Aneurysmal Subarachnoid Hemorrhage Research Articles

Contribution of an Automatic Algorithm for Quantifying the Volume of Aneurysmal Subarachnoid Hemorrhage to the Evaluation of the Risk of Occurrence of Delayed Cerebral Ischemia: A Cohort Study.

This study focuses on aneurysmal subarachnoid hemorrhage (aSAH) with a high risk of delayed cerebral ischemia (DCI) and acute hydrocephalus (AH). The aim was to compare the performance of an automatic algorithm for quantifying the volume of intracranial blood with the reference radiological scales to predict DCI, AH, and neurological outcome. This was a single-center retrospective observational study of a cohort of patients with aSAH. We developed an automated blood detection algorithm based on the specific density of the blood clot. The blood clot was segmented on the first brain scan (total, supratentorial, cisternal, intraventricular). The predictive value of our model was compared, using the area under the receiver operating characteristic curve (ROCAUC), to eight radiological scales: Fisher, modified Fisher, Claassen, Barrow Neurological Institute, Hijdra, Graeb, LeRoux scales, and intraventricular hemorrhage score. We analyzed the scans of 145 patients with aSAH. In our cohort, 51 patients (43%) had DCI and 70 patients (54%) had AH. At 3 months, 22% of patients had died and 19% had poor outcome (Glasgow Outcome Scale extended 2-4). Cisternal blood volume was significantly correlated with cisternal Hijdra scale (R2 = 0.79; P < 0.001). The ROCAUC of cisternal blood volume was comparable to the ROCAUC of the Hijdra scale in predicting the occurrence of DCI (ROCAUC = 0.83 [95% confidence interval {CI} 0.75-0.89] vs. 0.86 [95% CI 0.79-0.9]; P = 0.23). The ROCAUC of intraventricular blood volume was not significantly different from the intraventricular hemorrhage score in predicting the occurrence of AH (ROCAUC = 0.78 [95% CI 0.70-0.84] vs. 0.79 [95% CI 0.72-0.85]; P = 0.28). The ROCAUC and supratentorial blood volumes were not significantly different from the Simplified Acute Physiology Score II in predicting the occurrence of poor neurological outcome at 3 months (ROCAUC = 0.75 [95% CI 0.67-0.82] vs. 0.81 [95% CI 0.74-0.87]; P = 0.073). With no manual intervention, our algorithm performed as well as the best radiological scores in predicting the occurrence of DCI, AH, and neurological outcome.

Discontinuation of Cerebro-Spinal Fluid (CSF) Drainage in Acute Hydrocephalus: A Prospective Cohort Study and Exploratory Data Analysis.

The optimal management of CSF drainage in acute hydrocephalus, in particular when to initiate drain weaning, remains uncertain. This study aimed to evaluate the impact of timing and method of drain weaning on patient outcomes. This prospective observational study in a large-volume tertiary neuroscience centre included all adult patients who required temporary CSF drainage for acute hydrocephalus of any cause between January 2020 and March 2021. Contemporaneous data collection was conducted, including patient demographics, time to clamp, weaning methods, and clinical outcomes of hospital length of stay (LOS), rate of shunt insertion, drain-related infections, and mechanical complications. Univariate and multivariate statistical analyses were performed to identify the independent associations of timing-related factors. A total of 69 patients were included (mean age = 59.4 years). A total of 59% had CSF diversion for aneurysmal subarachnoid haemorrhage, and 88% had EVD drainage. The length of drainage prior to the first clamp was significantly associated with the overall length of drainage (p < 0.0001), LOS (p = 0.004), and time to shunt (p = 0.02) following multivariate adjustment. For each day delayed in initiating the drain challenge, the overall LOS increased by an additional 1.25 days. There was no association between the weaning method and LOS, the rate of shunting, or CNS infection; however, those in the gradually weaned group had more mechanical complications, such as drain blockage or CSF leakage, than those rapidly weaned (p = 0.03) after adjustment. This study recommends challenging the drain early via a rapid wean to reduce LOS, mechanical complications, and possibly infections. The consequences of temporary CSF diversion have significant implications at financial and patient levels, but the quality of evidence regarding weaning remains poor. Further randomised multicentre studies and national databases of practice are required to allow definitive conclusions to be drawn.

CT perfusion imaging in aneurysmal subarachnoid hemorrhage. State of the art.

CT perfusion (CTP) images can be easily and rapidly obtained on all modern CT scanners and have become part of the routine imaging protocol of patients with aneurysmal subarachnoid haemorrhage (aSAH). There is a growing body of evidence supporting the use of CTP imaging in these patients, however, there are significant differences in the software packages and methods of analysing CTP. In. addition, no quantitative threshold values for tissue at risk (TAR) have been validated in this patients' population. Here we discuss the contribution of the technique in the identification of patients at risk of aSAH-related delayed cerebral ischemia (DCI) and in the assessment of the response to endovascular rescue therapy (ERT). We also address the limitations and pitfalls of automated CTP postprocessing that are specific to aSAH patients as compared to acute ischemic stroke (AIS).

Genetic Determinants of Telomere Length and Risk of Aneurysmal Subarachnoid Hemorrhage: A Bidirectional Two-Sample Mendelian Randomization Study

Background Our objective is to investigate the potential causal relationship between telomere length (TL) and aneurysmal subarachnoid hemorrhage (aSAH) and intracranial aneurysms (IAs) by conducting a bidirectional two-sample Mendelian Randomization (MR) study. Methods We utilized publicly available summary data from genome-wide association studies (GWAS) for comprehensive analysis. Telomere length-associated data were sourced from the Epidemiology Unit (IEU) GWAS database (n = 472,174), while data pertaining to intracranial aneurysms were derived from a GWAS meta-analysis conducted by Bakker et al, encompassing aneurysmal subtypes including aSAH (n = 77,074), IAs (n = 79,429), and unruptured intracranial aneurysms (uIA) (n = 74,004), all sampled from European populations. The primary method for MR analysis employed was the Inverse Variance Weighted (IVW) method. Additionally, we conducted various sensitivity analyses to assess the heterogeneity and pleiotropy of study findings. Reverse MR analysis was employed to explore potential reverse causality. Results In the forward MR analysis, the IVW method indicated a negative association between TL and aSAH (OR = 0.636, 95% CI: 0.459–0.883, p = 0.006) as well as IAs (OR = 0.670, 95% CI: 0.499–0.900, p = 0.0079). There was no evidence of heterogeneity or horizontal pleiotropy in the forward MR analysis. Reverse MR analysis did not reveal any causal relationship between aSAH, IAs, uIA and TL. Conclusions In European populations, there exists a causal relationship between longer TL and reduced risks of aSAH and IAs Further research is warranted to elucidate the underlying mechanisms and the potential of TL as an intervention target for lowering the incidence of aSAH and IAs.

Fenestrated clipping of previously coiled posterior-superiorly projecting anterior communicating artery aneurysms: How I do it.

Anterior communicating artery (ACOM) aneurysms are among the most common aneurysms associated with aneurysmal subarachnoid hemorrhage (International Study of Unruptured Intracranial Aneurysms I (N Engl J Med 339:1725-1733, 1998), Wiebers (Lancet 362:103-110, 2003)). Surgical clipping of posterior-superiorly projecting ACOM aneurysms can be challenging, as the ipsilateral A2 can interfere with clip trajectory and ACOM perforating vessels obstructed from view. Intraluminal coils can further increase the difficulty of the procedure. The relevant surgical anatomy with illustration is presented. A video detailing our technique on an illustrative case is provided. Surgical clipping of posterior-superiorly projecting ACOM aneurysms can require complex clip configurations. We describe the key steps of posterior-superiorly projecting ACOM aneurysm clipping through a lateral supraorbital craniotomy and fenestrated tandem clipping.

Trial of the cerebral perfusion response to sodium nitrite infusion in patients with acute subarachnoid haemorrhage using arterial spin labelling MRI

Aneurysmal subarachnoid haemorrhage (SAH) is a devastating subset of stroke. One of the major determinants of outcome is an evolving multifactorial injury occurring in the first 72 hours, known as early brain injury. Reduced nitric oxide (NO) bioavailability and an associated disruption to cerebral perfusion is believed to play an important role in this process. We sought to explore this relationship, by examining the effect on cerebral perfusion of the in vivo manipulation of NO levels using an exogenous NO donor (sodium nitrite).We performed a double blind placebo controlled randomised experimental medicine study of the cerebral perfusion response to sodium nitrite infusion during the early brain injury period in 15 low grade (World Federation of Neurosurgeons grade 1–2) SAH patients. Patients were randomly assigned to receive sodium nitrite at 10 mcg/kg/min or saline placebo. Assessment occurred following endovascular aneurysm occlusion, mean time after ictus 66h (range 34–90h). Cerebral perfusion was quantified before infusion commencement and after 3 hours, using multi-post labelling delay (multi-PLD) vessel encoded pseudocontinuous arterial spin labelling (VEPCASL) magnetic resonance imaging (MRI).Administration of sodium nitrite was associated with a significant increase in average grey matter cerebral perfusion. Group level voxelwise analysis identified that increased perfusion occurred within regions of the brain known to exhibit enhanced vulnerability to injury. These findings highlight the role of impaired NO bioavailability in the pathophysiology of early brain injury.

Association of serum glucose/potassium index levels with poor long-term prognosis in patients with Aneurysmal Subarachnoid Hemorrhage

IntroductionThe glucose/potassium index (GPI) has been reported as a predictor biomarker of in-hospital complications in patients with aneurysmal subarachnoid hemorrhage (aSAH). ObjectivesTo determine the association between GPI and functional outcome at 3–6 months after discharge in patients diagnosed with aSAH in a Peruvian referral hospital during 2018–2021. Materials and MethodsWe conducted a retrospective cohort observational study with a secondary database in patients with aSAH during 2018–2021 in a Peruvian referral hospital. We evaluated the relationship between GPI values and motor functionality from 3 m to 6 months post-discharge, using a Poisson family generalized linear model with Log link function and robust variance according to categorization of good and poor outcome. We considered a value of p<0.05 as statistically significant. We used restricted cubic splines with five nodes to evaluate the linear correlation between the 2 main variables. Results212 patients were included in the analysis. 21.1 % and 19.3 % had poor outcome at 3 and 6 months after discharge, respectively. Multivariate analysis showed that GPI was not associated with poor outcome at 3 (RR=0.999; 95 %CI=0.979–1.018) or 6 months after discharge (RR=0.979; 95 %CI=0.979–1.020). On the other hand, Splines plots showed no correlation between GPI and modified Rankin. ConclusionsDespite the usefulness of GPI to prognosticate in-hospital complications, its association with functional outcome is inconclusive.

Association of dynamic changes in arterial partial pressure of carbon dioxide with neurological outcomes in aneurysmal subarachnoid hemorrhage

BackgroundCerebral blood flow (CBF) is closely regulated by carbon dioxide (CO2). In patients with aneurysmal subarachnoid hemorrhage (aSAH), abnormal arterial partial pressure of CO2 (PaCO2) might deteriorate brain injuries. Nevertheless, the impact of dynamic PaCO2 fluctuations on neurological outcomes in aSAH patients has not been extensively studied. Our study aimed to investigate the association between dynamic PaCO2 levels and unfavorable neurological outcomes in aSAH patients. MethodsIn this retrospective observational study, we consecutively enrolled 159 aSAH patients from December 2019 to July 2021. Arterial blood gas measurements within 10 days after intensive care unit (ICU) admission for each patient were recorded to calculate the time-weighted average (TWA)-PaCO2, an indicator representing the dynamic changes in PaCO2 levels. For the association between TWA-PaCO2 levels and unfavorable neurological outcomes in aSAH patients, multivariable logistic analysis was used to explore TWA-PaCO2 levels as categorical variables, and restricted cubic spline (RCS) was used to explore TWA-PaCO2 levels as continuous variables. ResultsIn multivariable logistic analysis, after adjusting confounders, when TWA-PaCO2 35–45 mmHg was as a reference, TWA-PaCO2 < 35 mmHg (odds ratio [OR] 2.15, 95 % confidence interval [CI] 0.83–5.55, P = 0.113) and TWA-PaCO2 > 45 mmHg (OR 8.31, 95 % CI 0.72–96.14, P = 0.090) were not independently associated with unfavorable neurological outcomes (modified Rankin score of 3–6). The RCS shows a “U” shape curve between TWA-PaCO2 levels and unfavorable neurological outcomes, with a nonlinear P-value of 0.023. The lowest ORs of unfavorable neurological outcomes were within PaCO2 32.8–38.1 mmHg. ConclusionsBoth lower and higher PaCO2 levels are harmful to aSAH patients. PaCO2 in the range of 32.8–38.1 mmHg is associated with lowest unfavorable neurological outcomes.

Predictors of survival after aneurysmal subarachnoid hemorrhage: The long-term observational cohort study

ObjectiveDespite recent advances in neuro-intensive care, there is still considerable mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). In this long-term monocentric observational cohort study, we aimed to analyze the rates, timing, and predictors of mortality after SAH. MethodsAll consecutive SAH cases treated between January 2003 and June 2016 were included. Patients’ demographic characteristics, previous medical history, SAH-related parameters, and available post-treatment follow-up data were collected and evaluated as potential mortality predictors in univariate and multivariate analyses. ResultsOf 992 patients, 179 died during the initial treatment and 33 during the follow-up time reaching an overall mortality rate of 21.4 %. Of over 119 tested variables, we identified the following independent predictors in the final multivariate Cox regression analysis: age >55 years (p<0.0001); World Federation of Neurosurgical Societies (WFNS) admission grade IV or V (p=0.025); Hijdra sum score ≥15 points (p=0.003); intracranial pressure (ICP) increase (p<0.0001); and delayed cerebral ischemia (DCI) (p<0.0001). Being exposed to all five risk factors resulted in the case fatality rate of 75 % within a median survival of 14 days, compared to 2.5 % within a median of 1525 days when none of these features were present. ConclusionsThe initial impact of aneurysmal bleeding is amongst the major mortality causes after SAH. Of potentially preventable adverse events, ICP increase and DCI occurring during initial treatment also present eminent clinical relevance for patients’ survival in the long-term follow-up. Further ICP and DCI management optimization might help to decrease the mortality rate after SAH.

Plasma Estrogen Levels and Aneurysmal Subarachnoid Hemorrhage in Women

ObjectivesAneurysmal subarachnoid hemorrhage is more prevalent in post-menopausal women and it has been postulated that this relationship is hormonally driven by lower circulating levels of estrogens. We examined the association between circulating plasma estrogen levels and subsequent development of aneurysmal subarachnoid hemorrhage in women. MethodsWomen from the Nurses’ Health Study with confirmed aneurysmal subarachnoid hemorrhage (n=38) were matched with controls (n=38) on age, smoking, menopausal status, and other reproductive factors. Plasma estriol, estradiol and sex hormone-binding globulin (SHBG) were measured at baseline, prior to the development of aSAH. Conditional logistic regressions were performed to assess the association between hormone levels and incident aSAH. ResultsPlasma estradiol, estriol, and SHBG were not associated with the subsequent development of aneurysmal subarachnoid hemorrhage. Women with a history of current or former smoking were associated with lower levels of circulating estriol (β = -0.35±0.12, p=0.004), and estradiol (β = -0.63±0.16, p=0.0002) levels. ConclusionsIn this study, we did not find an association between estrogen levels and incidence of aneurysmal subarachnoid hemorrhage in women.

Dietary factors and the incidence of intracranial aneurysms: a Mendelian randomization research

ABSTRACT Background Intracranial aneurysms (IAs) pose a significant threat to morbidity and mortality, yet their etiology remains inadequately comprehended. The present study employs Mendelian randomization (MR) to investigate the relationship among dietary elements with IAs, encompassing unruptured intracranial aneurysms (uIA) as well as aneurysmal subarachnoid hemorrhage (aSAH). Methods The current study employed a double-sample MR test utilizing genome-wide association study (GWAS) summary data from the IEU and IAs’ meta-analysis to investigate the genetically predicted consumption levels of various dietary factors using GWAS data. Causation was assessed by techniques of MR-Egger, weighted mode, and median, as well as IVW. To guarantee the accuracy of the results, pleiotropy and heterogeneity evaluations were also carried out. Results The findings of the study indicate a positive correlation between the intake of alcohol, lamb/mutton, and pork with the risk of IAs (IVW all p < 0.05). Conversely, a negative correlation was observed regarding dried fruit consumption and the risk of aSAH (IVW p < 0.05). There was only scant evidence supporting the association between alcohol intake frequency and an elevated risk of uIA (IVW method p < 0.05). The MR analysis outcomes were authenticated by the MR-PRESSO method and were deemed reliable. Furthermore, sensitivity calculations, such as pleiotropy and homogeneity test, leave-one-out evaluation, and funnel charts, validated the robustness of the results. Conclusions The findings suggest that reducing alcohol, lamb/mutton, and pork intake, and increasing dried fruit intake may be potential strategies for the prevention of IAs and aSAH. Additional research is necessary to validate these outcomes and elucidate the underlying mechanisms.

Letter to the Editor Regarding “Clinical Characteristics as Predictors of Early and Delayed Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage Patients: A Meta-Analysis of 4527 Cases”

Letter to the Editor Regarding “Clinical Characteristics as Predictors of Early and Delayed Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage Patients: A Meta-Analysis of 4527 Cases”

The value of IL-6 in cerebrospinal fluid for determining the development of cerebral vasospasm after subarachnoid hemorrhage

An inflammatory response following aneurysmal SubArachnoid Hemorrhage (aSAH) plays a significant role in the development of cerebral vasospasm. This study analyzes the correlation between the level of InterLeukin-6 (IL-6) in CerebroSpinal Fluid (CSF) after aSAH and the occurrence of cerebral vasospasm. We analyzed clinical manifestations, laboratory data, and instrumental examination methods in 45 patients who were treated for intracranial aSAH within 21 days, studying the relationship between the development of cerebral angiospasm and the concentration of the inflammatory factor. We found the potential significance of IL-6 in predicting vasospasm, confirmed by cerebral angiography. As a control, we analyzed the CSF samples of 15 patients treated for unruptured cerebral aneurysms. According to the study results, vasospasm developed in 44% of patients, on average on the 6th day from the onset of the disease. Patients with aSAH demonstrated statistically significant (p&lt;0.05) higher mean IL-6 values in CSF on the 3rd, 7th, and 10th days compared to the control group. Patients with vasospasm showed statistically significant (p&lt;0.05) higher mean IL-6 values in CSF on the 3rd day, while the differences on the 7th and 10th days (p&lt;0.05) were not statistically significant. The threshold value for predicting the formation of cerebral vasospasm was determined to be 325 pg/ml on the 3rd day from the onset of the disease. We concluded that IL-6 in cerebrospinal fluid is a potential early marker for predicting vascular spasm after subarachnoid hemorrhage on the 3rd day of the disease, before the onset of clinical manifestations. We concluded that monitoring the value of IL-6 in the cerebrospinal fluid on the third day after aneurysm rupture is potentially significant for the early diagnosis of vasospasm. Keywords: intracranial aneurysm, vasospasm, stroke, cytokines.

Causal relationships between gut microbiota and Aneurysmal Subarachnoid Hemorrhage: A Bidirectional Mendelian Randomization Study

Background and PurposeAneurysmal Subarachnoid Hemorrhage (aSAH) poses a significant health burden globally, necessitating a deeper understanding of its etiology and potential preventive strategies. Recent research has suggested a possible link between gut microbiota composition and the risk of vascularity, prompting investigation into this association using Mendelian Randomization (MR) analysis. Here, we aimed to elucidate the causal relationship between gut microbiota composition and aSAH risk utilizing MR analysis. MethodsWe employed four distinct MR methodologies, including inverse variance weighted (IVW), MR-Egger, weighted median, and weighted mode, to assess the causal nexus between gut microbiota composition and aSAH risk. Genetic instrumental variables (IVs) associated with gut microbiome composition were selected from a comprehensive multiethnic genome-wide association study (GWAS) involving 18,473 individuals across diverse geographic regions. Sensitivity analyses were conducted to detect potential heterogeneity and pleiotropy. ResultsOur Mendelian Randomization (MR) analyses unveiled a substantial and statistically significant causal relationship between gut microbiota composition and the risk of Aneurysmal Subarachnoid Hemorrhage (aSAH). Employing the Inverse Variance Weighted (IVW) method, we observed negative associations between aSAH and specific taxonomic levels of gut microbiota. Specifically, the IVW approach identified significant associations with one order, Victivallales (PIVW=0.047, OR: 0.78, 95 % CI: 0.62-0.99), one family, Porphyromonadaceae (PIVW=0.03, OR: 0.64, 95 % CI: 0.43-0.95), one class, Lentisphaeria (PIVW=0.047, OR: 0.78, 95 % CI: 0.62-0.99), and three genera: Bilophila (PIVW=0.02, OR: 0.68, 95 % CI: 0.50-0.93), Fusicatenibacter (PIVW=0.04, OR: 0.69, 95 % CI: 0.49-0.98), and Ruminococcus1 (PIVW=0.01, OR: 0.51, 95 % CI: 0.32-0.84). These findings were consistent across various MR methodologies, underscoring the robustness of our results. Sensitivity analyses further validated the stability of our findings, with no evidence of heterogeneity or pleiotropy detected. ConclusionOur study provides compelling evidence supporting a causal relationship between gut microbiota composition and the risk of aSAH. These findings underscore the potential therapeutic implications of modulating gut microbiota to prevent and manage aSAH. Further research is warranted to explore the underlying mechanisms and develop targeted interventions aimed at mitigating aSAH risk through gut microbiota modulation.

MiRNA expression profiling reveals a potential role of microRNA-148b-3p in cerebral vasospasm in subarachnoid hemorrhage

Cerebral vasospasm (CVS) is an important contributor to delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage (aSAH), leading to high morbidity and long-term disability. While several microRNAs (miRNAs) have been implicated in vasospasm, the underlying mechanisms for CVS remain poorly understood. Our study aims to identify miRNAs that may contribute to the development of CVS. Whole-blood samples were obtained during or outside of vasospasm from aSAH patients whose maximal vasospasm was moderate or severe. MiRNAs were isolated from serial whole-blood samples, and miRNA sequencing was performed. Differentially expressed miRNAs were identified and the expression levels in patients’ samples were verified using real-time qPCR. The biological functions of identified miRNA were evaluated in human brain endothelial cells (HBECs). MiRNA profiling revealed significant upregulation of miR-148b-3p in patients during CVS. We demonstrated that miR-148b-3p directly targeted and decreased the expression of ROCK1, affecting cell proliferation, migration, and invasion of HBECs through the ROCK-LIMK-Cofilin pathway. We propose that the upregulation of miRNA-148b-3p plays a role in the development of CVS by regulating actin cytoskeletal dynamics in HBECs, which is crucial for vascular function. Our study highlights miR-148b-3p as a potential diagnostic marker as well as therapeutic target for CVS following aSAH.

Sex Differences in Intracranial Aneurysms: A Matched Cohort Study.

Background: Aneurysmal subarachnoid hemorrhage (SAH) predominantly affects women, accounting for 65% of cases. Women have a 1.3 times higher relative risk than men, with the incidence rising particularly in women aged 55-85 years. Women also have a higher prevalence of unruptured intracranial aneurysms (IAs), especially after the age of 50 years, and are at greater risk of aneurysm growth and rupture. This study aimed to isolate the influence of sex on rupture rate, bleeding severity, functional outcomes, and complications by using a matched cohort, while also examining the impact of sex on aneurysm localization and multiplicity. Methods: We utilized a retrospectively collected database of 300 patients with 511 IAs. Inclusion criteria included the availability of clinical data and 3D angiography for semi-automatic reconstruction of IA morphology. Female patients and their IA were matched with male patients according to clinical parameters and 21 morphological characteristics using an interactive visual exploration tool for multidimensional matching. Results: Contrary to previously published results, our study found no significant sex differences in rupture rates or vasospasm rates between male and female patients. The severity of SAH, functional outcomes, and complications such as hydrocephalus were also similar in women and men. However, women exhibited a higher prevalence of multiple aneurysms and distinct localization patterns. Conclusions: This study underscores the complex role of sex in IA development and rupture. Although sex-specific biological factors influence aneurysm characteristics, they do not necessarily translate into differences in clinical outcomes. Further research is needed to explore these factors and their impact on aneurysm development and management.

Indications and scientific support for supratentorial unilateral decompressive craniectomy for different subgroups of patients: A scoping review.

Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice. A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials. Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors. To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.

High levels of blood lipid and glucose predict adverse prognosis in patients with aneurysmal subarachnoid hemorrhage

ObjectiveWe conducted a retrospective study on the prognostic factors of aneurysmal subarachnoid hemorrhage (aSAH) patients in the author's Hospital from January 2019 to May 2023. To discuss the association of the blood lipid and glucose levels of patients with the prognosis of aSAH, and verify that high blood lipid and glucose levels are important factors affecting adverse prognosis. MethodsAll patients with aSAH were collected as the case group, which was divided into two groups according to the modified Rankin Scores (mRS), the good prognosis group (Group A, mRS ＜ 3) and the adverse prognosis group (Group B,mRS ≥3). The clinical data of age, gender, accompanied chronic diseases (hypertension, diabetes), smoking, drinking, Glasgow Coma Scale (GCS), Hunt-Hess (H-H) grade, Modified Fisher grade, total cholesterol (TC) , triglyceride (TG) , high-density cholesterol lipoprotein (HDL-C) , low-density cholesterol lipoprotein (LDL-C) , blood glucose (BG) , responsible aneurysm diameter and location were recorded too. Correlations between blood lipid and glucose levels and Modified Fisher grade were assessed by the Spearman correlation analysis. The receiver operating characteristic (ROC) curve was utilized to evaluate the diagnostic efficacy. The effect of blood lipid and glucose levels on adverse prognosis was analyzed by Logistic regression models. ResultA total of 259 patients with aSAH were enrolled. The average age of all patients is (56.54 ± 10.52) years, including 96 males and 163 females. They were divided into Group A (n = 146) and Group B (n = 113). Univariate analysis results show that age, the levels of TC, TG, LDL-C, and BG were higher in Group B (P < 0.05). Besides, Group B had more severe GCS, H-H grade, and Modified Fisher grade than Group A, and a higher proportion of intracranial aneurysms with larger diameter (P < 0.05). Correlation analysis showed that TC, TG, LDL-C, and BG levels were positively correlated with Modified Fisher grade (P < 0.05) and H-H grade (P < 0.05). Multivariate logistic regression model analysis showed that high level of Modified Fisher grade (OR = 0.079, 95%CI: 0.027–0.230) , high level of H-H grade (OR = 0.204, 95%CI: 0.067–0.622) , TC (OR = 10.711, 95%CI: 2.457–46.700) , LDL-C (OR = 0.178, 95%CI: 0.039–0.823) and BG (OR = 1.273, 95%CI: 1.012–1.602) increased the risk of adverse prognosis. The AUC of “H-H grade”, “Modified Fisher grade”, “TC level”, “LDL-C level” and “BG level” was 0.822, 0.885, 0.860, 0.772, and 0.721, respectively, in the ROC curve. ConclusionModified Fisher grade, H-H grade, TC, LDL-C, and BG levels at admission were independent predictors of adverse prognosis of aSAH. Besides, TC, LDL-C, and BG levels were positively correlated with Modified Fisher grade and Hunt-Hess grade. What's more, high levels of TC, LDL-C, and BG combined with Modified Fisher grade and H-H grade can identify high-risk groups with adverse prognoses in aSAH patients.

Quantitative analysis of HSV‑1 shedding as a predictor of cerebral vasospasm severity in patients with subarachnoid hemorrhage.

Cerebral vasospasm (CV) is a critical determinant of outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Despite advances in neurocritical care, modifiable risk factors for CV remain poorly understood, and identifying them could significantly enhance patient management and treatment strategies. The present study explored the potential link between the reactivation of herpes simplex virus type 1 (HSV-1), a common resident virus in cranial nerves, and CV severity. It was hypothesized that higher HSV-1 viral load in saliva may be associated with increased CV severity. Saliva samples were collected on days 4, 7, 10 and 14 post-aSAH, and HSV-1 DNA levels were measured using quantitative PCR. CV severity was assessed using the Lindegaard ratio (LR), with an LR >3 considered the diagnostic threshold for CV. A total of 36 patients were enrolled, and 139 saliva samples were collected. HSV-1 DNA was detected in 19.4% of samples (27/139), and 44% of patients (16/36) developed CV. HSV-1 seropositive patients made up 88.9% (32/36) of the cohort, with 50% exhibiting viral shedding during the study period. None of the HSV-1 seronegative patients (11.1%, 4/36) exhibited viral shedding or developed CV. Regression analysis showed a positive association between HSV-1 viral load and CV severity, with viral load explaining 27.8% of the variability (P=0.005). Age was also significant, with older patients experiencing less severe CV (P<0.001). Supervised machine learning identified viral load thresholds that aligned with standard LR values for moderate and severe CV. While the small sample size and observational design limit the generalizability of the results, these findings suggested that earlier detection and intervention for CV could be informed by assessing HSV-1 serostatus and monitoring viral activity through saliva samples or other non-invasive methods, highlighting the need for larger, controlled studies to validate these results.

Comparison of Risk Factors for Early Seizures Between Angiogram-Negative and Aneurysmal Subarachnoid Hemorrhage.

Early-onset seizures are common in aneurysmal subarachnoid hemorrhage (aSAH), with risk factors that have been explored. However, early-onset seizures in patients with angiogram-negative nonperimesencephalic SAH (an-SAH) are less understood. We sought to compare the incidence and risk factors of early-onset seizures between these groups. We conducted a retrospective study of a cohort of consecutive patients admitted to an academic center between July 2016 and July 2023. Patients were categorized into aSAH or an-SAH based on imaging findings. Clinical data and electroencephalogram findings were retrieved and analyzed. Multivariable logistic regression analysis was used to determine risk factors for clinical or electrographic seizures, as well as other epileptic features. We included 473 patients (63% female) in the final analysis, of whom 79 had an-SAH and 394 had aSAH. Patients with an-SAH were older (mean age 61.9years [standard deviation 15.9] vs. 56.7 [standard deviation 13.4]; p = 0.02). The rate of clinical or electrographic seizures was similar between the two groups (13% in aSAH vs. 11% in an-SAH; p = 0.62). Highly epileptic features (electrographic seizures, ictal-interictal continuum, and periodic epileptic discharges) occurred more frequently in the aSAH group compared with the an-SAH group, although this difference was not significant (15% vs. 8%; p = 0.09). Risk factors for seizures in aSAH were Hunt and Hess grade (odds ratio [OR] 1.25 per grade increase, 95% confidence interval [CI] 1.05-1.49; p = 0.011), modified Fisher score (OR 1.64 per point increase, 95% CI 1.25-2.15; p < 0.001), cerebral infarct (OR 3.64, 95% CI 2.13-6.23; p < 0.001), and intracerebral hemorrhage (OR 10, 95% CI 1.35-76.9; p = 0.017). However, none of these factors were associated with seizures in an-SAH. Early-onset seizures occur at similar rates in patients with an-SAH and aSAH. However, seizure risk factors appear to differ between these groups. Larger prospective studies are needed to identify predictors of seizures in patients with an-SAH.