Cases Of Nontraumatic Subarachnoid Hemorrhage Research Articles

Abstract P443: Identification of Traumatic and Non-Traumatic Intracranial Bleeding Subtypes in Patients With Non-Valvular Atrial Fibrillation Receiving Oral Anticoagulant Therapy Using Primary Care Data From the United Kingdom

Introduction: Classification of intracranial bleeding (ICB) by trauma status is important in research relating to anticoagulant therapy. We evaluated trauma status of ICB subtypes - intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) - in a large population of patients with non-valvular atrial fibrillation (NVAF) receiving oral anticoagulant (OAC) therapy. Methods: Using the IQVIA Medical Research Data UK primary care database, we followed 45,164 patients with NVAF newly prescribed OAC therapy to identify incident ICB cases, and categorized them as ICH, SAH or SDH based on the coded description. We identified cases with a code suggesting the event was traumatic (e.g. head injury) or non-traumatic within 90 days either side of the ICB event, and manually reviewed the patient records for cases without such a code to identify other entries indicating trauma in the time period. ICH and SAH cases without a trauma/non-trauma code were classed as non-traumatic and SDH cases without a trauma/non-trauma code were classed as traumatic. Results: A total of 286 ICB cases were identified: 45.5% ICH, 41.9% SDH, 12.6% SAH. Classification of cases is shown in the Table. Most traumatic cases were SDH (77.3%, 85/110); most non-traumatic cases were ICH (66.5%, 117/176). Classification by the presence of a trauma/non-trauma code was 82.5% for SDH, 33.3% for SAH and 10.8% for ICH. Classification of all but one non-traumatic ICH case and all non-traumatic SAH cases were by the absence of a trauma/non-trauma code. For SDH, 75.3% of traumatic SDH cases were based on a trauma code, and 100% of non-traumatic SDH cases were based on a non-trauma code. Conclusion: Among patients with NVAF receiving OAC therapy, the majority of incident ICB cases were non-traumatic. Classification of SDH was predominantly made from trauma/non-trauma codes; cases of ICH and SAH were mostly based on the absence of trauma/non-trauma codes using non-trauma as the default category.

Factors determining outcome of post-angiogram-negative subarachnoid hemorrhage.

Aim:To determine the risk factors affecting outcome at the end of 90 days of post-angiogram-negative subarachnoid hemorrhage (SAH).Methods:Non-traumatic SAH cases were reviewed from the case records of patients who had reported to the Department of Neurology of a tertiary care hospital and 50 angio-negative SAH cases were included after excluding all the cases with known cause of hemorrhage after doing computed tomography angiography (CTA)/digital subtraction angiography (DSA). The presence of hypertension, diabetes mellitus, coronary artery disease (CAD), history of alcohol and smoking, and various scales like Hunt and Hess Scale (HHS), World Federation of Neurological Surgeons (WFNS), and Fisher scale had been recorded at admission. The outcome was assessed at 90 days post-SAH using the Modified Rankin Scale (mRS).Statistical analyses:The association between the outcome and the factors was assessed using the Pearson Chi-Square test and the risk factors/predictors of outcome were assessed using logistic regression.Results:The following variables were important risk factors for predicting poor outcome of angio-negative SAH (mRS 3 to 6): hypertension (P = 0.011), diabetes mellitus (P = 0.032), being an alcoholic (P = 0.019), HHS grade 4 to 5 (P < 0.01), and WFNS grade 4 to 5 (P < 0.01). On multivariate regression analysis, hypertension (P = 0.032) was an independent predictor of unfavorable outcome.Conclusions:At time of admission, presence of hypertension, diabetes mellitus, history of alcohol consumption, and poor grades of HHS and WFNS scale are predictors of poor outcome of angio-negative SAH.

Impact of Ruptured Aneurysm Circulation on Mortality: A Nationwide Inpatient Sample Analysis

ObjectiveThis study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States. MethodsA retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality. ResultsThe NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality. ConclusionsMortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families.

Endovascular treatment of ruptured and unruptured intracranial dissecting aneurysms

ObjectivesDissecting aneurysms are rare as contrasted with their saccular counterparts, yet they stay hard to treat and are related with high rates of rebleeding and morbidity. Material & methodsIn this study, we have reviewed dissecting aneurysms of both anterior and posterior circulation, both ruptured and unruptured, including natural history, endovascular treatment and clinical outcome. They account for 3–7% of cases of nontraumatic subarachnoid hemorrhage. Surgical treatment carries a significant risk of neurological complications predominantly lower cranial nerve deficits because of the close relationship of the posterior circulation aneurysm with the brain stem and cranial nerves. ResultsA total of 28 ruptured and unruptured dissecting aneurysms in both anterior and posterior circulation were treated endovascularly from January 2015 till October 2018. Out of 28, 23 of the aneurysms were in posterior circulation and 5 were in anterior circulation. All the cases were technically successful except in 1 case. Procedure related complications were seen in 9 patients which were transient except in one patient who died. Follow up studies showed stable and complete occlusion of aneurysms in all patients except in 1 case in which recanalization was seen. ConclusionDissecting aneurysms are dynamic lesions with variable and unpredictable evolution and a through treatment is warranted. Endovascular treatment by coiling and parent artery occlusion is relatively safe and effective treatment of dissecting intracranial aneurysms.

No Disparity in Outcomes Between Surgical Clipping and Endovascular Coiling After Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) can be treated with either endovascular coiling or surgical clipping. The International Subarachnoid Aneurysm Trial (ISAT) found that endovascular coiling provided lower mortality rates at 1-year follow-up, starting a trend toward the endovascular treatment approach for SAH. Subsequently, specific procedural indications have driven an approach to SAH management involving a patient-specific procedural choice. The present study evaluates whether specific indications for these procedures have eliminated the differences in risk-adjusted mortality and in-hospital complications from SAH in a large nationally representative set of hospitalizations from 2013 to2014. All cases of nontraumatic subarachnoid hemorrhage were queried from the National Inpatient Sample using codes from the International Classification of Diseases, 9th edition. These patients were assigned to cohorts based on whether they were treated by surgical clipping or by endovascular coiling. Subsequent univariate and multivariate analyses were used to characterize and compare demographics, in-hospital complications, and total charges between the 2 groups. In 2013 to 2014, 6555 patients hospitalized for SAH underwent surgical clipping and 15,350 underwent endovascular coiling. The patients undergoing coiling were older (55.3 vs. 54.1, P= 0.02) and had lower severity scores (3.24 vs. 3.44, P < 0.0001); however, they had higher average risk of mortality scores (2.96 vs. 2.44, P < 0.0001) and longer lengths of stay (19.0 vs. 17.8 days, P= 0.009) than did those undergoing surgical clipping. Multivariate logistic regression analysis comparing clipping to coiling showed no differences in rates of complication (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.67-1.13), death (OR: 0.78; 95% CI: 0.57-1.05), or total charges (-$3282, 95% CI:-$8376-$14,941) between both cohorts. Concerns about overzealous use of endovascular coiling in treating SAH after the ISAT stemmed from a lag in condition-specific indications. The allure of endovascular coiling stems from its noninvasiveness and initial results; however, in the years after ISAT, evaluation of SAH conditions led to more patient-specific indications for SAH. The results presented here suggest that more rigorous procedural selection has allowed for an optimization of outcomes for the 2 procedures.

Evolution from invasive arterial puncture to a venous access for cerebral angiography: “Cath Lab to CT suite”

Background: Digital subtraction angiography (DSA) is considered as the gold standard in the evaluation of intracranial aneurysms. This study was undertaken to evaluate the effectiveness of computed tomogram angiography (CTA) in the detection and accurate characterization of intracranial aneurysms in suspected cases of nontraumatic subarachnoid hemorrhage. The importance of three‑dimensional volume rendering of the intracranial vasculature and it’s used as an aid in improving diagnostic capabilities with regards to intracranial aneurysms in multi‑detector computed tomography angiography (MDCTA), was stressed upon. This study also tried to probe whether MDCTA alone can be used in detection and treatment of intracranial aneurysms in emergency situations. Materials and Methods: Suspected cases of nontraumatic acute subarachnoid hemorrhage, over an 18 months period, underwent CTA in 16‑slice‑computed tomography suite. Fifty cases where CTA demonstrated intracranial aneurysms were studied. A set protocol of three‑dimensional reconstruction was followed. Comparison of findings of MDCTA with surgical notes was performed. DSA was done in ambiguous cases. Results: Aneurysm was confidently diagnosed by CTA in 48 cases, and further confirmed on surgery. In doubtful cases, DSA was performed and then diagnosed as aneurysm. Thus, the sensitivity of CTA is diagnosing aneurysm is 96.6%, with a specificity of 100%. Conclusions: Digital subtraction angiography is an invasive, relatively costly, procedure to be done by highly skilled personnel with serious complication rate of 1%. This can be replaced by MDCTA, which is noninvasive, cost effective and easy to perform, and DSA can be reserved for doubtful or difficult cases. Following a set protocol of three‑dimensional reconstruction helps in reducing errors.

Antihypertensives Are Administered Selectively in Emergency Department Patients with Subarachnoid Hemorrhage

Elevated blood pressure is common in patients with acute subarachnoid hemorrhage (SAH). American Heart Association guidelines do not specify a blood pressure target, but limited data suggest that systolic blood pressure (SBP)≥160 mmHg is associated with increased risk of rebleeding and neurologic decline. In a population-based study, we determined the frequency of antihypertensive therapy in emergency department (ED) patients with SAH and the proportion of those patients with SBP≥160 mmHg who received this therapy. In 2005, nontraumatic SAH cases were retrospectively ascertained at 16 hospitals in our region by screening for International Classification of Diseases Ninth Revision diagnostic codes 430-436. Blood pressure was recorded at ED presentation and also before and after any treatment with antihypertensives. Hypotension was defined as SBP<100 mmHg. The Mann-Whitney U test and χ2 test were used for comparisons. Our cohort comprised 82 patients with SAH presenting to an ED; 4 patients were excluded. The median age of the included patients was 54 years, 74.4% were female, 29.5% were black, and 31 (39.7%) had SBP≥160 mmHg. Antihypertensive therapy was given to 22 of 31 patients (70.9%) with SBP≥160 mmHg and to 4 of 47 patients (8.5%) with SBP<160 mmHg. No patients became hypotensive after receiving treatment. Age, sex, Glascow Coma Scale score, and National Institutes of Health Stroke Scale score were similar between treated and untreated patients. In the absence of definitive evidence, current blood pressure management in local EDs appears reasonable. Further studies of blood pressure management in acute SAH are warranted.

Automated detection of intracranial aneurysms based on parent vessel 3D analysis

The detection of brain aneurysms plays a key role in reducing the incidence of intracranial subarachnoid hemorrhage (SAH) which carries a high rate of morbidity and mortality. The majority of non-traumatic SAH cases is caused by ruptured intracranial aneurysms and accurate detection can decrease a significant proportion of misdiagnosed cases. A scheme for automated detection of intracranial aneurysms is proposed in this study. Applied to the segmented cerebral vasculature, the method detects aneurysms as suspect regions on the vascular tree, and is designed to assist diagnosticians with their interpretations and thus reduce missed detections. In the current approach, the vessels are segmented and their medial axis is computed. Small regions along the vessels are inspected and the writhe number is introduced as a new surface descriptor to quantify how closely any given region approximates a tubular structure. Aneurysms are detected as non-tubular regions of the vascular tree. The geometric assumptions underlying the approach are investigated analytically and validated experimentally. The method is tested on 3D-rotational angiography (3D-RA) and computed tomography angiography (CTA). In our experiments, 100% sensitivity was achieved with average false positives rates of 0.66 per study on 3D-RA data and 5.36 false positive rates per study on CTA data.

Endovascular treatment of ruptured posterior circulation dissecting aneurysms

and aim: Dissecting aneurysms of the posterior circulation constitute a relatively uncommon subgroup of aneurysms. They account for 3-7% of cases of nontraumatic subarachnoid hemorrhage. Because of high risk, in most cases the patients require surgical or endovascular therapy. In this study we discuss the clinical efficacy of endovascular treatment with long-term follow-up in ruptured dissecting aneurysms of the posterior circulation. This retrospective study was conducted at our institution between January 1995 and June 2005. Eight patients (4 male; 4 females) ranging in age from 24 to 65 years (mean, 46.75 years), were included. All presented with SAH. Endovascular treatment was based on the configuration of the dissecting aneurysm. Attempt was made to occlude the dissecting aneurysm. A total of 8 ruptured dissecting aneurysms in the posterior circulation were treated. Out of them 5 were in the intradural vertebral artery, 2 in the basilar trunk and one in the proximal PCA. All the cases were technically successful. We have seen only two complications. The pre and post procedure (at the time of discharge) mean modified Rankin scores in the patients were 4.6 (SD 0.51) and 1.7 (SD 1.98). This improvement in Rankin score after endovascular treatment was statistically significant (Wilcoxon signed rank test, P=.017). Endovascular management of these lesions is safe and effective mode of treatment and gives adequate protection from rebleed.

Prevention of rebleeding after operation for subarachnoid hemorrhage of unknown cause.

This study is presented to promote prophylactic operation to prevent rebleeding after subarachnoid hemorrhage (SAH) of unknown cause. Twenty-two cases of nontraumatic SAH of unknown cause of a total of 254 cases of SAH treated during a 5-year period (1980-1984) were available for this study. A follow-up study (4 to 61 months after treatment; median, 43 months) revealed a 4.5% mortality rate. Four patients chosen from among the 22 SAH cases underwent prophylactic operation. The decision to operate was based on repeated angiography showing regional cerebral vasospasm corresponding to a limited hyperdense area on the computed tomographic scan at the time of the onset of SAH. Microsurgery revealed a minute protrusion (less than 2 mm in diameter) or thinning of the arterial wall with old hematoma of the surrounding brain in all 4 cases, and treatment required only coating of the abnormal site. All 4 patients are now fully recovered. Frequently, abnormal changes of such cerebral arteries as the anterior communicating artery, the internal carotid artery (C-1 and C-2), and the middle cerebral artery (M-1) may occur. Therefore, the authors emphasize the necessity of surgical treatment for specific cases of SAH with an unknown cause.