High-grade Aneurysmal Subarachnoid Hemorrhage Research Articles

A High-grade Aneurysmal Subarachnoid Hemorrhage in the Peripartum Period

Abstract Aneurysmal subarachnoid hemorrhage (aSAH) is a rare but devastating complication with increased morbidity and mortality. It is still unclear whether the incidence is increased during pregnancy and in the peripartum period. However, the incidence of cerebral aneurysmal rupture is higher during the third trimester than in the first trimester. The risk of aneurysmal rupture and subarachnoid hemorrhage (SAH) during general anesthesia or spinal anesthesia is unclear. We report a case of left supraclinoid aneurysm rupture after spinal anesthesia for Low Segment Caesarean Section (LSCS) in the immediate postpartum period causing high-grade aSAH.

Explainable machine learning in outcome prediction of high-grade aneurysmal subarachnoid hemorrhage.

Accurate prognostic prediction in patients with high-grade aneruysmal subarachnoid hemorrhage (aSAH) is essential for personalized treatment. In this study, we developed an interpretable prognostic machine learning model for high-grade aSAH patients using SHapley Additive exPlanations (SHAP). A prospective registry cohort of high-grade aSAH patients was collected in one single-center hospital. The endpoint in our study is a 12-month follow-up outcome. The dataset was divided into training and validation sets in a 7:3 ratio. Machine learning algorithms, including Logistic regression model (LR), support vector machine (SVM), random forest (RF), and extreme gradient boosting (XGBoost), were employed to develop a prognostic prediction model for high-grade aSAH. The optimal model was selected for SHAP analysis. Among the 421 patients, 204 (48.5%) exhibited poor prognosis. The RF model demonstrated superior performance compared to LR (AUC = 0.850, 95% CI: 0.783-0.918), SVM (AUC = 0.862, 95% CI: 0.799-0.926), and XGBoost (AUC = 0.850, 95% CI: 0.783-0.917) with an AUC of 0.867 (95% CI: 0.806-0 .929). Primary prognostic features identified through SHAP analysis included higher World Federation of Neurosurgical Societies (WFNS) grade, higher modified Fisher score (mFS) and advanced age, were found to be associated with 12-month unfavorable outcome, while the treatment of coiling embolization for aSAH drove the prediction towards favorable prognosis. Additionally, the SHAP force plot visualized individual prognosis predictions. This study demonstrated the potential of machine learning techniques in prognostic prediction for high-grade aSAH patients. The features identified through SHAP analysis enhance model interpretability and provide guidance for clinical decision-making.

Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States

Background and objectiveAlthough high-grade (Hunt and Hess 4 and 5) aneurysmal subarachnoid hemorrhage (aSAH) typically portends a poor prognosis, early and aggressive treatment has previously been demonstrated to confer a...

A correlation and prediction study of the poor prognosis of high-grade aneurysmal subarachnoid hemorrhage from the neutrophil percentage to albumin ratio

ObjectiveInflammatory response and nutritional status play crucial roles in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study mainly investigated the correlation between neutrophil percentage to albumin ratio (NPAR) and clinical prognosis in aSAH patients with high-grade Hunt-Hess and its predictive model. MethodsA retrospective analysis was conducted based on 806 patients with aneurysmal subarachnoid hemorrhage who were admitted to the studied hospital from January 2017 to December 2021. Modified Fisher grade and Hunt-Hess grade were obtained according to their status at admission and hematological parameters within 48 h after hemorrhage. Univariate and multivariate logistic regression analysis were conducted to evaluate the relationship between NPAR and the clinical prognosis of patients with aSAH. And propensity matching analysis of patients with aSAH in the severe group. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value of NPAR at admission to predict prognosis and its sensitivity and specificity. The nomogram diagram and Calibration curve were further used to examine the prediction model. ResultsAccording to the mRS score at discharge, 184 (22.83 %) cases were classified as having poor outcomes (mRS > 2). Through multivariate logistic regression analysis, it was found that the Modified Fisher grade at admission, Hunt-Hess grade, eosinophils, neutrophil to lymphocyte ratio (NLR), and NPAR were independent risk factors for poor outcome in patients with aSAH (p < 0.05). The NPAR of aSAH patients with poor outcomes in the high-grade group was significantly higher than that in the low-grade group. The optimal cut-off value for NPAR was 21.90, the area under the ROC curve was 0.780 (95 % CI 0.700 – 0.861, p < 0.001). The Calibration curves show that the predicted probability of the drawn nomogram is overall consistent with the actual probability. (Mean absolute error = 0.031) ConclusionThe NPAR value of patients with aSAH at admission is significantly correlated with Hunt-Hess grade in a positive manner, namely, the higher the Hunt-Hess grade, the higher the NPAR value, and the worse the prognosis. Findings indicate that early NPAR value can be used as a feasible biomarker to predict the clinical prognosis of patients with aSAH.

Appropriate treatment within 13 hours after onset may improve outcome in patients with high-grade aneurysmal subarachnoid hemorrhage

ObjectiveThis retrospective study evaluated whether earlier timing of appropriate treatment of high-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as management of ruptured intracranial aneurysm (RIA) combined with required additional surgical measures for control of increased intracranial pressure (ICP), is associated with more favorable outcomes. MethodsThe study cohort comprised 253 patients with high-grade aSAH. Modified Rankin Scale score of 0–3 at 3-month follow-up after the ictus was considered as favorable outcome. ResultsAppropriate treatment of aSAH was completed in 205 patients (81 %), and included clipping or coiling of RIA without (64 cases) and with (141 cases) additional surgical measures for control of increased ICP (evacuation of intracranial hematoma, decompressive craniotomy, and/or cerebrospinal fluid drainage). Favorable outcome was noted significantly more often if appropriate treatment was completed within 13 h after aSAH than between 13 and 72 h (37 % vs. 17 %; adjusted P = 0.0475), which was confirmed by evaluation in the multivariate model along with other prognostic factors. Subgroup analysis revealed that completion of the appropriate treatment within 13 h was associated with more favorable outcome in those patients, who underwent management of RIA in combination with additional surgical measures for control of increased ICP (P = 0.0023), and in those, who felt into poor outcome predicting group (P = 0.0046). ConclusionsAppropriate treatment of high-grade aSAH with management of RIA in combination with required additional surgical measures for control of increased ICP, may be associated with more favorable outcomes if completed within 13 h after the ictus.

Persistent Primitive Olfactory Artery Aneurysm

A middle-aged patient presented to the hospital as a high-grade aneurysmal subarachnoid hemorrhage. The patient was treated with endovascular coil embolization of the ruptured basilar tip aneurysm. Angiography also demonstrated multiple other aneurysms including Type I persistent primitive olfactory artery (PPOA) aneurysm. After complete recovery and return to independence the patient underwent elective treatment of the PPOA aneurysm with endovascular placement of a flow diversion stent. Persistent primitive olfactory artery is an extremely rare variant of the anterior cerebral artery with an incidence of 0.14% and a known increased risk of aneurysm formation.

Ultra-early endovascular treatment improves prognosis in High grade aneurysmal subarachnoid hemorrhage: A single-center retrospective study.

BackgroundThe long-term survival prognosis of patients with high-grade (Hunt-Hess grade IV–V or World Federation of Neurosurgical Societies grade IV–V) aneurysmal subarachnoid hemorrhage (aSAH) is generally poor, and the association between endovascular treatment timing and the prognosis of high-grade aSAH has not been explored in depth. This retrospective cohort study aimed to determine whether endovascular treatment within 24 h of high-grade aSAH is associated with a better prognosis.MethodsWe retrospectively analyzed the clinical data of patients with high-grade aSAH who were admitted to our institution between January 2018 and January 2021. The Modified Rankin Scale score was used to assess the 6-month prognosis of patients. Univariate and multivariate logistic regression analyses were used to identify the factors associated with prognosis. The area under the receiver operating characteristic (ROC) curve was used to assess the model's discriminatory ability.ResultsEighty-six patients were included in the study. In the multivariate analysis, the timing of endovascular treatment (odds ratio = 7.003 [1.800–27.242], P = 0.005) was an independent risk factor for prognosis. The ROC curve showed that the predictive power of the timing of endovascular treatment was 0.744, the best cut-off value was 12.5 h, and the corresponding sensitivity and specificity were 71.4 and 70.5%, respectively. Hydrocephalus (P = 0.005) and pulmonary infection (P = 0.029) were also associated with prognosis. In addition, cerebrospinal fluid drainage immediately after endovascular treatment had a significant effect on reducing hydrocephalus formation.ConclusionsEndovascular therapy within 24 h is feasible and improves the prognosis of patients with high-grade aSAH.

NT-proBNP and troponin I in high-grade aneurysmal subarachnoid hemorrhage: Relation to clinical course and outcome

PurposeTo investigate the association between two cardiac biomarkers, NT-proBNP and TnI, with intracranial pressure (ICP)−/cerebral perfusion pressure (CPP)-insults, cerebral pressure autoregulation, delayed ischemic neurological deficits (DIND), and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). MethodsIn this retrospective study, 196 aSAH patients treated at the neurointensive care unit, Uppsala University Hospital, Sweden, 2011–2018, with ICP-monitoring and serial NT-proBNP and TnI measurements were included. The first 10 days were divided into early phase (day 1–3) and vasospasm phase (day 4–10). ResultsNT-proBNP and TnI were elevated above the reference interval at least once the first 10 days in 175 (89%) and 116 (59%) patients, respectively. In the vasospasm phase, higher NT-proBNP and TnI were associated with increased percentage of CPP below 60 mmHg. Higher TnI also correlated with more ICP-insults above 20 mmHg. NT-proBNP and TnI did not predict worse pressure autoregulation and DIND. Higher NT-proBNP and TnI were associated with mortality and unfavorable outcome in univariate, but not multivariate, analyses. ConclusionElevated NT-proBNP and TnI correlated with an increased burden of secondary ICP-/CPP-insults, but not with worse pressure autoregulation, DIND, and without independent association with clinical outcome.

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

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

Outcomes of high-grade aneurysmal subarachnoid hemorrhage patients treated with coiling and ventricular intracranial pressure monitoring.

BACKGROUNDHigh-grade aneurysmal subarachnoid hemorrhage is a devastating disease with a low favorable outcome. Elevated intracranial pressure is a substantial feature of high-grade aneurysmal subarachnoid hemorrhage that can result to secondary brain injury. Early control of intracranial pressure including decompressive craniectomy and external ventricular drainage had been reported to be associated with improved outcomes. But in recent years, little is known whether external ventricular drainage and intracranial pressure monitoring after coiling could improve outcomes in high-grade aneurysmal subarachnoid hemorrhage.AIMTo investigate the outcomes of high-grade aneurysmal subarachnoid hemorrhage patients with coiling and ventricular intracranial pressure monitoring.METHODSA retrospective analysis of a consecutive series of high-grade patients treated between Jan 2016 and Jun 2017 was performed. In our center, followed by continuous intracranial pressure monitoring, the use of ventricular pressure probe for endovascular coiling and invasive intracranial pressure monitoring in the acute phase is considered to be the first choice for the treatment of high-grade patients. We retrospectively analyzed patient characteristics, radiological features, intracranial pressure monitoring parameters, complications, mortality and outcome.RESULTSA total of 36 patients were included, and 32 (88.89%) survived. The overall mortality rate was 11.11%. No patient suffered from aneurysm re-rupture. The intracranial pressure in 33 patients (91.67%) was maintained within the normal range by ventricular drainage during the treatment. A favorable outcome was achieved in 18 patients (50%) with 6 mo follow-up. Delayed cerebral ischemia and Glasgow coma scale were considered as significant predictors of outcome (2.066 and -0.296, respectively, P < 0.05). CONCLUSIONVentricular intracranial pressure monitoring may effectively maintain the intracranial pressure within the normal range. Despite the small number of cases in the current work, high-grade patients may benefit from a combination therapy of early coiling and subsequent ventricular intracranial pressure monitoring.

Targeted temperature management at 33 degrees Celsius in patients with high-grade aneurysmal subarachnoid hemorrhage: a protocol for a multicenter randomized controlled study.

Studies on the use of therapeutic hypothermia (TH) to improve the outcome of high-grade aneurysmal subarachnoid hemorrhage (aSAH), show promising, though conflicting results because of the lack of high-quality trials. The aim of this study is to evaluate the safety and efficacy of TH (maintaining bladder temperature at 33 °C for ≥72 h) to treat patients with high-grade aSAH (Hunt-Hess grade IV-V). A multicenter, randomized, controlled clinical trial will be conducted for October 2020 to September 2024 involving 10 clinics. Patients who meet the inclusion criteria will be randomized 1:1 to a TH group and a normothermia group. The trial will enroll 96 participants in TH group and normothermia one, respectively. The trial was registered with ClinicalTrials.gov (NCT03442608) on February 22, 2018. Following conventional treatment for aSAH, patients will undergo either TH for at least 72 h or normothermia. The primary endpoint is the Glasgow outcome scale at 6 months after bleeding. The secondary endpoints are: (I) mortality at 6 months after bleeding; (II) intracranial pressure; (III) intensive care unit stay; and (IV) hospital stay. The safety endpoints include neurological, infectious, intestinal, circulatory, coagulation, and bleeding complications, electrolyte disorders, and other complications. If the study hypothesis is confirmed, TH at 33 °C in patients with high-grade aSAH may become a promising treatment strategy for improving 6-month outcome. The trial has been registered at ClinicalTrials.gov (ID: NCT03442608).

Optimal timing and safety of the external ventricular drainage in patients with high-grade aneurysmal subarachnoid hemorrhage treated with endovascular coiling

The presented retrospective analysis has evaluated the optimal timing and safety of external ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). The study cohort comprised 102 patients, 49 of whom underwent EVD at 3–120 h (mean, 16 h) after the clinical onset of aSAH, either before (N = 27) or after (N = 22) ruptured aneurysm coiling. Among those treated with EVD, favorable and fair outcomes at discharge (modified Rankin Scale [mRS] scores 0–3) were noted in 14 (29%) and unfavorable (mRS scores 4–6) in 35 (71%). The former was more common among women (P = 0.019) and patients without chronic arterial hypertension (P = 0.028). The cut-off value for optimal timing of EVD was defined at 13 h after the onset of aSAH. Favorable and fair outcomes were more frequent after early (≤13 h; N = 30) than late (>13 h; N = 19) EVD (40% vs. 11%; P = 0.026), whereas did not differ significantly between those in whom such procedure was done before or after ruptured aneurysm coiling (19% vs. 41%; P = 0.083). In the entire study cohort, 2 patients had re-rupture of the aneurysm, and while both of them were treated with EVD, neither case of complication was directly associated with the procedure and, in fact, preceded it. In conclusion, EVD for management of acute hydrocephalus in patients with high-grade aSAH should be preferably applied within 13 h after the clinical onset of stroke, which may be considered sufficiently safe regardless whether it is performed before or after ruptured aneurysm coiling.

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

BackgroundHigh intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome.MethodsIn this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008–2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP–CPPopt) < − 10 mm Hg (%).ResultsOf the 242 patients, 63 (26%) had favorable (GOS-E 5–8) and 179 (74%) had unfavorable (GOS-E 1–4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5–10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups.ConclusionsAvoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.

Intraventricular Hematoma Removal with Combined Drainage Techniques in Patients with High-Grade Subarachnoid Hemorrhage: A Surgical Technique.

To describe a surgical technique for removal of hematomas in the third ventricle in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH) and report our intraoperative observations and surgical and clinical outcomes. Ninety-four patients with high-grade aneurysmal subarachnoid hemorrhagic were included in the study. Prior to Sylvian dissection, a ventricular catheter was inserted as soon as possible. After surgical corridor opening and aneurysm clipping, the lamina terminalis (LT) was fenestrated. The free flow of isotonic solution from the back-side open syringe to the distal end of the catheter inside the third ventricle was allowed under gravitational force. The blood clot trapped in the third ventricle was removed through the aperture of the LT by propulsion of blood through the anterior movement of the solution. The procedure was continued until the clearance of solution was observed. The study population consisted of two groups, the combined surgical technique group and the control group, which included patients who underwent operation before the planned study, with 47 patients in each group. The Glasgow Coma, Hunt and Hess, and Fisher scales were used to determine the clinical and radiological severities of the cases. The Modified Rankin Scale was used to evaluate the surgical outcomes at presentation and the 6 < sup > th < /sup > and 12 < sup > th < /sup > postoperative months. Our reported surgical technique, which combines ventricular drainage and opening of the LT, will be useful for removing blood clots and blood breakdown products, and recirculating cerebrospinal fluid as much and as soon as possible in high-grade SAH patients with ventricular hemorrhage. Although combining these two well-known procedures as a novel technique does not have any reducing effect on mortality, it may have a significant reducing effect on hydrocephalus and shunt dependency.

Initial pupil status is a strong predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage

Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Anonymized data of 477 aSAH patients admitted to our medical center from November 2010 to August 2018 were retrospectively analyzed. Identification of variables independently predicting in-hospital mortality was performed by multivariable logistic regression analysis. Final regression models included Hunt & Hess scale (H&H), pupil status and age or in a simplified variation only H&H and pupil status, leading to the design of novel H&H-Pupil-Age score (HHPA) and simplified H&H-Pupil score (sHHP), respectively. In an external validation cohort of 402 patients, areas under the receiver operating characteristic curves (AUROC) of HHPA (0.841) and sHHP (0.821) were significantly higher than areas of H&H (0.794; p < 0.001) or World Federation of Neurosurgical Societies (WFNS) scale (0.775; p < 0.01). Accordingly, including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. HHPA and sHHP allow simple, early and detailed prognosis assessment while predictive performance remained strong in an external validation cohort suggesting adequate generalizability and low interrater variability.

High-Grade Aneurysmal Subarachnoid Hemorrhage: Predictors of Functional Outcome

Because the prognosis of high-grade aneurysmal subarachnoid hemorrhage (aSAH), classified as World Federation of Neurosurgical Societies (WFNS) grade IV-V, is generally poor, the functional outcomes of survivors have not been thoroughly explored. The aim of this retrospective cohort study is to determine predictors of functional independence in patients who survive a high-grade aSAH. We retrospectively evaluated consecutive patients with aSAH admitted to a single institution from January 2000 to April 2015. Adult (age ≥18 years) patients with WFNS grade IV-V aSAH were included for analysis. Patients without sufficient baseline data, those who died before discharge, and those without follow-up data were excluded. Univariable and multivariable logistic regression analyses were used to identify factors associated with functional independence, defined as a modified Rankin Scale score of 0-2, at last follow-up. Of the 260 patients with a WFNS grade IV-V aSAH during the study period, 139 met the inclusion criteria. After a mean follow-up of 6.3 months, functional independence was achieved in 73% of high-grade aSAH survivors (101/139 patients) and in 39% of all high-grade aSAH cases (101/260 patients). Only a lack of cerebrospinal fluid shunt placement was found to be an independent predictor of functional independence in the multivariable analysis (odds ratio 0.28 [0.109-0.722]; P= 0.008). Because functional independence can be achieved in the majority of high-grade aSAH survivors, aggressive initial management of high-grade aSAH is warranted. Strategies that reduce the need for permanent cerebrospinal fluid diversion may improve functional outcomes in survivors of high-grade aSAH.

Association between Early Hyperoxia and Neurologic Outcome in Patient with High Grade Aneurysmal Subarachnoid Hemorrhage

Background: Oxygenation support is a common practice in patients with aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to analyze the association between early hyperoxia and the neurological outcome in patients presenting a High Grade SAH, using the modified Rankin Scale (mRS) at 6 months. Methods: We retrospectively analyzed data of SAH in a single center, retrospective, observational study. The inclusion criteria were patients’ ≥ 18 years-old, under mechanical ventilation upon admission to the intensive care unit (ICU) and presenting an aneurysmal SAH with a WFNS score ≥3. Hyperoxia was defined as PaO2 > 120 mmHg and classified into 3 subgroups: mild (121-200 mmHg), moderate (201-300 mmHg) and severe (> 300 mmHg). Patients with a 6 months-mRS >3 were considered as having a poor outcome. Results: One hundred and thirty-nine patients with aneurysmal SAH were included. 82% of patients were exposed to hyperoxia with predominance of mild hyperoxia (42.8%). A higher yet non-statistical, poor neurologic outcome was identified in the hyperoxic compared to normoxic group (72% vs. 87.7% OR 2.8 [1.02-7.71], p 0.12). Following a multivariate analysis, a statistical trend was identified between the hyperoxic group and a 6-month poor neurological outcome (OR 2.84, 95% CI, 0.99-8.19; p=0.052), but no statistical association was found with delayed cerebral ischemia (OR 1.68, 95% CI, 0.5-5.71, p=0.39) nor with 28-day mortality (OR 2.17, 95% CI, 0.82-5.75, p=0.11). Conclusions: Our findings suggest a statistical trend between early hyperoxia and a poor neurological outcome at 6 months, in patients with a high grade aneurysmal SAH admitted to the ICU. Further, large-scale studies are required to fully evaluate the effects of hyperoxia.

Somatosensory evoked potentials in patients with high-grade aneurysmal subarachnoid hemorrhage.

OBJECTIVE The aim of this prospective study was to investigate the value of somatosensory evoked potentials (SEPs) in predicting outcome in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH). METHODS Between January 2013 and January 2015, 48 patients with high-grade SAH (Hunt and Hess Grade III, IV, or V) who were admitted within 3 days after hemorrhage were enrolled in the study. Right and left median and tibial nerve SEPs were recorded on Day 3 after hemorrhage and recorded again 2 weeks later. Glasgow Outcome Scale (GOS) scores were determined 6 months after hemorrhage and dichotomized as poor (Scores 1-3) or good (Scores 4-5). Results of SEP measurements were dichotomized (present or missing cortical responses or normal or prolonged latencies) for each nerve and side. These variables were summed and tested using logistic regression and a receiver operating characteristic curve to assess the value of SEPs in predicting long-term outcome. RESULTS At the 6-month follow-up visit, 29 (60.4%) patients had a good outcome, and 19 (39.6%) had a poor outcome. The first SEP measurement did not correlate with clinical outcome (area under the curve [AUC] 0.69, p = 0.52). At the second measurement of median nerve SEPs, all patients with a good outcome had cortical responses present bilaterally, and none of them had bilateral prolonged latencies (p = 0.014 and 0.003, respectively). In tibial nerve SEPs, 7.7% of the patients with a good GOS score had one or more missing cortical responses, and bilateral prolonged latencies were found in 23% (p = 0.001 and 0.034, respectively). The second measurement correlated with the outcome regarding each of the median and tibial nerve SEPs and the combination of both (AUC 0.75 [p = 0.010], 0.793 [p = 0.003], and 0.81 [p = 0.001], respectively). CONCLUSIONS Early SEP measurement after SAH did not correlate with clinical outcome, but measurement of median and tibial nerve SEPs 2 weeks after a hemorrhage did predict long-term outcome in patients with high-grade SAH.

Increased mortality of patients with aneurysmatic subarachnoid hemorrhage caused by prolonged transport time to a high-volume neurosurgical unit

BackgroundTime has shown to be a relevant factor in the prognosis for a multitude of clinical conditions. The current analysis aimed to establish whether delayed admission to specialized care is a risk factor for increased mortality in case of high-grade aneurysmal subarachnoid hemorrhage. Material and methodsConsecutive patients with aneurysmal subarachnoid hemorrhage were enrolled retrospectively if they had a World Federation of Neurological Surgeons Grading System grade of 5. Predictor variables for in-hospital mortality reflecting demographic, spatial, temporal treatment, and neurological factors were recorded from hospital medical records and emergency physicians' reports. We performed statistical analysis on the influence between the predictor variables and in-hospital mortality. ResultsThe study included 61 patients with an average age of 58 years. The overall in-hospital mortality rate was 28% (17/61 patients). A delayed transport to specialized neurosurgical care was associated with increased in-hospital mortality. Transportation time was mainly prolonged in cases where an alternative diagnosis was made by the emergency physician. Mortality was highest in patients with cardiovascular complications of subarachnoid hemorrhage. ConclusionDelayed admission to specialized care is associated with a higher mortality rate in patients with high-grade aneurysmal subarachnoid hemorrhage. Accompanying non-neurosurgical, mainly cardiac complications might be a significant factor leading to delayed admission. The emergency physician should be aware that cardiovascular abnormalities are a relevant complication and sometimes the first identified clinical feature of high-grade subarachnoid hemorrhage.

Default Mode Network Perfusion in Aneurysmal Subarachnoid Hemorrhage.

The etiology of altered consciousness in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH) is not thoroughly understood. We hypothesized that decreased cerebral blood flow (CBF) in brain regions critical to consciousness may contribute. We retrospectively evaluated arterial-spin labeled (ASL) perfusion magnetic resonance imaging (MRI) measurements of CBF in 12 patients with aneurysmal SAH admitted to our neurocritical care unit. CBF values were analyzed within gray matter nodes of the default mode network (DMN), whose functional integrity has been shown to be necessary for consciousness. DMN nodes studied were the bilateral medial prefrontal cortices, thalami, and posterior cingulate cortices. Correlations between nodal CBF and admission Glasgow Coma Scale (GCS) score, admission Hunt and Hess (HH) class, and GCS score at the time of MRI (MRI GCS) were tested. Spearman's correlation coefficients were not significant when comparing admission GCS, admission HH, and MRI GCS versus nodal CBF (p>0.05). However, inter-rater reliability for nodal CBF was high (r=0.71, p=0.01). In this retrospective pilot study, we did not identify significant correlations between CBF and admission GCS, admission HH class, or MRI GCS for any DMN node. Potential explanations for these findings include small sample size, ASL data acquisition at variable times after SAH onset, and CBF analysis in DMN nodes that may not reflect the functional integrity of the entire network. High inter-rater reliability suggests ASL measurements of CBF within DMN nodes are reproducible. Larger prospective studies are needed to elucidate whether decreased cerebral perfusion contributes to altered consciousness in SAH.