Diagnosis Of aSAH Research Articles

Aneurysmal Subarachnoid Hemorrhage: Is the Time Until Intervention Related to Minor Disabilities in 6 Months?

Abstract Background Aneurysmal subarachnoid hemorrhages (aSAHs) account for 5% of all strokes, an appalling number when it comes to the second most common cause of death worldwide. The basis of the treatment is clinical support and either endovascular or surgical intervention. The purpose of the present study is to analyze if the time from the onset of the thunderclap headache until treatment intervention is related to the degree of disability after 6 months. Methods In the present prospective observational study, data were collected from all patients (n = 223) admitted to the hospital with a diagnosis of aSAH. Patients whose data were missing or who missed the follow-up after 6 months were excluded. Then, the number of days from the thunderclap headache until the surgical intervention (Delta T) was obtained. The degree of disability was evaluated using standardized scales, Rankin Scale (RS) and Glasgow Outcome Scale (GOS), at the time of discharge as well as 6 months later. Then, the RS and GOS were correlated with Delta T. Results An average of 6.8 days was found from the onset of symptoms to the intervention, the average age was 54 years old, 73% were women and 55% were smokers. The mean Glasgow Coma Scale on admission was 13. The mean score on the Hunt and Hess scale was 2.1. From the radiological point of view, the mean size of the aneurysm was 6 mm, and the modified Fisher Scale was 3.1. Of the total number of patients at the end of the study (n = 78), 50 underwent microsurgical treatment (63%). Rankin scale at discharge was 1.9 and GOS was 4.5, with no statistically significant change at 6 months. Analyzing the data distribution using linear regression, no statistically significant correlation was found between the time until treatment and disability using RS and GOS (p > 0.05). The same results were found even analyzing age subgroups (≤ 45 years old, 45 to 55 years old, 55 to 70 years old, and > 70 years old with a p-value > 0.05). Conclusions The present study suggests that there is no linear correlation between Delta T and disability at 6 months for the population studied. However, more studies are needed to assess whether these findings may be present in other populations, especially with a shorter time from symptoms to intervention, since the greatest risk of rebleeding occurs in the first 3 days after the event.

Impact of Early Out-of-Bed Mobilization on Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study

Effects of early mobilization are not well documented in patients with aneurysmal subarachnoid hemorrhage (aSAH). Only a few studies have investigated it through progressive mobilization protocols and suggested that it is safe and feasible. This study aimed to determine the impact of early out-of-bed mobilization (EOM) on 3-month functional outcome and cerebral vasospasm (CVS) occurrence in patients with aSAH. A retrospective review of consecutive patients admitted to the intensive care unit with a diagnosis of aSAH was performed. EOM was defined as out-of-bed (OOB) mobilization performed before or on day 4 after aSAH onset. The primary outcome was 3-month functional independence (i.e., a modified Rankin Scale below 3) and the occurrence of CVS. A total of 179 patients with aSAH met the inclusion criteria. Thirty-one patients constituted the EOM group, and 148 patients were in the delayed out-of-bed mobilization group. Functional independence was more frequent in the EOM group than in the delayed out-of-bed mobilization group (n= 26 [84%] vs. n= 83 [56%], P= 0.004). In a multivariable analysis, EOM was an independent predictor of functional independence (adjusted odds ratio=3.11; 95% confidence interval, 1.11-10.36; P < 0.05). The delay between bleeding and first OOB mobilization was also identified as an independent risk factor for the occurrence of CVS (adjusted odds ratio=1.12; 95% confidence interval=1.06-1.18, P < 0.001). EOM was independently associated with favorable functional outcome after aSAH. The delay between bleeding and OOB mobilization was an independent risk factor for reduced functional independence and CVS occurrence. Prospective randomized trials are necessary to confirm these results and improve clinical practice.

Surgical management of Aneurysmal Subarachnoid Haemorrhage in a resource-constrained region: A Nigerian regional experience

BackgroundAneurysmal Subarachnoid Haemorrhage (aSAH) is a vascular injury with significantly high mortality, especially when poorly managed. This study seeks to outline the experiences in setting up a neurovascular service in Lagos, Nigeria. MethodsA series of 45 patients were operated after aSAH over a period of 10 years. Patients consecutively were recruited following computed tomography angiography (CTA) diagnosis of aSAH. Clinical data were recorded on a predesigned form after obtaining informed consent; aSAH was classified using the WFNS classification, intraoperative findings were documented. Challenges in the management were analysed in a post-operative root cause analysis (RCA) review. Outcomes and factors responsible for the observed outcomes and actions taken were recorded. ResultsForty-five patients were operated after aSAH was confirmed; there were 29 females and 16 males. (M:F 1:1.8), the age ranged from 14 to 76 years (mean 49.1±13.58). All the aneurysms were on the anterior circle of Willis, mainly on Anterior Communicating Artery aneurysm (18/48).Thirty-eight patients (84.4%) survived and were discharged within an average of 10 days after surgery. Lower GCS at presentation was associated with poor prognosis (p = 0.026); however, data analysis demonstrated that other factors (financial issues, lack of appropriate instrumentation and equipment, experience of the surgeon) played a significant role in determining the outcome. ConclusionsAneurysmal Subarachnoid Haemorrhage (aSAH) is a challenging pathology and its management may be further burdened in resource constrained countries, as shown by the data analysed in this study from Lagos, Nigeria. Specialized and well-funded Neurovascular centres are needed to overcome the challenges faced and to improve care for aSAH patients in Nigeria.

"Atypical" Mild Clinical Presentation in Elderly Patients With Ruptured Intracranial Aneurysm: Causes and Clinical Characteristics.

ObjectiveThunderclap-like severe headache or consciousness disturbance is the common “typical” clinical presentation after aneurysmal subarachnoid hemorrhage (aSAH); however, a slowly developing “atypical” clinical pattern, with mild headache, vomiting, or dizziness, is frequently noted in elderly patients. The aim of this study was to evaluate the clinical characteristics of this “atypical” subgroup, as well as related factors associated with the presence of these mild symptoms.MethodsThe data of 176 elderly patients (≥70 years old) with ruptured intracranial aneurysms (IAs) treated at our center from January 2016 to January 2020 were retrospectively collected and analyzed. The patients were divided into “typical” and “atypical” groups based on their initial and development of clinical symptoms after the diagnosis of aSAH. Intergroup differences were analyzed, and factors related to the presence of these two clinical patterns were explored through multiple logistic regression analyses.ResultsDespite significant admission delay (P < 0.001) caused by mild initial symptoms with slow development, patients in the “atypical” group achieved better clinical prognosis, as indicated by a significantly higher favourable outcome ratio and lower death rate upon discharge and at different time points during the 1-year follow-up, than the “typical” group (P < 0.05). Multiple logistic regression analysis revealed that modified Fisher grade III-IV (OR = 11.182, P = 0.003), brain atrophy (OR = 10.010, P = 0.001), a larger lesion diameter (OR = 1.287, P < 0.001) and current smoking (OR = 5.728, P < 0.001) were independently associated with the presence of “typical” symptoms. Aneurysms with wide necks (OR = 0.013, P < 0.001) were independently associated with the presence of “atypical” symptoms.Conclusions“Atypical” presentations, with mild clinical symptoms and slow development, were commonly recorded in elderly patients after the onset of aSAH. Despite the prolonged admission delay, these “atypical” patients achieved better clinical outcomes than those with “typical” symptoms. Modified Fisher grade (III-IV), current smoking, brain atrophy and larger lesion diameter were factors predictive of “typical” symptoms, while aneurysms with wide necks were independently associated with “atypical” symptoms.

Impact of COVID-19 Pandemic on Treatment Management and Clinical Outcome of Aneurysmal Subarachnoid Hemorrhage - A Single-Center Experience.

BackgroundPrevious studies reported decreased volumes of acute stroke admissions during the COVID-19 pandemic. We aimed to examine whether aneurysmal subarachnoid hemorrhage (aSAH) volumes demonstrated similar declines in our department. Furthermore, the impact of the pandemic on disease progression should be analyzed.MethodsWe conducted a retrospective study in the neurosurgical department of the university hospital Frankfurt including patients with the diagnosis of aSAH during the first year of the COVID pandemic. One year cumulative volume for aSAH hospitalization procedures was compared to the year before (03/2020 – 02/2021 vs. 03/2019 – 02/2020) and the last 5 pre-COVID-pandemic years (2015-2020). All relevant patient characteristics concerning family history, disease history, clinical condition at admission, active/past COVID-infection, treatment management, complications, and outcome were analyzed.ResultsCompared to the 84 hospital admissions during the pre-pandemic years, the number of aSAH hospitalizations (n = 56) declined during the pandemic without reaching significance. No significant difference in the analyzed patient characteristics including clinical condition at onset, treatment, complications, and outcome, between 56 patients with aSAH admitted during the COVID pandemic and the treated patients in the last 5 years in the pre-COVID period were found. In our multivariable analysis, we detected young age (p < 0.05; OR 4.2) and no existence of early hydrocephalus (p < 0.05; OR 0.13) as important factors for a favorable outcome (mRS ≤ 0–2) after aSAH during the COVID pandemic. A past COVID-infection was detected in young patients suffering from aSAH (Age <50years, p < 0.05; OR 10.5) with an increased rate of cerebral vasospasm after aSAH onset (p < 0.05; OR 26). Nevertheless, past COVID-infection did not reach significance as a high-risk factor for unfavorable outcomes.ConclusionThere was a relative decrease in the number of patients with aSAH during the COVID-19 pandemic. Despite the extremely different conditions of hospitalization, there was no impairing significant effect on the treatment and outcome of admitted patients with aSAH. A past COVID infection seemed to be an irrelevant limiting factor concerning favorable outcomes.

Unaccounted for enteral volume loss linked to delayed cerebral ischemia after subarachnoid hemorrhage

Delayed ischemic neurological deficit (DIND) is seen as a clinical manifestation of cerebral vasospasm and is a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Currently, the standard of care for DIND prevention in patients who have sustained aSAH is prophylactic nimodipine therapy and ensuring adequate fluid intake, alongside other treatments such as bowel care. Osmotic laxatives trap water within the bowel lumen to accelerate the transport of the gut contents through the bowel. Given the potential for DIND secondary to cerebral vasospasm, it is perhaps counterintuitive that gastrointestinal fluid loss and use of osmotic laxatives are not commonly considered in many aSAH management protocols. A retrospective case note analysis was performed for all adult patients (aged > 16 years) admitted to the Department of Neurosurgery at Leeds General Infirmary with a diagnosis of aSAH between August 2019 and September 2020. A total of 105 patients were included, 62% of whom were female, with a mean and median age of 54 years (range 24-84 years). Diarrhea was noted in 12 patients (11.4%), 58% of whom subsequently developed DIND (OR 15.30, CI 3.92-59.14; p = 0.0001). All patients received osmotic laxatives (97% having received ≥ 2 laxative agents). Patients with aSAH who subsequently developed diarrhea had significantly increased odds of developing DIND. Enteral volume loss due to osmotic laxative use is a potential risk factor for DIND after aSAH.

Initiating Mobilization Is Not Associated with Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Multicenter Case-control Study.

The study aim was to investigate the association between initiating mobilization within 7 days after onset and symptomatic cerebral vasospasm (SCV) in patients with aneurysmal subarachnoid hemorrhage (aSAH). This was a retrospective multicenter case-control study in Japan. Patients with a diagnosis of aSAH who underwent physical therapy with/without occupational therapy were included and categorized into 2 groups according to the presence or absence of SCV. Initiating mobilization was defined as sitting on the bed edge (at least once, with/without assist, regardless of duration) within 7 days after aSAH onset. Cox proportional hazards regression analysis was performed to evaluate the association between initiating mobilization within 7 days after onset and SCV. The analysis included 510 patients. Among all included patients, 57 (11.2%) patients had SCV. In the univariate Cox proportional hazards regression analysis, initiating of mobilization was not associated with SCV (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.45-1.32). In the multivariate analysis, only the modified Fisher scale was significantly associated with SCV (HR = 26.23; 95% CI = 1.21-571.0). Initiating mobilization within 7 days after aSAH onset was not associated with SCV in patients with aSAH.

Abstract 13783: Predictors and Prognostic Implications of Stress Cardiomyopathy in Aneurysmal Sub-Arachnoid Hemorrhage: Findings From a 14-year Prospective Registry

Objective: Stress cardiomyopathy(SCM) occurs between 4-15% in aneurysmal sub-arachnoid hemorrhage(aSAH). Predictors and prognostic implications of SCM in aSAH remains incompletely known. Methods: Adult patients between January 2006-December 2019 with diagnosis of aSAH and echocardiogram during same admission were identified from a prospectively maintained aSAH registry. Presence of SCM was confirmed using the echocardiographic criteria. Severity of aSAH was categorized using the modified Fisher(mFisher) and the World Federation of Neurological Scale(WFNS). Results: Among 570 aSAH patients during study period, 194 aSAH cases had echocardiography and 37(19%) of them had SCM. In comparison to aSAH without SCM, aSAH with SCM were mainly females(76% vs 62%; p= 0.12) and postmenopausal(57±12 vs 59±13 years; p= 0.39). Echocardiographic findings in Table . aSAH with SCM was associated with WFNS grade&gt;3(68% vs 42%; p= 0.005) and mFisher grade&gt;2(87% vs 81%; p= 0.39), intraventricular hemorrhage(IVH)(81% vs 64%; p= 0.04) and larger size of the ruptured aneurysm(8±5 vs 6±4; p= 0.04). Medical management, microsurgical clipping and endovascular coil embolization rates were similar in patients with and without SCM, yet patients with SCM had lower rates of disposition to home(8% vs 27%; p =0.02) and higher in-hospital mortality(41% vs 25%, p= 0.05). On multivariate analysis, ruptured ophthalmic artery aneurysms had 13-times higher odds for formation of SCM(OR 13.43 [1.22-147.8]; p= 0.02). Conclusion: aSAH with SCM predominantly occurred in postmenopausal females with larger aneurysms, and higher severity of bleeds. Ophthalmic artery aneurysms were associated with substantially increased risk of SCM after adjustment for aSAH severity. Despite similar treatment rates, SCM was associated with higher in-hospital mortality. These findings will require further confirmation in a larger subset of aSAH with SCM patients.

Intracranial Pressure Monitoring in Poor-Grade Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Coiling

The main objective of the present study was to analyze the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes during coiling. We also evaluated the prevalence of rebleeding and outcomes for patients monitored before and after coiling. Ninety-nine consecutive poor-grade patients with aneurysmal subarachnoid hemorrhage (aSAH; World Federation of Neurological Surgeons grade IV and V) were enrolled in our prospective observational study. For 31 patients, ICP and CPP monitoring was started immediately after the diagnosis of aSAH, and the values were recorded every 15 minutes during coiling (early ICP group). For 68 patients, ICP and CPP monitoring began after coiling (late ICP group). The outcomes were evaluated at 90 days using the modified Rankin scale. At the beginning of coiling, the ICP was >20 mm Hg in 10 patients (35.7%). The median ICP was 18 mm Hg (range, 5-60 mm Hg). The CPP was <60 mm Hg in 6 patients (24%). The median CPP was 70 mm Hg (range, 30-101 mm Hg). Despite medical treatment and/or cerebrospinal fluid drainage, 51.6% of the patients monitored during coiling had at least one episode of intracranial hypertension (defined as ICP >20 mm Hg), and 51.6% had at least one episode of reduced CPP (defined as CPP <60 mm Hg). Early monitoring (before aneurysm repair) was not associated with rebleeding. At 90 days, the functional recovery was better in the early ICP group (P= 0.004). During coiling, patients with poor-grade aSAH can experience episodes of intracranial hypertension and reduced CPP. Early and appropriate treatment of elevated ICP was not associated with rebleeding and might have improved the outcomes.

Abstract P823: Evaluating Time-To-Aneurysm Repair as a Performance Measure in Aneurysmal Subarachnoid Hemorrhage

Background: Implementation of evidence-based performance metrics drive standardized care and improve patient outcomes. Limited performance metrics have been developed for implementation in the aneurysmal subarachnoid hemorrhage (aSAH) population. Timely aneurysm repair following an aSAH is associated with rebleeding prevention and mortality. The purpose of this study was to evaluate time to aneurysm repair as a candidate performance metric by testing a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, with time to aneurysm repair as a potential influence on these relationships in aSAH. Methods: A retrospective, cross-sectional analysis of patient discharge data from 2014 in the state of Florida was conducted. Data were derived from The Agency for Healthcare Research and Quality, HealthCare Utilization Project, State Inpatient Dataset, and the American Hospital Association Annual Survey. Patients with a primary ICD-9 diagnosis of aSAH and principle procedure of clipping or coiling were included (n=387). The study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. Results: Patients who underwent endovascular repair of an aneurysm were more likely to be treated in &lt;24 hours compared to those undergoing aneurysm clipping (OR = 0.54, CI = .35-.84, p =0.01). Patients treated at a comprehensive stroke center (CSC) had a 72% reduction in odds of death compared to those treated at primary stroke centers (OR =0.28, CI = 0.10-0.77, p =0.01), controlling for disease severity and comorbidity. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. Conclusions: Treatment at a certified CSC was the only significant predictor of surviving aSAH. Time to aneurysm repair did not influence the relationship between hospital and patient characteristics associated with mortality. Further research is needed to identify appropriate measures and to define what should be tracked for performance in the aSAH population.

Hyponatremia as predictor of symptomatic vasospasm in aneurysmal subarachnoid hemorrhage

BackgroundSubarachnoid hemorrhage is one of high morbidity in vascular neurology and neurosurgery and one of the clipart for this is symptomatic vasospasm that can leads to delayed cerebral ischemia. Other common complication is electrolytes and fluid homeostasis disturbance and among these, is Sodium disequilibrium, either hypo- or hypernatremia. In our institution we observed that hyponatremia is common, and it is more evident in patient with symptomatic vasospasm. For that we retrospectively looked at the association of hyponatremia and the occurrence of symptomatic vasospasm or delayed cerebral ischemia in aSAH. MethodsRetrospective chart review with daily monitoring of sodium level from day 1to day 21 from the ictus, aSAH. We include all adult patients (Age > 18 years) who were admitted to intensive care with diagnosis of aSAH and undergone aneurysm securing procedures within 48 h. ResultsAmong 45 patients 24 (43%) developed symptomatic vasospasm and delayed cerebral ischemia and it was most common in males (13/22: 59%). Sodium level especially hyponatremia in period between days (1–4) with median of 134 in vasospasm group (50%). ConclusionsDelayed cerebral ischemia/symptomatic vasospasm occurs more commonly in males and associated with hyponatremia (Na+ <134) and can be predicted in the first 4 days.

Pituitary Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study.

The prevalence of pituitary dysfunction after aneurysmal subarachnoid hemorrhage (aSAH) remains incompletely elucidated. Furthermore, it is not clear whether these abnormalities impact patient outcomes. The aim of this study was to evaluate the prevalence of pituitary dysfunction after aSAH and its effect on outcomes. We carried out a prospective, cohort study including adult patients (18 y of age or older) with a diagnosis of aSAH who were admitted to the intensive care unit in 3 centers between January 2017 and January 2019. Exclusion criteria were previous hypopituitarism, hormonal replacement therapies for pituitary dysfunction or any corticosteroid treatment. Endocrine function was tested within the first 48 hours after aSAH onset (acute phase), after 1 to 3 weeks (subacute phase), and after 6 to 12 months (chronic phase). Clinical outcomes were assessed at 6 to 12 months using the modified Rankin Scale. Fifty-six patients were included in the study; all were studied in the acute phase, 34 were studied in the subacute phase, and 49 in the chronic phase. Pituitary dysfunction was identified in 92.3% (95% confidence interval; [CI]: 86.6%-98.0%) of cases in the acute phase, in 83.3% (95% CI: 70.8%-95.8%) in the subacute phase, and in 83.3% (95% CI: 72.7%-93.9%) of cases in the chronic phase. The most commonly identified abnormality was dysfunction of the pituitary-gonadal axis. There was no correlation between pituitary dysfunction and clinical outcome. Pituitary dysfunction is common after aSAH, but does not affect 6 to 12-month clinical outcomes.

Abstract TP452: Long Term Opioid Use in Patients With Aneurysmal Subarachnoid Hemorrhage

Background: Headache and neck pain are common in patients with aneurysmal subarachnoid hemorrhage (aSAH) throughout their course. Because pain is often a sequela, these patients are at risk for opioid dependence. Long term opioid use has not been well studied in this population. Methods: We analyzed a cohort of consecutive patients who were admitted with diagnosis of aSAH to an academic referral center from 2015 to 2018. We excluded patients who died during hospitalization or were discharged to hospice or were previously taking any opioids. The following variables were collected: demographics, any opioid use during hospitalization, short-term low-dose steroid use (mostly for headache management but some cases for immediate post craniotomy for aneurysm clipping), opioid prescription at the time of discharge and 3-month or longer opioid use verified by pharmacy and any follow up out patient records. Results: Of 200 patients with aSAH, 144 patients (72%) met our inclusion criteria. Mean age was 58 years (SD 14.8); Ninety-four patients (65%) were women; All patients received opioids at some point during hospitalization but 66% (96/144) were discharged with opioid prescription. Of these, 31% (30/96) continued to use opioids at ≥3 months. The overall rate of chronic opioid use was 20% (30/144). The rate of opioid prescription at discharge was 72% (52/72) in patients who received short course steroids and 61% (44/72) in patients who did not receive steroids. (p=0.21; OR 2.6, 95% CI 0.82-3.3). Steroids did not prevent long term opioid use. (p=0.30; OR 0.6, 95% CI 0.26-1.3) Conclusion: Opioids are regularly used as the main treatment option for pain control in patients with aSAH. A noteworthy number of patients continue to use opioids beyond their initial hospitalization. Steroid use does not prevent long term opioid use in these patients. Non-opioid pain control strategies should be explored in the future.

The effect of anaesthetic exposure in presurgical period on delayed cerebral ischaemia and neurological outcome in patients with aneurysmal subarachnoid haemorrhage undergoing clipping of aneurysm: A retrospective analysis.

Background and Aims:Delayed cerebral ischaemia is one of the major contributors to morbidity in aneurysmal subarachnoid haemorrhage (aSAH). General anaesthesia (GA) in the presurgical period may have a preconditioning effect. The primary aim was to assess the effect of preoperative exposure to GA during digital subtraction angiography (DSA) on neurological outcome in patients presenting with aSAH.Methods:After Ethical Committee approval, we conducted a retrospective analysis of the data of patients with aSAH treated surgically. Patients, admitted to neurosurgical ICU (June 2014 and December 2017) with a computed tomography (CT) diagnosis of aSAH and underwent DSA, were included. DSA, done with or without exposure to a general anaesthetic, was classified to GA group and LA group, respectively. Propensity score matching was done on the baseline variables. Appropriate statistical methods were applied.Results:Of the 278 patients, 116 (41.7%) patients had received GA during DSA. Propensity matching yielded 114 (57 in each group) matched patients. In a logistic regression model, the odds ratio (OR) for poor outcome at discharge in GA group as compared to LA group was 4.4 (CI: 2.7–7.4), P = 0.001, whereas, in the matched data, the OR for poor outcome at discharge in GA group as compared to LA group was 1.2 (CI: 0.6–2.6), P = 0.57.Conclusion:The presurgical exposure to GA did not offer any neuroprotection and the odds of poor outcome were higher compare to non-exposure to GA group.

Abstract TP540: Effects of Stimulant Use on the Temporal Course of Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Background: Comorbid use of stimulants (cocaine and amphetamines) has been associated with worse outcomes in aneurysmal SAH (aSAH), however its effect on the course of cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) has not been consistently established. If stimulant use changes the temporal course of CV, an inexpensive toxicology screen could help to inform decisions on length of ICU stay or timing of more resource intensive monitoring tools such as conventional angiography (DSA). Methods: After IRB approval, data from an academic center encompassing 6/2012 and 10/2017 were retrospectively reviewed to identify adult patients who had 1) diagnosis of aSAH with known ictus, 2) vascular imaging and tox screen within 72 hours of ictus, and 3) imaging or transcranial Doppler (TCD) documentation of CV. Clinical trial enrollment or early transition to comfort care were exclusions. Standard clinical care for SAH was provided by a multidisciplinary team in a dedicated neuroscience ICU. By institutional protocol, patients receive at least one post-aneurysm exclusion DSA study and typically, surveillance for CV by TCD every weekday independent of clinical symptoms. This is supplemented by symptom triggered DSA/CTA/MRA. These reports were reviewed to establish the day of onset, duration, and peak severity (mild, moderate, severe) of CV. Baseline factors known to affect CV such as age, gender, and SAH grade were also collected. Statistical comparisons were done using Wilcoxon rank-sum and Student’s t-test. Results: 40 patients met inclusion criteria, of which 8 (20%) were positive for stimulant use. There were no statistically significant differences between stimulant positive and negative groups with respect to age, gender, Hunt-Hess grade, modified Fisher score, or EVD placement. The stimulant positive group had an earlier onset of CV (day 3.4 vs 5.4, p=0.019) and higher severity (p=0.044), but non-significant difference in duration (5.2 vs 6.3 days, p=0.565). Rate of confirmed DCI by infarct on CT/MRI was the same (25%) in both groups. Conclusion: Stimulant use was associated with earlier onset and severity of vasospasm in this sample of aSAH patients. Further exploration with a larger population is warranted to better establish this relationship.

Bedside optical coherence tomography for Terson's syndrome screening in acute subarachnoid hemorrhage: a pilot study.

Approximately 10% of patients with subarachnoid hemorrhage (SAH) become permanently, legally blind. The average cost of lifetime support and unpaid taxes for each blind person amounts to approximately $900,000. This study evaluates the feasibility and potential role of bedside optical coherence tomography (OCT) in Terson’s syndrome (TS) in patients with acute SAH (aSAH) and its potential role in blindness prevention. The authors conducted an open-label pilot study, in which 31 patients with an angiographic diagnosis of aSAH were first screened for TS with dilated funduscopy and then with OCT in the acute phase and at 6-week followup visits. Outpatient mood assessments (Patient Health Questionnaire–depression module, Hamilton Depression Scale), and quality of life general (NIH Patient-Reported Outcomes Measurement Information System) and visual scales (25-item National Eye Institute Visual Functioning Questionnaire) were measured at 1 and 6 weeks after discharge. Exclusion criteria included current or previous history of severe cataracts, severe diabetic retinopathy, severe macular degeneration, or glaucoma. OCT identified 7 patients with TS, i.e., a 22.6% incidence in our aSAH sample: 7 in the acute phase, including a large retinal detachment that was initially missed by funduscopy and diagnosed by OCT in follow-up clinic. Dilated retinal funduscopy significantly failed to detect TS in 4 (57.1%) of these 7 cases. Intraventricular hemorrhage was significantly more common in TS cases (85.7% vs 25%). None of the participants experienced any complications from OCT examinations. Neither decreased quality of life visual scale scores nor a depressed mood correlated with objective OCT pathological findings at the 6-week follow-up after discharge. There were no significant mood differences between TS cases and controls. OCT is the gold standard in retinal disease diagnosis. This pilot study shows that bedside OCT examination is feasible in aSAH. In this series, OCT was a safe procedure that enhanced TS detection by decreasing false-negative/inconclusive funduscopic examinations. It allows early diagnosis of macular holes and severe retinal detachments, which require acute surgical therapy to prevent legal blindness. In addition, OCT aids in ruling out potential false-positive visual deficits in individuals with a depressed mood at follow-up.

Cerebral perfusion pressure threshold to prevent delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

ObjectiveTo seek a cerebral perfusion pressure (CPP) threshold that can reduce the occurrence of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). MethodsWe analyzed the clinical data of patients with the diagnosis of aSAH and underwent CPP monitoring in our department from February 2014 to December 2015. CPP was divided into four specified thresholds by every 10 mmHg increments, which were from 50 mmHg to 80 mmHg. The totally time ratio of CPP below each threshold was calculated. The correlation between the time ratio and DCI were analyzed using binary logistic regression. And receiver operating characteristic curve was performed to identify the cutoff time ratios at higher risk of DCI. ResultsFinally, 17 patients developed DCI from 60 patients who were recruited. The time ratios of CPP which was below 50 mmHg, 60 mmHg and 70 mmHg were found predictors of DCI by the binary logistic regression. The cutoff time ratios were 0.4% (AUC = 0.777), 7.0% (AUC = 0.702), 28.7% (AUC = 0.696) respectively. While at the level of 80 mmHg, the cutoff time ratio was 65% (AUC = 0.595). It was not related to DCI (P = 0.167). Patients suffered from DCI had a worse outcome than who did not at 3 month after aSAH (P = 0.018). ConclusionTime ratios at higher risk of DCI had a positive relationship with the CPP thresholds. Keeping CPP above 70 mmHg may be helpful to prevent DCI after aSAH, but it still needs further investigation.

Subarachnoid Hemorrhage and Readmissions: National Rates, Causes, Risk Factors, and Outcomes in 16,001 Hospitalized Patients.

The acute complications of aneurysmal subarachnoid hemorrhage (aSAH) often lead to readmissions, which are linked to hospital reimbursement. The national rates, causes, risk factors, and outcomes associated with 30-day and 90-day readmission after aSAH have not previously been reported. The Nationwide Readmissions Database was queried from January to September 2013 for all patients (age ≥18 years) with a diagnosis of aSAH. Data points included demographics, comorbidities, complications, and discharge outcomes. Causes and risk factors for 30-day and 90-day readmission were identified in univariate and multivariable analysis. In 12,777 patients discharged alive after hospitalization for aSAH, 962 (7.5%) were readmitted within 30 days and 2153 (16.7%) within 90 days. Common causes of readmission included stroke, hydrocephalus, septicemia, and headache. At 30-day and 90-day readmission, 39.7% and 51.2% of patients with diagnosis of hydrocephalus underwent ventriculoperitoneal shunt placement, respectively. In multivariable analysis, cannabis use and diabetes were predictors of both 30-day and 90-day readmission and older patients were uniquely susceptible to 30-day readmissions. Risk factors for 90-day readmission included Medicare insurance, hypothyroidism, initial discharge to skilled nursing facility, and several index complications including bowel obstruction, gastrostomy, acute lung injury, and cerebral edema. Average cost and length of stay were calculated at 30-day ($16.647, 7.1 days) and 90-day readmission ($17,926, 6.7 days). Mortality was 2.8% within 30 days and 3.8% within 90 days. Many readmissions occur outside the 30-day follow-up period in patients subarachnoid hemorrhage and possess unique risk factors, which may help identify high-risk patients.

Trends in Transcranial Doppler Monitoring in Aneurysmal Subarachnoid Hemorrhage: A 10-Year Analysis of the Nationwide Inpatient Sample

Transcranial Doppler (TCD) is endorsed by national guidelines for use in aneurysmal subarachnoid hemorrhage (aSAH) for surveillance of cerebral vasospasm (CV). However, nationwide data on utilization of TCD for CV detection and monitoring in aSAH are lacking. Analysis of nationwide trends in TCD prevalence was performed using Nationwide Inpatient Sample (NIS) data from 2002 to 2011. Raw counts were converted into weighted counts, which were used to generate national estimates. Teaching hospitals were examined separately for TCD utilization rates. All analyses accounted for the complex sampling design and sample discharge weights of the NIS, following Healthcare Cost and Utilization Project-NIS recommendations. The objective was to estimate the proportion of patients with aSAH receiving TCD monitoring using the NIS. Between 2002 and 2011, a total of 256,089 patients were discharged with a diagnosis of aSAH, of which 3850 underwent TCD monitoring. aSAH accounted for an average of 67.1 discharges per 100,000 annually (95% confidence interval [CI] 61.3-72.8). Of these, 1.5% (95% CI 0.4-2.6) underwent TCD examination. In teaching hospitals, aSAH accounted for an average of 108.5 discharges per 100,000 biennially (95% CI, 96.2-120.8), of which 2% (95% CI 1.0-4.0) underwent TCD examination. TCD utilization increased from <1% during the 2002-2005 period to ≥1.5% during the 2006-2011 period (odds ratio 2.3, 95% CI 1.0-5.7), an increase also seen in teaching hospitals. TCD is underused nationally in the care of aSAH. Whereas the prevalence of TCD is low in teaching hospitals, it is nearly nonexistent in nonteaching hospitals.

Vitamin D Deficiency Is Not Associated with Outcomes in Aneurysmal Subarachnoid Hemorrhage Patients: A Case Control Study

Vitamin D deficiency has been associated with increased risk and adverse outcomes in many clinical settings including cardiovascular disease, stroke, and critically ill patients. Therefore we aimed to determine whether vitamin D deficiency had any effect in aneurysmal subarachnoid hemorrhage (aSAH) clinical outcomes. A retrospective record review was conducted in a tertiary community hospital in Puerto Rico. Adult patients admitted to the neurosurgical intensive care unit with a diagnosis of aSAH from January 2013 to July 2014, who had a 25-hydroxyvitamin-D level drawn, were included. A total of 40 patients were admitted with a diagnosis of aSAH, and 33 met the inclusion criteria. Overall, 81% of patients were vitamin D deficient or insufficient. Subjects were grouped into those with vitamin D deficiency (n= 13) and those without (n= 20). Except for a larger prevalence of coronary artery disease, all other baseline parameters were similar. No significant difference in hospital mortality was observed (P= 0.676). The percentage of vasospasms, vasopressor use, hydrocephalus, and infections was also similar. An increase in length of neurosurgical intensive care unit stay and respiratory failure was observed in the vitamin D-deficient group, but it was not statistically significant. A high prevalence of vitamin D deficiency and insufficiency was found among patients admitted with a diagnosis of aSAH in this cohort. Despite this no difference in clinical outcomes was observed in patients when compared by vitamin D group. Further studies are needed to assess potential effects of vitamin D deficiency in this patient population including long term follow-up after discharge.