Fisher Grade Research Articles

Impact of Seizures and Status Epilepticus on Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

BackgroundWe aimed to evaluate the association between seizures as divided by timing and type (seizures or status epilepticus) and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH).MethodsAll consecutive patients with aSAH admitted to the neurocritical care unit of the University Hospital Zurich between 2016 and 2020 were included. Seizure type and frequency were extracted from electronic patient files.ResultsOut of 245 patients, 76 experienced acute symptomatic seizures, with 39 experiencing seizures at onset, 18 experiencing acute seizures, and 19 experiencing acute nonconvulsive status epilepticus (NCSE). Multivariate analysis revealed that acute symptomatic NCSE was an independent predictor of unfavorable outcome (odds ratio 14.20, 95% confidence interval 1.74–116.17, p = 0.013) after correction for age, Hunt-Hess grade, Fisher grade, and delayed cerebral ischemia. Subgroup analysis showed a significant association of all seizures/NCSE with higher Fisher grade (p < 0.001 for acute symptomatic seizures/NCSE, p = 0.031 for remote symptomatic seizures). However, although acute seizures/NCSE (p = 0.750 and 0.060 for acute seizures/NCSE respectively) were not associated with unfavorable outcome in patients with a high Hunt-Hess grade, they were significantly associated with unfavorable outcome in patients with a low Hunt-Hess grade (p = 0.019 and p < 0.001 for acute seizures/NCSE, respectively).ConclusionsAcute symptomatic NCSE independently predicts unfavorable outcome after aSAH. Seizures and NCSE are associated with unfavorable outcome, particularly in patients with a low Hunt-Hess grade. We propose that NCSE and the ictal or postictal reduction of Glasgow Coma Scale may hamper close clinical evaluation for signs of delayed cerebral ischemia, and thus possibly leading to delayed diagnosis and therapy thereof in patients with a low Hunt-Hess grade.

Prevalence and Outcomes of Bicuspid Aortic Valve in Patients With Aneurysmal Sub-Arachnoid Hemorrhage: A Prospective Neurology Registry Report.

BackgroundIntracranial aneurysms are reported in 6%–10% of patients with bicuspid aortic valve (BAV), and routine intracranial aneurysm surveillance has been advocated by some. We assessed the prevalence and features of the most important patient‐outcome: aneurysmal sub‐arachnoid hemorrhage (aSAH), as compared with controls without aSAH, and tricuspid aortic valve (TAV) with aSAH.Methods and ResultsAdult patients with accurate diagnosis of aSAH and at least one echocardiogram between 2000 and 2019 were identified from a consecutive prospectively maintained registry of aSAH admissions. Controls without a diagnosis of SAH were age‐ and sex‐matched. BAV prevalence was confirmed echocardiographically. Severity of aSAH was categorized using modified Fisher and World Federation of Neurological Scale. Neurologic outcome was assessed using modified Rankin score. A total 488 aSAH cases and 990 controls were identified and BAV status was confirmed. Prevalence of BAV in patients with aSAH was 1.2% (6/488) versus 3.5% (35/990) in controls, P=0.01. BAV+aSAH were noted to be younger than TAV+aSAH (56±11 versus 68±14; P=0.03) with smaller aneurysms (5±2 versus 7±4; P=0.31). The severity of aSAH was lesser in BAV+aSAH than TAV (modified Fisher grade>2 50% versus 74%; P=0.19, World Federation of Neurological Scale grade>3 17% versus 36%; P=0.43). BAV+aSAH had less severe neurologic disability (modified Rankin score 3%–6 33% versus 49% in TAV; P=0.44) and comparable in‐hospital mortality rates (P=0.93). BAV had lower odds for aSAH on multivariate analysis (odds ratio 0.23[CI 0.08–0.65]; P=0.01).ConclusionsPrevalence of BAV was 3 times lower in the aSAH registry than in controls without aSAH. BAV+aSAH had clinically smaller aneurysms, clinically smaller bleeds, and better neurologic outcome as compared with TAV+aSAH, which needs to be confirmed in larger studies. These findings argue against routine surveillance for intracranial aneurysms in patients with BAV without aortic coarctation.

WEB vs coiling in ruptured aneurysms: A propensity score matched comparison of safety and efficacy.

We aim to compare the safety and efficacy of WEB with coiling for acutely ruptured aneurysms.METHODS: All consecutive ruptured aneurysms with width suitable for WEB (2-10 mm) treated over 5 years (1/1/2015 to 31/12/2019) were included. We recorded WFNS, Fisher grade, patient demographics and aneurysm characteristics (size, location, D/W and aspect ratio, lobulation). Primary endpoints were mRS status at 3 months, aneurysm occlusion on latest available imaging follow-up, retreatment rate and procedural complications. We applied propensity score matching using aneurysm morphology (size, D/N ratio, ASPECT ratio and lobulation) to optimise matching for WEB versus coil comparison and minimise the effects of confounding. A total of 493 patients were identified, 97 treated with the WEB device. 1:1 propensity score matching was used to establish a matched group of 97 patients treated with coiling. The WEB arm showed 3% procedural complication rate, with no haemorrhagic complications and use of adjunctive device in 4%. Satisfactory occlusion on follow-up (mean 14 months) was 79%, with 19% retreatment rate. The coil arm had 8% complication rate, with use of an adjunctive device in 52% of cases (balloon 44%, stent 8%). Satisfactory occlusion on follow-up (mean 22 months) was 90%, with 8% retreatment rate. Treatment of ruptured wide-necked bifurcation aneurysms with WEB has a lower complication rate than coiling with high rate of satisfactory occlusion. However, there was a higher retreatment rate when compared with patients treated with coiling. An adjunct device (balloon or stent), was used in over 50% of aneurysms in the coiling group.

Quality of life after surgical clipping of ruptured aneurysms from a developing country: differential independent impact of grading scales & baseline factors.

Detailed Quality of Life(QOL) burden among patients with ruptured aneurysms has not been thoroughly studied, especially from developing countries. This is to evaluate the independent impact of factors influencing QOL following clipping. Patients who underwent clipping for ruptured anterior circulation aneurysms were prospectively studied for demography, site of aneurysm, H&H, WFNS, and Fisher grades, with QOL, assessed as per WHOQOL-BREF(range 4-20 in 4 domains), and analyzed. A total of 275 patients underwent prospective assessment of WHOQOL-BREF at 3 months after surgery, with a median age of 48. The sites of ruptured aneurysms were anterior cerebral(139), followed by middle cerebral(MCA)(82) and internal carotid(54) arteries. In univariate analyses, H&H grade had a significant rank order correlation with physical and psychological QOL domains, while WFNS grade had no significant correlation with QOL domains. Age showed a significant correlation with the social domain. The location of the ruptured aneurysm had a significant association as well, with MCA aneurysms having better scores in the environmental domain of QOL. Multivariate analysis using the generalized linear model confirmed the independent impact of these factors on QOL. Amongst all the factors studied, the age had the strongest independent impact, followed by H&H grade, location, and Fisher grade in the order of magnitude ofWald χ2. Following surgical clipping of ruptured aneurysms, age has the most substantial independent impact on QOL, followed by H&H grade, while WFNS grade shows no significant correlation. MCA aneurysms have better QOL scores than the rest.

The Association Between Illness Severity Scores and In-hospital Mortality After Aneurysmal Subarachnoid Hemorrhage.

The purpose of this study was to examine the association with in-hospital mortality of 8 illness severity scores in patients with aneurysmal subarachnoid hemorrhage (aSAH). In a retrospective cohort study, we investigated the association with in-hospital mortality of admission Hunt and Hess (HH) score, Fisher grade, severity of illness and risk of mortality scores, and serial Glasgow coma scale (GCS) score in patients with aSAH. We also explored the changes in GCS between admission and discharge using a multivariate model adjusting for age, clinical vasospasm, and external ventricular drain status. Data from 480 patients with aSAH, of which 383 (79.8%) aneurysms were in the anterior circulation, were included in analysis. Patients were female (n=340, 70.8%) with a median age of 56 (interquartile range: 48 to 66) years. The majority (n=332, 69.2%) had admission HH score 3 to 5, Fisher grade 3 to 4 (n=437, 91%), median severity of illness 3 (range: 1 to 4), median risk of mortality 3 (range: 1 to 4), and median admission GCS of 13 (interquartile range: 7 to 15). Overall, 406 (84.6%) patients received an external ventricular drain, 469 (97.7%) underwent aneurysm repair, and 60 died (12.5%). Compared with admission HH score, GCS 24 hours after admission (area under the curve: 0.84, 95% confidence interval [CI]: 0.79-0.88) and 24 hours after aneurysm repair (area under the curve: 0.87, 95% CI: 0.82-0.90) were more likely to be associated with in-hospital mortality. Among those who died, the greatest decline in GCS was noted between 24 hours after aneurysm repair and discharge (-3.38 points, 95% CI: -4.17, -2.58). Compared with admission HH score, GCS 24 hours after admission (or 24 h after aneurysm repair) is more likely to be associated with in-hospital mortality after aSAH.

Preoperative predictors of poor outcomes in Thai patients with aneurysmal subarachnoid hemorrhage

ObjectiveA scoring system for aneurysmal subarachnoid hemorrhage (aSAH) is useful for guiding treatment decisions, especially in urgent-care limited settings. This study developed a simple algorithm of clinical conditions and grading to predict outcomes in patients treated by clipping or coiling.MethodsData on patients with aSAH hospitalized in a university’s neurovascular center in Thailand from 2013 to 2018 were obtained for chart review. Factors associated with poor outcomes evaluated at one year were identified using a stepwise logistic regression model. For each patient, the rounded regression coefficients of independent risk factors were linearly combined into a total score, which was assessed for its performance in predicting outcomes using receiver operating characteristic analysis. An appropriate cutoff point of the scores for poor outcomes was based on Youden’s criteria, which maximized the summation between sensitivity or true positive rate and the specificity or true negative rate.ResultsPatients (n, 121) with poor outcomes (modified Rankin Scale, mRS score, 4–6) had a significantly higher proportion of old age, underlying hypertension, diabetes and chronic kidney disease, high clinical severity grading, preoperative rebleeding, and hydrocephalus than those (n, 336) with good outcomes (mRS score, 0–3). Six variables, including age >70 years, diabetes mellitus, World Federation of Neurosurgical Societies (WFNS) scaling of IV-V, modified Fisher grading of 3–4, rebleeding, and hydrocephalus, were identified as independent risk factors and were assigned a score weight of 2, 1, 2, 1, 3 and 1, respectively. Among the total possible scores ranging from 0–10, the cut point at score 3 yielded the maximum Youden’s index (0.527), which resulted in a sensitivity of 77.7% and specificity of 75.0%.ConclusionA simple 0–10 scoring system on six risk factors for poor outcomes was validated for aSAH and should be advocated for use in limited resource settings.

The Role of Soluble Urokinase Plasminogen Activator Receptor (suPAR) in the Context of Aneurysmal Subarachnoid Hemorrhage (aSAH)-A Prospective Observational Study.

ObjectiveOutcome after aneurysmal subarachnoid hemorrhage (aSAH) is highly variable and largely determined by early brain injury and delayed cerebral ischemia (DCI). Soluble urokinase plasminogen activator receptor (suPAR) represents a promising inflammatory marker which has previously been associated with outcome in traumatic brain injury and stroke patients. However, its relevance in the context of inflammatory changes after aSAH is unclear. Here, we aimed to characterize the role of circulating suPAR in both serum and cerebrospinal fluid (CSF) as a novel biomarker for aSAH patients.MethodsA total of 36 aSAH patients, 10 control patients with unruptured abdominal aneurysm and 32 healthy volunteers were included for analysis. suPAR was analyzed on the day of admission in all patients. In aSAH patients, suPAR was also determined on the day of DCI and the respective time frame in asymptomatic patients. One- and two-sample t-tests were used for simple difference comparisons within and between groups. Regression analysis was used to assess the influence of suPAR levels on outcome in terms of modified Rankin score.ResultsSignificantly elevated suPAR serum levels (suPAR-SL) on admission were found for aSAH patients compared to healthy controls, but not compared to vascular control patients. Disease severity as documented according to Hunt and Hess grade and modified Fisher grade was associated with higher suPAR CSF levels (suPAR-CSFL). In aSAH patients, suPAR-SL increased daily by 4%, while suPAR-CSFL showed a significantly faster daily increase by an average of 22.5% per day. Each increase of the suPAR-SL by 1 ng/ml more than tripled the odds of developing DCI (OR = 3.06). While admission suPAR-CSFL was not predictive of DCI, we observed a significant correlation with modified Rankin's degree of disability at discharge.ConclusionElevated suPAR serum level on admission as a biomarker for early inflammation after aSAH is associated with an increased risk of DCI. Elevated suPAR-CSFL levels correlate with a higher degree of disability at discharge. These distinct relations and the observation of a continuous increase over time affirm the role of inflammation in aSAH and require further study.

An Audacious Voyage during COVID-19 Pandemic in Management of Patients with Aneurysmal Subarachnoid Hemorrhage at Annapurna Neurological Institute and Allied Sciences

Introduction: Aneurysmal Subarachnoid Hemorrhage(SAH) is a neurosurgical emergency for which testing for COVID PCR was not an option and was unlikely to change the management of the case. Hence, all surgeries were performed without COVID PCR and Rapid Diagnostic Test (RDT) at our center for the welfare of the patient despite risks involved for the surgeons and supporting staff.&#x0D; Methods: Data were collected retrospectively of all cerebral aneurysm patients who received treatment at Annapurna Neurological Institute and Allied Sciences during the covid pandemic between February 2020 to May 2021. Their demographic profile, clinical and imaging characteristics, treatment decision, postoperative complication, postoperative functional status in terms of Modified Rankin Scale were taken into consideration and analyzed.&#x0D; Result: 63 patients were enrolled in study with patient age ranging from 9 years to 81 years. Male to female ratio was 1:3. Amongst them, 28% had hypertension. 82% underwent microsurgical clipping while three patients underwent coiling. Basilar Top aneurysm, Para clinoid aneurysm, PICA aneurysm underwent simple coiling. Wrapping, bypass and trapping were performed in 1,1, and 3 cases respectively. At the time of discharge, most of the patients (77%) achieved good functional recovery (mRS ≤ 2) while mortality was reported in 8% of patients. Based on our experience and limited dataset, posterior location of aneurysm, increasing HuntHess Grade and modified fisher grade had poor prognosis, related with degree of cerebral vasospasm, and delayed cerebral ischemia.&#x0D; Conclusion: Results from our study showed outcomes in surgical patients with aneurysmal SAH at par with international standards. COVID pandemic although posed initial difficulties, with proper guidelines and protocols in place, we were able to perform the emergency surgeries without compromising our standards.&#x0D;

Time trends in the risk of delayed cerebral ischemia after subarachnoid hemorrhage: a meta-analysis of randomized controlled trials.

Delayed cerebral ischemia (DCI) contributes to morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Continuous improvement in the management of these patients, such as neurocritical care and aneurysm repair, may decrease the prevalence of DCI. In this study, the authors aimed to investigate potential time trends in the prevalence of DCI in clinical studies of DCI within the last 20 years. PubMed, Embase, and the Cochrane library were searched from 2000 to 2020. Randomized controlled trials that reported clinical (and radiological) DCI in patients with aSAH who were randomized to a control group receiving standard care were included. DCI prevalence was estimated by means of random-effects meta-analysis, and subgroup analyses were performed for the DCI sum score, Fisher grade, clinical grade on admission, and aneurysm treatment method. Time trends were evaluated by meta-regression. The search strategy yielded 5931 records, of which 58 randomized controlled trials were included. A total of 4424 patients in the control arm were included. The overall prevalence of DCI was 0.29 (95% CI 0.26-0.32). The event rate for prevalence of DCI among the high-quality studies was 0.30 (95% CI 0.25-0.34) and did not decrease over time (0.25% decline per year; 95% CI -2.49% to 1.99%, p = 0.819). DCI prevalence was higher in studies that included only higher clinical or Fisher grades, and in studies that included only clipping as the treatment modality. Overall DCI prevalence in patients with aSAH was 0.29 (95% CI 0.26-0.32) and did not decrease over time in the control groups of the included randomized controlled trials.

302 Outcomes in Aneurysmal Subarachnoid Hemorrhage Patients with Diabetes on Sulfonylureas: A Propensity Match Analysis

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with an increase blood-brain-barrier permeability, disruption of tight junctions, and increased cerebral edema. Sulfonylureas has been associated with less disturbance in tight junctions and reduced edema following aSAH in animal models. METHODS: Patients from the Post-Barrow Ruptured Aneurysm Trail (PBRAT) databse from August 1st, 2007, to July 31st, 2019, were retrospectively reviewed. Initial analysis grouped patients into two cohorts: diabetes and no-diabetes. A second analysis in diabetic patients separated patients based on prescription of sulfonylureas on hospital admission. A 4:1 nearest neighbor propensity match (match for age, gender, Hunt and Hess (HH), Fisher Grade, aneurysm location, aneurysm size, aneurysm type, Charlson Comorbidity Score (CCI), and treatment) was performed. Primary outcome was neurological status at last follow-up, with a poor outcome defined as a modified Rankin Score &gt;2 and a good outcome as mRS &lt;/= 2. Significance was established as p &lt; 0.05. RESULTS: A total of 1014 aSAH patients were treated during the study period. Of these patients, 129 (13%) were found to have a history of diabetes on admission. Compared to non-diabetic patients, the diabetic cohort had an increase age (59, sD 14. vs 55, sD 14.1; p &lt; 0.006) and a higher CC I(2.5 vs 1.5; p &lt; 0.001). Patients with diabetes (N = 77, 60%) were found to have a significantly higher odd of a mRS &gt;2 on last follow-up compared to non-diabetics (N = 43, 49%) (p = 0.02). In the diabetic cohort, 16 patients (12%) were found to be on a sulfonylurea medication. Following propensity score matching, diabetic patients on a sulfonylurea (31%, N = 5) were found to have a significantly decrease percentage of a mRS &gt;2 on last follow-up compared to non-sulfonylurea patients (63%, N = 40/64) (p = 0.02). On univariate analysis, besides the administration of a sulfonylurea, a HH &lt; 4 was found to be associated with a decrease percentage of a mRS &gt;2 (49%, N = 28 of 57) (p = 0.04). However, on multivariable logistic regression analysis, only the administration of a sulfonylurea was found to be a predictor of a good neurological outcome (OR 3.4, 95% CI: 1.1-11.3, p = 0.04). CONCLUSION: Diabetes appears to be associated with poor neurological outcomes in aSAH patients. However, the poor neurological outcome in diabetic patients appears to be mitigated by the administration of sulfonylureas.

Neuroprotective effect of dapsone in patients with aneurysmal subarachnoid hemorrhage: a prospective, randomized, double-blind, placebo-controlled clinical trial.

In this study, the authors sought to define the differences in the incidence of delayed cerebral ischemia (DCI) between patients treated with dapsone and those treated with placebo. Secondary objectives were to define the clinical outcome at discharge and 3 months and the incidence of brain infarction. A prospective, randomized, double-blind, placebo-controlled study was performed and included patients with aneurysmal subarachnoid hemorrhage (SAH) within 5 days from ictus who were candidates for aneurysm occlusion, and who had a Fisher grade of 3 or 4. Patients with sulfa or sulfone drug allergies, hemoglobin < 11 g/dl, known G6PD deficiency, and those refusing informed consent were excluded. A minimal relevant effect decrease of 35% in the incidence of DCI was established. Patients were randomly assigned to receive a regimen of dapsone 2.5 ml (100 mg) daily or a placebo (aluminum hydroxide suspension, 2.5 ml daily). Both groups received validated treatment for aneurysmal SAH. The appearance of DCI on CT was assessed in every patient at discharge and 3 months later. We used the chi-square test to compare the DCI incidence between both groups, and the Student t-test or nonparametric tests to compare quantitative variables. Overall, 48 patients (70.8% women and 29.2% men) were included. The mean age was 50 years (SD 14.28 years, range 18-72 years). Prerandomization and postrandomization characteristics were balanced, except for the necessity of intra-arterial nimodipine administration in patients treated with placebo (15.4% vs 45.5%, p = 0.029. The incidence of DCI, the primary endpoint, for the whole cohort was 43.8% and was significantly lower in the dapsone group (26.9% vs 63.6%, p = 0.011). In addition, the irreversible DCI incidence was lower in the dapsone group (11.5% vs 54.5%, p = 0.12). A favorable modified Rankin Scale score was more frequent in the dapsone group at discharge and at 3 months (76.9% vs 36.4%, p = 0.005 and 80% vs 38.9%, p = 0.019, respectively). Also, the brain infarction incidence was lower in the dapsone group (19.2% vs 63.6%, p = 0.001). There was no difference between groups regarding adverse events. Dapsone seems to play a role as a prophylactic agent in patients at high risk of developing DCI after aneurysmal SAH. A multicenter investigation is necessary to increase the study population and confirm the consistency of the results observed in this study.

True Posterior Communicating Artery Aneurysms with High Risk of Rupture despite Very Small Diameter.

ObjectiveThis retrospective study investigated the clinical and angiographic characteristics of ruptured true posterior communicating artery (PCoA) aneurysms in comparison with junctional PCoA aneurysms presenting with a subarachnoid hemorrhage. MethodsThe medical records and radiological data of 93 consecutive patients who underwent three-dimensional rotational angiography and surgical or endovascular treatment for a ruptured junctional or true PCoA aneurysm over an 8-year period were examined. ResultsThe maximum diameter of the ruptured true PCoA aneurysm (n=13, 14.0%) was significantly smaller than that of the ruptured junctional PCoA aneurysms (n=80, 4.45±1.44 vs. 7.68±3.36 mm, p=0.001). In particular, the incidence of very small aneurysms <4 mm was 46.2% (six of 13 patients) in the ruptured true PCoA aneurysm group, yet only 2.5% (two of 80 patients) in the ruptured junctional PCoA aneurysm group. Meanwhile, the diameter of the PCoA was significantly larger in the true PCoA aneurysm group than that in the junctional PCoA aneurysm group (1.90±0.57 vs. 1.15±0.49 mm, p<0.001). In addition, the ipsilateral PCoA/P1 ratio was significantly larger in the true PCoA aneurysm group than that in the group of a junctional PCoA aneurysm (mean PCoA/P1 ratio±standard deviation, 2.67±1.22 vs. 1.14±0.88; p<0.001). No between-group difference was identified for the modified Fisher grade, clinical grade at admission, and 3-month modified Rankin Scale score. ConclusionA true PCoA aneurysm was found to be associated with a larger PCoA and ruptured at a smaller diameter than a junctional PCoA aneurysm. In particular, the incidence of a ruptured aneurysm with a very small diameter <4 mm was significantly higher among the patients with a true PCoA aneurysm.

The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era.

Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity regardless of treatment. Herein, we re-evaluate the safety and efficacy of microsurgical treatment for managing PGASAH patients in the current endovascular era. We retrospectively reviewed 141 consecutive patient records in a single institution who underwent microsurgical (n = 80) or endovascular (n = 61) treatment for PGASAH. Baseline characteristics were similar, except for more intracerebral hematomas (46.3% vs 24.6%, p = 0.009), fewer intraventricular hemorrhages (26.3% vs 59%, p < 0.001), and fewer posterior circulation aneurysms (5.1% vs 44.3%, p < 0.001) in the microsurgery group. Decompressive craniectomy (58.5% vs 24.6%, p < 0.001) and shunt-dependent hydrocephalus (63.7% vs 41%, p = 0.01) were more common for microsurgery, while procedural ischemic complications were less common (5% vs 24.6%, p = 0.001). Both early (12.5% vs 32.8%, p = 0.006) and late mortality rates (22.5% vs 39.3%, p = 0.041) were lower for microsurgery, and favorable 12-month outcomes (modified Rankin scale = 0-2) were better (62.5% vs 42.6%, p = 0.026). Multivariate analysis revealed that advanced age, neurological grade, modified Fisher grade, larger aneurysm size, rebleeding, and cerebral infarctions were independent predictors of poor outcome. Microsurgery fared marginally better than endovascular treatment (OR: 2.630, 95% CI: [0.991-6.981], p = 0.052). Timely and efficient treatment, either via open microsurgery or endovascular surgery, provided favorable outcomes for over half of PGASAH patients in this series. Therefore, early treatment should be offered to all PGASAH patients regardless of clinical and/or radiological factors. Microsurgery remains an effective treatment modality for selected PGASAH patients in the endovascular era.

Abstract TMP12: Artificial Intelligence Prediction Of Delayed Cerebral Ischemia After Cerebral Aneurysm Rupture

Background: Aneurysmal subarachnoid hemorrhage (aSAH) results in significant mortality and disability, which is worsened by the development of Delayed Cerebral Ischemia (DCI). Tests to identify patients with DCI prospectively are needed. Objective: We created a machine learning (ML) system based on clinical variables to predict DCI in aSAH patients and to determine which variables have the most impact on DCI prediction. Methods: We performed a retrospective cohort study of aSAH patients from January 2006 to September 2014. The ML algorithm was trained on age, sex, HTN, diabetes, hyperlipidemia, CHF, CAD, smoking history, family history of aneurysm, Fisher Grade, Hunt and Hess score, and external ventricular drain (EVD) placement. Prediction outcome of the ML algorithm was DCI+, which was defined as new neurologic deterioration that could not be attributed to aneurysm re-bleeding, hydrocephalus, infection, seizure, hyponatremia or other metabolic abnormality. SHAP was used to explain and visualize the role of each feature’s contribution to the model prediction. Results: 500 aSAH patients were identified and 369 met inclusion criteria: 70 patients developed DCI (DCI+) and 299 did not (DCI-). Random Forest was selected for this project after a 5-fold cross validation. 276 cases (222 DCI- and 54 DCI+) were used for training and 93 cases (77 DCI- and 16 DCI+) were used for testing the algorithm. The Random Forest ML algorithm predicted DCI: Accuracy: 81.7%, Sensitivity: 12.5%, Specificity: 96.1%, PPV: 40%, and NPV: 84.1%. SHAP value demonstrated Age, EVD placement, Fisher Grade, and Hunt and Hess score, and HTN had the highest predictive values for DCI. Lower age, absence of hypertension, higher Hunt and Hess score, higher Fisher Grade, and EVD placement increased risk of DCI. Conclusion: ML models based upon clinical variable predict DCI with high specificity and modest accuracy. The addition of imaging or other biomarkers may improve the sensitivity of the ML algorithm.

Abstract TMP11: Predictors Of Timely Treatment Of Aneurysmal Subarachnoid Hemorrhage - The Reddish Study

Background: Receiving early treatment for aneurysmal subarachnoid hemorrhage (aSAH) is associated with better outcomes for the patient. However, delays in treatment of aSAH are common but the causes are not well understood. We explored predictors of early treatment within 12.5 hours or 24 hours after aSAH. Methods: Consecutive cases of confirmed first-ever aSAH were identified from two Australian tertiary referral centers between 2010 and 2016. We used medical and ambulance records to extract details of participants, including time from onset to definitive treatment of either endovascular coiling or neurosurgical clipping, demographics, severity of aSAH (modified Fisher grade; World Federation of Neurosurgeons Scale [WFNS]), risk factors, pre-hospital care, and presenting symptoms. Factors associated with treatment to secure the aneurysm within 12.5 hours or 24 hours on univariable logistic regression were entered into a multivariable model to identify factors independently associated with (odds ratio [OR], 95% CI) earlier treatment. Results: Among 482 patients (mean [SD] age 54.1 [14.5]; 69.9% female) with aSAH, median (IQR) time to treatment was 19.4 (10.6, 31.0) hours, 30% were treated &lt;12.5h and 62% were treated &lt;24h from onset. In multivariable analyses (see figure), arriving by ambulance, urgent triage category (1-2) and severe aSAH (modified Fisher Scale 3-4) predicted treatment &lt;12.5h and &lt;24h. Less severe aSAH (WFNS score 1-3) and arriving overnight (11pm to 7am) were associated with treatment &lt;24h. In contrast, people with no risk factors for aSAH (smoking, hypertension or alcohol use), presenting with a stiff neck or interfacility transfer more often had treatment ≥12.5h. Conclusions: A substantial proportion of people after aSAH were not treated within timeframes associated with better outcomes. Recognition of the urgency and severity aSAH cases were associated with more timely treatment of aSAH.

Early Microcirculatory Hemodynamic Changes Are Correlated With Functional Outcomes at Discharge in Patients With Aneurysmal SAH.

PurposeThe technique of color-coding blood flow analysis was used to explore the correlation between the microcirculatory hemodynamic changes on digital subtraction angiography (DSA) images in patients with aneurysmal subarachnoid hemorrhage (SAH) at the early stage and functional outcomes at discharge.MethodsData of 119 patients who underwent DSA examination due to SAH were retrospectively analyzed. The following hemodynamic parameters of the four region of interests (ROIs) [an ophthalmic segment of the internal carotid artery (ICA), frontal and parietal lobe, and superior sagittal sinus] were analyzed: the time-to-peak (TTP), the area under the curve (AUC), the full width at half maximum (FWHM), mean transit time (MTT), and circulation time. Multifactor regression analysis was performed to explore the correlation between the hemodynamic parameters and functional outcomes in patients at discharge.ResultsOf 119 patients with SAH, good and poor outcomes were found in 83 (69.7%) and 36 (30.3%) patients, respectively. The hemodynamic parameters including the FWHM, relative TTP (rTTP), and circulation time were significantly correlated with the Hunt–Hess grade (p < 0.005, p = 0.03, and p < 0.005) and the World Federation of Neurological Societies Scale grade (p < 0.005, p = 0.02, and p = 0.01). The FWHM was significantly prolonged with the increase of modified Fisher grade (p = 0.02). The multifactor analysis showed that the FWHM [odds ratio (OR) 17.56, 95% CI: 1.13–272.03, p = 0.04] was an independent risk factor predicting the functional outcomes in patients at discharge.ConclusionThe technique of color-coding blood flow analysis could be suitable for the qualified evaluation of disease conditions at an early stage of SAH as well as the prediction of outcomes.

Admission Lower Serum Phosphate Ion Levels Predict Acute Hydrocephalus of Aneurysmal Subarachnoid Hemorrhage.

Introduction: The relationship between serum phosphate ion (sPi) and the occurrence of acute hydrocephalus (aHCP) in aneurysmal subarachnoid hemorrhage (aSAH) remains largely unknown and controversial. The primary aim of this study was to investigate the association between sPi on admission and aHCP following aSAH.Methods: The study included 635 patients over the age of 19 years diagnosed with aSAH in our institution from September 2012 to June 2018. Data on clinical characteristics, laboratory parameters, treatments, and outcomes were collected and analyzed. The association between lower sPi levels and aHCP was assessed in univariate and multivariate analyses. Propensity-score matching (PSM) analysis was performed to reduce significant differences in baseline characteristics between the aHCP group and non-HCP group.Results: The overall incidence of aHCP following aSAH was 19.37% (123/512). Lower sPi levels were detected in patients with aHCP compared with those without [0.86 (0.67–1.06) vs. 1.04 (0.84–1.21) mmol/L] in the univariate analysis. In the multivariate analysis, lower sPi level, high modified Fisher (mFisher) grade, and high Hunt-Hess grade were associated with aHCP [odds ratios (OR) 1.729, 95% confidence interval (CI) 1.139–2.623, p = 0.01; mFisher OR 0.097,95% CI 0.055–0.172, p < 0.001; Hunt-Hess, OR 0.555, 95% CI 0.320–0.961, P = 0.036]. After PSM, the matched aHCP group had a significantly lower sPi level than the matched non-aHCP group [0.86 (0.67–1.06) vs. 0.94 (0.76–1.12) mmol/L, p = 0.044]. The area under the curve (AUC) of the sPi level and the logistic regression model based on these predictors (sPi, Hunt-Hess grade, and mFisher grade) was 0.667 and 0.840 (sensitivity of 88.6% and specificity of 68.4%) for predicting aHCP, respectively.Conclusions: Lower sPi levels predict the occurrence of aHCP, and the model constructed by sPi levels, Hunt-Hess grade, and mFisher grade markedly enhances the prediction of aHCP after aSAH.

Effect of cerebrospinal fluid drainage on clinical outcomes following aneurysmal subarachnoid hemorrhage

ObjectivesWe study the relationship between external ventricular drainage (EVD) of cerebrospinal fluid output and functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). MethodsA retrospective chart review of patients presenting to a single center with aSAH was performed. The primary outcome was good functional outcomes assessed by a composite of the modified Rankin scale (mRS 0–2) at last follow-up. Secondary outcomes were clinical and radiographic vasospasm. For data analysis, multivariable generalized estimating equations adjusting for potential confounders were used. ResultsA total of 119 patients were included; 91 (75.6%) presented with a modified Fisher grade 4 and 76 (63.9%) had hydrocephalus. The median EVD duration was 13 days. On average, most EVDs were set at 15 cmH2O (50, 42%). Follow-up was available in 109 patients; median time was 10.7 months; 69 (63.3%) had good outcomes. Multivariable analysis showed that EVDs set at 10 cmH2O had increased odds of good outcomes for every ml increase in the EVD output (OR = 1.02; 95% CI 1.01–1.03; p = 0.001). Post estimation analyses show that EVDs at 10 cmH2O with output close to 200 ml predicted a 50% probability of good outcomes. ConclusionsIncreased EVD outputs were associated with favorable outcomes at the last follow-up.

Endovascular Treatment of Ruptured Very Small Intracranial Aneurysms: Complications, Recurrence Rate, and Clinical Outcomes.

Objective: The aim of this study was to evaluate the safety and efficacy of endovascular treatment for ruptured very small (≤3 mm) intracranial aneurysms (VSIAs).Methods: The clinical data and imaging results for 152 patients with VSIAs treated with coil embolization from August 2014 to June 2020 were retrospectively reviewed. The influential factors related to the preoperative complications, aneurysm recurrence, and clinical outcomes for these patients were analyzed.Results: Among 152 patients with ruptured VSIAs, 90 were treated with coil embolization alone, while 62 were treated with stent-assisted coil embolization. Eighteen patients experienced intra and/or postoperative complications (overall incidence = 11.8%). One person died of intraoperative aneurysm re-rupture and postoperative rebleeding (mortality rate = 0.65%). Twenty patients had various degrees of neurological dysfunction (morbidity rate = 13.1%). Statistical analysis showed that there was no independent risk factor associated with perioperative complications. The rate of complete aneurysm occlusion at discharge and follow-up was 76.3 and 86.2%, respectively. A total of 105 patients underwent digital subtraction angiography during follow-up, and 18 of them experienced postoperative recurrence (recurrence rate = 17.1%). Seven patients were retreated (retreatment rate = 6.7%). The use of stents was the only factor that affected the postoperative recurrence of aneurysm. The incidence of favorable clinical outcomes (Glasgow Outcome Scale score ≥ 4) at discharge and follow-up was 86.2 and 97.1%, respectively. Univariate analysis showed that the preoperative Hunt-Hess grade, CT Fisher grade, and perioperative complications were risk factors for poor clinical outcomes. Multiple logistic regression analysis showed that perioperative complication was the most significant risk factor for the clinical prognosis of patients with ruptured VSIAs.Conclusion: Endovascular treatment is a safe and efficient approach for ruptured VSIAs. Stent-assisted coiling reduced the recurrence rate of aneurysm without increasing the incidence of perioperative complications. The Hunt-Hess grade, CT Fisher grade, and perioperative complications were independent factors associated with the clinical outcomes of patients with ruptured VSIAs, and perioperative complication was the most significant risk factor for poor prognosis in patients.

Management of aneurysmal subarachnoid hemorrhage with surgical clipping: A single center perspective

Background/Aim: There is no consensus on the optimal treatment for intracranial aneurysm rupture due to subarachnoid hemorrhage (SAH). In this study, we analyzed a series of ruptured intracranial aneurysms treated with the clipping method at our center. Methods: In this retrospective cohort study; we searched our patient database for patients who developed SAH due to ruptured intracranial aneurysm treated at the Neurosurgery Clinic of Sivas Cumhuriyet University. A total of 304 patients who underwent the clipping operation due to aneurysmal SAH between 2010 and 2020 were included in the study. Cases with aneurysmal SAH who underwent endovascular coiling which is consisted of 22 patients were excluded. Results: A significant inverse correlation was found between age and Glasgow coma scores (GCS) (r=−0.137, P=0.017). Hunt–Hess and Fisher grades increased significantly with increasing age (r=0.187, P 0.05). No significant differences were observed in GCS scores and Hunt–Hess and Fisher grades between genders (P>0.05). There were no significant effects of aneurysm locations on mortality (P>0.05). Conversely, GCS scores were significantly lower and Hunt–Hess and Fisher grades were significantly higher in the surviving group than in the deceased group (P<0.001). Conclusion: Our study presented the outcomes of patients treated in our clinic with surgical clipping. Based on our findings, we believe that surgical clipping is still a safe and valid treatment method.