Incidence Of Cerebral Vasospasm Research Articles

Early Intravenous Magnesium Sulfate and Its Impact on Cerebral Vasospasm as well as Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Retrospective Matched Case-Control Analysis

Magnesium sulfate (MgSO4) is a potential neuroprotective agent for patients with aneurysmal subarachnoid hemorrhage (SAH). We analyzed the effect of early application of intraoperative intravenous MgSO4 and compared cerebral vasospasm (CV), delayed cerebral ischemia (DCI), and neurological outcome in 2 patient cohorts. A retrospective matched-pair analysis from patients at a single center in Germany was performed without (group A) and with (group B) MgSO4 application <24 hours after diagnosis. Pairs were matched according to the known risk factors for DCI and CV (age, Fisher grade, smoking, severity of SAH). Incidence of CV and DCI and neurological outcome using the modified Rankin Scale score 3 and 12 months after SAH were recorded. The inclusion criteria were met by 196 patients. After risk stratification, 48 patients were included in the final analysis (age 54.2 ± 8.1 years; 30 women and 18 men) and were assigned to group A (n= 24) or group B (n= 24). CV occurred less frequently in group B (33%) than in group A (46%). Likewise, DCI was present in 13% in group B compared with 42% in group A. After 12 months, 22 patients in group B had a favorable functional outcome (modified Rankin Scale score 0-3) compared with 15 patients in group A. In this study, the incidence of CV and DCI was lower in patients receiving intravenous MgSO4 within 24 hours after aneurysmal SAH onset. Favorable functional outcome was more likely in the MgSO4 group after 12 months of follow-up.

Vasospasm risk following aneurysmal subarachnoid hemorrhage in older adults.

Cerebral arterial vasospasm is a dreaded sequela of aneurysm rupture and can result in significant narrowing of the surrounding vasculature and subsequent cerebral ischemia. Treatment interventions are associated with distinct side effect profiles, including the risk of thrombosis and worsened ischemia, which may be associated with increased mortality-especially in older adults. An improved understanding of the likelihood of vasospasm in elderly patients would enable clinicians and patients to better consider the risks and benefits of vasospasm prophylaxis in this vulnerable population. This retrospective chart review aimed to assess the relationship between age at onset and the incidence of cerebral vasospasm among patients treated at the University of North Carolina Medical Center with spontaneous aneurysmal subarachnoid hemorrhage (aSAH). Electronic health record data from the Epic Systems Corp. database, compiled by the Carolina Data Warehouse for Health, were analyzed for patients older than 18 years who were previously treated for an SAH secondary to aneurysm at the University of North Carolina Medical Center within the past 10 years, ranging from June 2011 through June 2021. Logistic regression was used to calculate odds ratios and to determine the association of age with the occurrence of vasospasm following aSAH. Of the 386 cases analyzed, 149 patients (38.6%) were older than 65 years at the time of aSAH. A total of 192 of the 386 patients (49.7%) developed vasospasm within the first 3-21 days following aSAH. Among the patients who developed vasospasm, only 31 of 192 patients (16.1%) were older than 65 years at the time of aneurysm rupture. Odds ratio calculations revealed that older adults (> 65 years) were 8 times less likely to develop vasospasm compared to their younger counterparts (p < 0.0001; 95% CI 5.0-13.0). This study found that older patients are less likely to develop cerebral vasospasm following aSAH than are younger individuals. Age-associated changes in arteriosclerosis, inflammatory responses, and CSF dynamics may mitigate vascular narrowing in response to aSAH. This finding suggests that the aSAH treatment and vasospasm prevention paradigms should be revised to minimize potentially unnecessary interventions and avoid adverse outcomes for older adults.

Microsurgical clipping and endovascular intervention for middle cerebral artery aneurysm: A meta-analysis.

The purpose of this study is to compare the prognosis and effective rate of interventional embolization and surgical clipping in the treatment of middle cerebral artery aneurysms, to provide evidence-based basis for the selection of clinical treatment. By searching PubMed, Cochrane library, Medline, Embase and other databases, we collected the related studies interventional embolization and surgical clipping in the treatment of middle cerebral artery aneurysms, whether it was a randomized controlled trial or not. According to the relevant inclusion and exclusion criteria, 2 researchers independently screened and extracted the relevant data. Quality of life, residual neck and recurrence rate, incidence of ischemic cerebral infarction, intracranial infection rate, incidence of vasospasm and rebleeding rate were measured. Revman5.4 software was used for Meta-analysis. There were 3658 patients included in 30 literatures, including 1478 patients treated with interventional embolization and 2180 patients treated with surgical clipping. The rate of low quality of life (odds ratio [OR] = 1.68, 95% confidence interval [CI]: 1.36-2.07, P < .00001) and intracranial infection rate (OR = 8.79,95% CI: 4.47-17.27, P < .00001) in the interventional embolization group were lower than those in the surgical clipping group. The postoperative rebleeding rate (OR = 0.46, 95% CI: 0.29-0.73, P = .0009), residual neck and recurrence rate (OR = 0.32, 95% CI: 0.24-0.43, P < .00001) in the interventional embolization group were higher than those in the surgical clipping group. The heterogeneity of residual neck and recurrence rate were high, so subgroup analysis was performed. We divide them into short-term group (OR = 0.68, 95% CI: 0.40-1.13, P = .13) and long-term group (OR = 0.23, 95% CI: 0.16-0.33, P < .00001). The results showed that the residual neck and recurrence rate in the interventional embolization group were higher than those in the surgical clipping group. There was no significant difference in the incidence of cerebral vasospasm (OR = 1.09, 95% CI: 0.64-1.86, P = .74) and ischemic stroke (OR = 0.87, 95% CI: 0.63-1.19, P = .37) between the 2 treatments. According to the current clinical research evidence, compared with interventional embolization in the treatment of middle cerebral artery aneurysms, the quality of life of patients after clipping is lower, the incidence of intracranial infection is higher, but the residual neck, and recurrence rate are reduced. The risk of rebleeding is also reduced. There was no significant difference in the incidence of vasospasm and ischemic stroke between the 2 groups.

Abstract WMP66: Early Rising Pain Scores Predict Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Introduction: Persistent pain following subarachnoid hemorrhage (SAH) is common and follows distinct trajectories. Cerebral vasospasm (CV) and delayed cerebral ischemia are late complications of SAH and may represent modifiable causes of secondary brain injury. Headache and CV share common risk factors including age, blood burden and cigarette smoking, however the relationship between pain and CV is unknown. We hypothesize that patients with increasing pain will be at increased risk for developing CV. Methods: We conducted a retrospective review of patients with non-traumatic SAH at two large academic medical centers from 2015-2022. Pain scores were recorded for 14 days. We excluded patients with onset of CV before post-bleed day (PBD) 4. We employed group-based trajectory modeling to identify distinct trajectories of 24 q2h pain scores during PBDs 2 and 3. Pain scores prior to PBD 2 were omitted due to the large amount of missing data. The incidence of CV was compared between trajectory groups using chi-squared analysis. Results: We identified 442 patients (median [IQR] age 56 [47-64] years, 294 (66%) women, 33 (7.4%) peri-mesencephalic, 330 (75%) Hunt-Hess 1-3, 393 (88%) modified Fisher 3-4) for analysis. We considered 3 through 8-group models and compared model fit by comparing AIC, BIC, and visual inspection of trajectories between models. Ultimately, a 4-group model fit the data best with four distinct trajectories of pain: persistently low (41% of patients), persistently high (24%), falling (18%) and rising (16%). Baseline clinical variables were comparable between trajectory groups. The median [IQR] day of CV onset was PBD 7 [5-10]. Patients with rising pain had significantly higher rates of vasospasm than those with persistently high or falling pain (54% vs 34% and 36%, respectively, Chi2 P = 0.02). Results were similar in a sensitivity analysis limited to patients with verbally reported pain scores. Conclusion: Distinct pain trajectories exist in the early hospital course following SAH. Our multicenter, retrospective cohort found that an initial rising pain trajectory is associated with development of CV. Future studies should validate this finding in separate cohorts and explore the pathophysiological mechanisms of this association.

Vitamin D as a modifiable risk factor, predictor, and theoretical therapeutic agent for vasospasm in spontaneous subarachnoid hemorrhage.

Delayed deterioration associated with cerebral vasospasm (CVS) is a feared complication after spontaneous subarachnoid hemorrhage (SAH) and is one of the leading causes of death in patients with intracranial hemorrhage. The pathophysiology of vasospasm is complex and not fully understood, involving multiple inflammatory pathways in addition to vasoconstriction induced ischemia. Current treatment with anti-inflammatory or vasodilatory medications has been met with limited success and has not led to a decrease in vasospastic associated mortality prompting continued investigation of potential treatment options. The active form of vitamin D, 1,25-dihydroxyvitamin D3 (1,25-VitD3), is a hormone with downstream effects that induce anti-inflammatory pathways, promote nitric oxide (NO) induced vasodilation, and lead to neuroprotective-gene expression, which may be useful in mitigating the vascular pathogenesis associated with CVS. A high prevalence of vitamin D deficiency has been identified in patients admitted with SAH. Low vitamin D levels in patients, as determined by time of year, has also been correlated to an increased incidence and severity of CVS. Further, the therapeutic usefulness of 1,25-VitD3 has been demonstrated in animal models leading to a decreased incidence of CVS but has yet to be thoroughly investigated in human studies. In this review, we will discuss the findings that suggest the potential of utilizing vitamin D as a predictive indicator, method of prevention, and or treatment option for CVS in patients following spontaneous SAH.

Clinical Efficacy of Shenmai Injection in the Treatment of Cerebral Vasospasm after Ruptured Aneurysm Surgery

Objective: To investigate the therapeutic effect of Shenmai Injection on postoperative cerebral vasospasm in patients with ruptured aneurysms. Methods: Seventy patients undergoing craniotomy for ruptured aneurysms in our hospital were selected as study subjects and randomly divided into control (n = 33) and research (n = 37) groups, they were treated with nimodipine and nimodipine combined with Shenmai injection after operation. The blood flow velocity in the middle cerebral artery (MCA) before and at 1, 3, 7, 11 and 14 days after surgery and the incidence of cerebral vasospasm during these days were compared, and the GCS scores at 14 days postoperatively and GOS scores at 6 months postoperatively were compared between the two groups. Results: There were no statistically significant differences in the occurrence of cerebral vasospasm, GCS or GOS scores between the two groups (P > 0.05), but the period of postoperative cerebral vasospasm in the study group was significantly shorter than that in the control group. Conclusion: Shenmai injection has the effect of shortening the cycle of occurrence of cerebral vasospasm after the operation of ruptured aneurysms, promoting patients to recover as early as possible and reducing their physical and mental burden.

Stress-Related Gastrointestinal Bleeding in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Observational Study.

Stress-related mucosal bleeding (SRMB) occurs in approximately 2-4% of critically ill patients. Patients with aneurysmal subarachnoid hemorrhage (aSAH) have a (diffuse) space-occupying lesion, are critically ill, often require mechanical ventilation, and frequently receive anticoagulation or antiplatelet therapy after aneurysm embolization, all of which may be risk factors for SRMB. However, no studies have evaluated SRMB in patients with aSAH. Aims of the study were to determine the incidence of SRMB in aSAH patients, evaluate the effect of acid suppression on SRMB, and identify specific risk factors for SRMB. This was a multicenter, retrospective, observational study conducted across 17 centers. Each center reviewed up to 50 of the most recent cases of aSAH. Patients with length of stay (LOS) < 48h or active GI bleeding on admission were excluded. Variables related to demographics, aSAH severity, gastrointestinal (GI) bleeding, provision of SRMB prophylaxis, adverse events, intensive care unit (ICU), and hospital LOS were collected for the first 21days of admission or until hospital discharge, whichever came first. Descriptive statistics were used to analyze the data. A multivariate logistic regression modeling was utilized to examine the relationship between specific risk factors and the incidence of clinically important GI bleeding in patients with aSAH. A total of 627 patients were included. The overall incidence of clinically important GI bleeding was 4.9%. Of the patients with clinically important GI bleeding, 19 (61%) received pharmacologic prophylaxis prior to evidence of GI bleeding, while 12 (39%) were not on pharmacologic prophylaxis at the onset of GI bleeding. Patients who received an acid suppressant agent were less likely to experience GI bleeding than patients who did not receive pharmacologic prophylaxis prior to evidence of bleeding (OR 0.39, 95% CI 0.18-0.83). The multivariate regression analysis identified any instance of elevated intracranial pressure, creatinine clearance < 60ml/min and the incidence of cerebral vasospasm as specific risk factors associated with GI bleeding. Cerebral vasospasm has not previously been described as a risk for GI bleeding (OR 2.5 95% CI 1.09-5.79). Clinically important GI bleeding occurred in 4.9% of patients with aSAH, similar to the general critical care population. Risk factors associated with GI bleeding were prolonged mechanical ventilation (> 48h), creatinine clearance < 60ml/min, presence of coagulopathy, elevation of intracranial pressure, and cerebral vasospasm. Further prospective research is needed to confirm this observation within this patient population.

Assessment of two prophylactic fluid strategies in aneurysmal subarachnoid hemorrhage: A randomized trial.

ObjectiveTo compare the effect of two prophylactic euvolemic fluid strategy regimens on the incidence of cerebral vasospasm and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH).MethodsNinety-six patients with a basal intravenous intake of 15 mL/kg/day of Ringer’s lactate solution were included, and an additional 15 to 50 mL/kg/day Ringer’s lactate (RL-group) or hydroxyethyl starch 130/0.4 solution (HES-group) was administered to maintain the targeted mean arterial pressure. The primary end point was the occurrence of cerebral vasospasm during the first 14 days. The secondary end points were case fatality, Barthel’s index, and Glasgow Outcome Scores (GOS) at 30 days after SAH.ResultsCerebral vasospasm developed in 42 patients (43.7%), and nine of these events were severe. The vasospasm rate among the RL- and HES-based groups was 25/48 and 17/48, respectively. For the secondary endpoint, four patients (4%) died by the end of follow-up (two in each group). Unfavorable outcome cases were not different in the RL and HES groups (9 vs. 14, respectively). There was no difference between the Barthel’s scores at 30 days between the two groups.ConclusionsUsing starches in a prophylactic treatment strategy in aneurysmal SAH in not supported by the study.The trial was registered at Clinicaltrials.gov under the number NCT02064075

Literature Review of Aneurysmal Subarachnoid Hemorrhage from Incidence to Treatment Options

Summary Introduction Aneurysmal subarachnoid haemorrhage (SAH) is associated with high mortality and morbidity. Rebleeding, cerebral vasospasm (VS) with delayed cerebral ischemia (DCI) are major complications after SAH associated with poor neurological outcome. Aim of the study To summarize the existing research data on the SAH from incidence, risk factors and clinical presentation to diagnostic, monitoring and treatment options after SAH. Materials and Methods Literature review was carried out to identify factors associated with SAH using specific keywords (aneurysmal subarachnoid haemorrhage, rebleeding, cerebral vasospasm, delayed cerebral ischemia) in the PUBMED database. In the time period from 2000 to 2019, 34 full articles were reviewed. Results According to the literature, the key risk factors for cerebral aneurysms and the SAH are hypertension, smoking, chronic alcohol abuse, family history of intracranial aneurysms in first-degree relatives and female sex. The key risk factor for early complication - rebleeding after SAH - is hypertension. The factors responsible for late complications - cerebral VS and DCI after SAH - are initially lower Glasgow coma scale and higher grades of Fisher scale, where grade IV and III predict cerebral VS in 31–37%. Furthermore, hyperglycaemic state, hyponatremia, hypotension and cerebral hypoperfusion, increased level of Troponin correlate with the incidence of cerebral VS and DCI. Although the golden standard to detect cerebral VS is digital subtraction angiography, CT angiography has become a routine examination. Transcranial doppler sonography is recommended and regional cerebral oximetry also seems to be promising. To avoid rebleeding for wide-necked, gigantic aneurysms or when SAH is combined with intraparenchymal hematoma, surgical clipping is preferred. For posterior circulation aneurisms, poor grade SAH and patients with age &gt;70 years superior is endovascular treatment. To avoid late complications, the pharmacological method is used with Nimodipine. Conclusions SAH is still associated with poor clinical outcome due to the development of early and late complications. The highest risk patients are those with low Glasgow coma scale and high grades of Fisher scale. Timely performed obliteration methods of the ruptured aneurysm are crucial and Nimodipine is the main agent to prevent cerebral VS and DCI.

Incidence of Cerebral Vasospasm and Delayed Cerebral Ischemia Following Non‐Traumatic Aneurysmal Subarachnoid Hemorrhage

BackgroundNon‐traumatic aneurysmal subarachnoid hemorrhage (aSAH), comprising ~ 3 percent of strokes, is one of the deadliest stroke subtypes with mortality reaching as high as 40 percent. This high rate of mortality is associated with delayed cerebral ischemia (DCI), likely due to cerebral vasospasm (CV). CV is characterized by progressive narrowing of cerebral arteries, diagnosed by neuroimaging, that occurs within 4–14 days of aSAH, and CV leads to DCI and infarction in ~ 25 percent of patients. While the etiology of CV remains unknown, autonomic nervous system dysfunction, specifically excessive sympathetic nervous system induced vasoconstriction, may play a role. The purpose of this study is to review clinical cases of aSAH from 2017–2019 from our local hospital and describe the frequency of aSAH, CV, and DCI for all cases.MethodsInstitutional review board approval was received from West Virginia University. We performed a retrospective chart review of all patients diagnosed with non‐traumatic aSAH from January 1, 2017 – October 1, 2019 (n= 156). The following variables were collected from the medical record: location of aneurysm, presence and location of SAH blood clot (Fisher grade), frequency and severity of CV‐diagnosed by angiography or transcranial doppler, frequency of DCI within 7 days of CV – diagnosed by CT or MRI. Frequencies of CV and DCI were compared between location of aneurysm. Other potentially confounding variables were also collected, including age, sex, cardiovascular risk factors, and treatment with an alpha‐1 antagonist at time of aSAH presentation. Statistical analysis was performed using IBM Statistics (Version 26). Frequencies were compared between groups using Fisher’s exact test, and correlations between variables were assessed by Spearman correlation. Binary logistic regression was used to identify factors that may predict incidence of CV. Statistical significance was determined at p &lt; 0.05.ResultsaSAH occurred in the anterior circulation in 71 percent of cases – middle cerebral artery (MCA) (23%), anterior cerebral artery (ACA) (20%), anterior communicating artery (20%), and internal carotid artery (ICA) (8%). CV occurred in 36 percent of all cases ‐ MCA (60%), ACA (26%) and ICA (12%). Hypertension was the only significant predictor associated with a higher incidence of CV (p=.032). Interestingly, the actual incidence of CV was not correlated with the expected incidence of CV predicted by Fisher grade (p=.656). CV led to DCI in 31 percent of cases, and there were no differences in DCI incidence compared between Fisher grade or vessel affected by CV.ConclusionsOur preliminary data provides a description of the incidence of CV and DCI following non‐traumatic aSAH at our institution. The observed incidence of CV and DCI are comparable to previously reported estimates; however, our results suggest that Fisher grade alone may not provide an accurate prediction for the incidence of CV, as the incidence of CV may vary across the cerebrovasculature. This study provides evocative evidence for further investigation into the factors that may contribute to CV and subsequent DCI. Upon validation, this information may be used by clinicians in the diagnosis and medical management of CV to prevent DCI and subsequently lower mortality associated with aSAH.

Temporal Relationship between Hyponatremia and Development of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage Patients: A Retrospective Observational Study

Background: Hyponatremia is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Previous studies have reported an association between hyponatremia and vasospasm, however whether hyponatremia directly contributes to the pathogenesis of cerebral vasospasm (CVS), or is a by-product is still unclear. The aim of this study was to explore an association between hyponatremia and CVS after aSAH, and evaluating the temporality of these 2 events. Methods: A retrospective study of consecutive patients with aSAH admitted to the Baylor St. Luke's Medical center between January 2008 and December 2012 was conducted. Demographics, baseline characteristics, serum sodium levels, and evidence of vasospasm detected by transcranial Doppler, CT Angiogram, MR angiogram, and digital subtracted angiography were collected. Patients were dichotomized into a hyponatremic and a normonatremic group. CVS incidence and clinical outcome was compared between groups. Timing of CVS after initial hyponatremia episodes was recorded Results: One hundred and sixty 4 patients with aSAH were included. Hyponatremia was identified in 66 patients (40.2%) and CVS occurred in 71 subjects (43.2%). The incidence of CVS was higher in the hyponatremic group compared to the normonatremic group, 65.1 % versus 28.5%, respectively (P < .001). Hyponatremia preceded CVS by median 1.5 days suggesting a temporal trend. Conclusions: Our study shows a significant association between hyponatremia and CVS, with hyponatremia preceding CVS events. This retrospective finding denotes the need for larger prospective studies, aiming to clarify the temporal relationship of serum sodium levels and CVS.

Abstract TP550: Clinical and Demographic Predictors of Cerebral Vasopasm Occurrence Following Sub-arachnoid Hemorrhages

Introduction: Cerebral vasospasm (CV) often follows aneurysmal subarachnoid hemorrhage (SAH) and, when severe, may lead to delayed cerebral ischemia (DCI) that can contribute substantially to morbidity and mortality. It is important to identify patients at high risk for DCI in order to allow for closer monitoring and timely treatment. This study analyzes the association of DCI with co-morbidities and demographic variables. Hypothesis: Diseases of the circulatory system may be predictive of DCI risk in SAH patients. Methods: Data from a total of 20039 SAH events between 2013 and 2018 were collected from 178 US hospitals. The occurrence of DCI during the SAH hospitalization was determined with ICD 9/10 diagnosis codes. Patient age was compared between the DCI and non-DCI SAH cases using t-tests. Odds ratios and Fisher exact tests were used to evaluate the relative incidence of DCI according to patient sex and the presence/absence of comorbidities and other clinical covariates (only those that occurred in at least 5% of SAH patients). Statistical significance of co-morbidities associated with DCI occurrence was evaluated following adjustment for false discovery rates. Results: In our cohort, 874 (4.36%) SAH patients experienced an episode of DCI. SAH patients with DCI were significantly younger than non-DCI SAH patients (DCI mean 60.40, non-DCI 66.95, p &lt;&lt; 0.001), and there was a significantly higher relative incidence of DCI in female vs male patients (OR = 1.967, p &lt;&lt; 0.001). Several co-morbidities were strongly associated with DCI occurrence, most notably hypoosmolality (OR=2.67), anemia (OR=2.15), hyperglycemia (OR=2.15), disorders of phosphorus metabolism (OR =2.55) and hyperlipidemia (OR=1.52), all with p &lt;&lt; 0.001. In contrast, conditions such as hyperosmolality (OR=0.233), acidosis (OR=0.354), sepsis (0.393), diabetes (0.581) and kidney failure (OR=0.483) have a significant (p &lt;&lt;0.001) negative association with DCI. Hypertension does not appear to be significantly predictive of DCI or its absence. Conclusions: The data in this study suggest that age and sex are strongly predictive of DCI risk, and that several facets of an SAH patient’s metabolite and ion balance may either protect or predispose him/her to CV and DCI incidence.

Efeitos do sulfato de magnésio e da milrinona sobre o vasoespasmo cerebral após hemorragia subaracnoidea por aneurisma: estudo randômico

BackgroundAneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. MethodsThe study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day−1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg−1.min−1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s−1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). ResultsThe mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). ConclusionsThe incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study

BackgroundAneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. MethodsThe study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day−1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg−1.min−1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s−1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). ResultsThe mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). ConclusionsThe incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

Effects of evidence-based nursing on the psychological status and complications after interventional embolization of intracranial aneurysms

Objective To investigate the effects of evidence-based nursing on the psychological status, operation associated complications and short-term prognosis of patients with intracranial aneurysms after interventional embolization. Methods A total of 150 patients undergoing elective interventional embolization in the hospital from May 2012 to May 2016 were randomly divided into the control group and the observation group with 75 patients each. The control group were given routine nursing care while the observation group were given evidence-based nursing. The incidence of operation associated complications and postoperative cerebral vasospasm were compared between the two groups. The changes in scores of the Self-Rating Anxiety Scale (SAS) , Self-Rating Depression Scale (SDS) , Somatization Symptom Checklist (SCL-90) and Glasgow Outcome Scale (GOS) before and after intervention were compared. Results No postoperative cerebral vasospasm was observed in the observation group, and the incidence of operative complications was 4%. In the control group, cerebral vasospasm occurred in 7 cases, and the incidence of operative complications was 17.3%. Before discharge, SAS score (42.26±3.77) and SDS score (40.67±6.44) in the observation group were lower than those in the control group (t=8.478, 4.507; P<0.001) . No death cases in these two groups. Three months later after operation, patients with GOS grade 5 in the observation group was 30.67%, and it was 13.33% in the control group. There was significant difference of GOS classification between the two groups (H=15.520, P<0.01) . Conclusions Evidence-based nursing can help reduce the incidence of cerebral vasospasm after interventional embolization in patients with intracranial aneurysms, improve their anxiety and depression, and optimize short-term prognosis. Key words: Intracranial aneurysm; Evidence-based nursing; Cerebral vasospasm; Interventional embolization

Effect of cerebrospinal fluid drainage after aneurysm clipping on hydrocephalus, cerebral vasospasm and serum IGF-1, sVCAM-1

Objective To investigate the value of cerebrospinal fluid drainage after aneurysm clipping in patients with intracranial aneurysm complicated with subarachnoid hemorrhage. Methods 84 intracranial aneurysms patients with subarachnoid hemorrhage were selected, and they were randomly divided into study group (n=42) and control group (n=42). The control group used simple suture after aneurysm clipping, the study group was given lumbar cistern drainage by implementation of the dural suture tube after aneurysm clipping.Before and after hydrocephalus and cerebral vasospasm, treatment changes of serum insulin-like growth factor 1 (IGF-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) levels were compared between the two groups. Results The incidence rate of hydrocephalus of the study gruop was 4.8%, which was significantly lower than the 14.3% of the control group (χ2=9.743, P 0.05). The serum levels of IGF-1 and sVCAM-1 between the two groups had no statistically significant differences before operation (t=0.417, 0.603, all P>0.05). At the 8th day after operation, the serum levels of sVCAM-1 and IGF-1 of the study group were significantly lower than those of the control group (t=7.335, 6.856, all P<0.05). Conclusion After aneurysm clipping, the lumbar cistern drainage tube drainage is beneficial to reduce hydrocephalus and cerebral vasospasm incidence, inhibit the expression of serum IGF-1, sVCAM-1, with less adverse reactions, it is worthy of application. Key words: Aneurysm clipping; Subarachnoid hemorrhage; Cerebrospinal fluid drainage; Hydrocephalus; Cerebral vasospasm

The clinical application of transcranial doppler ultrasonography in severe traumatic brain injury post decompressive craniectomy

Objective To explore the clinical application of transcranial doppler ultrasonography (TCD) in severe traumatic brain injury (sTBI)post decompressive craniectomy. Methods A retrospective study was conducted on 58 patients with sTBI who were admitted to Neurosurgical Intensive Care Unit of Tangdu Hospital, the Fourth Military Medical University From January 2015 to October 2016. All patients underwent hematoma evacuation, decompressive craniectomy and placement of intracerebral pressure (ICP) probe. The parameters of cerebral blood flow including mean velocity (Vmean), end of diastolic (Vedv) and pulsatility index (PI) in sTBI patients were measured by TCD post operation to assess the cerebral blood supply. Results The trend of Vmean and Vedv manifested U-shaped mode during the next 7 days, reaching the lowest levels [(72.5±22.6) cm/s and (43.6±19.8) cm/s, respectively] on day 3. There was significant difference in the value of Vmean between day 3 and day 1, 2, 5, 6, 7 (all P<0.05). There was significant difference in the value of Vedv between day 3 and day 1, 2, 6, 7 (all P<0.05). The trend of pulsatility index (PI) and intracranial pressure (ICP) showed parabolic shape during the next 7 days, reaching the highest level [(1.5±0.7) and (17.2±4.5)mmHg, respectively] on day 4. Significant difference was observed in ICP between day 4 and day 1, 2, 3, 6, 7 (P<0.05). The incidence of cerebral hyperemia showed the trend of declining during the next 7 days. There was significant difference in cerebral hyperemia between day 1 and day 5, 6, 7 (all P<0.05). The incidence of cerebral ischemia was up to 36.2% (12/58) on day 4, and it was significantly higher than that on day 1 (P<0.05). The incidence of cerebral vasospasm showed the rising trend and reached the highest level (15.5%) on day 6, which had significant difference compared with the incidences on day 1, 2 and 3 (all P<0.05). Conclusion TCD, as a noninvasive, portable, easy-to-use monitoring tool, could help effectively evaluate postoperative changes of cerebral hemodynamics in patients with sTBI. Key words: Craniocerebral trauma; Ultrasonography, doppler, transcranial; Decompressive craniectomy

Efficacy of continuous stellate ganglion block for prevention of cerebral vasospasm following interventional treatment of intracranial aneurysms

Objective To evaluate the efficacy of continuous stellate ganglion block(SGB)for prevention of cerebral vasospasm(CVS)following interventional treatment of intracranial aneurysms. Methods Forty patients of both sexes with ruptured intracranial aneurysm, aged 20-60 yr, of American Society of Anesthesiologists physical status Ⅱor Ⅲ, with Hunt-Hess grade Ⅰ-Ⅲ, scheduled for elective interventional treatment of intracranial aneurysms, were divided into 2 groups(n=20 each)using a random number table: control group(C group)and continuous SGB group(SGB group). After induction of anesthesia, patients received ipsilateral continuous SGB with 0.25% ropivacaine 6-8 ml followed by continuous infusion of 0.2% ropivacaine 2 ml/h for 3 days in group SGB.Transcranial Doppler ultrasound was used to measure the blood flow in bilateral middle cerebral arteries and internal carotid arteries within 3 days after operation, and the development of CVS was assessed.Before operation and at 2 and 6 h and 1 and 3 days after operation, blood samples were collected from the internal jugular vein for determination of plasma melatonin(MT)and endothelin-1(ET-1)concentrations by enzyme-linked immunosorbent assay. Results Compared with group C, the incidence of CVS (5%)was significantly decreased, and the plasma ET-1 concentration was decreased at 2 and 6 h and 1 and 3 days after operation(P﹤0.05), and no significant change was found in plasma MT concentrations at each time point in group SGB(P>0.05). Conclusion Continuous SGB can effectively prevent the development of CVS following interventional treatment of intracranial aneurysms, and the mechanism may be related to inhibited release of ET-1 from vascular endothelial cells, but not related to MT. Key words: Stellate ganglion; Nerve block; Vasospasm, intracranial; Intracranial aneurysm

Identification of specific age groups with a high risk for developing cerebral vasospasm after aneurysmal subarachnoid hemorrhage

The impact of age on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a matter of ongoing discussion. The aim of this study was to identify age groups with a higher risk for developing vasospasm, delayed ischemic neurological deficit (DIND), or delayed infarction (DI) and to identify a cut-off age for a better risk stratification. We defined six age groups (<30, 30-39, 40-49, 50-59, 60-69, and >70years). ROC analysis was performed to determine a cutoff age with the highest positive predictive value (PPV) for developing vasospasm, defined as a blood-flow-velocity-increase >120cm/s in transcranial-Doppler-sonography (TCD). Multivariate binary-logistic-regression-analysis was then performed to evaluate differences in the incidence of cerebral vasospasm, DIND, and DI among the different age groups. A total of 753 patients were included in the study. The highest incidence (70%) of TCD-vasospasm was found in patients between 30 and 39years of age. The cutoff age with the highest PPV (65%) for developing TCD-vasospasm was 38years. Multivariate analysis revealed that age <38years (OR 3.6; CI 95% 2.1-6.1; p < 0.001) best predicted vasospasm, followed by the need for cerebrospinal fluid drainage (OR 1.5; CI 95% 1.0-2.3; p = 0.04). However, lower age did not correlate with higher rates of DIND or infarcts. The overall vasospasm-incidence after aSAH is age-dependent and highest in the age group <38years. Surprisingly, the higher incidence in the younger age group does not translate into a higher rate of DIND/DI. This finding may hint towards age-related biological factors influencing the association between arterial narrowing and cerebral ischemia.

CEREBRAL VASOSPASM IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY

Cerebral vasospasm (CV) is one of the factors of secondary brain lesion in patients with brain injury (BI) that increases the risk of unfavorable outcomes of the disease. The incidence of CV varies from 18 to 70% and depends not only on the patients but also on the methods and criteria of diagnosis. Like digital subtraction angiography is a gold standard in CV diagnosis, the transcranial doppler ultrasonography is the only bed-side test with high sensitivity and specificity for revealing CV. The spectrum of effective treatment options is limited and methods used in treatment of patient with aneurismal subarachnoid hemorrhage are not matched to patients suffered from severe brain injury complicated by CV because of unclear outcomes. Nowadays there are limited clinical data for drawing up guidelines for diagnosis and management of CV in patients with severe BI. This fact urges prospective researches for elaborating management programs for such patients.