decreased from 38.9% to 25.9% (p<0.001), and the proportion investigated with CTA increased from 18.8% to 21.6% (p=0.036). The additional testing rate (i.e. LP or CTA) diminishedfrom 50.1% to 40.8% (p<0.001). The proportion admitted declined from 9.8% to 7.3% (p=0.008), while the mean length of ED stay was stable (6.2 +/− 4.0 to 6.4 +/− 4.1 hours; p=0.45). For the 1,201 patients with CT 6 hours, there was an absolute decrease in additional testing (i.e. LP or CTA) of 15.0% (46.6% versus 31.6%; p<0.001). The sensitivity of the Ottawa SAH Rule was 100% (95%CI: 98-100%), and the 6-Hour CT Rule was 95.3% (95%CI: 88.9-98.3) for SAH. Five patients with early CT had SAH with CT reported as normal: 2 unruptured aneuryms on CTA and presumed traumatic LP (determined by treating neurosurgeon); 1 missed by the radiologist on the initial interpretation; 1 dural vein fistula (i.e. non-aneuyrsmal); and 1 profoundly anemic (Hgb 63g/L). Conclusion: The Ottawa SAH Strategy is highly sensitive and can be used routinely when SAH is being considered in alert and neurologically intact headache patients. Its implementation was associated with a decrease in LPs and admissions to hospital.

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

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.

Abstract 121: Mechanisms of Cortical Superficial Siderosis in Cerebral Amyloid Angiopathy

Introduction: Mechanisms of cortical superficial siderosis (cSS) in cerebral amyloid angiopathy (CAA) are unknown, but might include in situ bleeding from amyloid laden superficial vessels or blood products redistribution from acute lobar intracerebral hemorrhage (ICH). Hypothesis: We aimed to identify factors related to the extent and multifocality of cSS. Methods: We analyzed consecutive CAA-related ICH patients diagnosed with Boston criteria from a prospective cohort. cSS multifocality, was rated for spatially distinct foci involvement and bi-hemispheric distribution on a 0-4 scale (1 point: 1 sulcus or focal immediately adjacent sulci, 2 points: 2 or more non-adjacent sulci OR more than 3 adjacent sulci, in each hemisphere) with excellent interrater reliability (k=0.87). Radiological markers of CAA and ICH characteristics were assessed using quantitative methods or validated visual scales, and their association with cSS multifocality was investigated in multivariable regression. Results: The cohort included 312 CAA patients (53% male; mean age 71.7). cSS was found in 34.6%: unifocal in 42 patients (13.5%), multifocal in 66 (23.1%). Presence and multifocality of cSS were not related with characteristics of the acute ICH such as ICH volume, ICH side or areas of acute subarachnoid blood on initial CT. ICH side did not predict cSS side or multifocality at that side. cSS multifocality was related to the presence of IVH in patients who had a single ICH without microbleeds (MB), but not in patients with multiple hemorrhagic lesions (ICH and/or MBs). In ordinal logistic regression, cSS multifocality was related to lobar microbleeds burden (OR: 1.57; 95%CI: 1.27-1.94; p<0.0001) and MRI centrum semiovale perivascular spaces (PVS, OR: 2.05; 95%CI: 1.26-3.33; p=0.004) but not basal ganglia PVS or leukoaraiosis volume. A secondary analysis using Cox regression showed that cSS multifocality was an independent risk factor for recurrent ICH (HR: 2.21; 95%CI: 1.09-4.52 and 3.91; 95%CI: 1.40-10.9 for multifocality presence and severity) after adjusting for other confounders. Conclusion: Extent and multifocality of cSS appear to be markers of CAA severity and independent predictors of ICH recurrence, and can provide insights potential into pathomechanisms.