Aneurysmal Spontaneous Subarachnoid Hemorrhage Research Articles

Radiographic predictors of aneurysmal etiology in patients with aneurysmal pattern subarachnoid hemorrhage.

Spontaneous angiogram-negative nonperimesencephalic subarachnoid hemorrhage (an-NPSAH) can represent a diagnostic and management dilemma. The authors sought to determine radiographic predictors of aneurysmal etiology based on admission noncontrast head CT scans. The authors performed a retrospective cohort study of prospectively collected data from consecutive patients who were admitted for spontaneous subarachnoid hemorrhage (SAH) with suspected aneurysmal etiology to an academic center from 2016 to 2021. They compared blood thickness in the basal cisterns and sylvian fissures and modified Graeb scores on admission head CT scans between the two groups and subsequently developed a predictive model to identify aneurysmal etiology. Of 259 included patients (mean age 56 years [SD 12.7 years]; 55% female), 209 had aneurysmal SAH (aSAH) and 50 had an-NPSAH. The median modified Graeb scores were similar for aSAH and an-NPSAH (6 [IQR 2-10] vs 3.5 [IQR 0-8.5], p = 0.33). The mean blood thickness was greater in the sylvian fissure (p = 0.010) and interhemispheric cisterns (p = 0.002), and there was a greater median degree of extension of blood in the sylvian fissures (p = 0.001) in aSAH than in an-NPSAH patients, but the mean blood thickness was less in the prepontine cistern (p = 0.014). The authors' scoring model was constructed based on differences in radiographic features. Receiver operating characteristic curve analysis showed acceptable accuracy in predicting aneurysmal etiology (area under the curve 0.71, 95% CI 0.62-0.79). There are differences in radiographic features on admission head CT between an-NPSAH and aSAH patients. The authors' proposed risk stratification model may be considered for further development and use in clinical practice in the future.

Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage

Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P= 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P= 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P= 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P= 0.272). Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.

Clinical Profile and Outcome in Patients with Spontaneous Subarachnoid Hemorrhage from a South Indian Tertiary Centre: A Prospective Observational Study.

Objective Spontaneous subarachnoid hemorrhage (SAH) is a neurological condition that causes significant morbidity and mortality. It is known to have regional differences in its incidence. Indian studies have shown conflicting results about the incidence of aneurysms as the cause of SAH, varying from 35% to 80%. The data available on the epidemiology of spontaneous SAH in the South Indian population are very few. Our study aims to describe the clinical profile of patients presenting with spontaneous SAH to the emergency department in a tertiary center in South India and describe the factors influencing the clinical outcome. Materials and Methods The study included 75 patients diagnosed with spontaneous SAH in our emergency department. Demographic data, medical history, details about the first medical contact, clinical features at admission, complications during the hospital stay, and interventions underwent were recorded. The study participants were followed-up at 6 weeks after discharge from hospital to assess the neurological outcome based on modified Rankin Scale (mRS) score, using a 9-point questionnaire. Results Of the 75 patients with spontaneous SAH, the majority were females, and in the age group of 50 to 69 years. The median time to first medical contact was observed to be 2 hours; and SAH was diagnosed at the first medical contact only in 37% of the patients. Hypertension was the most common comorbid condition associated with SAH (53%). Almost 80% of the patients who underwent angiographic studies had aneurysmal SAH (aSAH). Hydrocephalus was the most common complication seen in 37% of the patients, followed by hyponatremia (28%) and vasospasm (25%). At the time of follow-up after 6 weeks, we found that 36% of the patients were having a neurologically favorable outcome with an mRS score of 0 to 2, 8% of patients were having moderate to severe disability (mRS 3 to 5) and were living a dependent life. The mortality rate (mRS 6) was observed to be around 50% (6% lost to follow-up). Conclusion We observed a relatively higher incidence of aneurysmal rupture among the patients with spontaneous SAH in our region. The misdiagnosis rate at first medical contact was higher. The mortality rate was observed to be around 50% at 6 weeks. Loss of consciousness at ictus, aneurysmal rupture, WFNS grades IV-V, hydrocephalus, vasospasm, hypernatremia, and delayed cerebral ischemia were found to be the mortality predictors in SAH.

Genesis of Antibiotic Resistance (AR) LXXXII: Turbulence Modeling(TM) of Hemodynamics in Simplified Severe Sepsis Protocol‐2 (SSSP‐2)‐NCT01663701: The “Von Kármán Vortex Street” (Vasospasm probability index(VPI)) Fillip Zone of Obstruction Consequent Comatose to ihm

Based on Flow‐3DÒ Hydro FD simulation Model 04 (Courtesy: Flow‐3DÒ), clinical data for spontaneous subarachnoid hemorrhage (SAH) and flow gauge, here we present a plausible physiological basis for fluid bolus induced alteration of velocity profile with a fluid volume expansion, that leads to 100% ihm usual care cohort of SSSP‐2 (PMID: 28973227). Subsequent to SAH, an increase in blood flow velocity in cerebral arteries has been observed. The blood flow velocity after SAH was observed to be between 73 and 215 cm/sec (the frequency range of the pure tones: 140 to 820 Hz). The murmurs occurred after SAH has been suggested to be a transitional state between silent flow(laminar) and the phenomenon of bruit (DDx: Carotid Artery Stenosis, carotid cavernous fistula, fibromuscular dysplasia, Takayasu’s arteries, arteriovenous fistula). The cause of the murmur has been suggested to be periodic shedding of vortices in the cerebral arteries, referred to as “a von Kármán vortex street”.Murmurs are an indication of a pathological increase in blood velocities to reflect the degree of spasm(vascular) (PMID: 6689725). VPI, is a combination of transcranial Doppler(TCD) velocities, cerebral blood flow, and clinical risk factors to predict cerebral vasospasm after aneurysmal SAH (PMID: 18077946). Geometry: Lindegaard ratios and spasm indexes (TCD velocities/hemispheric CBF) to evaluate the probability of cerebral vasospasm after aneurysmal SAH. An increase in blood flow velocity (BFV) is the principal criterion for vasospasm. The Middle Cerebral Artery (MCA) /internal carotid artery (ICA) index (Lindegaard Index) is used to distinguish between vasospasm and cerebral hyperperfusion. The intracranial arteriovenous index (AVI) is used to assess vasospasm after SAH. (PMID 29243981). CPP=MAP‐ICP. The blood flow rate in carotid arteries, Table 4.14 p172, ISBN 9780128024089. Governing Equation:Part A: Strouhal number (St): This formula will generally hold true for the range 250 &lt; Red &lt; 200000: St=0.198 (1‐19.7/Red); where St=fd/U, f = vortex shedding frequency, d = diameter of the cylinder, U = flow velocity.Part B: To calculate pressure drop in cylindrical pipe Poiseuille Equation (Hagen‐Poiseuille Eq): Vmax= DPR2 / 4μL, (Eq 1.47, p32) where DP= pressure difference between the two ends, μ = dynamic viscosity, L= length of the pipe, Q= volumetric flow rate, π = 22/7 @3.14, R= pipe radius. For volumetric flow rate (Q) equals cross‐section area multiplied by velocity (Q=ṼA), so DP=8μL/πR4. To represent pressure drop and flow rate in cerebral arteries Poiseuille’s equation is written as Q=DP π R4/ 8ηL where η = viscosity. Derivation and Prospect:Taken together, direct correlation of S&amp;SX of SSSP‐2 (NCT01663701), that subsequent to the fluid bolus, the usual care cohort of SSSP‐2, may have had SAH within 24 to 48 hrs. During that period the LPE aggregates‐toxins of AR‐ClPrs origin forming the ZoO with a concurrent increase ICP, CBF, CBV, PRx, CPPopt, may have caused the cerebral vessel collapse eliciting CCP followed by 100% ihm.

Abstract WP104: Radiographic Predictors Of Aneurysmal Etiology In Patients With Aneurysmal Pattern Subarachnoid Hemorrhage

Introduction: Spontaneous angiogram-negative subarachnoid hemorrhage (anSAH) can represent a diagnostic dilemma as there is no vascular etiology identified and patients may require further imaging, including multiple angiograms, and have prolonged hospital stays. We sought to determine radiographic predictors of aneurysmal cause based on admission non-contrast head CT. Methods: We performed a retrospective case control study of patients who were admitted for spontaneous subarachnoid hemorrhage (SAH) with suspected aneurysmal etiology to an academic center from 2016 to 2021. Patients with pure convexity SAH were excluded. We compared blood thickness (continuous variable) in the basal cisterns and Sylvian fissures and modified GRAEB scores on admission head CT between the two groups. We subsequently developed a predictive model to identify aneurysmal etiology. Results: Of 148 included patients (mean age 56 years [SD 12.7]; 55% female, 70% white), 61 were aneurysmal SAH (aSAH) and 87 were anSAH with no vascular etiology. Median modified GRAEB score was higher in aSAH than anSAH (6 [IQR2-10] vs 0 [IQR0-4], p&lt;0.001). Mean blood thickness was greater in the Sylvian fissure (8mm [SD 5.8]vs 3mm [SD 5.2]; p&lt;0.001), interpeduncular (9mm [SD 5.3]vs 6mm [SD 4.2]; p=0.005), quadrigeminal (3mm [SD 3.7] vs 1mm [SD 2]; p=0.003), crural (6mm [SD 3.7] vs 3mm [SD 2.2]; p=0.014), and ambient cisterns (6mm [SD 7.1] vs 3mm [SD 2.6], p=0.0015) in aSAH compared to anSAH, but less in prepontine cistern (3mm [SD 3.8] vs 5mm [5.2], p=0.006). Our 8-point scoring model is based on differences in radiographic features. Receiver operating characteristics (ROC) curve analysis showed high accuracy in predicting aneurysmal etiology (area under the curve [AUC] 0.79, 95% CI 0.70-0.88; odds ratio 1.45 per point increase, 95% CI 1.24-1.70; p&lt;0.001). Conclusion: The proposed scoring tool can aid clinicians in predicting aneurysmal etiology in patients with aneurysmal pattern SAH using measurements from admission head CTs. Eliminating an aneurysmal etiology of anSAH earlier may reduce the need for further extensive work up, hospital length of stay and associated complications, thereby reducing health care related costs. This model needs to be validated in a larger multi-center study.

Судомний напад у дебюті як ізольований предиктор незадовільного результату після спонтанного субарахноїдального крововиливу аневризматичного генезу

Актуальність. Близько 6–8 % всіх інсультів становить субарахноїдальний крововилив (САК) внаслідок розриву артеріальної аневризми. 10–15 % із них є фатальними, тобто пацієнт помирає ще до того, як надійшов до стаціонару. За даними деяких авторів, судоми в гострий період САК (перші 7 діб) асоціюються із збільшенням ризику смерті й інвалідності, тоді як інші автори заперечують вплив судом на перебіг САК. З огляду на суперечливість цих даних судоми не входять у класичні шкали з оцінки прогнозу перебігу САК. Мета: провести аналіз поширеності гострого симптоматичного епінападу при САК і дослідити його вплив на перебіг цього захворювання. Розробити прогностичну шкалу оцінки САК з урахуванням судомних нападів. Матеріали та методи. Проведено аналіз серії 127 клінічних випадків САК. Усіх пацієнтів оцінено за стандартними шкалами: Hunt — Hess Scale, the World Federation of Neurological Surgeons Scale, Glasgow Coma Scale. Досліджено поширеність гострого симптоматичного епінападу. Всіх пацієнтів оцінено за створеною шкалою комбінованої оцінки прогнозування наслідку у пацієнта після субарахноїдального крововиливу (ШКОП). Результати лікування оцінено за Glasgow Outcome Scale (шкала наслідку Глазго). Результати. У 13 пацієнтів із 127 спостерігалися судоми в гострий період захворювання. У кожного 10­го пацієнта епілептичний напад був першим клінічним симптомом хвороби. Поширеність епілептичних нападів становила 10,2 %, до того ж у 5 з 13 пацієнтів із судомами САК закінчився летально, що станоить 35,7 % всіх летальних випадків, зафіксованих у нашій групі пацієнтів. Запропоновано враховувати судоми в дебюті САК як ізольований предиктор поганого наслідку у пацієнтів. Розроблено ШКОП, до якої включено критерій наявності/відсутності судом у дебюті. Летальність серед пацієнтів, які набрали 5–6 балів за ШКОП, становила 77 %, серед пацієнтів, які набрали 7–8 балів, — 100 %. Висновки. Судомний напад у дебюті САК асоціюється з вірогідним підвищенням ризику смерті (p = 0,001). ШКОП із субарахноїдальним крововиливом дозволяє прогнозувати перебіг захворювання, що сприяє вчасним корекції лікування, призначенню швидкодіючих парентеральних антиконвульсантів і, відповідно, визначає кращий наслідок у пацієнтів.

Validation of shunt dependency prediction scores after aneurysmal spontaneous subarachnoid hemorrhage.

Currently available scores for predicting shunt dependency after aneurysmal spontaneous subarachnoid hemorrhage (aSAH) are limited and not widely accepted. The key purpose of this study was to validate a recently created score for shunt dependency in aSAH (SDASH) in an independent population of aSAH patients. We compared this new SDASH score based on a combination of the Hunt and Hess grade, Barrow Neurological Institute (BNI) score, and the presence or not of acute hydrocephalus with other published predictive scores. The SDASH score, Hijdra score, BNI grading system, chronic hydrocephalus ensuing from SAH score (CHESS), Graeb score, and modified Graeb score (mGS) were calculated for a cohort of aSAH patients. Logistic regression analysis was used to determine the reliability of the SDASH score, and the area under the curve (AUC) of the receiver operating characteristics (ROC) curve was used to assess the discriminative ability of the model. In 214 patients with aSAH, 40 (18.7%) developed shunt-dependent hydrocephalus (SDHC). The AUC for the SDASH score was 0.816. The SDASH score reliably predicted SDHC in aSAH (odds ratio: 2.93, 95% CI: 1.99-4.31; p < 0.001) with no statistically significant differences being found between the SDASH score and the CHESS score (AUC: 0.816), radiological-based Graeb score (AUC: 0.742), or modified Graeb score (AUC: 0.741). However, the Hijdra score (AUC: 0.673) and BNI grading system (AUC: 0.616) showed lower predictive values than the SDASH score. Our findings support the ability of the SDASH score to predict shunt dependency after SAH in a population independent to that used to develop the score. The SDASH score may aid in the early management of hydrocephalus in aSAH, and it does not differ greatly from other predictive scores.

Characteristics of aneurysmal subarachnoid hemorrhage associated with rheumatic disease.

Spontaneous subarachnoid hemorrhage (SAH) occurs due to intracranial aneurysm rupture in most cases. Rheumatic disease may cause vessel wall inflammation, which can increase the risk of rupture. However, the characteristics of SAH with rheumatic disease are unknown. This study aimed to evaluate SAH features in patients with rheumatic disease. We retrospectively analyzed clinical data of 5066 patients from the Nagasaki SAH Registry Study who had been diagnosed with aneurysmal SAH between 2001 and 2018. We evaluated the SAH characteristics in patients with rheumatic disease using multivariable logistic regression analysis. In total, 102 patients (2.0%, 11 men and 91 women, median age 69.0 [57.0-75.5]) had rheumatic disease. In these patients, univariate logistic regression analysis showed that sex, hypertension, family history of SAH, smoking history, World Federation of Neurosurgical Societies grade on admission, aneurysm size, multiple aneurysms, treatment, and symptomatic spasms were associated with SAH. Multivariable logistic regression analysis showed that characteristics independently associated with SAH in rheumatic disease were female sex (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.81-6.93, P < 0.001), hypertension (OR 0.60; 95% CI 0.40-0.90, P = 0.012), family history of SAH (OR 0.18; 95% CI 0.01-0.80, P = 0.020), small ruptured aneurysms (OR 1.50; 95% CI 1.02-2.24, P = 0.048), and multiple aneurysms (OR 1.69; 95% CI 1.09-2.58, P = 0.021) in comparison with SAH without rheumatic disease. In conclusion, SAH in patients with rheumatic disease was characterized by small multiple aneurysms, regardless of the low incidence of hypertension and family history of SAH.

Higher mean arterial pressure increases risk of in-hospital mortality in aneurysmal subarachnoid hemorrhage

Background The majority (80%) of spontaneous subarachnoid hemorrhage (SAH) cases are caused by cerebral aneurysm rupture. The reported case fatality rate of aneurysmal SAH is still as high as 25 to 50%. Even though studies on aneurysmal SAH have been conducted, the mechanism and factors contributing to its mortality have not yet been clearly understood. The present study aimed to determine the predictors of mortality in aneurysmal SAH.Methods This was an observational analytic cross-sectional study. Data of 264 patients with aneurysmal SAH was obtained retrospectively from the medical records. Age, degree of consciousness, blood pressure, absence of aneurysmal treatment and mortality were collected. The simple and multiple logistic regression were used to analyze the data.Results The in-hospital mortality rate of aneurysmal SAH was still very high, with 140 (53.1%) patients dying during hospitalization. Simple logic regression analysis showed that patients with older age, lower Glasgow Coma Scale (GCS) score, higher mean arterial pressure (MAP) and no aneurysm treatment had higher in-hospital mortality risk. However, multivariate logistic regression showed that the strongest in-hospital mortality predictor was higher MAP (aOR 2.29; p=0.025), while younger age (aOR 0.39; p=0.006) and aneurysm treatment (aOR 0.34; p=0.006) were independent protective factors against in-hospital death.Conclusion Patients with higher mean arterial pressure on initial measurement had higher risks of mortality. More endovascular neurointervention facilities are needed to decrease the mortality rate of aneurysmal SAH.

The Yield of Repeat Angiography in Angiography-Negative Spontaneous Subarachnoid Hemorrhage.

Objective Despite the technological advancement in imaging, digital subtraction angiography (DSA) remains gold standard imaging modality for spontaneous subarachnoid hemorrhage (SAH). But even after DSA, around 15% of SAH remains elusive for the cause of the bleed. This is an institutional review to solve the mystery, “when is second DSA really indicated?” Methods In a retrospective review from January 2015 to December 2017, we evaluated cases of spontaneous SAH with initial negative DSA with repeat DSA after 6 weeks to rule out vascular abnormality. The spontaneous SAH was confirmed on noncontrast computed tomography (NCCT) and divided into two groups of perimesencephalic SAH (PM-SAH) or nonperimesencephalic SAH (nPM-SAH). The outcome was assessed by a modified Rankin’s score (mRS) at 6 months postictus. Results During the study period, we had 119 cases of initial negative DSA and 98 cases (82.3%) underwent repeat DSA after 6 weeks interval. A total of 53 cases (54.1%) had PM-SAH and 45 cases (45.9%) had nPM-SAH. Repeat DSA after 6 weeks showed no vascular abnormality in 53 cases of PM-SAH and in 2 (4.4%) out of 45 cases of nPM-SAH. At 6 months postictus, all cases of PM-SAH and 93% of nPM-SAH had mRS of 0. Conclusion We recommend, a repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH. Although the overall outcome for nonaneurysmal spontaneous SAH is better than aneurysmal SAH, nPM-SAH has poorer eventual outcome compared to PM-SAH.

A Model for Prediction of In-Hospital Mortality in Patients with Subarachnoid Hemorrhage.

Despite being a rare cause of stroke, spontaneous subarachnoid hemorrhage (SAH) is associated with high mortality rates. The prediction models that are currently being used on SAH patients are heterogeneous, and few address premature mortality. The aim of this study was to develop a mortality risk stratification score for SAH. A retrospective study was carried out with 536 patients diagnosed with SAH who had been admitted to the intensive care unit (ICU) at the University Hospital Complex of A Coruña (Spain) between 2003 and 2013. A multivariate logistic regression model was developed to predict the likelihood of in-hospital mortality, adjusting it exclusively for variables present on admission. A predictive equation of in-hospital mortality was then computed based on the model's coefficients, along with a points-based risk-scoring system. Its discrimination ability was also tested based on the area under the receiver operating characteristics curve and compared with previously developed scores. The mean age of the patients included in this study was 56.9 ± 14.1years. Most of these patients (73.9%) had been diagnosed with aneurysmal SAH. Their median length of stay was 7days in the ICU and 20days in the general hospital ward, with an overall in-hospital mortality rate of 28.5%. The developed scales included the following admission variables independently associated with in-hospital mortality: coma at onset [odds ratio (OR) = 1.87; p = 0.028], Fisher scale score of 3-4 (OR = 2.27; p = 0.032), Acute Physiology and Chronic Health Evaluation II (APACHE II) score within the first 24h (OR = 1.10; p < 0.001), and total Sequential Organ Failure Assessment (SOFA) score on day 0 (OR = 1.19; p = 0.004). Our predictive equation demonstrated better discrimination [area under the curve (AUC) = 0.835] (bootstrap-corrected AUC = 0.831) and calibration properties than those of the HAIR scale (AUC = 0.771; p ≤ 0.001) and the Functional Recovery Expected after Subarachnoid Hemorrhage scale (AUC = 0.814; p = 0.154). In addition to the conventional risk factors for in-hospital mortality, in our study, mortality was associated with the presence of coma at onset of the condition, the physiological variables assessed by means of the APACHE II scale within the first 24h, and the total SOFA score on day 0. A simple prediction model of mortality was developed with novel parameters assessed on admission, which also assessed organ failure and did not require a previous etiological diagnosis.

Epidemiology of spontaneous subarachnoid hemorrhage in the state of Qatar.

Background: Spontaneous subarachnoid hemorrhage (SAH) is one of the significant etiologies for stroke. SAH causes higher morbidity and mortality with loss of productivity, resulting in increased disease burden. Only few studies in Qatar have reported on SAH, and the epidemiological features of SAH and aneurysmal SAH (aSAH) have not been comprehensively studied before in Qatar. Our study aimed to describe the epidemiological profile of patients with SAH and aSAH in the State of Qatar.Methods: We reviewed the medical records of all patients with SAH and/or ruptured aneurysm who were consecutively admitted to Hamad General Hospital (600-bed tertiary care facility) from January 1, 2007 to December 31, 2016. We performed a quantitative analysis of demographics, clinical characteristics, diagnostic findings, interventions, and overall mortality. We used SPSS version 18 for data entry. We used chi-square and student t tests to compare the groups. We considered p < 0.05 as statistically significant.Results: The study included 323 patients with aneurysmal and non-aneurysmal SAH. The mean age at presentation was 47.4 ± 12.2 years. Men comprised 68.7% of the cases. Further, 86.6% of the patients presented with acute-onset headache. Additionally, 217 patients had 1 aneurysm, and 32 patients had multiple aneurysms. Anterior communicating artery aneurysm has been found to be the most common aneurysm. Non-aneurysmal SAH occurred in 74 patients (22.9%), with male predominance. Moreover, 23.7% and 52.6% of the patients underwent microsurgical clipping and coiling of the aneurysm, respectively. The overall mortality in World Federation of Neurosurgeon Score (WFNS) grades 1 and 2 SAH was lesser than that in higher grades (28.6% vs 71.4%). Of 323 patients, 69 died within 1 month post-ictus, accounting for an overall mortality rate of 21.2% in our study.Conclusions: The annual incidence of aneurysmal SAH in Qatar has been increasing. Men had a higher incidence of aSAH. Internal carotid aneurysms have been found to be more common in Qatari women, which may have a genetic basis. Lower WFNS grades of aSAH have been associated with better prognosis. The overall mortality associated with aSAH in Qatar has declined over the last 3 years.

Descriptive Study of Aneurysmal and Nonaneurysmal Subarachnoid Hemorrhage and the Role of Confirmative Digital Subtraction Angiography in Patients with Nonaneurysmal Subarachnoid in Puerto Rico

Cerebrovascular disease is the fifth cause of mortality in Puerto Rico. There is no descriptive study for the presentation of spontaneous subarachnoid hemorrhage (SAH) in our institution. Therefore, our primary aim was to perform a retrospective analysis of adult patients with spontaneous SAH and assess the need for digital subtraction angiography (DSA) after initially aneurysm-negative computed tomography angiography (CTA) in nonaneurysmal SAH, specifically perimesencephalic SAH (PM-SAH). Medical records of 324 adult patients with aneurysmal and nonaneurysmal SAH treated at the Puerto Rico Medical Center from 2015 to 2018 were retrospectively analyzed. Demographics, past medical history, clinical characteristics, and imaging information were extracted. Acute hydrocephalus, mortality at 30 days, prevalence of diffuse SAH pattern, and Fisher and World Federation of Neurosurgical Societies grades >2 on initial examination were higher in the aneurysmal SAH subgroup. Patients with nonaneurysmal SAH had a significantly higher prevalence of chronic kidney disease and diabetes mellitus. Of the patients with nonaneurysmal PM-SAH with initial aneurysm-negative CTA, 100% were subsequently confirmed by DSA. Patients in the aneurysmal SAH subgroup correlated with an increased disease burden. Furthermore, this study shows that in our population, patients with nonaneurysmal PM-SAH with a low Fisher and World Federation of Neurosurgical Societies grade and with comorbid diabetes mellitus and chronic kidney disease may not need DSA after a negative initial CTA result.

Thromboelastometry Shows Early Hypercoagulation in Patients with Spontaneous Subarachnoid Hemorrhage

The ability to achieve hemostasis after spontaneous subarachnoid hemorrhage (SAH) plays a pivotal role in outcome. Changes in coagulation in the early hours after SAH have been only sparsely investigated. To investigate changes in coagulation after SAH and illuminate underlying mechanisms. We enrolled 46 patients with spontaneous aneurysmal SAH. Blood samples were collected at admission and 24 hours after symptom onset. Thromboelastometry (ROTEM) was performed using the standard assays EXTEM, INTEM, and FIBTEM. Platelet maximum clot elasticity was calculated based on ROTEM results. Thrombin generation, levels of thrombin-antithrombin complex, fibrinogen, and coagulation factor XIII were measured. All data were compared with a gender-matched healthy control group. At admission (median, 3 hours 39 minutes from symptom onset), maximum clot firmness (EXTEM, P < 0.0001; INTEM, P= 0.08; FIBTEM, P < 0.0001) and platelet maximum clot elasticity (P < 0.0001) were higher in patients with SAH than in healthy controls. Thrombin generation showed higher, although nonsignificant, endogenous thrombin potential in patients with SAH than in healthy controls (P= 0.06), and thrombin-antithrombin complex levels were above the reference interval. Median fibrinogen and coagulation factor XIII levels were both within the reference parameters and remained increased 24 hours after symptom onset, whereas endogenous thrombin potential (P= 0.01) and thrombin-antithrombin complex levels decreased (P < 0.0001). Patients with SAH were in a hypercoagulable state at admission and remained so 24 hours after SAH. Increased clot firmness could be caused by increased platelet function, because platelet maximum clot elasticity was increased despite normal fibrinogen and coagulation factor XIII levels.

Atmospheric Pressure Variation is a Delayed Trigger for Aneurysmal SubarachnoidHemorrhage.

There is an ongoing search for conditions that induce spontaneous subarachnoid hemorrhage (SAH). The seasonal pattern of SAH is shown in a large meta-analysis of the literature, but its explanation remains undecided. There is a clear need for sound meteorologic data to further elucidate the seasonal influence on SAH. Because of the stable and densely monitored atmospheric situation in the north of the Netherlands, we reviewed our unique cohort on the seasonal incidence of SAH and the association between SAH and local atmospheric changes. Our observational cohort study included 1535 patients with spontaneous SAH admitted to our neurovascular center in the north of the Netherlands between 2000 and 2015. Meteorologic data could be linked to the day of the ictus. To compare SAH incidences over the year and to test the association with meteorologic conditions, incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs) were used, calculated by Poisson regression analyses. Atmospheric pressure variations were significantly associated with aneurysmal SAH. In particular, the pressure change on the second and third day before the ictus was independently correlated to a higher incidence of aneurysmal SAH (IRR, 1.11; 95% CI, 1.00-1.23). The IRR for aneurysmal SAH in July was calculated 0.67 (95% CI,0.49-0.92) after adjustment for temperature and atmospheric pressure changes. Atmospheric pressure variations are a delayed trigger for aneurysmal SAH. Also, a significantly decreased incidence of aneurysmal SAH was noted in July.

Mortality after Spontaneous Subarachnoid Hemorrhage: Causality and Validation of a Prediction Model

To evaluate primary causes of death after spontaneous subarachnoid hemorrhage (SAH) and externally validate the HAIR score, a prognostication tool, in a single academic institution. We reviewed all patients with SAH admitted to our neuro-intensive care unit between 2010 and 2016. Univariate and multivariate logistic regressions were performed to identify predictors of in-hospital mortality. The HAIR score predictors were Hunt and Hess grade at treatment decision, age, intraventricular hemorrhage, and rebleeding within 24 hours. Validation of the HAIR score was characterized with the receiver operating curve, the area under the curve, and a calibration plot. Among 434 patients with SAH, in-hospital mortality was 14.1%. Of the 61 mortalities, 54 (88.5%) had a neurologic cause of death or withdrawal of care and 7 (11.5%) had cardiac death. Median time from SAH to death was 6 days. The main causes of death were effect of the initial hemorrhage (26.2%), rebleeding (23%) and refractory cerebral edema (19.7%). Factors significantly associated with in-hospital mortality in the multivariate analysis were age, Hunt and Hess grade, and intracerebral hemorrhage. Maximum lumen size was also a significant risk factor after aneurysmal SAH. The HAIR score had a satisfactory discriminative ability, with an area under the curve of 0.89. The in-hospital mortality is lower than in previous reports, attesting to the continuing improvement of our institutional SAH care. The major causes are the same as in previous reports. Despite a different therapeutic protocol, the HAIR score showed good discrimination and could be a useful tool for predicting mortality.

Epidemiological Features of Nontraumatic Spontaneous Subarachnoid Hemorrhage in China: A Nationwide Hospital-based Multicenter Study.

Background:Nontraumatic spontaneous subarachnoid hemorrhage (SAH) is associated with a high mortality. This study was conducted to investigate the epidemiological features of nontraumatic spontaneous SAH in China.Methods:From January 2006 to December 2008, the clinical data of patients with nontraumatic SAH from 32 major neurosurgical centers of China were evaluated. Emergent digital subtraction angiography (DSA) was performed for the diagnosis of SAH sources in the acute stage of SAH (≤3 days). The results and complications of emergent DSA were analyzed. Repeated DSA or computed tomography angiography (CTA) was suggested 2 weeks later if initial angiographic result was negative.Results:A total of 2562 patients were enrolled, including 81.4% of aneurysmal SAH and 18.6% of nonaneurysmal SAH. The total complication rate of emergent DSA was 3.9% without any mortality. Among the patients with aneurysmal SAH, 321 cases (15.4%) had multiple aneurysms, and a total of 2435 aneurysms were detected. The aneurysms mostly originated from the anterior communicating artery (30.1%), posterior communicating artery (28.7%), and middle cerebral artery (15.9%). Among the nonaneurysmal SAH cases, 76.5% (n = 365) had negative initial DSA, including 62 cases with peri-mesencephalic nonaneurysmal SAH (PNSAH). Repeated DSA or CTA was performed in 252 patients with negative initial DSA, including 45 PNSAH cases. Among them, the repeated angiographic results remained negative in 45 PNSAH cases, but 28 (13.5%) intracranial aneurysms were detected in the remaining 207 cases. In addition, brain arteriovenous malformation (AVM, 7.5%), Moyamoya disease (7.3%), stenosis or sclerosis of the cerebral artery (2.7%), and dural arteriovenous fistula or carotid cavernous fistula (2.3%) were the major causes of nonaneurysmal SAH.Conclusions:DSA can be performed safely for pathological diagnosis in the acute stage of SAH. Ruptured intracranial aneurysms, AVM, and Moyamoya disease are the major causes of SAH detected by emergent DSA in China.

Stress-Induced Hyperglycemia After Spontaneous Subarachnoid Hemorrhage and Its Role in Predicting Cerebrospinal Fluid Diversion.

Stress-induced hyperglycemia (SIH) after acute cerebrovascular disease is common and is associated with adverse clinical outcomes. The incidence of SIH after spontaneous subarachnoid hemorrhage (SAH) and its role in shunt placement have not been systematically investigated. The present study is designed to investigate the incidence of SIH after spontaneous SAH and its determinants. The role of SIH and premorbid hyperglycemia (using glycated hemoglobin [HbA1c]) in predicting external ventricular drainage (EVD) and ventriculoperitoneal shunt (VPS) placement is also investigated. This study defined SIH using the glycemic gap (GG) and admission glucose:HbA1c ratio. The receiver operating characteristic curve determined threshold values for GG and the ratio that best predicted incidence of adverse clinical outcomes, including in-hospital mortality. We defined SIH using thresholds of 26.7 mg/dL for GG and 26 mg/dL for admission glucose:HbA1c ratio. The incidence of SIH was higher in patients with aneurysmal SAH (aSAH) (99/200 [49.5%]) than in those with nonaneurysmal SAH (16/50 [32.0%]; P= 0.03). Among 200 patients with aSAH, diabetics had higher mortality than nondiabetics (10/24 [41.7%] vs. 39/137 [21.2%]; P= 0.045). SIH among nonhydrocephalic aSAH was more likely to have EVD placed than those without (42/64 [65.6%] vs. 38/79 [48.1%]; P= 0.043). Among 143 patients with aSAH without hydrocephalus, EVD was placed more often in those with HbA1c level ≥6.4% (15/19 [78.9%] vs. 65/124 [52.4%]; P=0.045). Neither SIH nor HbA1c level could predict VPS placement among aSAH survivors. SIH is common after aSAH. In nonhydrocephalic aSAH, both SIH and premorbid uncontrolled hyperglycemia determine EVD but not VPS placement.

Computed Tomographic Angiography for Cerebral Aneurysms in Spontaneous Subarachnoid Hemorrhage

Computed tomographic angiography (CTA) has recently gained popularity as an initial imaging test for spontaneous subarachnoid hemorrhage (SAH). This study evaluated 59 patients presenting aneurysmal SAH who underwent microsurgical clipping based on CTA findings alone and digital subtraction angiography (DSA) at postoperative follow-up. Multiple aneurysms were identified by CTA in 27% of patients and in 10% of patients, DSA identified aneurysms in addition to those diagnosed with CTA. The time between CTA and surgical treatment ranged from 0–4 days. Postoperative DSA revealed that 24% of patients had residual neck. The use of CTA alone may not be enough to detect small unruptured aneurysms in patients with multiple lesions or aneurysm remnants adjacent to an aneurysm clip. However, the advantages of CTA compared with DSA include its rapidity, reduced invasiveness, and lower cost, which allow us to proceed to ruptured aneurysm repair entirely on the basis of good-quality CTA studies.

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

Emerging evidence demonstrating the high sensitivity of early brain computed tomography (CT) brings into question the necessity of always performing lumbar puncture after a negative CT in the diagnosis of spontaneous subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity of brain CT using modern scanners (16-slice technology or greater) when performed within 6 hours of headache onset to exclude SAH in neurologically intact patients. After conducting a comprehensive literature search using Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset. Our study adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). A total of 882 titles were reviewed and 5 articles met inclusion criteria, including an estimated 8907 patients. Thirteen had a missed SAH (incidence 1.46 per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987 (95% confidence intervals, 0.971-0.994) and specificity was 0.999 (95% confidence intervals, 0.993-1.0). The pooled likelihood ratio of a negative CT was 0.010 (95% confidence intervals, 0.003-0.034). In patients presenting with thunderclap headache and normal neurological examination, normal brain CT within 6 hours of headache is extremely sensitive in ruling out aneurysmal SAH.