Acute 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.

Contour Neurovascular System for endovascular embolization of cerebral aneurysms: a multicenter cohort study of 10 European neurovascular centers

BackgroundIntrasaccular devices have become increasingly popular in the treatment of cerebral aneurysms, particularly at the bifurcation. Here we evaluate the Contour Neurovascular System, an intrasaccular device for the endovascular treatment...

Evaluation of an Artificial Intelligence Model for Identification of Intracranial Hemorrhage Subtypes on Computed Tomography of the Head

BACKGROUND Intracranial hemorrhage is a critical finding on computed tomography (CT) of the head. This study compared the accuracy of an artificial intelligence (AI) model (Annalise Enterprise CTB Triage Trauma) to consensus neuroradiologist interpretations in detecting 4 hemorrhage subtypes: acute subdural/epidural hematoma, acute subarachnoid hemorrhage, intra‐axial hemorrhage, and intraventricular hemorrhage. METHODS A retrospective stand‐alone performance assessment was conducted on data sets of cases of noncontrast CT of the head acquired between 2016 and 2022 at 5 hospitals in the United States for each hemorrhage subtype. The cases were obtained from patients aged ≥18 years. The positive cases were selected on the basis of the original clinical reports using natural language processing and manual confirmation. The negative cases were selected by taking the next negative case acquired from the same CT scanner after positive cases. Each case was interpreted independently by up to 3 neuroradiologists to establish consensus interpretations. Each case was then interpreted by the AI model for the presence of the relevant hemorrhage subtype. The neuroradiologists were provided with the entire CT study. The AI model separately received thin (≤1.5 mm) and thick (>1.5 and ≤5 mm) axial series as available. RESULTS The 4 cohorts included 571 cases of acute subdural/epidural hematoma, 310 cases of acute subarachnoid hemorrhage, 926 cases of intra‐axial hemorrhage, and 199 cases of intraventricular hemorrhage. The AI model identified acute subdural/epidural hematoma with area under the curve of 0.973 (95% CI, 0.958–0.984) on thin series and 0.942 (95% CI, 0.921–0.959) on thick series; acute subarachnoid hemorrhage with area under the curve 0.993 (95% CI, 0.984–0.998) on thin series and 0.966 (95% CI, 0.945–0.983) on thick series; intraaxial hemorrhage with area under the curve of 0.969 (95% CI, 0.956–0.980) on thin series and 0.966 (95% CI, 0.953–0.976) on thick series; and intraventricular hemorrhage with area under the curve of 0.987 (95% CI, 0.969–0.997) on thin series and 0.983 (95% CI, 0.968–0.994) on thick series. Each finding had at least 1 operating point with sensitivity and specificity >80%. CONCLUSION The assessed AI model accurately identified intracranial hemorrhage subtypes in this CT data set. Its use could assist the clinical workflow, especially through enabling triage of abnormal CTs.

Cerebral Venous Sinus Thrombosis Presenting as Intracerebral Hemorrhage and Subarachnoid Hemorrhage: A Case Report

We present a 66-year-old male presenting with sudden onset of headache. Medical decompression was done and neuroimaging of plain cranial CT angiogram (CTA) and CT venogram (CTV) showed components of subarachnoid hemorrhage, intracerebral hemorrhage and hyperdense appearance of the superior sagittal sinus and proximal left transverse sinus. The following were done to look for etiologic factors: 1. fungal swab to determine the cause of the intracerebral hemorrhage secondary to venous thrombosis as the patient presented with a chronic history of sinusitis, 2. coagulopathy workup to look for a hypercoagulable state, and 3. workup for systemic disease of autoimmune in etiology. Anticoagulation was safely initiated within several days given the regression of the intracerebral hemorrhage along with stable findings of subarachnoid hemorrhage. Here we report cerebral venous sinus thrombosis rarely presenting as acute subarachnoid hemorrhage and intracerebral hemorrhage. Keywords: Cerebral venous thrombosis, superior sagittal sinus thrombosis, subarachnoid hemorrhage, intracerebral hemorrhage

Vessel wall imaging in the diagnosis of antiphospholipid syndrome presenting as Moyamoya syndrome-A case report.

Objectives: We describe a case of anti-phospholipid syndrome (APLS) vasculopathy presenting with Moyamoya syndrome (MMS) and show the associated intracranial vessel wall MRI (VWI) findings. Methods: A 37-year-old-woman presented with acute onset dizziness and left-sided weakness. Neurologic exam revealed a left facial droop and left hemiparesis. She underwent a comprehensive laboratory work-up for stroke. Neuroimaging included a CT head, CT angiogram, VWI, and digital subtraction angiography. Results: Work-up revealed a triple-positive APLS antibody profile. CT of the head showed an acute right basal ganglia infarction and right frontal subarachnoid hemorrhage. CT angiogram revealed severe stenosis of the right internal carotid artery terminus in a Moyamoya pattern. Intracranial VWI showed long-segment concentric vessel wall thickening and homogeneous vessel wall enhancement and T2-hyperintense wall edema of the stenotic right ICA terminus, M1 middle cerebral artery, and A1 anterior cerebral artery. She was treated with long-term anticoagulation with warfarin and a right superficial temporal artery to middle cerebral artery bypass. Discussion: We present intracranial VWI features of vessel wall pathology in a patient with primary APLS presenting with MMS.

Acute Subarachnoid Hemorrhage as a Result of Ruptured C1–C2 Cervical Spinal Arteriovenous Malformation: A Unique Case Report (P11-5.010)

Acute Subarachnoid Hemorrhage as a Result of Ruptured C1–C2 Cervical Spinal Arteriovenous Malformation: A Unique Case Report (P11-5.010)

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.

Blood Pressure Variability in Acute Stroke: A Narrative Review.

The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.

Safety and effectiveness of stent-assisted coiling with adjunctive techniques in ruptured acute aneurysms: a propensity score-matched cohort study.

The use of stent-assisted coiling (SAC) in acute subarachnoid hemorrhage cases is associated with higher incidence rates of bleeding and ischemic complications. The aim of this study was to evaluate the safety and efficacy of the SAC technique in the treatment of ruptured intracranial aneurysms (RIAs). A retrospective analysis was conducted on patients with RIAs treated with SAC or coiling alone (CA). Univariate analysis compared clinical information between the two groups. Propensity score matching was used to select patients for comparison and analyze surgical complications, prognosis, and imaging outcomes in both groups. A total of 394 aneurysms were included, and 272 aneurysms remained after application of propensity score matching, with an equal distribution of 136 cases in both the SAC and CA groups. There was no statistically significant difference in the immediate postoperative outcomes between the two groups (63.2% of SAC patients achieved class 1 on the Raymond-Roy occlusion classification scale vs 58.8% of CA patients, difference [95% CI] 4.4% [-0.076 to 0.163]; 33.1% achieved class 2 vs 38.2%, 5.1% [-0.065 to 0.170]; 3.7% achieved class 3 vs 2.9%, 0.8% [-0.047 to 0.062], p = 0.506). At the 1-year follow-up, the SAC group exhibited higher rates of complete occlusion (59.5% vs 42.4%, 17.1% [0.040-0.294]) and stability (24.0% vs 19.2%, 4.8% [-0.061 to 0.156]), while experiencing lower rates of improvement (12.4% vs 22.4%, 10.0% [0.001-0.201]) and recanalization (4.1% vs 16.0%, 11.9% [0.036-0.120]), with statistically significant differences in these outcomes (p < 0.001). No significant disparities were observed in clinical outcomes in terms of modified Rankin Scale (mRS) scores at discharge (76.5% vs 77.2% had mRS score 0-2, 0.7% [-0.098 to 0.113]; 23.5% vs 22.8% had mRS score 3-6, 0.7% [-0.098 to 0.113], p = 0.886) and 1-year follow-up (90.8% vs 92.2% had mRS score 0-2, 1.4% [-0.063 to 0.091]; 9.2% vs 7.8% had mRS score 3-6, 1.4% [-0.063 to 0.091], p = 0.683). Intraoperative rupture occurred more frequently in the SAC group compared with the CA group, although the difference was not statistically significant (5.1% vs 2.9%, 2.2% [-0.035 to 0.081], p = 0.356). The SAC group demonstrated a higher incidence of intraoperative thrombosis, but the difference was not statistically significant (8.1% vs 2.9%, 5.2% [-0.010 to 0.117], p = 0.063). Postoperative thrombosis in the SAC group was 3 times higher, but this difference was not statistically significant (6.6% vs 2.2%, 4.4% [-0.013, 0.106], p = 0.076). The surgery-related mortality rates did not differ significantly between the two groups (4.4% vs 5.9%, 1.5% [-0.048 to 0.077], p = 0.583). Although stent treatment for RIA results in some incidents of complications, it is safe and effective. Besides, the SAC group showed better vascular imaging results compared with the CA group.

Abstract WP158: Cortical Superficial Siderosis is Associated With Ischemia After Intracerebral Hemorrhage

Background: Ischemia on diffusion weighted imaging (DWI) after intracerebral hemorrhage (ICH) increases the risk of future ischemic stroke. Radiographic markers of small vessel disease, including cerebral microbleeds (CMB), are associated with DWI lesions. Though cortical superficial siderosis (cSS) is also a hemorrhagic small vessel disease subtype, it is unclear if cSS similarly relates to DWI lesions. We hypothesized that cSS would represent a more severe phenotype of small vessel disease and would associate with DWI lesions after ICH independent to other small vessel disease markers. Methods: Using the Intracerebral Hemorrhage Outcomes Project (ICHOP), we included all cases of spontaneous ICH who underwent DWI and susceptibility imaging/gradient echo. DWI hyperintensities were identified if &gt;10mm from the hematoma with decreased ADC signal. cSS were identified as subarachnoid hemosiderin deposition without acute subarachnoid hemorrhage. The relationship of cSS with DWI lesion presence as the outcome was assessed with logistic regression adjusted for ICH score, blood pressure change within 24 hours, and small vessel disease markers (CMB and white matter hyperintensity). Sensitivity analyses were performed to adjust for demographics and ICH location. A secondary analysis using linear regression assessed the association with the number of DWI lesions adjusted for similar covariates. Results: Of 198 patients analyzed, DWI lesions were observed in 31.3% and cSS in 10.6%. The presence of cSS was associated with DWI lesions (adjusted OR 3.72, CI: 1.29-10.72), independent of other small vessel disease markers. Separate sensitivity analyses adjusting for sex, race, and ICH location did not change the association of cSS with DWI lesions. In secondary analyses, cSS was not associated with greater number of DWI lesions counts (b 0.213, CI -0.53-0.63). Discussion: cSS is associated with the presence of DWI lesions, independent to other small vessel disease markers. cSS may represent a severe phenotype of small vessel disease with a risk of ICH recurrence and ischemia. Further work is required to investigate underlying mechanisms and optimal strategies to mitigate competing risks of future hemorrhage and ischemic events in these patients.

Abstract 134: Thrombotic Complications of Ovarian Hyperstimulation Syndrome

Introduction: Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of ovarian stimulation used during assisted reproductive technology cycles. In severe OHSS, increases in capillary permeability can result in hemoconcentration and hypercoagulability leading to thrombotic events, including stroke and cerebral venous thrombosis. Herein we sought to determine the prevalence of hospitalization for thrombotic events shortly after OHSS using population-level data. Methods: We conducted two separate retrospective cohort studies of patients with OHSS using publicly available datasets: (1) administrative claims data from the Healthcare Cost and Utilization Project (HCUP) across 11 states from 2016 to 2020 and (2) National Inpatient Sample (NIS) registry data from the end of 2015 to 2020. HCUP contains both emergency department and inpatient encounters whereas NIS contains a nationally representative sample of inpatient encounters. For our study, all female patients with an encounter for OHSS, defined using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code N98.1 were included from each dataset. Our primary study outcome was any stroke or major thrombotic event identified within 60 days of OHSS diagnosis in HCUP or during the index admission for OHSS in NIS. We used previously validated ICD-10-CM codes for acute ischemic stroke, intracerebral and subarachnoid hemorrhage, cerebral venous thrombosis, acute myocardial infarction, pulmonary embolism, and acute deep venous thrombosis to define our study outcome. Results: We identified a total of 747 patients with OHSS in HCUP. Within the HCUP cohort, fewer than 10 patients (&lt;1%) were hospitalized with a stroke or thrombotic event within 60 days of OHSS diagnosis. There were 1,955 hospitalizations for OHSS in NIS. There were 20 (1%) pulmonary embolisms and 35 (1.8%) acute deep venous thromboses, but no other stroke/thrombotic complications in NIS. Conclusions: We found very few thrombotic events shortly after OHSS diagnosis using two large datasets. The low rate of outcome events after OHSS seen in each of our population-level analyses increases the reliability of these study results.

Comparison of brain imaging and physical health between research and clinical neuroimaging cohorts of ageing.

To compare brain MRI measures between Adult Changes in Thought (ACT) participants who underwent research, clinical, or both MRI scans, and clinical health measures across the groups and non-MRI subjects. Retrospective cohort study leveraging MRI, clinical, demographic, and medication data from ACT. Three neuroradiologists reviewed MRI scans using NIH Neuroimaging Common Data Elements (CDEs). Total brain and white matter hyperintensity (WMH) volumes, clinical characteristics, and outcome measures of brain and overall health were compared between groups. 1166 MRIs were included (77 research, 1043 clinical, and 46 both) and an additional 3146 participants with no MRI were compared. Compared to the group with research MRI only, the clinical MRI group had higher prevalence of the following: acute infarcts, chronic haematoma, subarachnoid haemorrhage, subdural haemorrhage, haemorrhagic transformation, and hydrocephalus (each P < .001). Quantitative WMH burden was significantly lower (P < .001) and total brain volume significantly higher (P < .001) in research MRI participants compared to other MRI groups. Prevalence of hypertension, self-reported cerebrovascular disease, congestive heart failure, dementia, and recent hospitalization (all P < .001) and diabetes (P = .002) differed significantly across groups, with smaller proportions in the research MRI group. In ageing populations, significant differences were observed in MRI metrics between research MRI and clinical MRI groups, and clinical health metric differences between research MRI, clinical MRI, and no-MRI groups. This questions whether research cohorts can adequately represent the greater ageing population undergoing imaging. These findings may also be useful to radiologists when interpreting neuroimaging of ageing.

Coformulated quavonlimab and pembrolizumab (pembro) in combination with lenvatinib (lenva) as first-line (1L) therapy for patients (pts) with advanced hepatocellular carcinoma (HCC): Phase 2 KEYSTEP-004 study.

484 Background: Combinations of a PD-1/L1 inhibitor with a CTLA-4 or VEGF inhibitor have been approved as 1L treatment options for pts with advanced HCC. The multicenter, phase 2 KEYSTEP-004 study (NCT04740307) was conducted to evaluate the coformulation of quavonlimab (CTLA-4 inhibitor) and pembro (PD-1 inhibitor) in combination with lenva (multi–tyrosine kinase inhibitor) as 1L treatment for pts with advanced HCC. Methods: Pts were ≥18 y of age, had histologically or radiographically confirmed HCC with no prior systemic therapy, and were not amenable to curative therapy; had Child-Pugh class A; and ECOG PS 0 or 1. The study consisted of a safety lead-in phase (approximately 6-20 pts) to evaluate the tolerability of the recommended phase 2 dose of lenva with a possibility of dose modification based on dose-limiting toxicities (DLTs) and an efficacy expansion phase (approximately 110 pts). In the safety lead-in phase, pts received a fixed-dose coformulation of quavonlimab 25 mg and pembro 400 mg IV Q6W in combination with lenva 8 mg (body weight [BW] &lt;60 kg) or 12 mg (BW ≥60 kg) PO QD. Allocation to the efficacy expansion phase was allowed if the doses of lenva were determined to be tolerable. Primary end points were ORR per RECIST v1.1 by BICR and safety. Secondary end points included DOR, DCR, and PFS per RECIST v1.1 by BICR and OS. Results: No DLTs were observed in the 6 pts enrolled in the safety lead-in phase. 115 pts in the safety lead-in phase or the efficacy expansion phase were treated with the fixed-dose coformulation of quavonlimab and pembro plus lenva 8 or 12 mg. 94 pts (81.7%) were male, median age was 64 y (range, 32-83), and 80 pts (69.6%) had AFP ≤400 ng/mL. As of the June 22, 2023, data cutoff date, median follow-up (time from first dose to database cutoff date or death) was 7.7 mo (range, 0.9-22.1), and 89 pts (77.4%) discontinued treatment, most commonly due to progressive disease (39.1%). Confirmed ORR was 37.4% (95% CI, 28.5-46.9), with 5 CRs (4.3%) and 38 PRs (33.0%). DCR was 79.1% (95% CI, 70.6-86.1). Median DOR was 10.6 mo (range, 1.2+ to 23.1+). Median PFS and OS were 8.2 mo (95% CI, 6.2-10.2) and 22.1 mo (95% CI, 15.5-not reached), respectively; 12-mo PFS and OS rates were 32.2% and 65.2%, respectively. Treatment-related adverse events (TRAEs) occurred in 109 pts (94.8%); most common (≥25%) were hypertension (35.7%) and diarrhea (27.8%). Grade 3-5 TRAEs occurred in 66 pts (57.4%); most common (≥5%) were hypertension (8.7%) and immune-mediated enterocolitis (7.0%). 8 pts (7.0%) died due to AEs; 2 were considered treatment related (acute respiratory failure and subarachnoid hemorrhage). Conclusions: The coformulation of quavonlimab and pembrolizumab in combination with lenvatinib demonstrated manageable safety; further investigation is warranted to understand the efficacy of this triplet as 1L treatment for advanced HCC. Clinical trial information: NCT04740307 .

Nonconvulsive status epilepticus in patients with acute subarachnoid hemorrhage is associated with negative arterial spin labeling on peri-ictal magnetic resonance images

PurposeNon-convulsive status epilepticus (NCSE) is characterized by repetitive or continuous seizures without convulsions. Arterial spin labeling (ASL) is useful for assessing hyperperfusion due to neurovascular unit coupling in patients with NCSE; subarachnoid hemorrhage (SAH) impairs the neurovascular unit. We hypothesized that the sensitivity of ASL in detecting NCSE is low in patients with SAH during the acute phase. MethodsBased on ASL findings obtained within 48 h after the clinical suspicion of focal-onset NCSE, we divided 34 patients into ASL-negative (no hyperperfusion; n = 10) and ASL-positive (confirmed hyperperfusion; n = 24) groups. We further divided the two groups according to the NCSE etiology: patients who were diagnosed with NCSE within 14 days after SAH onset (acute SAH, n = 11) and patients with NCSE due to factors other acute SAH (n = 23) and compared their characteristics. ResultsIn 10 of the 34 patients (29.4 %) the ASL findings were normal. The rate of acute SAH was significantly higher in ASL-negative- (n = 8, 80.0 %) than ASL-positive patients (n = 3, 12.5 %). The rate of patients in aphasic status was significantly lower in ASL-negative patients (n = 1, 10 %) than in ASL-positive patients (n = 12, 50.0 %). ConclusionNormal ASL findings alone should not be used to exclude a diagnosis of NCSE particularly in patients in the acute phase of SAH with deterioration or no improvement in consciousness.

Multiple thrombotic coronary occlusions after acute traumatic subarachnoid hemorrhage.

Multiple thrombotic coronary occlusions after acute traumatic subarachnoid hemorrhage.

Relation of ECG Abnormalities to Clinical Severity and Troponin I Changes in Patients with Subarachnoid Hemorrhage

Relation of ECG Abnormalities to Clinical Severity and Troponin I Changes in Patients with Subarachnoid Hemorrhage

Prognostic factors and clinical nomogram for in-hospital mortality in traumatic brain injury

BackgroundTraumatic brain injury (TBI) is a major cause of death and functional disability in the general population. The nomogram is a clinical prediction tool that has been researched for a wide range of medical conditions. The purpose of this study was to identify prognostic factors associated with in-hospital mortality. The secondary objective was to develop a clinical nomogram for TBI patients' in-hospital mortality based on prognostic factors. MethodsA retrospective cohort study was conducted to analyze 14,075 TBI patients who were admitted to a tertiary hospital in southern Thailand. The total dataset was divided into the training and validation datasets. Several clinical characteristics and imaging findings were analyzed for in-hospital mortality in both univariate and multivariable analyses using the training dataset. Based on binary logistic regression, the nomogram was developed and internally validated using the final predictive model. Therefore, the predictive performances of the nomogram were estimated by the validation dataset. ResultsPrognostic factors associated with in-hospital mortality comprised age, hypotension, antiplatelet, Glasgow coma scale score, pupillary light reflex, basilar skull fracture, acute subdural hematoma, subarachnoid hemorrhage, midline shift, and basal cistern obliteration that were used for building nomogram. The predictive performance of the nomogram was estimated by the training dataset; the area under the receiver operating characteristic curve (AUC) was 0.981. In addition, the AUCs of bootstrapping and cross-validation methods were 0.980 and 0.981, respectively. For the temporal validation with an unseen dataset, the sensitivity, specificity, accuracy, and AUC of the nomogram were 0.90, 0.88, 0.88, and 0.89, respectively. ConclusionA nomogram developed from prognostic factors had excellent performance; thus, the tool had the potential to serve as a screening tool for prognostication in TBI patients. Furthermore, future research should involve geographic validation to examine the predictive performances of the clinical prediction tool.

Prevalence, predictors, and outcomes of acute respiratory distress syndrome in severe stroke.

Patients with severe stroke are at high risk of developing acute respiratory distress syndrome (ARDS), but this severe complication was often under-diagnosed and rarely explored in stroke patients. We aimed to investigate the prevalence, early predictors, and outcomes of ARDS in severe stroke. This prospective study included consecutive patients admitted to neurological intensive care unit (neuro-ICU) with severe stroke, including acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The incidence of ARDS was examined, and baseline characteristics and severity scores on admission were investigated as potential early predictors for ARDS. The in-hospital mortality, length of neuro-ICU stay, the total cost in neuro-ICU, and neurological functions at 90days were explored. Of 140 patients included, 35 (25.0%) developed ARDS. Over 90% of ARDS cases occurred within 1week of admission. Procalcitonin (OR 1.310 95% CI 1.005-1.707, P = 0.046) and PaO2/FiO2 on admission (OR 0.986, 95% CI 0.979-0.993, P < 0.001) were independently associated with ARDS, and high brain natriuretic peptide (OR0.994, 95% CI 0.989-0.998, P = 0.003) was a red flag biomarker warning that the respiratory symptoms may be caused by cardiac failure rather than ARDS. ARDS patients had longer stays and higher expenses in neuro-ICU. Among patients with ARDS, 25 (62.5%) were moderate or severe ARDS. All the patients with moderate to severe ARDS had an unfavorable outcome at 90days. ARDS is common in patients with severe stroke, with most cases occurring in the first week of admission. Procalcitonin and PaO2/FiO2 on admission are early predictors of ARDS. ARDS worsens both short-term and long-term outcomes. The conflict in respiratory support strategies between ARDS and severe stroke needs to be further studied.

Risk of stroke within 3, 7, 14, 21 and 30 days after influenza vaccination in Alberta, Canada: A population-based study.

Influenza vaccination is associated with a longer-term protective effect against stroke; however, it has a short-term inflammatory response which may increase short-term risk of stroke. The aim was to investigate the association between influenza vaccination and short-term risk of stroke in adults. Administrative data were obtained from the Alberta Health Care Insurance Plan for all adults in Alberta, Canada, from September 2009 to December 2018. The hazard of any stroke (acute ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage and transient ischaemic attack) within 3, 7, 14, 21 and 30 days of influenza vaccination compared to unexposed time was analysed using Andersen-Gill Cox models, with adjustment for age, sex, anticoagulant use, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, hypertension, income quintile, and rural or urban home location. In the entire cohort consisting of 4,141,209 adults (29,687,899 person-years), 1,769,565 (42.7%) individuals received at least one vaccination. In total 38,126 stroke events were recorded with 1309 occurring within 30 days of a vaccination event. Influenza vaccination was associated with a significantly reduced hazard of stroke within 3 days (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.73-0.93), 7 days (HR 0.87, 95% CI 0.80-0.95), 14 days (HR 0.87, 95% CI 0.81-0.93), 21 days (HR 0.85, 95% CI 0.80-0.91) and 30 days (HR 0.66, 95% CI 0.65-0.68). An increased early risk associated with vaccination was not observed. The risk of stroke was reduced at all time points within 30 days after influenza vaccination.

Subarachnoid Hemorrhage Following Drainage of Chronic Subdural Hematoma: A Case Report

Background: Acute subarachnoid hemorrhage (SAH) is a rare but severe complication after burr hole surgery for Subarachnoid hemorrhage (CSDH). Case presentation: An 86-year-old male was found fainted. Computed tomography (CT) scans showed a right fronto-temporo-parietal CSDH with a shift in the midline structures. Under local anesthetic with medical sedation a closed-system drainage of the hematoma was performed via one burr hole. Two days after surgery the patient complained of headache and a subsequent CT scan revealed SAH. The presence of intracranial aneurysms was excluded by CT angiogram. The patient survived with medical management.