Good-grade Aneurysmal Subarachnoid Hemorrhage Research Articles

Body Mass Index and the Risk of Poor Outcome in Surgically Treated Patients With Good-Grade Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND:Heterogeneity among study populations and treatment procedures has led to conflicting results on outcome predictors for patients with aneurysmal subarachnoid hemorrhage (aSAH). One such conflicting predictor is body mass index (BMI).OBJECTIVE:To clarify whether high BMI values protect patients from poor outcome after aSAH, as previously suggested.METHODS:We surveyed 6 prospective studies conducted in 14 different countries (93 healthcare units) between 1985 and 2016 and pooled the data on surgically treated patients with good-grade (Glasgow Coma Scale 13-15 on admission) aSAH. We calculated BMI for each patient and created 4 balanced categories based on the BMI quartiles of each cohort. We calculated adjusted odds ratios (ORs) with 95% CIs for the 3-month poor outcome (Glasgow Outcome Scale 1-3) by BMI.RESULTS:The pooled study cohort included 1692 patients with good-grade aSAH (mean age 51 years; 64% female). At 3 months, 288 (17%) had poor outcomes. The risk for poor outcomes increased with increasing BMI values (OR = 1.15 [1.02-1.31] per each standard deviation increase of BMI). The risk for poor outcome was over 1.6 times higher (OR = 1.66 [1.13-2.43]) in the highest BMI category (range 27.1-69.2) compared with the lowest BMI category (range 14.4-23.8). These associations were found in each of the 6 study cohorts in both men and women, regardless of age.CONCLUSION:Because higher BMI values seem to associate with poor outcomes in surgically treated patients with good-grade aSAH, it seems unlikely that obesity protects patients with aSAH from poor outcomes.

Unfavorable Outcome After Good Grade Aneurysmal Subarachnoid Hemorrhage: Exploratory Analysis

Patients with good-grade aneurysmal subarachnoid hemorrhage (aSAH) are thought to recover well, yet some do not. This work sought to identify predictors of unfavorable functional outcome after good-grade aSAH. We performed a post-hoc analysis of the CONSCIOUS-1 trial. Patients with World Federation of Neurosurgical Societies grades I or II aSAH were included. The primary outcome was unfavorable functional outcome (defined as a modified Rankin Scale score >2) at 12 weeks. Parametric and nonparametric testing were used as appropriate. Variables were classified as modifiable or nonmodifiable, depending on whether they were present at patient admission. Stepwise logistic regression models were created for modifiable and nonmodifiable predictors of outcome. Independent predictors in the respective multivariate analyses were combined into a final multivariate regression model. We included 301 patients, 67 of whom (22%) had an unfavorable outcome. Of the nonmodifiable predictors, higher admission systolic blood pressure (P= 0.002) and female sex (P= 0.011) were independently associated with unfavorable outcome. Potentially modifiable independent predictors of outcome were delayed cerebral ischemia (P= 0.039), higher maximum temperature (0.036), suffering a respiratory system complication (P= 0.004), and suffering an intracranial hemorrhagic complication (P= 0.022). All variables found to be independently predictive of poor outcome in their respective models retained statistical significance in the combined multivariate analysis. About 1 in 5 good-grade aSAH patients enrolled in CONSCIOUS-1 suffered an unfavorable functional outcome. Admission systolic blood pressure, female sex, hyperthermia, delayed cerebral ischemia, respiratory complications, and intracranial hemorrhagic complications may be predictive of outcome.

Comparison of Ketofol (Combination of Ketamine and Propofol) and Propofol Anesthesia in Aneurysmal Clipping Surgery: A Prospective Randomized Control Trial.

Background:The maintenance of hemodynamic stability is of pivotal importance in aneurysm surgeries. While administering anesthesia in these patients, the fluctuations in blood pressure may directly affect transmural pressure, thereby precipitating rupture of aneurysm and various other associated complications. We aimed to compare the effects of ketofol with propofol alone when used as an induction and maintenance anesthetic agent during surgical clipping of intracranial aneurysms.Materials and Methods:Forty adult, good-grade aneurysmal subarachnoid hemorrhage patients posted for aneurysm neck clipping were included in the study. The patients were randomized into two groups. One group received a combination of ketamine and propofol (1:5 ratio) and the other group received propofol for induction and maintenance of anesthesia. Intraoperative hemodynamic stability, intraventricular pressure, and quality of brain relaxation were studied in both the groups.Results:The patients were comparable with respect to demographic profile, Hunt and Hess grade, world federation of neurological surgeons (WFNS) grade, Fisher grade, duration of anesthesia, duration of surgery, optic nerve sheath diameter, and baseline hemoglobin. Intraoperative hemodynamics were better maintained in the ketofol group during induction, with only 15% of patients having >20% fall in mean arterial pressure (from baseline) intraoperatively, compared to 45% of patients receiving propofol alone (P = 0.038). The mean intraventricular pressure values in both the groups were in the normal range and the quality of brain relaxation was similar, with no significant difference (P > 0.05).Conclusion:Ketofol combination (1:5) as compared to propofol alone provides better hemodynamic stability on induction as well as maintenance anesthesia without causing an increase in intracranial pressure. Effect of ketofol on cerebral oxygenation and quality of emergence need to be evaluated further by larger multicentric, randomized control trials.

Initial inflammatory response is an independent predictor of unfavorable outcome in patients with good-grade aneurysmal subarachnoid hemorrhage.

Purpose of the present study was to determine if routine biochemical markers of acute phase response are associated with unfavorable outcome in patients with good-grade aneurysmal SAH. 231 patients admitted with aneurysmal SAH and WFNS grade I - II were included in the present study. C-reactive protein (CRP) and procalcitonin (PCT) were measured within 24 h of admission. Outcome was assessed according to the modified Rankin Scale (mRS) after 6 months and stratified into favorable (mRS 0-2) vs. unfavorable (mRS 3-6). The multivariate regression analysis revealed "elevated baseline CRP" (p = .001, OR 3.2, 95% CI 1.6-6.6), "elevated baseline PCT" (p = .004, OR 26.0, 95% CI 2.9-235.5), "male gender" (p = .02, OR 2.3, 95% CI 1.1-4.8), and "age ≥ 65 years" (p = .009, OR 2.7, 95% CI 1.3-5.8) as a model for the prediction of unfavorable outcome in patients with good-grade SAH. An initial inflammatory response could be a possible explanation for poor outcome in good-grade SAH patients. These findings might help to identify a subgroup of good grade SAH patients who are at greater risk for unfavorable outcome early during treatment course/at baseline, and who could benefit most from potential anti-inflammatory therapy.

Safety and Clinical Outcome of Good-Grade Aneurysmal Subarachnoid Hemorrhage in Non-Intensive Care Units

BackgroundWhile patients with good grade aneurysmal subarachnoid hemorrhage are routinely admitted in intensive care units, critical care capacity in low-middle income countries (LMICs) is limited. In this study, we report the outcomes of good-grade SAH (Hunt and Hess grades I & II) patients admitted in ICU and non-ICU settings at a center in the Philippines and determine if site of care is predictive of outcome. MethodsWe performed a retrospective study of all adults diagnosed with good-grade SAH in a five-year period. Patients were analyzed according to three groups based on site of care: Group A (>50% of length of stay in ICU), Group B (>50% of LOS in non-ICU), and Group C (100% of LOS in non-ICU). The primary outcome measures were in-hospital mortality and mRS score at discharge. The secondary outcome measures were complication rate and LOS. ResultsA total of 242 patients was included in the cohort, which had a mean age of 51.16 years and a female predilection (64%). The rates of in-hospital mortality and favorable functional outcome at discharge were 0.82% and 93.8%, respectively, with no difference across groups. Delayed cerebral ischemia and infection were more frequently diagnosed in ICUs (p < 0.001), while rebleeding occurred more commonly in non-ICUs (p = 0.02). The median LOS was significantly longer in patients who developed complications. ConclusionsAdmission of good-grade aneurysmal SAH patients in non-ICU settings did not adversely affect both in-hospital mortality and functional outcome at discharge. Prospective, randomized studies may lead to changes in pattern of ICU utilization which are critical for LMICs.

Safety and Clinical Outcome of Good-Grade Aneurysmal Subarachnoid Hemorrhage in Non-Intensive Care Units (2498)

Safety and Clinical Outcome of Good-Grade Aneurysmal Subarachnoid Hemorrhage in Non-Intensive Care Units (2498)

Outcomes of microsurgical clipping vs coil embolization for ruptured aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a complex neurovascular syndrome with high disability and mortality. SAH patients may be managed with surgical clipping or coil embolization. In this study, we provided a real-world analysis of the outcome and prognostic factors of aneurysmal SAH in patients treated with coil embolization or microsurgical clipping.We retrospectively analyzed the medical records of aneurysmal SAH patients (n = 583) who underwent treatment at the First Hospital and the Second Hospital of Hebei Medical University, and Tangshan Worker's Hospital in China. All patients were evaluated by a combined neurosurgery and interventional neuroradiology team. Microsurgical aneurysmal clipping was performed using the skull base approach, while coil embolization was performed with bare platinum coils (with or without balloon assistance). The primary outcome was the Glasgow Outcome Scale (GOS) score at discharge.A total of 583 patients were included in this study, of which 397 (68.1%) of them underwent clipping and 186 (31.9%) received coil embolization. The patient cohort consisted of both poor grade and good grade aneurysmal SAH: 441 (75.6%) patients had good-grade (Hunt and Hess grade II or III) and 142 (24.4%) had poor grade (Hunt and Hess grade IV or V). Overall, 123 (21%) patients had unfavorable neurologic outcome (GOS score 1–3) and 460 (78.9%) patients had favorable neurologic outcome (GOS score 4 or 5). The mean GOS score at discharge was comparable for patients who underwent clipping and those received coil embolization (P > .05). Multivariate analysis showed that clipping only [OR (95%CI): 0.03 (0.01, 0.36); P = .000] and clipping with CSF drainage [OR (95%CI): 0.41 (0.18, 0.89); P = .001] were independent factors of a favorable outcome in patients with aneurysmal SAH. Coil embolization with hematoma removal [OR (95%CI): 0.03 (0.01, 0.36); P = .000] was also an independent determinant of a favorable outcome. High baseline Fisher grades were associated with significantly increased risk of an unfavorable outcome [OR (95%CI): 2.08 (1.30, 3.33); P = .002].Our findings suggested that both coil embolization and microsurgical clipping are viable treatment options for aneurysmal SAH patients. Procedures, such as CSF drainage and hematoma removal, performed in parallel with coil embolization and chipping should be considered when treating individual patients.

Neurological, neuropsychological, and functional outcome after good grade aneurysmal subarachnoid hemorrhage.

There is a paucity of information about which impairments, cognitive or neurological, determine the functional outcome after aneurysmal subarachnoid hemorrhage (SAH). The present study aims to determine the relative contributions of each of the above impairments for determining the functional outcome after SAH. This is a prospective observational study including patients with aneurysmal SAH. Patients underwent assessment at 6 months after discharge for neurological deficits, cognitive impairment, and functional outcome using the National Institute of Health and Social Sciences (NIHSS) score, National Institute of Mental Health and Neurosciences (NIMHANS) Neuropsychology Test Battery, and Glasgow Outcome Scale - Extended (GOSE), respectively. The correlation of GOSE with NIHSS scores and neuropsychological test scores was done using Spearman's rho correlation coefficient. Fifty-six patients underwent assessment using all the three tools, i.e., NIHSS, neuropsychological tests, and GOSE. Fifty-one healthy volunteers participated in the study for neurological examination and neuropsychological assessment. At 6 months, patients with SAH had significant cognitive impairment as compared to controls. The mean NIHSS score was 10.01 ± 9.04, indicating moderately severe impairment. The median GOSE at 6 months was 6 (range: 3-8) indicating the upper level of moderate disability. There was a significant correlation of NIHSS scores with GOSE, Spearman's rho -0.653 (<0.001). There was a significant correlation of neuropsychological test scores with GOSE and NIHSS. The Spearman's rho for NIHSS vs GOSE was within range for neuropsychological scores vs GOSE. Both the neurological deficits and cognitive impairment determine functional outcome after SAH at 6 months.

Apolipoprotein E ε4: A Possible Risk Factor of Intracranial Pressure and White Matter Perfusion in Good-Grade Aneurysmal Subarachnoid Hemorrhage Patients at Early Stage.

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and complicated disease with significant morbidity and mortality. Previous studies have shown that genetic susceptibility may play an important role in the outcome of a given individual with aSAH. This study evaluates the potential association in effects of the APOE allele on the early brain injury (EBI) in light of elevated intracranial pressure (ICP) and cerebral perfusion disorders in a consecutive series of non-comatose Chinese patients with aSAH. A total of 122 patients with aSAH (54 males and 68 females) were enrolled in this study. Demographic and clinical data were collected. We measured ICP before microsurgical clipping or endovascular coiling during the first 72 h after aneurysm rupture. Computed tomography perfusion (CTP) examination in patients was performed before treatment. The distributions of APOE genotypes and alleles matched Hardy–Weinberg law (p > 0.05). In this study, 68 patients (55.7%) had a normal ICP, whereas 54 (44.3%) had an elevated ICP. Fourteen of 21 patients with APOE ε4 had an elevated ICP, which was significantly different from those without APOE ε4 (p = 0.03). The patients with the ε4 allele had a higher incidence of elevated ICP [p = 0.009, 95% confidence interval (CI) = 1.481–15.432, odds ratio = 4.780] than those without this allele. For CTP measurements, a lower mean cerebral blood flow (difference, −4.74; 95% CI, 0.53–8.94 s, p = 0.03), longer mean transit time (difference, 0.47; 95% CI, −0.87 to −0.78, p = 0.02), and time-to-peak (difference, 2.29; 95% CI, −3.64 to −0.93 s, p = 0.02) were observed in patients with ε4 allele than in those without in the internal capsule regions. In conclusion, the APOE ε4 allele predisposes patients to elevated ICP and perfusion disorders in white matter regions during the first 72 h after aSAH. The presence of an APOE ε4 allele plays an important role in the EBI response to aSAH.

Intracellular free magnesium of brain and cerebral phosphorus-containing metabolites after subarachnoid hemorrhage and hypermagnesemic treatment: a 31P–magnetic resonance spectroscopy study

Disturbance of cerebral phosphorus-containing metabolites occurs in many disease entities and has not been widely studied in patients with subarachnoid hemorrhage (SAH). Pilot studies have indicated that hypermagnesemic treatment may improve outcome in patients with aneurysmal SAH, but the precise mechanism is not known. The authors hypothesized that, by raising intracellular brain free magnesium in aneurysmal SAH, hypermagnesemic treatment would alter the cerebral energy status. The authors designed the current study to use ³¹P-MR spectroscopy (MRS) to investigate intracellular brain free magnesium and cerebral phosphorus-containing metabolites in patients with good-grade aneurysmal SAH, both those receiving and not receiving hypermagnesemic therapy. A total of 37 eligible patients and 23 healthy volunteers were recruited. A total of 81 MRS studies were performed. Hypermagnesemic treatment after aneurysmal SAH produced a small (mean difference 0.018 ± 0.007 mM [+ 13.0%]) but significant elevation of intracellular free magnesium during the 1st week. Aneurysmal SAH produced a depressed membrane metabolism with lower phosphodiester/total phosphate. The MRS finding of elevated brain free intracellular magnesium after intravenous magnesium sulfate infusion is novel, and the changes in membrane metabolism provide insight into the metabolic effects of aneurysmal SAH and future pathophysiological studies.

The efficacy of an abbreviated course of nimodipine in patients with good-grade aneurysmal subarachnoid hemorrhage.

Nimodipine therapy has become a standard component of the treatment regimen used in patients with aneurysmal subarachnoid hemorrhage (SAH). Its prescribed use at 60 mg every 4 hours for 21 days is based on reputable, randomized prospective studies. However, because only 20 to 30% of patients with SAH suffer clinical cerebral vasospasm, it is clear that most patients do not actually need the drug. Of course, this fact is not evident until several treatment days have passed. It is common practice, without well-documented consequences, to terminate nimodipine therapy before 21 days in certain clinical circumstances. The aim of this study was to evaluate the effectiveness of abbreviating the duration of nimodipine treatment in the setting of a good-grade aneurysmal SAH. A retrospective clinical review was made of 90 consecutive patients who experienced a Hunt and Hess Grade I through III aneurysmal SAH and were treated with nimodipine for 15 days or less. None of the patients studied suffered a delayed neurological deficit as a result of the abbreviated course of nimodipine.