Diagnosis Of Aneurysmal Subarachnoid Hemorrhage Research Articles

Neutrophil to Lymphocyte Ratio and Serum Biomarkers : A Potential Tool for Prediction of Clinically Relevant Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) is a condition characterized by bleeding in the subarachnoid space, often resulting from the rupture of a cerebral aneurysm. Delayed cerebral ischemia (DCI) caused by vasospasm is a significant cause of mortality and morbidity in SAH patients, and inflammatory markers such as systemic inflammatory response index (SIRI), systemic inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), and derived NLR (dNLR) have shown potential in predicting clinical vasospasm and outcomes in SAH patients. This article aims to investigate the relationship between inflammatory markers and cerebral vasospasm after aneurysmatic subarachnoid hemorrhage (aSAH) and evaluate the predictive value of various indices, including systemic inflammatory response index (SIRI), systemic inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), and derived NLR (dNLR), in predicting clinical vasospasm. A retrospective analysis was performed on a cohort of 96 patients who met the inclusion criteria out of a total of 139 patients admitted XXXXXXXXXXX hospital with a confirmed diagnosis of aneurysmal subarachnoid hemorrhage (aSAH) between January 2013 and December 2021. Diagnostic procedures, neurological examinations, and laboratory tests were performed to assess the patients' condition. The Student's t-test compared age variables, while the chi-square test compared categorical variables between the non-vasospasm (NVS) and vasospasm (VS) groups. Receiver operating characteristic (ROC) curve analyses were used to evaluate the diagnostic accuracy of laboratory parameters, calculating the area under the ROC curve (AUC), cut-off values, sensitivity, and specificity. A significance level of p < 0.05 was considered statistically significant. The study included 96 patients divided into two groups: NVS (non-vasospasm) and VS (vasospasm). Various laboratory parameters, such as NLR, SII, and dNLR, were measured daily for 15 days, and statistically significant differences were found in NLR on seven days, with specific cut-off values identified for each day. SII showed a significant difference on day 9, while dNLR had significant differences on days 2, 4, and 9. Graphs depicting the values of these markers for each day are provided. Neuroinflammatory biomarkers, when used alongside radiology and scoring scales, can aid in predicting prognosis, determining severity and treatment decisions for aneurysmal subarachnoid hemorrhage (aSAH), and further studies with larger patient groups are needed to gain more insights.

Risk of Aneurysm Rupture (ROAR) study: protocol for a long-term, longitudinal, UK multicentre study of unruptured intracranial aneurysms

IntroductionUnruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to...

Correlation between tomographic scales and vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage.

To determine the prevalence of sonographic vasospasm and delayed ischemic deficit in patients with aneurysmal subarachnoid hemorrhage, to evaluate the correlation between different tomographic scales and these complications, and to study prognostic factors in this group of patients. This was a prospective study of patients admitted to the intensive care unit with a diagnosis of aneurysmal subarachnoid hemorrhage. The prevalence of sonographic vasospasm and radiological delayed cerebral ischemia was analyzed, as was the correlation between different tomographic scales and these complications. A total of 57 patients were studied. Sixty percent of the patients developed sonographic vasospasm, which was significantly associated with delayed cerebral ischemia and mortality. The Claassen and Hijdra scales were better correlated with the development of cerebral vasospasm (areas under the curve of 0.78 and 0.68) than was Fisher's scale (0.62). Thirty-two patients (56.1%) developed cerebral infarction on CT; the significantly associated factors were poor clinical grade at admission (p = 0.04), sonographic vasospasm (p = 0.008) and severity of vasospasm (p = 0.015). Only the semiquantitative Hijdra scale was significantly correlated with the development of radiological delayed cerebral ischemia (p = 0.009). The patients who presented cerebral infarction had worse neurological evolution and higher mortality. This is the first study in our environment on the subject. The Claassen and Hijdra tomographic scales showed better prognostic performance than the Fisher scale for the development of cerebral vasospasm. The finding of sonographic vasospasm could be a noninvasive criterion for the early detection of delayed cerebral ischemia and neurological deterioration in patients with aneurysmal subarachnoid hemorrhage.

Changes in Outcome Prediction During the First Week After Subarachnoid Hemorrhage

BACKGROUND: Prediction of long-term outcome based on initial neurological condition after aneurysmal subarachnoid hemorrhage varies with time. To date, studies have been limited to early time points and have reported that prognostication is best after resuscitation. OBJECTIVE: To describe how prediction of outcome varies from ictus through the first week of admission. METHODS: A retrospective analysis of patients with a diagnosis of aneurysmal subarachnoid hemorrhage recruited to a prospective database. Neurological condition was recorded on each day of the inpatient stay, up to day 7, using World Federation of Neurological Societies score (WFNS). Poor outcome was defined by modified Rankin scale of 3-6 at 3 months. Outcome prediction was assessed using area under the curve (AUC) after binary logistic regression. RESULTS: Of 645 patients, 55(14%) patients with WFNS 1&amp;2 and 77(45%) patients with WFNS 4&amp;5 on day 0 had a poor outcome. 30(8%) patients with WFNS 1&amp;2 and 54(81%) patients with WFNS 4&amp;5 on day 7 had a poor outcome. Prognostication using WFNS improved from day 0 to day 7 (AUC = 70.1%, CI 65.0%–75.1% vs AUC = 81.9%, CI 77.4%–86.0%) with an incremental improvement with each day in between, and the largest increases early around the time of resuscitation. CONCLUSION: Prediction of outcome improves beyond the initial resuscitation, up to day 7 of admission, with no evidence of any deterioration around the time of treatment or delayed complications like delayed cerebral ischemia. This is important when prognosticating for clinical purposes and emphasizes the importance of standardization of timing of WFNS in research.

Angiographic Treatment of Asymptomatic Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage for the Prevention of Delayed Cerebral Ischemia

Angiographic treatment of asymptomatic cerebral vasospasm (CVS) in aneurysmal subarachnoid hemorrhage remains controversial. We sought to investigate its relationship with the development of delayed cerebral ischemia. Consecutive patients admitted between July 2017 and June 2019, with a diagnosis of aneurysmal subarachnoid hemorrhage, were retrospectively analyzed. The rate of development of delayed cerebral ischemia was compared between a group of patients who underwent cerebral angiography for asymptomatic CVS and those who did not. The Mann-Whitney U test or χ2 test was used to compare the 2 groups. Thirty-seven of the 94 patients with aneurysmal subarachnoid hemorrhage were screened for CVS, of whom 16 (43%) had moderate-severe vasospasm. When patients who underwent therapeutic cerebral angiography were compared with those who did not and after adjusting for sex, age, and grade of subarachnoid hemorrhage, treatment was not found to be significantly associated with delayed cerebral ischemia (hazard ratio= 0.82, 95% confidence interval: 0.19-3.52, P= 0.79). We found that the median length of stay in the intensive care unit and hospital increased significantly with the severity of CVS (P< 0.001). Cerebral angiography has a low rate of detecting moderate-severe CVS in asymptomatic patients. Moreover, there was no statistically significant difference in the rate of delayed cerebral ischemia between asymptomatic patients treated versus those not treated for CVS. There was significant association between the severity of CVS and the intensive care unit and hospital length of stay. More studies are needed to evaluate the utility of treating asymptomatic CVS in high-grade aneurysmal subarachnoid hemorrhage.

Hyperoxemia and Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage.

Cerebral vasospasm is a major contributor to disability and mortality after aneurysmal subarachnoid hemorrhage. Oxidation of cell-free hemoglobin plays an integral role in neuroinflammation and is a suggested source of tissue injury after aneurysm rupture. This study sought to determine whether patients with subarachnoid hemorrhage and cerebral vasospasm were more likely to have been exposed to early hyperoxemia than those without vasospasm. This single-center retrospective cohort study included adult patients presenting with aneurysmal subarachnoid hemorrhage to Vanderbilt University Medical Center between January 2007 and December 2017. Patients with an ICD-9/10 diagnosis of aneurysmal subarachnoid hemorrhage were initially identified (N = 441) and subsequently excluded if they did not have intracranial imaging, arterial PaO2 values or died within 96h post-rupture (N = 96). The final cohort was 345 subjects. The degree of hyperoxemia was defined by the highest PaO2 measured within 72h after aneurysmal rupture. The primary outcome was development of cerebral vasospasm, which included asymptomatic vasospasm and delayed cerebral ischemia (DCI). Secondary outcomes were mortality and modified Rankin Scale. Three hundred and forty five patients met inclusion criteria; 218 patients (63%) developed vasospasm. Of those that developed vasospasm, 85 were diagnosed with delayed cerebral ischemia (DCI, 39%). The average patient age of the cohort was 55 ± 13years, and 68% were female. Ninety percent presented with Fisher grade 3 or 4 hemorrhage (N = 310), while 42% presented as Hunt-Hess grade 4 or 5 (N = 146). In univariable analysis, patients exposed to higher levels of PaO2 by quintile of exposure had a higher mortality rate and were more likely to develop vasospasm in a dose-dependent fashion (P = 0.015 and P = 0.019, respectively). There were no statistically significant predictors that differentiated asymptomatic vasospasm from DCI and no significant difference in maximum PaO2 between these two groups. In multivariable analysis, early hyperoxemia was independently associated with vasospasm (OR = 1.15 per 50mmHg increase in PaO2 [1.03, 1.28]; P = 0.013), but not mortality (OR = 1.10 [0.97, 1.25]; P = 0.147) following subarachnoid hemorrhage. Hyperoxemia within 72h post-aneurysmal rupture is an independent predictor of cerebral vasospasm, but not mortality in subarachnoid hemorrhage. Hyperoxemia is a variable that can be readily controlled by adjusting the delivered FiO2 and may represent a modifiable risk factor for vasospasm.

Neuroimmune predictors of outcome after aneurysmal subarachnoid hemorrhage

Aim. To determine the possibility of predicting the course and outcomes of aneurysmal subarachnoid hemorrhage (aSAH) by using the detection of autoantibody level to neurospecific proteins.&#x0D; Methods. The autoantibody level to neurospecific proteins was detected in 65 people: 30 healthy volunteers and 35 with a confirmed diagnosis of aneurysmal subarachnoid hemorrhage. Autoantibodies to myelin basic protein (MBP), peripheral myelin, dopamine receptors, myosin, N-methyl-D-aspartate (NMDA) receptors and S100 protein detected by using an enzyme immunoassay. The severity of illness in dynamics was defined in all patients by using the following scales: Rivermead mobility index, HuntHess, Graeb and others. Statistical analysis was performed using Statistica 10.0, with the consistent use of descriptive statistics methods, the MannWhitney, KruskalWallis and Pearson tests, Spearman coefficient.&#x0D; Results. At the first stage, neurospecific proteins characterized by a large increase in autoantibody titers were identified. Further, based on the data obtained, a statistically significant correlation between autoantibody titers to S100 protein (360.4340.35 g/ml, p 0.05), MBP (145.9112.43 g/ml, p 0.05), NMDA receptors (66.176.42 g/ml, p 0.05) and aSAH outcome was established.&#x0D; Conclusion. The study revealed an increase in autoantibody level to neurospecific proteins in the blood plasma of patients, depending on the severity of subarachnoid hemorrhage and the development of delayed cerebral ischemia due to cerebral vasospasm; high antibodies titers to S100 protein in subarachnoid hemorrhage are associated with cerebral vasospasm and the development of secondary (delayed) ischemic changes in the brain.

Smoking habits and detection rate of unruptured intracranial aneurysms and incidence rate of subarachnoid haemorrhage in Norway between 2008 and 2015

ObjectiveThe aim of this study was to investigate the detection rate of unruptured intracranial aneurysms (UIAs) and incidence of aneurysmal subarachnoid haemorrhage (SAH) in relation to the rapidly changing smoking rates in Norway between 2008 and 2015.MethodsThe registry-based study included all patients (≥ 16 years old) admitted to a hospital in Norway between 2008 and 2015 with a primary diagnosis of aneurysmal SAH or an outpatient diagnosis of UIAs. Age group–specific and total detection rate of UIAs and incidence rate of SAH over the years were calculated. Age group–specific data on smoking habits was retrieved from a national annual survey representative of the whole Norwegian population.ResultsThe rate of daily smokers decreased by 48% between 2008 and 2015. The detection rate of UIAs decreased by 47% from 17.3 in 2008 to 9.3 per 100,000 persons in 2015, and the incidence of SAH decreased by 30% from 11.3 in 2008 to 7.9 per 100,000 persons in 2015. The average annual decline in prevalence of daily smoking, UIA detection rate, and SAH incidence was 6.9%, 6.7%, and 4.3% per year, respectively. Multinomial logistic regression analyses revealed that the correlation between the decline in estimated daily smoking rates and decline in detection rate of UIAs (hazard ratio 52.5 CI = (14.9,∞), p < 0.00001) and incidence of SAH (hazard ratio 11.8 CI=(5.6,32.5), p < 0.00001) are statistically significant. The association is particularly strong in young and middle-aged cohorts (< 66 years old).ConclusionIt is likely that reducing cigarette smoking on a population-based level strongly reduces the rates of UIAs and SAH.

Optic Nerve Sheath Diameter is not Related to Intracranial Pressure in Subarachnoid Hemorrhage Patients.

Intracranial pressure (ICP) monitoring is essential after subarachnoid hemorrhage (SAH) to prevent secondary brain insults and to tailor individualized treatments. Optic nerve sheath diameter (ONSD), measured using ultrasound (US), could serve as a noninvasive bedside tool to estimate ICP, avoiding the risks of hemorrhage or infection related to intracranial catheters. The aims of this study were twofold: first, to explore the reliability of US for measuring ONSD; second, to establish whether the US-ONSD can be considered a proxy for ICP in SAH patients early after bleeding. For the first aim, we compared the ONSD measurements given by magnetic resonance imaging (MRI-ONSD) with the US-ONSD findings. For the second aim, we analyzed the relationship between US-ONSD measurements and ICP values. Adult patients with diagnosis of aneurysmal SAH and external ventricular drainage system (EVD) were included. Ten patients were examined by MRI to assess ONSD, and the results were compared to the diameter given by US. In 20 patients, the US-ONSD values were related to ICP measured simultaneously through EVD. In ten of these patients, we explored the changes in the US-ONSD at the time of controlled and fairly rapid changes in ICP after cerebrospinal fluid (CSF) drainage. US-ONSD measurements at the bedside were accurate, very similar to the diameters measured by MRI (the mean difference in the Bland-Altman plot was 0.08mm, 95% limits of agreement: - 1.13; + 1.23mm). No clear relationship was detectable between the ICP and US-ONSD, and a linear regression model showed an angular coefficient very close to 0 (p > 0.05). US-ONSD and ICP values were in agreement after CSF drainage and shifts in ICP in a limited number of patients. US-ONSD measurement does not accurately estimate ICP in SAH patients in the intensive care unit.

Subarachnoid hemorrhage in the eighties: to treat or not to treat.

Life expectancy has in the last few years increased and, as a consequence, also the number of elderly patients admitted to an Emergency Department with aneurysmal subarachnoid hemorrhage. We wanted to detect any difference in term of outcomes and adverse events between two groups of patients of different age, in relation to types of treatment and clinical status at presentation. We selected and analyzed two groups of patients (group A and group B) among 458 retrospectively collected cases admitted to two neurosurgical centers with a diagnosis of aneurysmal subarachnoid hemorrhage over a 7.5-year period. Group A included 46 patients equal or older than 80 years and group B all the rest. Data were collected on age, sex, aneurysm location, size, comorbidities, clinical condition at presentation and at follow-up. In group A, 19 patients underwent surgery, 16 were embolized, 7 were treated conservatively and 4 died very soon after admission. After a median follow-up of 12 months 45.7% of patients had a good outcome, 24% were in poor conditions and 21.7% had died. When we compared these results with the youngest group, we found some important statistically significant differences. Older patients were more prone to have surgical and medical related complications, whereas endovascular treatment seemed to be a more sustainable treatment in the elderly age group. Elderly patients suffering from aneurysmal subarachnoid hemorrhage should be considered for treatment despite age, with endovascular embolization as the most preferable option. Without the treatment, the natural history can be very poor.

Enhanced Renal Clearance in Patients With Hemorrhagic Stroke.

To evaluate enhanced renal clearance over time in patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage via measured creatinine clearance and to compare measured creatinine clearance to creatinine clearance calculated by the Cockcroft-Gault equation and estimated glomerular filtration rate calculated by the Modification of Diet in Renal Diseases equation. Prospective, observational study. Neurosciences ICU in a tertiary care academic medical center. Study participants had an admission diagnosis of aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage, an expected neurosciences ICU length of stay greater than 48 hours, no evidence of renal dysfunction (admission serum creatinine < 1.5 mg/dL), and no history of chronic kidney disease. Eight-hour urine collections to measure creatinine clearance were collected daily as the primary method of measuring renal function. Creatinine clearance was also calculated using the Cockcroft-Gault equation and estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Enhanced renal clearance was defined as a measured creatinine clearance greater than the calculated creatinine clearance via Cockcroft-Gault and estimated glomerular filtration rate via Modification of Diet in Renal Disease. Augmented renal clearance was defined by a measured creatinine clearance greater than or equal to 130 mL/min/1.73 m. Relevant demographic, clinical, and outcome data were recorded. Fifty aneurysmal subarachnoid hemorrhage patients and 30 intracerebral hemorrhage patients were enrolled, contributing 590 individual measurements. Patients with aneurysmal subarachnoid hemorrhage had a higher mean measured creatinine clearance compared with the mean calculated creatinine clearance based on the Cockcroft-Gault equation (147.9 ± 50.2 vs 109.1 ± 32.7 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (147.9 ± 50.2 vs 126.0 ± 41.9 mL/min/1.73 m; p = 0.04). Ninety-four percent of participants with aneurysmal subarachnoid hemorrhage experienced augmented renal clearance on at least 1 day. In patients with intracerebral hemorrhage, there was a higher mean measured creatinine clearance over the study period compared with the mean calculated creatinine clearance (119.5 ± 57.2 vs 77.8 ± 27.6 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (119.5 ± 57.2 vs 93.0.0 ± 32.8 mL/min/1.73 m; p = 0.02). Fifty percent of participants with intracerebral hemorrhage experienced augmented renal clearance on at least 1 day. A substantial group of patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage experienced enhanced renal clearance, which may be otherwise unknown to clinicians. Enhanced renal clearance may lead to increased renal solute elimination over what is expected, resulting in subtherapeutic renally eliminated drug concentrations. This may result in underexposure to critical medications, leading to treatment failure and other medical complications.

Contemporary Management of Aneurysmal Subarachnoid Hemorrhage: A Literature Review

AbstractSubarachnoid hemorrhage (SAH) results in significant morbidity and mortality, which leads to additional economic and psychological burden. Atraumatic SAH is normally secondary to a ruptured aneurysm. Diagnosis of aneurysmal subarachnoid hemorrhage (aSAH) is usually made by computed tomography (CT) of the head: noncontrast CT identifies the hemorrhage, and CT angiography identifies the aneurysm.The management of aSAH is focused on securing the aneurysm and prevention of secondary brain injury. Definitive treatment of the aneurysm is done by endovascular coiling or surgical clipping, which should be performed as soon as possible with avoidance of hypertension and strict blood pressure management prior to aneurysm securement. Routine use of nimodipine is recommended by international guidelines as a neuroprotectant. Common neurological complications of aSAH are hydrocephalus, seizures, vasospasm, and delayed cerebral ischemia (DCI). Detection of DCI, especially in patients with poor-grade aSAH, can be challenging. In addition to clinical examination, multiple radiological modalities can be used, with digital subtraction angiography being the gold standard but CT perfusion gaining an increasingly important role. Extracranial complications including cardiac dysfunction, pulmonary edema, and electrolyte abnormalities are common, causing significant morbidity and mortality.In this review, a PubMed literature search was conducted using the terms “subarachnoid hemorrhage” and “management,” with results limited to past 5 years. Journal articles were hand-selected by the authors based on relevance, and the references were reviewed to identify additional relevant publications. Historically important publications were also included.

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.

Gastrostomy tube placement increases the risk of ventriculoperitoneal shunt infection: a multiinstitutional study.

Gastrostomy tube placement can temporarily seed the peritoneal cavity with bacteria and thus theoretically increases the risk of shunt infection when the two procedures are performed contemporaneously. The authors hypothesized that gastrostomy tube placement would not increase the risk of ventriculoperitoneal shunt infection. The object of this study was to test this hypothesis by utilizing a large patient cohort combined from multiple institutions. A retrospective study of all adult patients admitted to five institutions with a diagnosis of aneurysmal subarachnoid hemorrhage between January 2005 and January 2015 was performed. The primary outcome of interest was ventriculoperitoneal shunt infection. Variables, including gastrostomy tube placement, were tested for their association with this outcome. Standard statistical methods were utilized. The overall cohort consisted of 432 patients, 47% of whom had undergone placement of a gastrostomy tube. The overall shunt infection rate was 9%. The only variable that predicted shunt infection was gastrostomy tube placement (p = 0.03, OR 2.09, 95% CI 1.07-4.08), which remained significant in the multivariate analysis (p = 0.04, OR 2.03, 95% CI 1.04-3.97). The greatest proportion of shunts that became infected had been placed more than 2 weeks (25%) and 1-2 weeks (18%) prior to gastrostomy tube placement, but the temporal relationship between shunt and gastrostomy was not a significant predictor of shunt infection. Gastrostomy tube placement significantly increases the risk of ventriculoperitoneal shunt infection.

Early Dynamics of Interleukin-6 in Cerebrospinal Fluid after Aneurysmal Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) is a severe condition associated with high mortality. Early brain injury (EBI) plays an important role in the pathophysiology of SAH, and inflammation is a major contributor to EBI. Inflammation is a widely studied topic in both experimental and clinical conditions; however, just a few clinical studies have focused primarily on the early inflammatory response after SAH, and detailed information about the association between the dynamics of early inflammatory response with main clinical characteristics is lacking. This study analyzes the early dynamics of inflammatory response after SAH and evaluates the possible associations between the markers of early inflammatory response and main clinical characteristics. A total of 47 patients with a diagnosis of aneurysmal SAH within the last 24 hours were enrolled in the study. All treatments, including treatment of aneurysm (surgery/coiling) and implantation of a drainage system (external ventricular drainage/lumbar catheter), were conducted in the same way as in other patients with this diagnosis. Blood and cerebrospinal fluid (CSF) samples were collected three times a day for 4 days. The dynamics of proinflammatory cytokines were assessed, and associations between levels of the proinflammatory cytokines interleukin (IL)-6, IL-1β, or tumor necrosis factor (TNF)α and main clinical characteristics were evaluated using linear mixed-effect models. The CSF levels of IL-6 were massively increased initially after SAH (up to 72 hours) with an additional increase in later phases (after 72 hours), but there was high variability in IL-6 levels. A significant association was noted between the Glasgow Outcome Scale score and both overall levels of IL-6 (p = 0.0095) and their dynamics (p = 0.0208); the effect of the Hunt and Hess scale was borderline (p = 0.0887). No association was found between IL-6 levels and Fisher grade, modality of treatment (surgery, coiling, no treatment), and later development of cerebral vasospasm. Plasmatic levels of IL-6 increased slightly, but no significant association was found. The levels of IL-1β and TNFα were within the physiologic range in both CSF and plasma. Early dynamics of IL-6 in CSF are associated with a patient́s outcome. But it is difficult to use IL-6 alone for outcome prediction due to its high variability. The question is whether the dynamics of IL-6 could be used in combination with other early markers associated with brain injury. More detailed research is required to answer this question.

Hemorragia subaracnoidea aneurismática: descripción de 2 años en la Unidad de Paciente Crítico del Instituto de Neurocirugía – Dr. Alfonso Asenjo

Backgrond: Aneurysmal subarachnoid haemorrhage has an incidence of 7 per 100,000 patients / year and only a third of patients end up without severe sequelae or death. Arm: We reviewed the clinical records of patients with diagnosis of subarachnoid hemorrhage during two years of the neurosurgery institute Dr. Alfonso Asenjo (Chile). Material and Methods: An observational, retrospective study including 231 patients with a diagnosis of aneurysmal subarachnoid hemorrhage, 33 (12.5%) were excluded per stay less than 72 hours or not admitted to the unit, corresponding to bleeding from other causes or not found Information, the database was reviewed during January 2015 to December 2016 of the statistical department of the Institute of Neurosurgery. Results: A total of 231 patients, 165 (71%) women and 66 (29%) men, were analyzed. It was found that hypertension with 120 (51.9%) and smoking with 89 (38.5%) cases were the most frequent risk factors. Endovascular treatment was performed on 100 patients (43%) and 128 (57%) were operated and 3 were not operated. Vasospasm was present in 130 cases (56.3%). Mortality was present in 15 patients died, so the mortality was 6.5%. Conclusions: There was no statistical significance between the type of therapy resolution pathway (endovascular/surgical) with P = 0.6530 with a a 0.05, but because there was a limited access to endovascular therapy at the neurosurgery institute at daytime hours from Monday to Friday versus the neurosurgical availability 24x7, being discordant with the statistical results of equal amount of treatment between the two pathways.

Hemorragia subaracnoideia: um quadro atípico de uma patologia rara

Introduction: Subarachnoid hemorrhage is a rare cause of headache with a high mortality rate and serious long-term neurological sequelae. This case has an atypical presentation, which should raise suspicion for the diagnosis. Case report: We present the case of a 50 year-old man from Angola, with a history of allergic rhinitis and chronic sinusitis. He is a member of a nuclear family in phase V of the Duvall family life cycle, in Graffar social class IV. His father died at age 54 from an intracranial hemorrhage. The patient presented with fever, coryza, and headache of 12 hours’ duration, accompanied by vomiting. The patient had elevated blood pressure on physical examination, without neurological deficits, with pain on cervical flexion, without neck stiffness. Given the possibility of acute meningitis and, less likely, subarachnoid hemorrhage, he was sent to the emergency room of the local hospital, where the diagnosis of aneurysmal subarachnoid hemorrhage was confirmed. He was admitted for surgical treatment for the aneurysm. He survived the surgery without neurological deficits. Comment: The differential diagnosis of headache ranges from benign and prevalent causes, to life-threatening, rare diseases. This case report, in addition to addressing a rare disease in primary health care, shows an unusual presentation, which highlights the core competencies of the General Practitioner.

Serum nesfatin-1 levels: a potential new biomarker in patients with subarachnoid hemorrhage*

Background: Acute subarachnoid hemorrhage (SAH) is a neurological emergency with significant potential for long-term morbidity and mortality. Nesfatin-1 is a polypeptide which is found in various regions of the brain that play role in the feeding and metabolic regulation. Objective: So this study aimed to investigate if nesfatin-1 levels in patients with SAH, could be used as a marker for the severity and prognosis. Method: Forty-eight consecutive patients (except those excluded) admitted to the emergency service of our hospital and hospitalized at our clinic with the diagnosis of aneurysmal SAH between 2011 and 2013 were included in the study and followed up for six months for outcome. The control group consisted of 48 healthy individuals of similar age and gender. Results: During the 6-month follow-up, 7 of 48 patients died and 16 (33.3%) patients had poor Glasgow Outcome Score (GOS) scores. In the study group, the mean nesfatin-1 level was significantly higher than the control group (7.36 ± 2.5 pg/ml and 4.29 ± 2.02 pg/ml, respectively; p < 0.01). The mean nesfatin-1 level was 11.58 ± 0.87 pg/ml in the non-survival group and 6.64 ± 1.89 pg/ml in the survival group. Furthermore, it was 10.22 ± 1.42 pg/ml in patients with poor outcome in terms of GOS and 5.93 ± 1.46 pg/ml in those with good outcome. The nesfatin-1 levels significantly increased with worsening of GOS, the World Federation of Neurological Surgeons grading system, and Fisher scores and increasing plasma C-reactive protein levels (p < 0.01 for all). Conclusion: The present study is the first that shows the mortality/poor outcome of the SAH with assessing serum nesfatin-1 levels. So levels of nesfatin-1 might be useful in SAH management.

Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.

IntroductionApplication of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study’s objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED) patients with aSAH and a normal mental status.MethodsPatients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age ≥40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) were abstracted from the chart and assessed for inter-rater reliability.ResultsOne hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9–98.2]). The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9–98.2]). Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6–100.0]).ConclusionNeither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.

Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage: A Quantitative Volumetric Study.

Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis. To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome. A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume. Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding. Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk. : aSAH, aneurysmal subarachnoid hemorrhage.