Temperature management targeted on normothermia versus conventional fever control in patients with ruptured intracranial aneurysms A single center, retrospective study

Stroke-associated immunosuppression and inflammation are increasingly recognized as factors triggering infections and thus potentially influencing outcome after stroke. Several studies have demonstrated that elevated neutrophil-to-lymphocyte ratio (NLR) is a significant predictor of adverse outcomes for patients with ischemic stroke or intracerebral hemorrhage. Thus far, in patients with subarachnoid hemorrhage the association between NLR and outcome is insufficiently established. The authors sought to investigate the association between NLR on admission and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH). This observational study included all consecutive aSAH patients admitted to a German tertiary center over a 5-year period (2008-2012). Data regarding patient demographics and clinical, laboratory, and in-hospital measures, as well as neuroradiological data, were retrieved from institutional databases. Functional outcome was assessed at 3 and 12 months using the modified Rankin Scale (mRS) score and categorized into favorable (mRS score 0-2) and unfavorable (mRS score 3-6). Patients' radiological and laboratory characteristics were compared between aSAH patients with favorable and those with unfavorable outcome at 3 months. In addition, multivariate analysis was conducted to investigate parameters independently associated with favorable outcome. Receiver operating characteristic (ROC) curve analysis was undertaken to identify the best cutoff for NLR to discriminate between favorable and unfavorable outcome in these patients. To account for imbalances in baseline characteristics, propensity score matching was carried out to assess the influence of NLR on outcome measures. Overall, 319 patients with aSAH were included. Patients with unfavorable outcome at 3 months were older, had worse clinical status on admission (Glasgow Coma Scale score and Hunt and Hess grade), greater amount of subarachnoidal and intraventricular hemorrhage (modified Fisher Scale grade and Graeb score), and higher rates of infectious complications (pneumonia and sepsis). A significantly higher NLR on admission was observed in patients with unfavorable outcome according to mRS score (median [IQR] NLR 5.8 [3.0-10.0] for mRS score 0-2 vs NLR 8.3 [4.5-12.6] for mRS score 3-6; p < 0.001). After adjustments, NLR on admission remained a significant predictor for unfavorable outcome in SAH patients (OR [95% CI] 1.014 [1.001-1.027]; p = 0.028). In ROC analysis, an NLR of 7.05 was identified as the best cutoff value to discriminate between favorable and unfavorable outcome (area under the curve = 0.614, p < 0.001, Youden's index = 0.211; mRS score 3-6: 94/153 [61.4%] for NLR ≥ 7.05 vs 67/166 [40.4%] for NLR < 7.05; p < 0.001). Subanalysis of patients with NLR levels ≥ 7.05 vs < 7.05, performed using 2 propensity score-matched cohorts (n = 133 patients in each group), revealed an increased proportion of patients with unfavorable functional outcome at 3 months in patients with NLR ≥ 7.05 (mRS score 3-6 at 3 months: NLR ≥ 7.05 82/133 [61.7%] vs NLR < 7.05 62/133 [46.6%]; p = 0.014), yet without differences in mortality at 3 months (NLR ≥ 7.05 37/133 [27.8%] vs NLR < 7.05 27/133 [20.3%]; p = 0.131). Among aSAH patients, NLR represents an independent parameter associated with unfavorable functional outcome. Whether the impact of NLR on functional outcome is related to preexisting comorbidities or represents independent causal relationships in the context of stroke-associated immunosuppression should be investigated in future studies.

Implementing a strict fever control protocol for resuscitated cardiac arrest patients

Subarachnoid hemorrhage (SAH) is a common and frequently devastating condition, accounting for ≈5% of all strokes and affecting as many as 30 000 Americans each year.1,2 The American Heart Association (AHA) previously published “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage.”3 Since then, considerable advances have been made in endovascular techniques, diagnostic methods, and surgical and perioperative management paradigms. Nevertheless, outcome for patients with SAH remains poor, with population-based mortality rates as high as 45% and significant morbidity among survivors.4–9 Several multicenter, prospective, randomized trials and prospective cohort analyses have influenced treatment protocols for SAH. However, rapid evolution of newer treatment modalities, as well as other practical and ethical considerations, has meant that rigorous clinical scientific assessment of the treatment protocols has not been feasible in several important areas. To address these issues, the Stroke Council of the AHA formed a writing group to reevaluate the recommendations for management of aneurysmal SAH. A consensus committee reviewed existing data in this field and prepared the recommendations in 1994.3 In an effort to update those recommendations, a systematic literature review was conducted based on a search of MEDLINE to identify all relevant randomized clinical trials published between June 30, 1994, and November 1, 2006 (search terms: subarachnoid hemorrhage , cerebral aneurysm , trial ; Table 1). Each identified article was reviewed by at least 2 members of the writing group. Selected articles had to meet one of the following criteria to be included: randomized trial or nonrandomized concurrent cohort study. Case series and nonrandomized historical cohort studies were reviewed if no studies with a higher level of evidence were available for a particular topic covered in the initial guidelines. These were chosen on the basis of sample size and the relevance of the particular studies to subjects that …

Fever after therapeutic hypothermia – Does rebound pyrexia matter?

Background: The prognosis of patients with cerebral hemorrhage is strongly linked to systemic inflammatory responses. This study aimed to investigate the correlation between the systemic immune inflammation index (SII) and adverse outcomes in patients diagnosed with aneurysmal subarachnoid hemorrhage (aSAH). Method: Between February 2020 and September 2022, we conducted a retrospective cohort analysis involving 102 aSAH patients who visited our hospital. We collected baseline and clinical data to assess the relationship between SII and prognosis. Patients were categorized into either the good or poor prognosis group based on the modified Rankin Scale (mRS) score three months post-discharge. Comparative analysis of baseline and clinical data at admission and three months post-discharge was conducted between the two groups. Result: The study included 51 patients in the good prognosis group and 51 patients in the poor prognosis group. Statistically significant differences were observed between the groups in terms of age, the number of patients undergoing craniotomy clipping surgery, the number of patients receiving endovascular embolization treatment, main grade of Fisher at admission, and postoperative complications ( p &lt; 0.05). The Area Under Curve (AUC) for predicting adverse outcomes in aSAH using SII was 0.812 (95% confidence interval (CI): 0.730&#x2013;0.894, p &lt; 0.001), with a sensitivity of 0.863, specificity of 0.627, and an optimal cut-off value of 2214.5. Furthermore, the odds ratio (OR) of SII as an independent influencing factor was 10.586 (95% CI: 3.977&#x2013;28.177, p &lt; 0.001). Conclusion: The prognosis of aSAH patients at three months post-discharge is associated with their SII at admission. An elevated SII indicates a higher incidence of adverse outcomes in aSAH patients.

Older age and Fisher group scores predict poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, among aging societies, treatment indications and decisions in older patients with severe-grade aSAH (World Federation of Neurosurgical Societies [WFNS] grade IV or V) remain poorly understood. Therefore, we aimed to identify the risk factors associated with poor outcomes in non-older and older patients with severe-grade aSAH. We analyzed a database of patients with aSAH treated between April 2007 and December 2019 in Japan and divided them into either the non-older (< 75 years) or older group (age ≥ 75 years) to identify factors associated with poor outcomes (modified Rankin Scale score [mRS] 3-6) at discharge. The data analyzed included patient demographics, comorbidities, aneurysm characteristics, Fisher group, WFNS grade, treatment method, and mRS score at discharge. Among the 5,095 patients, 1,303 (986 non-older and 317 older) were classified as having severe-grade aSAH. In non-older patients, chronological age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.05) and Fisher groups 3 and 4 were associated with poor outcomes as compared with Fisher group 1 + 2 (OR, 2.98; 95% CI, 1.59-5.58 and OR, 5.49; 95% CI, 2.86-10.54, respectively). However, chronological age and Fisher groups 3 and 4 were not associated with poor outcomes in older patients with severe-grade aSAH. This study suggests that outcomes in older patients with severe-grade aSAH cannot be predicted in the same manner as in non-older patients. Further research on potential prognostic factors, such as biological age, is warranted. Clinical trial number Not applicable.

The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype. We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared. Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016). We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise.

Intraarterial Colforsin May Improve the Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

Fever during the first week after subarachnoid hemorrhage (SAH) is associated with poor outcome; however, eliminating fever has not been shown to improve outcome. We sought to explore the potential impact of induced normothermia using advanced fever control (AFC) methods on outcome after SAH. We identified 40 consecutive febrile patients enrolled in the Columbia University SAH Outcomes Project between 2003 and 2005 who underwent AFC (37 degrees C) with a surface cooling device during the first 14 days after SAH and randomly matched by age, Hunt and Hess grade, and SAH sum score to 80 SAH patients who underwent conventional fever control between 1996 and 2004. Average daily fever burden was calculated as the time and extent (degrees C x hours) above 37 degrees C. Poor outcome was defined as death or moderate to severe disability (modified Rankin Scale score of 4 or higher). A multivariate analysis was performed to identify factors associated with poor outcome 12 months after SAH. The fever burden was lower over 14 days in the AFC patients as compared with the patients receiving conventional fever control (P < .001). AFC patients had higher rates of hyperglycemia (P < .01) and arrhythmias (P = .02). Higher admission Hunt and Hess grade on admission and the development of pneumonia (P = .02) were associated with an increased risk for poor outcome at 12 months (P = .04), whereas AFC was associated with a reduced risk (P = .004) after adjusting for age, arrhythmia, and anemia. Elimination of fever with AFC may be associated with improved outcome after SAH. A prospective randomized trial of AFC vs conventional fever control is warranted.

Impact of Ultra-early Coiling on Clinical Outcome after Aneurysmal Subarachnoid Hemorrhage in Elderly Patients

Cerebral blood flow and cerebral oxygen consumption during hypothermia.

Previous studies found that lactate dehydrogenase (LDH) levels predicted poor outcomes in hemorrhagic stroke, but the prognostic role of LDH in ischemic stroke (IS) remains unclear. The aim of this study is to investigate the association between LDH and adverse clinical outcomes in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). All patients were enrolled from the Third China National Stroke Registry (CNSR-III). Adverse outcomes included all-cause death and poor functional outcomes [defined as modified Rankin Scale (mRS) score 3-6 and 2-6] at 3 months and 1 year. Multivariable Cox proportional hazards models and logistic regressions were used to evaluate the association of LDH with risk of all-cause death and poor functional outcomes, respectively. Among 9,796 included patients, the median [interquartile range (IQR)] of LDH was 175.00 (151.00-205.40) U/L. After adjustment for confounding factors, patients in the highest LDH quartile had a higher risk of all-cause death [hazard ratio (HR), 2.23; 95% confidence interval (CI), 1.27-3.90], and a higher proportion of mRS score 3-6 [odds ratio (OR), 1.54; 95% CI, 1.26-1.90] and mRS score 2-6 (OR, 1.56; 95% CI, 1.32-1.84) at 3 months. We also observed a J-shaped association between LDH and risk of each outcome. Consistent results were found at 1 year. Higher LDH levels are independently associated with adverse outcomes in patients with AIS or TIA.

T. Kiriş and J.H. Zhang, eds. Springer Wien; 2008, 450 pages, $289.00. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is one of the most difficult problems encountered by the clinicians who take care of these critically ill patients. The etiology of cerebral vasospasm after SAH

Nutritional deficiencies have been associated with the high prevalence of healthcare-associated infections (HAIs), which is particularly severe in elderly patients. The adverse effects of bloodstream infections (BSIs) in elderly patients are severe when they occur. The Geriatric Nutritional Risk Index (GNRI), specifically designed for the elderly, its prediction value of adverse outcomes of BSIs patients remains unclear. We conducted a two-year retrospective study in a large Chinese tertiary hospital, by collecting surveillance data on patients with bloodstream infections (BSI). We utilized descriptive analysis to delineate the demographic and clinical characteristics of BSI patients across different GNRI levels. The relationship between GNRI and adverse outcomes in BSI patients was investigated using logistic regression and restricted cubic spline (RCS) analysis. From 2020 to 2021, a total of 464 patients with BSI were identified. Among them, 203 (43.8%) were no risk, 70 (15.1%) at low risk, 118 (25.4%) at moderate risk and 73 (15.7%) at major risk for nutrition-related complications based on the GNRI classification. Patients whose GNRI at higher risk had higher mortality (P < 0.001). After adjusting for other covariates by multivariate logistic regression analysis, GNRI at major risk (GNRI < 82) [odds ratio (OR): 3.16; 95% confidence interval (CI): 1.52–6.58; P = 0.002] and GNRI at moderate risk (82 to < 92) (OR: 1.91; 95% CI: 1.00-3.62; P = 0.049) were associated with increased risk for mortality in patients with BSI, while GNRI score (per unit increase) had a protective effect (OR: 0.96; 95% CI: 0.94–0.98; P = 0.001). Furthermore, the RCS analysis showed that the risk of mortality decreased as GNRI scores increased and gradually became stable at GNRI scores above 96–98. We first report the prediction value of GNRI for BSIs patients' adverse outcomes by a two-year retrospective cohort study. There is significantly association between GNRI and adverse outcomes in patients with BSI. For those patients with a lower GNRI, clinicians need to provide more timely and rational nutritional intervention. 1. This study determines whether the GNRI is correlated with the prognosis of inpatients with BSIs, potentially enabling the early identification of those at great risk of adverse outcomes and facilitating timely interventions to enhance the prognosis and quality of care. 2. This study is helpful to improve the management of patients with bloodstream infections.

BackgroundWhile both hypercapnia and hypocapnia are harmful in patients with subarachnoid hemorrhage (SAH), it is unknown whether high-normal PaCO2 values are better than low-normal values. We hypothesized that high-normal PaCO2 values have more detrimental than beneficial effects on outcome.MethodsConsecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation treated in a tertiary care university hospital were retrospectively analyzed regarding the influence of PaCO2 on favorable outcome, defined as modified Rankin scale score < 3 at discharge. Primary endpoint was the difference in the proportion of PaCO2 values above 40 mmHg in relation to all measured PaCO2 values between patients with favorable and unfavorable outcome.Results150 patients were included. Median age was 57 years (p25:50, p75:64), median Hunt-Hess score was 4 (p25:3, p75:5). PaCO2 values were mainly within normal range (median 39.0, p25:37.5, p75:41.4). Patients with favorable outcome had a lower proportion of high-normal PaCO2 values above 40 mmHg compared to patients with unfavorable outcome (0.21 (p25:0.13, p75:0.50) vs. 0.4 (p25:0.29, p75:0.59)) resulting in a lower chance for favorable outcome (OR 0.04, 95% CI 0.00–0.55, p = 0.017). In multivariable analysis adjusted for Hunt-Hess score, pneumonia and length of stay, elevated PaCO2 remained an independent predictor of outcome (OR 0.05, 95% CI 0.00–0.81, p = 0.035).ConclusionsA higher proportion of PaCO2 values above 40 mmHg was an independent predictor of outcome in patients with aSAH in our study. The results need to be confirmed in a prospective trial.