Cause Of Spontaneous Subarachnoid Hemorrhage Research Articles

External Ventricular Drain Placement, Critical Care Utilization, Complications, and Clinical Outcomes after Spontaneous Subarachnoid Hemorrhage: A Single-Center Retrospective Cohort Study.

To examine the association between external ventricular drain (EVD) placement, critical care utilization, complications, and clinical outcomes in hospitalized adults with spontaneous subarachnoid hemorrhage (SAH). A single-center retrospective study included SAH patients 18 years and older, admitted between 1 January 2014 and 31 December 2022. The exposure variable was EVD. The primary outcomes of interest were (1) early mortality (<72 h), (2) overall mortality, (3) improvement in modified-World Federation of Neurological Surgeons (m-WFNSs) grade between admission and discharge, and (4) discharge to home at the end of the hospital stay. We adjusted for admission m-WFNS grade, age, sex, race/ethnicity, intraventricular hemorrhage, aneurysmal cause of SAH, mechanical ventilation, critical care utilization, and complications within a multivariable analysis. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CI). The study sample included 1346 patients: 18% (n = 243) were between the ages of 18 and 44 years, 48% (n = 645) were between the age of 45-64 years, and 34% (n = 458) were 65 years and older, with other statistics of females (56%, n = 756), m-WFNS I-III (57%, n = 762), m-WFNS IV-V (43%, n = 584), 51% mechanically ventilated, 76% White (n = 680), and 86% English-speaking (n = 1158). Early mortality occurred in 11% (n = 142). Overall mortality was 21% (n = 278), 53% (n = 707) were discharged to their home, and 25% (n = 331) improved their m-WFNS between admission and discharge. Altogether, 54% (n = 731) received EVD placement. After adjusting for covariates, the results of the multivariable analysis demonstrated that EVD placement was associated with reduced early mortality (aOR 0.21 [0.14, 0.33]), an improvement in m-WFNS grade (aOR 2.06 [1.42, 2.99]) but not associated with overall mortality (aOR 0.69 [0.47, 1.00]) or being discharged home at the end of the hospital stay (aOR 1.00 [0.74, 1.36]). EVD was associated with a higher rate of ventilator-associated pneumonia (aOR 2.32 [1.03, 5.23]), delirium (aOR 1.56 [1.05, 2.32]), and a longer ICU (aOR 1.33 [1.29;1.36]) and hospital length of stay (aOR 1.09 [1.07;1.10]). Critical care utilization was also higher in patients with EVD compared to those without. The study suggests that EVD placement in hospitalized adults with spontaneous subarachnoid hemorrhage (SAH) is associated with reduced early mortality and improved neurological recovery, albeit with higher critical care utilization and complications. These findings emphasize the potential clinical benefits of EVD placement in managing SAH. However, further research and prospective studies may be necessary to validate these results and provide a more comprehensive understanding of the factors influencing clinical outcomes in SAH.

Mirror Aneurysms of the Supraclinoid Internal Carotid Artery

Introduction: Intracranial aneurysms are bulge in the wall of the intracranial artery and are the most common cause of spontaneous subarachnoid haemorrhage (SAH), accounting for 85% of SAH. Intracranial mirror aneurysms (MirAns) are aneurysms located in similar positions on the bilaterally symmetrical arteries. MirAns are rare and make-up approximately &lt;5% of all intracranial aneurysms. Based on the literature evidence, our study was the first case series amongst supraclinoid internal carotid artery (ICA) MirAns. Case Report: We present two cases with mirror-type aneurysms arising from the supraclinoid segments of ICA. Both cases are managed with single-stage microsurgical clipping of both aneurysms. A brief review of the literature has been based on the available evidence. Conclusion: As MirAns are rare, further research into this field is needed to analyse the geographic variation, pathogenesis and management strategy. Based on our experience single staged clipping of Bilateral MiAns are recommended. The Aneurysm that has ruptured or the bigger sized is clipped first followed by the other one. We also noted that there is no visual hindrance by the initial clip on clipping the second, in our series of supraclinoid MirAns.

Retrospective study of spontaneous subarachnoid haemorrhage: vasospasm and other complications (Part III)

Background. Acute subarachnoid haemorrhage (SAH) is a dangerous condition: roughly 50% of patients die within 30 days, nearly 25% develop significant neuropsychological and cognitive deficits, about 10% suffer from other complications, and only around 15% recover fully. One of the main causes of mortality is cerebral vasospasm (CVS), a cause of delayed cerebral ischaemia (DCI), which can lead to secondary cerebral infarction. Thus, early detection of CVS is crucial for improving patient outcomes.The aim of this study was to analyse the demographic and clinical (including complications) data of patients diagnosed with SAH, to evaluate the diagnostic methods, and to investigate the prevalence and treatment of complications.Materials and methods. This retrospective study included 102 patients diagnosed with spontaneous SAH, aged at least 18 years, who were treated in the Vilnius University Hospital Santaros Klinikos (VUL SK) in 2014-2017. The obtained VUL SK data were selected by the I60 ICD-10-CM code and depersonalized. Head computerized tomography (CT), CT angiography (CTA), digital subtraction angiography (DSA), transcranial color-coded duplex sonography (TCCS), and magnetic resonance angiography (MRA) were used to evaluate the cerebral arteries.Results. In 102 patients (mean age 58±16 years; 55% female), the most common cause of spontaneous SAH was ruptured aneurysm, the most common arterial sites were the middle cerebral artery (36%), anterior cerebral artery and/or communicating artery (together 33%), and internal carotid artery (20%). In-hospital mortality was as high as 21%. All patients underwent head CT, 78% CTA, 33% DSA, 8% TCCS, and 1% MRA. 71% patients experienced SAH complications: 66% acute, 27% chronic. The most common acute complications were cerebral oedema (34%), rebleeding (29%), and acute ischaemia (23%), the most common chronic complications hydrocephalus (11%), DCI (9%), and CVS (8%).Conclusions. CVS was diagnosed considerably less frequently in this study compared to other studies. While the diagnosis rates of ischaemia and hyponatremia were likewise significantly lower in this study compared to those in others, they are in line with the CVS diagnosis rate. Aside from the CVS and CVS-related complications, all the other SAH complications were roughly within the range of the other studies.

ICGA combined with EP monitoring in microclipping of cerebral aneurysms.

Cerebral aneurysm is one of the common cerebrovascular diseases in neurosurgery, and rupture of cerebral aneurysm is the most important cause of spontaneous subarachnoid hemorrhage. How to precisely clip the aneurysm has been a topic worth discussing, so the authors explore the value of ICGA combined with electrophysiological monitoring in the microclipping of cerebral aneurysms. Using the method of retrospective analysis of cases, 661 patients with cerebral aneurysms admitted to the Department of Neurosurgery, Zhongnan Hospital of Wuhan University, from 2021.8 to 2022.10 were studied, 390 patients with aneurysm clipping were included, and patients with Hunt-Hess classification ≥ 4 were excluded, and whether to use ICGA combined with EP in microclipping of the ruptured and unruptured aneurysm in pterional approach was investigated at the time of discharge, respectively. The MRS and total hospital days were compared to investigate the value of ICGA combined with EP in the microclipping of cerebral aneurysms. All 390 patients enrolled in the group had successful aneurysm clipping, 178 patients were screened for ruptured aneurysm pterional approach and 120 patients for unruptured aneurysm pterional approach access; the MRS at discharge was significantly lower in the ICGA combined with EP group than in the no-EP group for ruptured aneurysm pterional approach microclipping (p < 0.001), and the mean number of days in hospital was significantly lower (p < 0.01). Patients in the ICGA combined with EP group in microclipping of unruptured aneurysms with pterional approach also had significantly lower MRS at discharge compared with patients in the ICGA alone group (p < 0.001), with no statistically significant difference in the mean number of days in hospital (p = 0.09). In open cerebral aneurysm microclipping, ICGA combined with EP monitoring for both ruptured and unruptured aneurysms can effectively reduce the false-negative rate of ICGA, significantly reduce the incidence of postoperative neurological deficits, and shorten the total hospital stay to some extent. ICGA combined with EP monitoring may be an effective means to reduce the rate of false clipping of the penetrating vessels and to avoid stenosis or occlusion of the aneurysm-carrying artery and is worth promoting in microclipping of cerebral aneurysms except for Hunt-Hess ≥ 4.

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.

Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool.

Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations. A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis. These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.

Intracranial Aneurysm Rupture Risk Estimation With Multidimensional Feature Fusion.

The rupture of aneurysms is the main cause of spontaneous subarachnoid hemorrhage (SAH), which is a serious life-threatening disease with high mortality and permanent disability rates. Therefore, it is highly desirable to evaluate the rupture risk of aneurysms. In this study, we proposed a novel semiautomatic prediction model for the rupture risk estimation of aneurysms based on the CADA dataset, including 108 datasets with 125 annotated aneurysms. The model consisted of multidimensional feature fusion, feature selection, and the construction of classification methods. For the multidimensional feature fusion, we extracted four kinds of features and combined them into the feature set, including morphological features, radiomics features, clinical features, and deep learning features. Specifically, we applied the feature extractor 3D EfficientNet-B0 to extract and analyze the classification capabilities of three different deep learning features, namely, no-sigmoid features, sigmoid features, and binarization features. In the experiment, we constructed five distinct classification models, among which the k-nearest neighbor classifier showed the best performance for aneurysm rupture risk estimation, reaching an F2-score of 0.789. Our results suggest that the full use of multidimensional feature fusion can improve the performance of aneurysm rupture risk assessment. Compared with other methods, our method achieves the state-of-the-art performance for aneurysm rupture risk assessment methods based on CADA 2020.

Potential Role of the Chemotaxis System in Formation and Progression of Intracranial Aneurysms Through Weighted Gene Co-Expression Network Analysis.

BackgroundIntracranial aneurysm (IA) is the most common and is the main cause of spontaneous subarachnoid hemorrhage (SAH). The underlying molecular mechanisms for preventing IA progression have not been fully identified. Our research aimed to identify the key genes and critical pathways of IA through gene co-expression networks.MethodsGene Expression Omnibus (GEO) datasets GSE13353, GSE54083 and GSE75436 were used in the study. The genetic data were analyzed by weighted gene co-expression network analysis (WGCNA). Then the clinically significant modules were identified and the differentially expressed genes (DEGs) with the genes were intersected in these modules. GO (gene ontology) and KEGG (Kyoto Gene and Genomic Encyclopedia) were used for gene enrichment analysis to determine the function or pathway. In addition, the composition of immune cells was analyzed by CIBERSORT algorithm. Finally, the hub genes and key genes were identified by GSE122897.ResultsA total of 266 DEGs and two modules with clinical significance were identified. The inflammatory response and immune response were identified by GO and KEGG. CCR5, CCL4, CCL20, and FPR3 were the key genes in the module correlated with IA. The proportions of infiltrating immune cells in IA and normal tissues were different, especially in terms of macrophages and mast cells.ConclusionThe chemotactic system has been identified as a key pathway of IA, and interacting macrophages may regulate this pathological process.

COMPARATIVE ANALYSIS OF SURGICAL AND ENDOVASCULAR TREATMENT OF INTRACRANIAL ANEURYSMS

With a prevalence of about 2.3%, intracranial aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Many studies compared currently most common therapeutic options-neurosurgical clipping and endovascular embolization, but so far no single solution in which therapeutic method should have an advantage has been found. The aim was to compare the outcome of treatment on discharge, among patients treated with clipping or embolization. The data of 62 patients treated at the Neurosurgery Clinic of the Clinical Center of Serbia, were obtained through discharge lists. The analysis included data on sex, age, Glasgow coma scale, aneurysm rupture, Hunt &amp; Hess scale, localization, number of aneurysms, length of overall and postoperative stay as well as the existence of complications. The condition on discharge was assessed using the Glasgow outcome scale. In our study 37 subjects (59.7%) had a subarachnoid hemorrhage, while 25 (41.9%) patients were without bleeding. 30 patients underwent surgery, while 32 were treated by embolization. No significant relationship between the treatment modality and outcome on discharge was observed (p=0.115). Patients without bleeding had a significantly better outcome on discharge when treated by endovascular method (p&lt;0.001), whereas in the group with a rupture no differences were found (p=0.35). Complications were significantly more common after surgery (p=0.026). No difference among the groups in the length of the total hospital stay was found (p=0.246), while a significantly longer postprocedural period was recorded following neurosurgical treatment (p=0.029). Groups treated with different modalities did not differ in the outcome on discharge. However, the percentage of complications was greater in the group of patients undergoing surgery, as well as the length of postoperative hospital stay. We believe that furthe detailed analyzes offering information on the condition of patients after a long period of follow-up iare required.

A study on clinical characteristics, computed tomography brain imaging, causes and complications of subarachnoid hemorrhage

Backgroud: Subarachnoid hemorrhage (SAH) is sudden bleeding into the subarachnoid space. The most common cause of spontaneous SAH is a ruptured aneurysm. Symptoms include sudden, severe headache, usually with loss or impairment of consciousness. It has a lot of dangerous complications especially re-bleeding and vasospasm which are the major causes of death and disability. Objective: To study on clinical characteristics, computed tomography brain imaging, causes and complications of subarachnoid hemorrhage. Subject and method: A cross-sectional prospective study on 202 patients who suffered from subarachnoid hemorrhage admitted to the Stroke Center, 108 Military Central Hospital from June 2018 to January 2020. Result and conclusion: The average age was 60.5 years. The most common age group was among the aged 45-64 years (71.2%). The most common symptoms of SAH was sudden severe headache (98%); neck stiff (86.1%), followed by consciousness disorders (56.9%), systolic blood pressure above 160mmHg (50.5%), focal neurologic deficits (20.3%). The Fisher classification: Grade 1 (4.5%), grade 2 (17.3%), grade 3 (19.3%), grade 4 (58.9%). The ruptured cerebral aneurysm accounted for 89.6% of the causes of SAH. The most common site of aneurysm was in the anterior communicating artery (34.8%), followed by the middle cerebral artery (21.5%) and in the internal carotid artery (16.6%). Posterior cerebral circulation accounted for 12.7%; 4.4% of patients had multiple aneurysms. The most common complications of SAH was cerebral vasospasm (26.2%) and typically occurred between 5 and 7 days after SAH, followed by rebleeding accounted for 7.9%, the most cases occurred within the first 24 hours, acute and subacute hydrocephalus (10.4%), hyponatremia (11.4%) and seizures (5.4%).

Is neutrophil-lymphocyte ratio a useful tool for predicting outcome in subarachnoid hemorrhage? A systematic review.

Ruptured intracranial aneurysms, as the leading cause of spontaneous subarachnoid hemorrhage (aSAH), represents an emergency with high morbi-mortality. The comprehension of the underlying pathology that involves inflammatory and immune responses, through the neutrophil-to-lymphocyte ratio (NLR), could help to predict complications such as delayed cerebral ischemia (DCI) or rebleeding and the functional outcome. Systematic review of English-based literature through PubMed and Biblioteca Vitural em Saúde (BVS) to find papers discussing the use of NLR in the aSAH setting. Area-under-curve (AUC) of receiver operating characteristics (ROC), cutoff value, sensitivity, and specificity were retrieved. From 53 articles included, 4 papers were evaluated after exclusion criteria. Rebleeding could be predicted with a NLR cutoff value of 9.88 (sensitivity 72.3%, specificity 63.3%). The mean cutoff value for DCI was 12.85, with sensitivity 66.3% and specificity 75.8%. Finally, a worse 3-month functional outcome could be predicted with a mean sensitivity of 73.3% and a mean specificity of 54%. NLR is a new issue in scientific community, especially neurosurgery. The current understanding points to a multifactorial process after aSAH that emerges as alterations on the NLR. As a measurement readily available and cost-effect after admission of the patient, its use signals that patients that need expedite surgical treatment or more aggressive treatment for vasospasm. As other medical subspecialties already use this ratio to predict outcomes, the literature reviewed by this paper constitute the earliest clues that higher NLR predicts re-bleeding, DCI, and functional outcome.

The impact of statin therapy after surgical or endovascular treatment of cerebral aneurysms.

Cerebral aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Statins are lipid-lowering agents that may expert multiple pleiotropic vascular protective effects. The authors hypothesized that statin therapy after coil embolization or surgical clipping of cerebral aneurysms might improve clinical outcomes. This was a retrospective cohort study using the National Health Insurance Service-National Sample Cohort Database in Korea. Patients who underwent coil embolization or surgical clipping for cerebral aneurysm between 2002 and 2013 were included. Based on prescription claims, the authors calculated the proportion of days covered (PDC) by statins during follow-up as a marker of statin therapy. The primary outcome was a composite of the development of stroke, myocardial infarction, and all-cause death. Multivariate time-dependent Cox regression analyses were performed. A total of 1381 patients who underwent coil embolization (n = 542) or surgical clipping (n = 839) of cerebral aneurysms were included in this study. During the mean (± SD) follow-up period of 3.83 ± 3.35 years, 335 (24.3%) patients experienced the primary outcome. Adjustments were performed for sex, age (as a continuous variable), treatment modality, aneurysm rupture status (ruptured or unruptured aneurysm), hypertension, diabetes mellitus, household income level, and prior history of ischemic stroke or intracerebral hemorrhage as time-independent variables and statin therapy during follow-up as a time-dependent variable. Consistent statin therapy (PDC > 80%) was significantly associated with a lower risk of the primary outcome (adjusted hazard ratio 0.34, 95% CI 0.14-0.85). Consistent statin therapy was significantly associated with better prognosis after coil embolization or surgical clipping of cerebral aneurysms.

Spontaneous Subarachnoid Haemorrhage in Neurological Setting in Burkina Faso: Clinical Profile, Causes, and Mortality Risk Factors.

To determine the prevalence, clinical profile, causes, and mortality risk factors of spontaneous arachnoid haemorrhage at Yalgado Ouedraogo University teaching Hospital, we conducted a 5-year retrospective study of 1803 stroke patients admitted to Neurology Department during the period from January 2012 to December 2016. During the study period, spontaneous subarachnoid haemorrhage accounted for 3.2 % of all stroke. The mean age of patients was 60 years (range 20-93 years). There was a female predominance in 55.9%. The common vascular risk factors were hypertension (79.7%) and chronic alcohol consumption (16.9%). The main symptoms were headache (76.2%), motor weakness (74.5%), and consciousness disorders (62.7%). Neurological examination revealed limb weakness in 76.2% and meningeal irritation in 47.4%. The best admission Glasgow Coma Scale score of 15 was found only in 37.3 % of patients. About 50.8% of patients were admitted to Hunt and Hess moderate grade (III) resulting in a mortality of 24.80%. The main cause of spontaneous subarachnoid haemorrhage was hypertension (77.9%). Cause could not be determined in 8.5 % of cases. The mortality rate was 37.3%. There was high mortality in patients with intraventricular haemorrhage and in patients with disturbances of consciousness. In conclusion, our study showed a poor frequency of spontaneous subarachnoid haemorrhage with high mortality. Hypertension was the most common cause of spontaneous subarachnoid haemorrhage.

Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians.

Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examinedtheirpractice pattern variation by observing their diagnostic approaches andtheir adherence to the ACEP Clinical Policy. We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs. Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006). Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

Neurosurgical aspects of hemorrhagic stroke

Introduction. The occurrence of hemorrhagic stroke (HS) is about 1/5 of that of ischemic stroke, but HS represents an important problem of neurology because of high mortality and disability rates. HS can manifest as spontaneous subarachnoid hemorrhage (SAH), intracerebral hematoma (ICH), spontaneous (non-traumatic) extradural and subdural hematomas, or as a combination of these conditions. HS is characterized by a high percentage of complications, most severe of which is intraventricular hemorrhage (IVH). Objective . To analyze the structure of HS, its complications and various methods of neurosurgical treatment. Materials and methods. We studied medical histories of 84 patients with HS were who were treated in the Neurosurgical Department of GBUZ RB Hospital ambulance Ufa for the 6-month period in 2016. All patients underwent neurological, instrumental and laboratory examination, CT scan and CT angiography, brain MRI and, if necessary, cerebral angiography (CAG). To assess the severity and outcome of IVH, we used the Graeb criteria of the ventricular system involvement and the Hounsfieid characteristics of the ventricular clot density. Results. The main causes of HS were arterial hypertension (54,7%) and aneurysmal disease of the brain (44%). Most of patients (63,8%) had putaminal ICH. Rupture of the aneurysm was the cause of SAH in 24 (28.6%) of patients. Aneurysms were located mostly in the basin of the middle cerebral artery. Surgical treatment was undertaken in 76 patients (90.4%t). IVH as a complication occurred in 21.4% of patients, main cause of this complication was massive SAH. Discussion. In most of our cases of HS, the clinical picture of SAH was seen – 59.5% of patients. Among all methods of neurosurgical treatment of ICH, we predominantly used minimally invasive high-tech techniques proven to be most effective: needle aspiration, endoscopic removal of hematomas under the control of neuronavigation, and fibrinolysis; these technologies were used in 52.5% of patients.

Spontaneous Subarachnoid Hemorrhage Induced by Warfarin Use

Introduction: The most frequent cause of spontaneous subarachnoid hemorrhage (SAH) is the rupture of a brain aneurysm. Approximately 5% of cases of spontaneous SAH did not show changes on magnetic resonance imaging (MRI) or angiography that explain such bleeding. The objective of this study was to report a case of spontaneous SAH induced by warfarin, where there was no evidence of any vascular malformation. Case Report: A 59 year-old male patient developed a sudden onset severe headache while in the shower. The patient had a history of mitral valve disease and valve replacement 23 years before and hypertension monitored by a cardiologist with 5 mg warfarin sodium daily. Computed tomography (CT) scan revealed a SAH. Laboratory tests showed an International Normalized Ratio (INR) of 2.22 (normal: 1 to 1.2). Cerebral angiography and neuraxis MRI were performed and showed no aneurysms or other vascular malformations. Conclusion: The occurrence of hemorrhageassociated with warfarin treatment is a well-documented event in the literature. However, the isolated occurrence of SAH in these patients is a rare event. To prove that SAH is indeed attributed to anticoagulation, it is necessary to excludethe presence of aneurysms and other vascular diseases by imaging techniques.

The Prevalence of Cerebrovascular Abnormalities Detected in Various Diagnostic Subgroups of Spontaneous Subarachnoid Hemorrhage in the Modern Era.

To determine prevalence of cerebrovascular abnormalities in diagnostic subgroups of spontaneous subarachnoid hemorrhage (SAH) in a regional neurosurgical center in the modern era. Data of 609 consecutive patients with spontaneous SAH in a 3-year period (August 2010 to August 2013) were prospectively collected. Patients were divided into 3 diagnostic subgroups: computed tomography (CT) positive for SAH; CT negative but positive cerebrospinal fluid examination by spectrophotometry for SAH; CT negative for SAH and inconclusive cerebrospinal fluid examination. All patients fit for intervention underwent CT angiography with or without digital subtraction angiography to identify vascular abnormalities for subsequent treatment. Of 609 patients, 554 were fit for further investigation and consideration of further intervention; 514 patients had confirmed SAH. Mean patient age was 54.0 years; 61.5% of patients were women. Of patients, 390 (75.9%) showed vascular abnormalities on angiography. There were 438 patients (85.2%) with confirmed SAH diagnosed on CT scan (group 1). Vascular abnormalities were detected in 81.1% of patients; 18.9% of patients with positive CT scan had no identifiable cause of SAH. Of patients with confirmed SAH, 76 (14.8%) had negative CT scan but positive lumbar puncture (group 2); 46.1% of patients in this group had vascular abnormalities. Three patients with inconclusive cerebrospinal fluid examination had lesions requiring treatment. Median length of hospital stay in group 1 patients was longer than median length of hospital stay in group 2 patients. Frequency of vascular abnormalities in spontaneous SAH is lower than the traditionally quoted figure, which has diagnostic and prognostic implications for patient management.

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.

Endovascular Treatments for Ruptured Intracranial Vertebral Artery Dissecting Aneurysms: Experience in 16 Patients.

ObjectiveIntracranial vertebral artery dissecting aneurysms are rare lesions that are considered an important cause of spontaneous subarachnoid hemorrhage. We report our decade-long experience in treating ruptured intracranial vertebral artery dissecting aneurysms.Materials and MethodsThis retrospective single-center study included 21 consecutive patients between February 2005 and March 2015. Their clinical features included radiologic finding at the initial examination, treatment modality, functional outcome at the last follow-up, mortality, and radiologic outcome at more than 6 months after the initial treatment.ResultsAll 16 aneurysms were treated endovascularly; aneurysm trapping was performed in 9 patients and vascular reconstruction was performed in 7 patients. For 6 aneurysms involving the posterior inferior cerebellar artery (PICA), the modalities of treatment were aneurysm trapping in 3 patients and vascular reconstruction in 3 patients. The mean duration of follow-up was 29 months (range, 6–70 months). Five patients expired, indicating a mortality rate of 31%. In surviving patients, the unfavorable outcome rate (modified Rankin Scale [mRS] > 2) was 36%. The overall mean mRS for survivors was 1.8. Angiographic follow-up in 11 survivors at 13 months, (range, 6–46 months) revealed recanalization of the aneurysm in one patient.ConclusionsRuptured intracranial vertebral artery dissecting aneurysm is associated with poor functional outcome and high mortality. More immediate treatments are needed due to the high rebleeding rate in this disease condition. Endovascular treatment may be a useful option for ruptured intracranial vertebral artery dissecting aneurysms.

Diagnostic accuracy of contrast enhancement MRI versus CTA in diagnosis of intracranial aneurysm in patients with non-traumatic subarachnoid hemorrhage

Abstract Aim of the study The most common cause of spontaneous SAH is the rupture of cerebral aneurysm. So it is very important to exclude it from circulation as soon as possible using endovascular therapy. The aim was to determine whether contrast enhancement magnetic resonance angiography (CEMRA) is preferable to computed tomography angiography (CTA) in detection of intracranial aneurysm in patients presenting with non-traumatic subarachnoid hemorrhage (SAH). Patients and methods Twenty-five patients who presented with non-traumatic SAH underwent CEMRA and CTA for detection of aneurysms. Digital subtraction angiography (DSA) was used as standard of reference. Results CEMRA and CTA were done for all patients. A total of 22 aneurysms were detected in 25 patients. 15 patients with single aneurysm, 2 patients with two aneurysms, one patient with 3 aneurysms and in 7 patients no aneurysm was found. CEMRA and CTA angiograms were interpreted for the detection of aneurysms, site and size. Conclusion The diagnostic performance of CEMRA does not significantly differ from that of CTA in patients presenting with SAH.