Acute Aneurysmal Subarachnoid Hemorrhage Research Articles

Modulation of the Immunological Milieu in Acute Aneurysmal Subarachnoid Hemorrhage: The Potential Role of Monocytes Through CXCL10 Secretion.

Emerging evidence indicates that aneurysmal subarachnoid hemorrhage (aSAH) elicits a response from both innate and adaptive immune systems. An upregulation of CD8 + CD161 + cells has been observed in the cerebrospinal fluid (CSF) after aSAH, yet the precise role of these cells in the context of aSAH is unkown.CSF samples from patients with aSAH and non-aneurysmal SAH (naSAH) were analyzed. Single-cell RNA sequencing (scRNAseq) was performed on CD8 + CD161 + sorted samples from aSAH patients. Cell populations were identified using "clustering." Gene expression levels of ten previously described genes involved in inflammation were quantified from aSAH and naSAH samples using RT-qPCR. The study focused on the following genes: CCL5, CCL7, APOE, SPP1, CXCL8, CXCL10, HMOX1, LTB, MAL, and HLA-DRB1. Gene clustering analysis revealed that monocytes, NK cells, and T cells expressed CD8 + CD161 + in the CSF of patients with aSAH. In comparison to naSAH samples, aSAH samples exhibited higher mRNA levels of CXCL10 (median, IQR = 90, 16-149 vs. 0.5, 0-6.75, p = 0.02). A trend towards higher HMOX1 levels was also observed in aSAH (median, IQR = 12.6, 9-17.6 vs. 2.55, 1.68-5.7, p = 0.076). Specifically, CXCL10 and HMOX1 were expressed by the monocyte subpopulation. Monocytes, NK cells, and T cells can potentially express CD8 + CD161 + in patients with aSAH. Notably, monocytes show high levels of CXCL10. The elevated expression of CXCL10 in aSAH compared to naSAH indicates its potential significance as a target for future studies.

Effect of astragalus membranaceus on neurological function in acute aneurysmal subarachnoid hemorrhage patients with high inflammation: A preliminary randomized, double-blind, placebo-controlled clinical trial

Background and aimAstragalus membranaceus (AM) is a traditional Chinese herb. Our previous study revealed that AM can enhance neurological function in patients with acute intracerebral hemorrhage. The aim of this study was to investigated the effects of AM on patients with acute aneurysmal subarachnoid hemorrhage (aSAH). Experimental procedureEighty-eight patients experiencing acute aSAH were randomly allocated to either the treatment group (TG) comprising 44 patients, who received 3 g of AM orally thrice daily for 14 days, or the control group (CG) with 44 patients, who received 3 g of a placebo. ResultsEighty-three patients (41 in CG and 42 in TG) completed the trial. Stratified analyses revealed serum interleukin-6 (IL-6) median ≥7.28 pg/mL at baseline. The percentage of good GOS scores (GOS 4 or 5) at two weeks (W2) and four weeks (W4) was significantly higher in TG than in CG (W2: 35.3 % vs. 7.7 %, p = 0.042; W4: 62.5 % vs. 30.8 %, p = 0.044). Moreover, a higher percentage of Barthel index scores (>60) was observed in TG than in CG at W2 (35.3 % vs. 7.7 %, p = 0.042) after AM or placebo administration. ConclusionAdministering AM for 14 days has shown potential in enhancing neurological function four weeks post-aSAH onset, especially in patients with a serum IL-6 level median ≥7.28 pg/mL. Therefore, further research is warranted to explore the anti-inflammatory role of AM. However, this study's limitations include a small sample size and the single-center design, signifying its status as a preliminary investigation.

Safety of dual antiplatelet therapy in the acute phase of aneurysmal subarachnoid hemorrhage: a propensity score-matched study.

With the evolution of neuroendovascular treatments, there is a great trend to treat acutely ruptured wide-necked aneurysms with stent-assisted coiling (SAC) and flow diverters (FDs), which inevitably requires dual antiplatelet therapy (DAPT). This therapy can increase the rate of hemorrhagic complications following other neurosurgical maneuvers, such as external ventricular drain (EVD) placement or removal. In this study, the authors aimed to evaluate the safety of DAPT in patients with aneurysmal subarachnoid hemorrhage (SAH) treated with SAC or FDs and the therapy's potential benefit in reducing cerebral ischemia and cerebral vasospasm. In this retrospective study, the authors reviewed the records of patients who had been admitted to their hospital with acute aneurysmal SAH and treated with SAC, FDs, and/or coiling between 2012 and 2022. Patients were classified into two groups: a DAPT group, including patients who had received DAPT for SAC or FDs, and a non-DAPT group, including patients who had not received any antiplatelet regimen and had been treated with coiling. Perioperative hemorrhagic and ischemic complications and clinical outcomes were compared between the two groups. From among 938 cases of acute ruptured aneurysms treated during 10 years of study, 192 patients were included in this analysis, with 96 patients in each treatment group, after propensity score matching. All basic clinical and imaging characteristics were equivalent between the two groups except for the neck size of aneurysms (p < 0.001). EVD-related hemorrhage was significantly higher in the DAPT group than in the non-DAPT group (p = 0.035). In most patients, however, the EVD-related hemorrhage was insignificant. Parent artery or stent-induced thrombosis was higher in the DAPT group than in the non-DAPT group (p = 0.003). The rate of cerebral ischemia was slightly lower in the DAPT group than in the non-DAPT group (11.5% vs 15.6%, p = 0.399). In the multivariate analysis, cerebral ischemia, rebleeding before securing the aneurysm, extracranial hemorrhage, and cerebral vasospasm were the predictive factors of a poor clinical outcome (p < 0.001, p < 0.001, p = 0.038, and p = 0.038, respectively). The DAPT regimen may be safe in the setting of acute aneurysmal SAH. Although EVD-related hemorrhage is more common in the DAPT group than the non-DAPT group, it is usually insignificant without any neurological deficit.

The frequency and impact of tramadol addiction on acute aneurysmal subarachnoid hemorrhage: cross-sectional multicenter study

BackgroundArterial hypertension, cigarette smoking, excessive alcohol abuse and drug addiction such as cocaine all are known risk factors for aneurysmal subarachnoid hemorrhage (SAH). However, there is little information on whether tramadol addiction should also be considered as a risk factor for SAH. The purpose of this study was to investigate the prevalence and the impact of tramadol addiction on the symptomatology of intracranial aneurysmal SAH. We recruited 237 cases with acute aneurysmal ASH with a mean age of 52.3 ± 11.8 ranging from 17 to 86 years old.ResultsThere were 124 males and 113 females; 43 cases had a history of tramadol addiction (18.1%). Tramadol addicts were significantly younger, more likely to be male (97.7%), and more commonly associated with seizure onset compared with non-addicts. Multiple aneurysms, wide neck, and sizable aneurysms were significantly more common in tramadol than non-tramadol addicts as were dissecting aneurysms. There is a high association of acute aneurysmal SAH with tramadol addiction, especially in young patients.ConclusionsTramadol addiction might be regarded as modifiable risk factor of aneurysmal ASH and tramadol addicts had a worse presentation than non-tramadol addicts. If this finding is proved, it will be of great importance in managing patients with ruptured and un-ruptured intracranial aneurysms. Tramadol is available over-counter in some countries, more studies are needed.

Diagnosis and Management of Takotsubo Syndrome in Acute Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Diagnosis and Management of Takotsubo Syndrome in Acute Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage

After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. ClinicalTrials.gov Identifier: NCT01258257.

Refractory intracranial pressure elevation (ICP) treatment in acute aneurysmal subarachnoid hemorrhage via the novel neurapharesis CSF management system (P13-7.004)

<h3>Objective:</h3> We present the novel use of the CSF Neurapheresis™ CSF Management System as a safe, controlled CSF diversion system to manage ICP elevation in acute aneurysmal subarachnoid hemorrhage. <h3>Background:</h3> Aneurysmal Subarachnoid Hemorrhage (aSAH) often presents with elevated intracranial pressure (ICP) and communicating hydrocephalus, resulting in increased morbidity/mortality. The PILLAR-XT clinical trial of the Neurapheresis™ CSF Management System (NP) (an automated lumbar drain with an option to divert blood/waste products and return filtered CSF) highlighted its ability to filter and reduce blood/contaminants in the CSF of aSAH patients. We present the novel use of NP as a safe, controlled CSF diversion system to manage ICP elevation in these patients. <h3>Design/Methods:</h3> After enrollment, NP was successfully placed in a 58-year-old female presenting with a high grade ruptured saccular aneurysm (PCoA, Hunt/Hess grade 4), which was coiled. Two days post-admission, the patient experienced refractory ICP elevation (&gt;22mmHg) due to acute communicating hydrocephalus and aSAH. The neuro-intensivist adjusted CSF filtration and waste rates using the NP system to successfully treat ICP elevation. The patient was discharged home without complications and did not require a shunt. <h3>Results:</h3> This case illustrates the novel use of NP to control and manage ICP in acute aSAH while filtering blood/contaminants from the CSF. <h3>Conclusions:</h3> Patients with acute aSAH face high risk complications due to ICP-elevation, and directly related to rupture grade. Current standard of care offers tiers-based approach therapies for ICP management with the use of external ventricular devices (EVDs) for CSF diversion. EVDs are manual, non-specific, and prevent real-time ICP monitoring during CSF diversion, often resulting in incorrect drainage. PILLAR-XT highlighted the potential of NP as a tool for CSF diversion and filtration of RBCs/inflammatory-mediators that are instrumental in common secondary complications. This is the first case of utilizing NP device to divert and filter CSF and also concurrently treat ICP elevation. <b>Disclosure:</b> Dr. Babi has nothing to disclose. Spiros Blackburn has nothing to disclose. Andrew Grande has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Medtronic. Omar Choudri has nothing to disclose. Erick Hauck has nothing to disclose. Christopher Kellner has nothing to disclose.

Pathogenesis of cerebral amyloid angiopathy caused by chaotic glymphatics-Mini-review.

Cerebral amyloid angiopathy (CAA) is a common cause of lobar intracerebral hemorrhage in the elderly. It is also associated pathologically with Alzheimer's disease (AD). Both CAA and AD share similar pathology of deposition amyloid beta fibrils (Aβ). Aβ is deposited mainly in the neurites in AD and vascular walls in CAA. Aβ is formed inside the brain parenchyma from the amyloid precursor protein. It is easier to understand how Aβ is deposited in the cerebral neurites in AD. However, the pathogenesis of CAA is still largely unknown. It is difficult to understand or visualize how Aβ fibrils formed inside the brain can be deposited against the cerebral perfusion pressure to be deposited in the cerebral and meningeal arterial walls. We encountered an unusual clinical case of acute aneurysmal subarachnoid hemorrhage which was followed after a few years with localized CAA involving mainly the sites of the subarachnoid hemorrhage. We reviewed the formation of Aβ and postulated how the Aβ fibrils are transported retrogradely toward the cerebral arteries and deposited in the arterial walls resulting in the final pathology of CAA. There is a clear disturbance of the glymphatic system, the aquaporin-4 channel, and the parenchymal border macrophages.

Cardiac patterns for differentiation of neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage versus acute ischemic stroke.

Neurogenic stunned myocardium (NSM) has heterogeneous presentations for acute ischemic stroke (AIS) and aneurysmal subarachnoid hemorrhage (SAH). We sought to better define NSM and differences between AIS and SAH by evaluating individual left ventricular (LV) functional patterns by speckle tracking echocardiography (STE). We evaluated consecutive patients with SAH and AIS. Via STE, LV longitudinal strain (LS) values of basal, mid, and apical segments were averaged and compared. Different multivariable logistic regression models were created by defining stroke subtype (SAH or AIS) and functional outcome as dependent variables. One hundred thirty-four patients with SAH and AIS were identified. Univariable analyses using the chi-squared test and independent samples t-test identified demographic variables and global and regional LS segments with significant differences. In multivariable logistic regression analysis, when comparing AIS to SAH, AIS was associated with older age (OR 1.07, 95% CI 1.02-1.13, p=0.01), poor clinical condition on admission (OR 7.74, 95% CI 2.33-25.71, p<0.001), decreased likelihood of elevated admission serum troponin (OR .09, 95% CI .02-.35, p<0.001), and worse LS basal segments (OR 1.18, 95% CI 1.02-1.37, p=0.03). In patients with neurogenic stunned myocardium, significantly impaired LV contraction by LS basal segments was found in patients with AIS but not with SAH. Individual LV segments in our combined SAH and AIS population were also not associated with clinical outcomes. Our findings suggest that strain echocardiography may identify subtle forms of NSM and help differentiate the NSM pathophysiology in SAH and AIS.

Validation of a cerebral hemodynamic model with personalized calibration in patients with aneurysmal subarachnoid hemorrhage.

This study aims to validate a numerical model developed for assessing personalized circle of Willis (CoW) hemodynamics under pathological conditions. Based on 66 computed tomography angiography images, investigations were obtained from 43 acute aneurysmal subarachnoid hemorrhage (aSAH) patients from a local neurovascular center. The mean flow velocity of each artery in the CoW measured using transcranial Doppler (TCD) and simulated by the numerical model was obtained for comparison. The intraclass correlation coefficient (ICC) over all cerebral arteries for TCD and the numerical model was 0.88 (N = 561; 95% CI 0.84-0.90). In a subgroup of patients who had developed delayed cerebral ischemia (DCI), the ICC had decreased to 0.72 but remained constant with respect to changes in blood pressure, Fisher grade, and location of ruptured aneurysm. Our numerical model showed good agreement with TCD in assessing the flow velocity in the CoW of patients with aSAH. In conclusion, the proposed model can satisfactorily reproduce the cerebral hemodynamics under aSAH conditions by personalizing the numerical model with TCD measurements. Clinical trial registration: [http://www.trialregister.nl/], identifier [NL8114].

Nicotine Replacement Therapy for Smokers with Acute Aneurysmal Subarachnoid Hemorrhage: An International Survey.

IntroductionSmoking prevalence is twice as high among patients admitted to hospital because of the acute condition of aneurysmal subarachnoid hemorrhage (aSAH) as in the general population. Smoking cessation may improve the prognosis of aSAH, but nicotine replacement therapy (NRT) administered at the time of aSAH remains controversial because of potential adverse effects such as cerebral vasospasm. We investigated the international practice of NRT use for aSAH among neurosurgeons.MethodsThe online SurveyMonkey software was used to administer a 15-question, 5-min online questionnaire. An invitation link was sent to those 1425 of 1988 members of the European Association of Neurosurgical Societies (EANS) who agreed to participate in surveys to assess treatment strategies for withdrawal of tobacco smoking during aSAH. Factors contributing to physicians’ posture towards NRT were assessed.ResultsA total of 158 physicians from 50 nations participated in the survey (response rate 11.1%); 68.4% (108) were affiliated with university hospitals and 67.7% (107) practiced at high-volume neurovascular centers with at least 30 treated aSAH cases per year. Overall, 55.7% (88) of physicians offered NRT to smokers with aSAH, 22.1% (35) offered non-NRT support including non-nicotine medication and counselling, while the remaining 22.1% (35) did not actively support smoking cessation. When smoking was not possible, 42.4% (67) of physicians expected better clinical outcomes when prescribing NRT instead of nicotine deprivation, 36.1% (57) were uncertain, 13.9% (22) assumed unaffected outcomes, and 7.6% (12) assumed worse outcomes. Only 22.8% (36) physicians had access to a local smoking cessation team in their practice, of whom half expected better outcomes with NRT as compared to deprivation.ConclusionsA small majority of the surveyed physicians of the EANS offered NRT to support smoking cessation in hospitalized patients with aSAH. However, less than half believed that NRT could positively impact clinical outcome as compared to deprivation. This survey demonstrated the lack of consensus regarding use of NRT for hospitalized smokers with aSAH.

Blood Pressure Variability After Cerebrovascular Events: A Possible New Therapeutic Target: A Narrative Review.

Blood pressure variability, the variation of blood pressure during a certain period, results from the interaction of hemodynamic, neuronal, humoral, behavioral, and environmental factors. Cerebral autoregulation is impaired in acute cerebrovascular disease. Hence, increased blood pressure variability (BPV) may provoke or exacerbate secondary brain injury. In fact, available data showed that increased blood pressure variability is associated with worse outcomes after acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Consequently, BPV may represent a usual modifiable therapeutic target. This concept is particularly attractive because reduction of BPV can be feasible in regions with lower resources and can be applicable to patients with various forms of acute stroke. Prospective studies are needed to further clarify the relationship between BPV and secondary brain damage and the determinants of BPV in different clinical populations. Ultimately, cerebrovascular disease-specific randomized controlled trials aimed at reducing BPV, irrespective of the absolute blood pressure values, are needed to determine whether reduction of BPV can improve outcomes in patients with acute cerebrovascular disease.

A Scoping Review of the Incidence, Predictors, and Outcomes of Delirium Among Critically Ill Stroke Patients.

BACKGROUND: Delirium is a common, often iatrogenically induced syndrome that may impede the physical, cognitive, and psychological recovery of critically ill adults. The effect delirium has on outcomes of intensive care unit patients having acute neurologic injury remains unclear because previous studies frequently exclude this vulnerable population. The aim of this scoping review was to describe the incidence, predictors, and outcomes of delirium among adults admitted to an intensive care unit experiencing an acute ischemic stroke, intracerebral hemorrhage, or aneurysmal subarachnoid hemorrhage. METHODS: PubMed, CINAHL, Web of Science, EMBASE, and Scopus were searched with the terms (1) stroke, (2) critical care, and (3) delirium. Inclusion criteria were original peer-reviewed research reporting the incidence, outcomes, or predictors of delirium after acute stroke among critically ill adults. Editorials, reviews, posters, conference proceedings, abstracts, and studies in which stroke was not the primary reason for admission were excluded. Title and abstract screening, full-text review, and data extraction were performed by 2 authors, with disagreements adjudicated by a third author. RESULTS: The initial search yielded 1051 results. Eighteen studies met eligibility criteria and were included in the review. Stroke type was not mutually exclusive and included persons given a diagnosis of acute ischemic stroke (11), intracerebral hemorrhage (12), aneurysmal subarachnoid hemorrhage (8), and other (1) strokes. Incidence of delirium among stroke patients ranged from 12% to 75%. Predictors of delirium included older age, preexisting dementia, higher severity of illness, and physical restraint use. Outcomes associated with delirium included higher mortality, longer length of stay, worse cognition and quality of life, and lower functional status. CONCLUSIONS: Current findings are limited by heterogenous populations, assessments, and measurement parameters. Detection and management of delirium among critically ill stroke patients requires an approach with specific considerations to the complexities of acute neurological injury and concomitant critical illness.

ED BP Management for Subarachnoid Hemorrhage

To review most recent literature on management of blood pressure in acute aneurysmal subarachnoid hemorrhage (SAH) and provide practice recommendations for the emergency clinician. There is increased risk of aneurysmal rebleeding with systolic blood pressure (SBP) greater than 160mmHg in the acute setting. Avoiding large degrees of blood pressure variability improves clinical outcomes in aneurysmal SAH. Acute lowering of SBP to a range of 140-160mmHg decreases risk of rebleeding while also maintaining cerebral perfusion pressure (CPP) after aneurysmal rupture. Treatment with a short acting antihypertensive agent allows for rapid titration of blood pressure (BP) and reduces BP variability. Elevations in intracranial pressure occur commonly after SAH due to increased intracranial blood volume, cerebral edema, or development of hydrocephalus. Clinicians should be familiar with changes in cerebral autoregulation and effects on CPP when treating elevated BP, in order to mitigate the risk of secondary neurological injury.

Treatment of acute aneurysmal subarachnoid haemorrhage with primary flow diversion: 5-year single-centre experience

To evaluate the safety and efficacy of treatment of patients presenting with acute aneurysmal subarachnoid haemorrhage (SAH) with primary flow-diverting stents (FDS; with or without adjuncts), with comparison to the published literature. A retrospective single-centre review was undertaken of prospectively obtained data on patients treated for SAH over a 60-month period. Of 354 patients treated for SAH during that time period, 24 patients with a total of 25 aneurysms were identified. Baseline patient demographics were recorded and clinical and imaging outcomes assessed. Eighty-eight per cent (22/25) of the aneurysms were completely occluded (Raymond-Roy 1) at mean 12-month follow-up. The minor complication rate was 12.5% (3/24) without permanent morbidity. Mortality rate was 4% (1/25) after one patient died following aneurysmal rebleed on day 7 post-procedure. Forty-two per cent (10/24) of patients had a high-pressure shunt placed prior to endovascular treatment, no haemorrhagic complications of neurosurgical intervention were observed. The necessity of dual antiplatelet therapy (DAPT) therapy when deploying FDS will rightly continue to limit their use in the acutely ruptured setting to a case-by-case basis whereby other treatment options are deemed unsafe. Methods employed to minimise subsequent haemorrhagic risks from DAPT in these patients may be worthy of further investigation.

Beneficial Effect of Sodium Nitrite on EEG Ischaemic Markers in Patients with Subarachnoid Haemorrhage

Subarachnoid haemorrhage (SAH) is associated with long-term disability, serious reduction in quality of life and significant mortality. Early brain injury (EBI) refers to the pathological changes in cerebral metabolism and blood flow that happen in the first few days after ictus and may lead on to delayed cerebral ischaemia (DCI). A disruption of the nitric oxide (NO) pathway is hypothesised as a key mechanism underlying EBI. A decrease in the alpha-delta power ratio (ADR) of the electroencephalogram has been related to cerebral ischaemia. In an experimental medicine study, we tested the hypothesis that intravenous sodium nitrite, an NO donor, would lead to increases in ADR. We studied 33 patients with acute aneurysmal SAH in the EBI phase. Participants were randomised to either sodium nitrite or saline infusion for 1 h. EEG measurements were taken before the start of and during the infusion. Twenty-eight patients did not develop DCI and five patients developed DCI. In the patients who did not develop DCI, we found an increase in ADR during sodium nitrite versus saline infusion. In the five patients who developed DCI, we did not observe a consistent pattern of ADR changes. We suggest that ADR power changes in response to nitrite infusion reflect a NO-mediated reduction in cerebral ischaemia and increase in perfusion, adding further evidence to the role of the NO pathway in EBI after SAH. Our findings provide the basis for future clinical trials employing NO donors after SAH.

Relationship between aneurysmal location in subarachnoid hemorrhagic patients and both blood clot thickness and radiological vasospasm

Objective The aim was to detect the relationship between site of cerebral aneurysms and the amount of blood in computerized tomography and liability for early vasospasm using transcranial Doppler (TCD). Background The mortality with subarachnoid hemorrhage (SAH) is associated with cerebral vasospasm, rebreeding hydrocephalus, and seizures. Patients and methods This randomized controlled clinical trial recruited 30 patients from both sexes with acute aneurysmal SAH. Patients were recruited from Matarya Teaching Hospital during the period from October 2018 to June 2019. Outcome was assessed by Glasgow coma scale, Hunt and Hess scale (HHS), and modified Fisher scale (MFS). Patients were followed up by TCD on first, third, fifth, seventh, and 10th day of appearance of symptoms. Results There was no significant difference between cases with positive vasospasm vs negative vasospasm regarding age and sex. There was a significant association between early vasospasm and hypertension (P = 0.001), as well as smoking (P = 0.007). There was a significant difference between cases with positive vasospasm vs negative vasospasm regarding systolic blood pressure and diastolic blood pressure and glycosylated hemoglobin. There is a significant association between early vasospasm and symptomatic to vasospasm (P = 0.018). There was a significant difference between cases with positive vasospasm vs negative vasospasm regarding Glasgow coma scale, HHS, and MFS (P = 0.001 for all). Conclusion Continuous TCD measurements are valuable methods for early detection of vasospasm following SAH. Glasgow coma scale, HHS, MFS, aneurysmal size, aneurysmal site, systolic blood pressure and diastolic blood pressure, and glycosylated hemoglobin seem to be important predictors for vasospasm severity.

Protocol Adherence in the Intensive Care Unit for the Management of Adult Patients Admitted with Acute Aneurysmal Subarachnoid Hemorrhage

AbstractBackground There are recognized protocols that exist for management with minimal data regarding protocol adherence. We conducted a retrospective analysis of aneurysmal subarachnoid hemorrhage (aSAH) to determine whether the level of protocol adherence varied based on patient demographics or specific aspects of management.Materials and Methods All cases of aSAH admitted to a tertiary-level intensive care unit (ICU) from 2014 to 2016 were identified from the Australia and New Zealand Intensive Care Society Core Database as well as the clinical records system. ICU demographic and descriptive data for protocol adherence, were collected from admission to discharge up to 22 days, or until death whichever was earlier.Results A total of 58 cases of aSAH were registered; mean age was 56.7 years, 70.7% of patients were female, and mean length of stay was 12.6 days. World Federation of Neurosurgical Societies (WFNS) scale was documented more than Fisher grading. Of the 58 cases, 63.7% (37) underwent surgical clipping, with 83.7% (30) patients having this surgery within 48 hours. SBP/MAP were the most consistently recorded observations within protocol ranges, with adherence of 82.4% and 82.1%, respectively. Thirty-two percent of temperature measurements were outside of the normothermic range of 36.5 to 37.5°C with a mean adherence of 47.5% (standard deviation = ±0.24, median = 40). There was no correlation between adherence and patient, disease, or admission factors.Conclusion This study demonstrated that there was no association between variation in protocol adherence based on age, admission dates, or disease factors including WFNS grade and Fisher scale. Best protocol adherence protocol for the management of aSAH within the ICU was blood pressure control. Areas for improvement were documentation of the WFNS and Fisher grading, and temperature measurement and management.

Acute hyponatremia after aneurysmal subarachnoid hemorrhage: Frequency, treatment, and outcome

We retrospectively examined the course of serum sodium levels in 180 patients with acute aneurysmal subarachnoid hemorrhage (SAH) who had been admitted to the anesthesiologic-neurosurgical intensive care unit of the University Medical Center Regensburg, Germany, between January 2014 and December 2018. Each patient file was analyzed regarding the frequency and intensity of hyponatremic episodes and the administered medication. At admission to the intensive care unit (ICU), 18patients had shown initial hyponatremia (<135 mmol/L) and 4 patients hypernatremia (greater than145 mmol/L). 88(48.9%) of the 158 patients with normal serum sodium levels developed at least one hyponatremic episode during ICU treatment. The number of hyponatremic episodes was similar between patients with higher-grade and lower-grade aneurysmal SAH (P = 0.848). At the end of ICU treatment, outcome did not differ between patients with and without hyponatremia (40/88, 45.5% vs. 38/70, 54.3%, P = 0.270). At 6 months after SAH, however, good outcome (Glasgow outcome scale, GOS 4–5) was more frequently observed in patients with hyponatremia (26/88, 29.5% vs. 32/70, 45.7%, P = 0.036). Medication with sodium chloride, fludrocortisone, or tolvaptan was initiated in 75.4% patients with mild hyponatremia (130–134 mmol/L) and in 92.9% with moderate hyponatremia (125–129 mmol/L). At 6 months after SAH, patients treated with tolvaptan had a lower rate of poor outcome than patients who had not received tolvaptan (1/14, 7.1% vs. 25/74, 33.8%, P = 0.045). In patients with acute aneurysmal SAH and hyponatremic episodes, consequent treatment of hyponatremia prevented impaired outcome. Because administration of tolvaptan rapidly normalized serum sodium levels, this therapy seems to be a promising treatment approach.

Acute Aneurysmal Subarachnoid Haemorrhage following Coital Headache successfully treated with Endovascular Flow Diversion

&#x0D; &#x0D; &#x0D; &#x0D; Headache associated with sexual activity is a difficult diagnosis for physicians and sometimes underlies grave etiologies. One such cause associated with high morbidity and mortality is subarachnoid hemorrhage due to aneurysm rupture.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; This is a case of a 39 year old male, presenting with coital headache for few episodes. CT showed subarachnoid hemorrhage, Fischer Grade 3.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Digital subtraction angiography revealed Right Internal carotid artery very small aneurysm which was endovascularly managed with FRED (flow-redirection endoluminal device, Microvention, Aliso Viejo, California, USA) flow diverter placement across the aneurysm. Follow up revealed complete resolution of aneurysm with no residual clinical symptoms. The following case reveals the importance of identifying sexual headache as a presenting symptom of grave etiology like aneurysmal rupture and its early diagnosis and management to avoid mortality.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;