High-grade Subarachnoid Hemorrhage Research Articles

Defining survivorship after high-grade aneurysmal subarachnoid hemorrhage

Background Outcome after high-grade aneurysmal SAH is poor. Various treatment paradigms have been advanced to improve treatment outcome and preserve resources, but none have addressed the potential salvageable life lost. Methods We retrospectively reviewed all patients with high-grade (H&H score, 4-5) aneurysmal SAH admitted to our institution from January 1998 to June 2002, all aggressively managed, to determine what clinical/radiographic criteria predicted favorable survival. Results There were 50 patients analyzed. All underwent emergency ventriculostomies or clot evacuations. Twenty-three patients (46%) improved and 7 (14%) worsened; 41 survived to receive definitive therapy. Twenty-one patients (42%) overall achieved a favorable outcome (GOS, 4-5). In the multivariate analysis (stepwise logistic regression), the postresuscitation GCSm alone predicted outcome ( P = .004) with 70% cases correctly identified, whereas age, location of aneurysm (anterior circulation or not), presence of intraventricular hemorrhage, time to definitive intervention, clot on computerized tomography, type of therapy used (coil vs clip), pupillary abnormalities, and preresuscitation GCSm did not. Because the sole predictive parameter is obtained postresuscitation, no clinical or radiographic factor on presentation appears valid to determine eligibility for definitive care. Conclusion Overall treatment outcome of our series is comparable with those of other articles. Our experience, as well as review of literature, does not support the existence of a validated “triage” schema to selectively treat patients with high-grade subarachnoid hemorrhage, implying that all such patients should be managed aggressively.

Predictors of Left Ventricular Regional Wall Motion Abnormalities After Subarachnoid Hemorrhage

Cardiac abnormalities that have been reported after subarachnoid hemorrhage (SAH) include the release of cardiac biomarkers, electrocardiographic changes, and left ventricular (LV) systolic dysfunction. The mechanisms of cardiac dysfunction after SAH remain controversial. The aim of this study was to determine the prevalence of LV regional wall motion abnormalities (RWMA) after SAH and to quantify the independent effects of specific demographic and clinical variables in predicting the development of RWMA. Three hundred patients hospitalized with SAH were prospectively studied with serial echocardiography. The primary outcome measure was the presence of RWMA. The predictor variables included the admission Hunt & Hess grade, age, gender, cardiac risk factors, aneurysm location, plasma catecholamine levels, cardiac troponin I (cTi) level, heart rate (HR), blood pressure, and phenylephrine dose. Univariate and multivariate logistic regression was performed with adjustment for serial measurements, reporting odds ratios (OR) and 95% confidence intervals (CI). In this study, 817 echocardiograms were analysed. RWMA were detected in 18% of those studied. The prevalence of RWMA in patients with Hunt & Hess grades 3 - 5 was 35%. Among patients with a peak cTi level greater than 1.0 m g/L, 65% had RWMA. Multivariate analysis demonstrated that high Hunt & Hess grade (OR 4.22 for grade 3 - 5 versus grade 1 - 2, p = 0.046), a cTi level greater than 1.0 microg/L (OR 10.47, p = 0.001), a history of prior cocaine or amphetamine use (OR 5.50, p = 0.037), and higher HR (OR 1.34 per 10 bpm increase, p = 0.024) were predictive of RWMA. RWMA were frequent after SAH. High-grade SAH, an elevation in cTi levels, a history of prior stimulant drug use, and tachycardia are independent predictors of RWMA.

Bedside microdialysis reflects dysfunction of cerebral energy metabolism in patients with aneurysmal subarachnoid hemorrhage as confirmed by 15O-H 2O-PET and 18F-FDG-PET

To compare microdialysis (MD) and positron emission tomography (PET) in the detection of ischemia in aneurysmal subarachnoid hemorrhage (SAH) patients. 15 SAH patients (13F/2M, 48+/-13 years, WFNS Grade I-V) were prospectively included in the study. A MD-catheter was inserted into the brain parenchyma most likely to be affected by vasospasm directly after aneurysm clipping. Glucose, pyruvate, lactate, glutamate and glycerol were analyzed hourly (CMA 600). 15O-H2O-PET scans (n=10) and 18F-FDG-PET scans (n=13) were performed between the day 2 and 17 after SAH. 15O-H2O-PET data were merged with CT scans to provide quantification of rCBF within the MD-ROI (rCBFMD; Amira, ZIB Berlin, Germany). 18F-FDG-PET data were evaluated visually by visual analysis. Regions of glucose hypometabolism were observed in 10 patients with symptoms of ischemia. Their rCBF was lower compared to asymptomatic patients (p<0.05). The MD levels of glutamate, lactate, the L/P ratio and glycerol were significantly higher in symptomatic than asymptomatic patients (p<0.05). Out of all measured MD parameters, glutamate showed the closest correlation with rCBF (r=-0.66, p=0.014). Microdialysis parameters were well correlated with glucose hypometabolism (18F-FDG-PET) and symptoms of ischemia. However, the threshold for a metabolic derangement was above the limits of cerebral ischemia defined by PET. MD is a useful tool to monitor ischemia, especially in patients with high-grade SAH.

Endovascular Treatment of Intracranial Aneurysms in the Elderly: Single-Center Experience in 63 Consecutive Patients

With a globally aging population, it is imperative to develop specific treatment strategies for intracranial aneurysms in the elderly. However, the optimal management of intracranial aneurysms in the elderly remains controversial, particularly for the unruptured aneurysms. Although endovascular treatment is increasingly being used for the management of aneurysms, large endovascular series in the elderly population are relatively lacking, especially with regard to the unruptured aneurysms. We present our single-center endovascular experience in treating intracranial aneurysms in 63 consecutive patients 70 years of age and older. Between November 1998 and December 2003, among a total of 990 patients with intracranial aneurysms treated endovascularly at our center, 63 patients (6%) were 70 years of age or older. Forty-one patients presented with subarachnoid hemorrhage (SAH), and 22 presented with symptomatic unruptured aneurysms. A total of 84 aneurysms were detected in these 63 patients. Only those responsible for either the subarachnoid hemorrhage or clinical symptoms (68 aneurysms) were treated. The aneurysm characteristics, endovascular procedures and techniques, angiographic and clinical outcomes, and complications were reviewed. Selective embolization failed in three aneurysms (4%). In the remaining 65 aneurysms, complete occlusion was achieved in 33 aneurysms (51%), neck remnant was observed in 17 aneurysms (27%), and residual aneurysmal filling was observed in six aneurysms (9%). Parent vessel occlusion was used in the treatment of nine aneurysms (13%). Thirteen procedure-related complications occurred (19%), six of which resulted in clinical complications (9%). Nine deaths (14%) occurred; three (5%) were directly related to the endovascular procedures, and six (9%) were related to the medical complications of SAH. The remaining 54 patients had a mean clinical follow-up time of 13 months (range, 1-47 mo). Ninety-one percent (20 out of 22) of the patients with unruptured aneurysms and 89% (25/28) of the patients with low-grade (Hunt and Hess Grade I and II) ruptured aneurysms achieved excellent outcomes (modified Rankin Scale score, 0-1), whereas 77% (10 out of 13) of the patients with high-grade (Hunt and Hess Grade > or = III) ruptured aneurysms either died or had very poor outcomes (modified Rankin Scale score, 4-5). Angiographic follow-up (mean, 11 mo; range, 3-38 mo) was obtained in 34 of the 54 living patients (63%). Two aneurysms demonstrated minor changes that required no further treatment (5%). Five aneurysms showed major recurrences (17%), all of which were successfully retreated endovascularly. The elderly patients should merit strong consideration for endovascular treatment of both ruptured and symptomatic unruptured intracranial aneurysms. However, in elderly patients with high-grade subarachnoid hemorrhage, morbidity and mortality rates remain high.

Contralateral subdural effusion after aneurysm surgery and decompressive craniectomy: case report and review of the literature

We report a complication of decompressive craniectomy in the treatment of aneurismal subarachnoid hemorrhage (SAH) and accompanying middle cerebral artery (MCA) infarction. A 56-year-old man presented with subarachnoid hemorrhage and right sylvian hematoma. He was diagnosed with high-grade SAH and medical therapy was employed. He showed rapid clinical deterioration on day 9 of his admission. Computed tomographic scans showed right MCA infarction and prominent midline shift. Because of the patient's rapidly worsening condition, further evaluation to find origin of SAH could not be obtained, and decompressive right hemicraniectomy was performed. During sylvian dissection, right middle cerebral and posterior communicant artery aneurysms were detected and clipped. One week after operation, a contralateral frontoparietal subdural effusion and left to right midline shift was detected and drained through a burr-hole. Through successive percutaneous aspirations, effusion recurred and complete resolution was achieved after cranioplasty and subduroperitoneal shunt procedures. Decompressive craniectomy is generally accepted as a technically simple operation with a low incidence of complications. In the light of this current case, we hypothesize that a large craniectomy may facilitate the accumulation of recurrent effusion on contralateral side creating a resistance gradient between two hemispheres. This point may be especially true for subarachnoid hemorrhage cases requiring aneurysm surgery. We conclusively suggest that subdural effusions may be resistant to simple drainage techniques if a large contralateral craniectomy does exist, and early cranioplasty may be required for treatment in addition to drainage procedures.

Use of Intraventricular Tissue Plasminogen Activator and Guglielmi Detachable Coiling for the Acute Treatment of Casted Ventricles from Cerebral Aneurysm Hemorrhage: Two Technical Case Reports

OBJECTIVE AND IMPORTANCE We report two cases of massive intraventricular hemorrhage resulting from subarachnoid hemorrhage. Both patients had experienced a ruptured cerebral aneurysm and were initially moribund. The patients were treated with Guglielmi detachable coiling and then administration of intraventricular tissue plasminogen activator (tPA). Rapid clot resolution was demonstrated radiographically in both. Both patients survived and had a meaningful functional neurological recovery. These are the first reported cases of the acute use of intraventricular tPA after Guglielmi detachable coiling treatment for ruptured cerebral aneurysm. CLINICAL PRESENTATION A 59-year-old woman and a 44-year-old man presented with high-grade subarachnoid hemorrhage. Both had had extensive casting of their ventricular systems with blood. INTERVENTION The patients were treated with Guglielmi detachable coiling thrombosis of the aneurysm and then intraventricular administration of tPA for dissolution of blood clots. Both patients survived; one is able to carry out activities of daily living with moderate assistance, and the other is able to communicate with his family. CONCLUSION This is a novel method to manage patients with high-grade aneurysms with massive intraventricular blood clots. The tPA reduced the mass effect of the blood clot, possibly helping to improve the neurological grade; in addition, the administration of tPA helped keep the external ventricular drains functional, enabling treatment of the acute hydrocephalus. The safety of administering tPA after endovascular thrombosis was demonstrated in these two patients. Further investigation is required to determine the applicability of this approach on a broader scale.

Abstracts of Literature

Abstracts of Literature

Toward More Rational Prediction of Outcome in Patients with High-grade Subarachnoid Hemorrhage

Accurate outcome prediction after high-grade subarachnoid hemorrhage remains imprecise. Several clinical grading scales are in common use, but the timing of grading and changes in grade after admission have not been carefully evaluated. We hypothesized that these latter factors could have a significant impact on outcome prediction. Fifty-six consecutive patients with altered mental status after subarachnoid hemorrhage, who were managed at a single institution, were studied retrospectively. On the basis of prospectively assessed elements of the clinical examination, each patient was graded at admission, at best before treatment, at worst before treatment, immediately before treatment, and at best within 24 hours after treatment of the aneurysm using the Glasgow Coma Scale (GCS), the World Federation of Neurological Surgeons (WFNS) scale, and the Hunt and Hess scale. Outcome at 6 months was determined using a modification of the Glasgow Outcome Scale validated against the Karnofsky scale. All grades and clinical and radiographic data collected were compared among good and poor outcome groups. Multivariate analyses were then performed to determine which grading scale, which time of grading, and which other factors were correlated with and contributed significantly to outcome prediction. A good outcome was achieved in 24 (43%) of 56 patients. Our study also had a 32% mortality rate. With the Hunt and Hess scale, only the worst pretreatment grade was significantly correlated with outcome. However, with the GCS and the WFNS scale, grading at all pretreatment times was significantly correlated with outcome, although outcome was best predicted before treatment, regardless of the scale used, if grading was performed at the patient's clinical worst. Multivariate analysis revealed that the best predictor of outcome was WFNS grade at clinical worst before treatment. Used alone, a WFNS Grade 3 at worst pretreatment predicted a 75% favorable outcome, and a WFNS Grade 5 at worst pretreatment predicted an 87% poor outcome. No significant correlation was found between direction or magnitude of change in grade and outcome. Age was found to be significantly correlated with outcome, but it was only an independent factor in outcome prediction when used in conjunction with the Hunt and Hess scale and not with the WFNS scale and the GCS. Timing of grading is an important factor in outcome prediction that needs to be standardized. This study suggests that the patient's worst clinical grade is most predictive of outcome, especially when the patient is assessed using the WFNS scale or the GCS.

Toward More Rational Prediction of Outcome in Patients with High-grade Subarachnoid Hemorrhage

Toward More Rational Prediction of Outcome in Patients with High-grade Subarachnoid Hemorrhage

Nutrition Management of Patients with High-grade Subarachnoid Hemorrhage

Nutrition Management of Patients with High-grade Subarachnoid Hemorrhage

Efficacy and risk of ventricular drainage in cases of grade V subarachnoid hemorrhage

We retrospectively evaluated efficacy and risk of external ventricular drainage which was performed in early management of high grade subarachnoid hemorrhage. Acute ventricular drainage was performed on 36.6% of 93 patients with grade V subarachnoid hemorrhage. The percentages of patients whose GCS improved following ventricular drainage were 14.3% from GCS 3, 61.5% from GCS 4, 42.9% from GCS 5 and 42.9% from GCS 6. The occurrence rate of rebleeding was approximately three-fold higher in patients who underwent ventricular drainage than in patients who did not. Aneurysmal surgery performed after ventricular drainage, compared with acute aneurysmal surgery, resulted in the smaller percentage of patients who became persistently vegetative and in the larger percentage of patients who became severely disabled, while it did not change the percentage of patients who resulted in favorable outcome 'and death. These results of retrospective study suggested that ventricular drainage performed on grade Vsubarachnoid hemorrhage increased the risk ofrebleeding and did not increase the percentage ofpatients who resulted in favorable outcome although it reduced the percentage of patients who resulted in persistent vegetative state. [Neural Res 1997; 19: 649-653]

Pre- and post-operative cerebral blood flow changes in subarachnoid haemorrhage

Assessment of cerebral perfusion on patients with subarachnoid haemorrhage (SAH) in the Neurologic Intensive Care Unit is difficult since nuclear medicine imaging modalities capable of measuring cerebral blood flow (CBF) are not generally available. We performed 101 quantitative (ml 100g-min) bedside CBF measurements on 40 individual patients to correlate SAH grade with CBF and to assess the effect of surgical intervention on CBF. Global CBF (G-CBF) and bihemispheric CBF (B-CBF) asymmetry were correlated with the grade of SAH pre- and post-operatively. Data analysis showed that pre-operative patients with low grade SAH (Hunt and Hess grades 0 to 2) had higher mean G-CBF values [44.2 +/- 71] than those with high grade SAH (Hunt and Hess grades 3 to 4): [mean G-CBF = 34.1 +/- 1.7]. Post-surgery there was a significant improvement in G-CBF; CBF increased [5.3 +/- 1.07] in the group of patients with low grade SAH. Patients with high grade SAH showed no significant improvement in their G-CBF during the first week post-operatively compared to pre-operative values. We conclude that portable units capable of measuring bedside CBF values are useful in monitoring CBF changes in patients with SAH. Patients with low grade SAH have G-CBF within normal limits both pre-operatively and post-operatively, with a statistically significant increase in CBF during two weeks post-operatively. Patients with high grade SAH show no significant increase in CBF one week post-operatively compared to their pre-operative measures.