Kosnik Grade Research Articles

Factors Affecting Outcomes of Poor-Grade Subarachnoid Hemorrhage

Poor-grade subarachnoid hemorrhage (SAH) accounts for 20% of all SAH and is associated with poor outcomes. The first step in improving outcomes is to analyze the factors that contribute to poor outcomes. This was a multicenter, retrospective, observational, cohort study. Data fields included demographic, clinical, radiological, and outcome data for all spontaneous patients with SAH treated at 4 hospitals in Aomori Prefecture in Japan. Patients with modified Rankin Scale score 0-2 at discharge were defined as the good outcome group, and those with modified Rankin Scale score 3-6 were defined as the poor outcome group, and comparisons were made between the 2 groups. There were 329 eligible patients with poor-grade SAH, 41 with good outcome group, and 288 with poor outcome group. On multivariate analysis of the outcome, conservative treatment (P < 0.001), Fisher group 4 (P < 0.007), age ≥65 years (P= 0.011), and Hunt and Kosnik grade V on admission (P= 0.021) were significant factors contributing to a poor outcome. Nonelderly patients who are not in grade V and Fisher group 4 should undergo aneurysm treatment as soon as possible because they are more likely to have a good outcome, whereas elderly patients in grade V and Fisher group 4 are unlikely to benefit from aneurysm treatment at present. The development of a treatment for early brain injury may be important to improve the outcomes of patients with poor-grade SAH.

Clinical Presentation, Treatment, and Outcome of Nontraumatic Subarachnoid Hemorrhage in Patients with Preceding Antithrombotic Therapy.

With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of nontraumatic subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade ≥4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.

Cognitive outcome in patients one month after mild to moderate aneurysmal subarachnoid hemorrhage: Focus on the location of the aneurysm

ObjectivePatients with good recovery after aneurysmal subarachnoid hemorrhage (SAH) are commonly discharged about one month after the event. However, these patients often still show cognitive symptoms, such as fatigue, difficulty concentrating, and irritability. Understanding the early cognitive outcome of patients with SAH with good recovery is thought to be crucial for neurosurgical nursing staff. We analyzed patient data to clarify whether cognitive outcome depends on the location of the ruptured aneurysm 1 month after SAH. MethodsFor 186 patients (72 men and 114 women; median age, 57 years; age range, 21–83 years) who had experienced SAH (Hunt & Kosnik grade I to III), we retrospectively analyzed data on the location of the ruptured aneurysm, Fisher grade at admission, treatment modality (coil embolization, clipping, or no surgical treatment), neuropsychological assessments 1 month after SAH, and modified Rankin Scale 6 months after SAH. ResultsCrystallized intelligence (i.e., IQ, assessed using the Mini-Mental State Examination and Kohs Block Design Test) improved to almost normal levels in all patients, irrespective of the location of the ruptured aneurysm. In contrast, fluid intelligence (e.g., executive function and attention, assessed using the Frontal Assessment Battery; Trail Making Test, Part A; and the Japanese Kana-hiroi test) did not improve as much, specifically in patients with a ruptured aneurysm in the basilar artery. ConclusionsThese results may help nursing staff to identify mild- to moderate-grade patients at greater risk of problems and to arrange appropriate support strategies for patients after discharge.

Plasma brain natriuretic peptide level on admission predicts long-term outcome in patients with non-traumatic subarachnoid hemorrhage

IntroductionNon-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH. MethodsWe studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation. ResultsTwenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p < 0.0001), neurological grade (p < 0.0001), elevated BNP level (p < 0.0001), increased plasma norepinephrine levels (p < 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p < 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p < 0.0001). ConclusionPlasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.

In Reply to the Letter to the Editor Regarding “Temporal Muscle as an Indicator of Sarcopenia Is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling”

In Reply to the Letter to the Editor Regarding “Temporal Muscle as an Indicator of Sarcopenia Is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling”

Letter to the Editor Regarding “Temporal Muscle as an Indicator of Sarcopenia Is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale Score at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling”

Letter to the Editor Regarding “Temporal Muscle as an Indicator of Sarcopenia Is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale Score at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling”

Temporal muscle thickness and area with various characteristics data of the patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling.

These data present the characteristics of patients with subarachnoid hemorrhage who underwent endovascular coiling. We retrospectively collected data from the medical records of Iwaki City Medical Center including physiological symptoms, laboratory data, radiological data on admission, and modified Rankin Scale scores at 6 months. Our article entitled “Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale at 6 Month of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling” was based on these data [1]. We previously reported similar small dataset of elderly patients with subarachnoid hemorrhage who underwent surgical clipping [2], [3]. However, remarkably, this is the largest and the first dataset on temporal muscle thickness or area of patients of all ages with subarachnoid hemorrhage who underwent endovascular coiling, not surgical clipping.

Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale Score at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling

Sarcopenia is defined as the loss of skeletal muscle mass and is considered an important factor for clinical outcomes in various diseases. Recent studies have shown that temporal muscle thickness (TMT) and area (TMA) can be novel indicators of sarcopenia. We examined clinical characteristics, including TMT and TMA, of patients with subarachnoid hemorrhage (SAH) treated by endovascular coiling. A retrospective analysis of 298 patients with SAH who were treated with endovascular coiling from 2009 to 2019 was conducted. Their premorbid modified Rankin Scale (mRS) score was 0-2. The association between the factors and Hunt and Kosnik (H-K) grades on admission and that between the clinical variables and mRS scores 6 months after the operation were analyzed. In all 298 patients with SAH, Fisher group 4 and TMA <200 mm2 were independently associated with H-K grade III-V on admission in the multivariate analysis. In 254 patients with H-K grades I-III on admission, age, H-K grade III, presence of ventriculoperitoneal shunt, presence of postoperative complications, and TMA <200 mm2 were independent factors related to poor outcomes in the multivariate analysis. The H-K grade on admission was independently associated with TMA. The mRS score 6 months after aneurysm treatment in patients with H-K grades I-III was also independently associated with TMA. Sarcopenia could be one of a few modifiable factors that prevent severe symptoms of SAH and improve outcomes after coiling by strengthened nutrition and physical activity.

Ruptured Aneurysms on the Cortical Segment of the Distal Posterior Inferior Cerebellar Artery:A Report of Two Cases and a Literature Review

Two unusual cases of ruptured distal posterior inferior cerebellar artery(PICA)aneurysm on the cortical segment were successfully treated with open surgery. A 76-year-old woman presented with a Hunt and Kosnik(H&K)grade II Subarachnoid hemorrhage(SAH). CT showed a slight SAH in the cisterna magna and around the vermis, and fourth intraventricular hematoma. Cerebral angiography revealed an aneurysm on the cortical segment of the distal PICA. Intraoperative findings identified the aneurysm as fusiform. Trapping of the aneurysm was performed, and the indocyanine green angiography fiuding confirmed aneurysmal flow disappearance and good circulation in the cerebellar cortex. An 89-year-old woman presented with H&K grade II SAH. CT revealed a thick SAH in the posterior cranial fossa, and third to fourth intraventricular hematoma with hydrocephalus. Cerebral angiography revealed an aneurysm on the cortical segment of the distal PICA. Intraoperative findings showed that the aneurysm was fusiform. Trapping and resection of the aneurysm were performed. Thirteen previous cases of aneurysms on the cortical segment of the distal PICA have been reported. Distal PICA aneurysms apparently show rebleeding more frequently than do aneurysms at other locations, so immediate direct surgery is necessary to avoid rebleeding. After proximal ligation or trapping of the aneurysm, indocyanine green angiography is useful to determine the need for revascularization.

Early Hyperoxia in The Intensive Care Unit is Significantly Associated With Unfavorable Neurological Outcomes in Patients With Mild-to-Moderate Aneurysmal Subarachnoid Hemorrhage.

Although oxygen administration is fundamental in the management of aneurysmal subarachnoid hemorrhage (SAH) patients in the acute stage, hyperoxia has harmful effects. The effects of hyperoxia on neurological outcomes in SAH patients are unclear. We aimed to examine the association of hyperoxia during the first 24 h in the intensive care unit (ICU) with unfavorable neurological outcomes in SAH patients. We retrospectively selected consecutive adult patients admitted to ICU for SAH between January 2009 and April 2018. We defined normoxia during the first 24 h in ICU as PaO2 of 60 mm Hg to 120 mm Hg, mild hyperoxia as PaO2 of 121 mm Hg to 200 mm Hg, moderate hyperoxia as PaO2 of 201 mm Hg to 300 mm Hg, and severe hyperoxia as PaO2 of >300 mm Hg. Univariate and multivariate analyses were performed to examine the association between hyperoxia during the first 24 h in ICU and unfavorable neurological outcomes (i.e., modified Rankin scale score of 3-6 at hospital discharge). Among 196 SAH patients, 90 had unfavorable neurological outcomes. Hyperoxia was observed in 93.4% of patients. No significant association was observed between unfavorable neurological outcomes and hyperoxia in overall patients. However, we found that early hyperoxia in ICU was significantly associated with unfavorable neurological outcomes in SAH patients with Hunt and Kosnik (H&K) grades I to III (Relative risk, 1.84; 95% confidence interval, 1.10-2.94; P = 0.02). Early hyperoxia was not associated with unfavorable neurological outcomes in overall SAH patients, but it was associated with unfavorable neurological outcomes in those with H&K grades I to III.

Association of abnormal carbon dioxide levels with poor neurological outcomes in aneurysmal subarachnoid hemorrhage: a retrospective observational study

BackgroundIn patients with aneurysmal subarachnoid hemorrhage (SAH), an association between hypocapnia and poor clinical outcomes has been reported. However, the optimal arterial carbon dioxide tension (PaCO2) remains unknown. The present retrospective study aimed to examine the association of abnormal PaCO2 levels with neurological outcomes and investigate the optimal target PaCO2 level in patients with SAH.MethodsWe retrospectively selected consecutive adult patients hospitalized in the intensive care unit (ICU) for SAH between January 2009 and April 2017. Univariate and multivariate analyses were performed to identify the independent predictors of unfavorable neurological outcomes (i.e., modified Rankin scale score of 3–6 on hospital discharge).ResultsAmong 158 patients with SAH, 73 had unfavorable neurological outcomes. During the first 2 weeks in the ICU, the median number of PaCO2 measurements per patient was 43. The factors significantly associated with unfavorable neurological outcomes were age, Hunt and Kosnik grade, maximum lactate levels during the first 24 h, and maximum (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.03–1.21; p < 0.01) and minimum PaCO2 levels (OR, 0.81; 95% CI, 0.72–0.92; p < 0.01). Receiver operating characteristic curve analysis revealed that the cutoff range of PaCO2 was 30.2–48.3 mmHg. Unfavorable neurological outcomes were noted in 78.8% of patients with PaCO2 levels outside this range and in 22.8% of patients with PaCO2 levels within this range.ConclusionsBoth the maximum and minimum PaCO2 levels during ICU management in patients with SAH were significantly associated with unfavorable neurological outcomes. Further prospective studies are required to validate our findings and explore their clinical implications. Our findings may provide a scientific rationale for these future prospective studies.

Ruptured vertebral artery dissection treated conservatively: a case report

68 歳男性．特記すべき既往歴なし．胃摘出術後3 日目に突然の後頸部痛と嘔吐を発症し，くも膜下出血（Hunt and Kosnik grade 2）の診断で当科に紹介となった．脳血管撮影で，両側椎骨動脈に狭窄病変や血管壁の不整を認め，MRI のT1 強調画像では，両側椎骨動脈に壁内血腫を示唆する高信号域を描出した．くも膜下出血で発症した両側椎骨動脈解離と診断したが，出血源が左右どちらの椎骨動脈か同定できなかった．出血側の椎骨動脈の治療を行えず，また非出血側を含めた両側椎骨動脈に対する治療も虚血合併症のリスクが高いと判断したため，保存的治療の方針とした．鎮静と降圧治療により良好に経過し，発症2 カ月後に退院した．毎年MRI のフォローを行って，5 年以上経過しているが再出血や解離病変の悪化もなく経過している．出血発症した椎骨動脈解離といえども，治療困難な場合には保存的治療も治療選択肢のひとつになりうる．

Serum glucose/potassium ratio as a clinical risk factor for aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage (SAH) can result in poor outcomes, and biomarkers for predicting poor prognosis have not yet been established. The aim of this study was to clarify the significance of the serum glucose/potassium ratio for predicting the prognosis of aneurysmal SAH. The authors retrospectively reviewed the records of 565 patients with aneurysmal SAH between 2006 and 2016. The patient group comprised 208 men and 357 women (mean age 61.5 years, range 10-95 years). A statistical analysis was conducted of the clinical and laboratory risk factors of poor outcome, including the serum glucose/potassium ratio. On estimation of the initial assessment using Hunt and Kosnik (H-K) grading, 233 patients (41.2%) were classified as the severe SAH group (H-K Grade IV or V). There were significant correlations between the severe SAH group and serum glucose/potassium ratio (p < 0.0001). Serum glucose/potassium ratio was elevated in an H-K grade-dependent manner (Spearman's r = 0.5374, p < 0.0001). With the estimation of the Glasgow Outcome Scale (GOS) score at discharge, 355 patients (62.8%) were classified as poor outcome (GOS score 1-3). The serum glucose/potassium ratio was elevated in a GOS score at discharge-dependent manner (Spearman's r = 0.4006, p < 0.0001), and was significantly elevated in the poor outcome group compared with the good outcome group (GOS score 4 or 5; p = 0.0245). There were significant correlations between poor outcome and serum glucose/potassium ratio (p < 0.0001), age (p < 0.0001), brain natriuretic peptide levels (p = 0.011), cerebral infarction due to vasospasm (p < 0.0001), and H-K grade (p < 0.0001). Multivariate logistic regression analyses showed significant correlations between poor outcome and serum glucose/potassium ratio (p = 0.009). In this study, the serum glucose/potassium ratio of patients with aneurysmal SAH at admission was significantly correlated with H-K grade and GOS score at discharge. Therefore, this ratio was useful for predicting prognosis of aneurysmal SAH, especially in severe cases.

Target Serum Sodium Levels During Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage.

Dysnatremia commonly occur in the intensive care unit (ICU) management of patients with aneurysmal subarachnoid hemorrhage (SAH). However, detailed management strategies have not been provided even by current guidelines. The purposes of this study were to examine the association of abnormal serum sodium levels with unfavorable neurologic outcomes and to identify the target range of serum sodium in patients with SAH. We retrospectively reviewed all patients who were consecutively hospitalized with a confirmed diagnosis of SAH between January 2009 and December 2015. Univariate/multivariate analyses were performed to identify the independent predictors of an unfavorable neurologic outcome (modified Rankin scale of 3-6 upon hospital discharge). There were 131 patients included in this study. Unfavorable neurologic outcomes occurred in 45% of patients. On multiple regression analysis, age, Hunt and Kosnik grade, and serum sodium levels in the ICU at the maximum [odds ratio (OR), 1.18; 95% CI, 1.05-1.35; P < 0.01] and minimum (OR, 0.88; 95% CI, 0.77-0.99; P = 0.048) values were significantly associated with unfavorable neurologic outcomes. The receiver operating characteristic curve analysis showed that the cut-off serum sodium levels were 145 mmol/L for maximum value and 132 mmol/L for minimum value. Patients with hyponatremia and hypernatremia during the first 2 weeks in the ICU accounted for 88.2% of patients with an unfavorable neurologic outcome; whereas, those with normal sodium levels accounted for only 15.6%. In patients with SAH, both hyponatremia and hypernatremia during ICU management were significantly associated with unfavorable neurologic outcomes.

Association between dexmedetomidine use and neurological outcomes in aneurysmal subarachnoid hemorrhage patients: A retrospective observational study

PurposeRecent studies in animal subarachnoid hemorrhage (SAH) models have reported that dexmedetomidine (DEX) use demonstrates significantly better neurological outcomes. This study aimed to evaluate whether DEX use is associated with favorable neurological outcomes (FO) in SAH patients. Materials and methodsWe retrospectively reviewed all SAH patients between 2009 and 2017. We calculated the total dosage of DEX administered for the first 24h after admission. All patients were classified into no use, low dosage, and standard dosage group. Multivariate analysis was performed to clarify the association between DEX use and FO (modified Ranking Scale score of 0–2 at hospital discharge). ResultsThere were 161 patients with 55.3% of FO. On univariate analysis, there were significant differences with regard to age, Hunt and Kosnik (H&K) grade, and DEX use. Multivariate analysis showed that age, H&K grade, and low dosage DEX (rather than no use) (odds ratio (OR) 3.17; 95% confidence interval (CI), 1.24–8.53; p=0.02) were significantly associated with FO. However, standard dosage DEX was not a significant factor (OR, 0.75; 95% CI, 0.25–2.16; p=0.59). ConclusionsLow dosage DEX during the first 24h after admission was associated with FO in SAH patients.

Common cold is the most frequent cause for misdiagnosing aneurysmal SAH

Abstract Background Misdiagnosis of subarachnoid hemorrhage has been hypothesized to affect outcomes. We studied patients with SAH who were admitted to our hospital to identify ways to prevent misdiagnosis. Methods A total of 709 patients with subarachnoid hemorrhage were admitted to the Department of Neurosurgery of our hospital from January 2003 through December 2014. Fifty patients (7.05%) received a misdiagnosis. The patients were divided into a misdiagnosis group and a correct diagnosis group and compared. We examined the clinical features associated with misdiagnoses in the 41 patients with a misdiagnosis. Results There were statistically significant differences between the misdiagnosis group and correct diagnosis group in age ( p = 0.017), status at onset ( p = 0.020), symptoms ( p = 0.000402), period from symptom onset ( p = 1.03 × 10 − 5 ), transportation ( p = 4.57 × 10 − 27 ), Hunt & Kosnik grade ( p = 3.23 × 10 − 48 ), WFNS grade ( p = 2.22 × 10 − 25 ), type of medical institution ( p = 2.17 × 10 − 39 ), bleeding source ( p = 0.041), and the modified Rankin Scale at discharge ( p = 2.24 × 10 − 5 ). Conclusions Subarachnoid hemorrhage was misdiagnosed as a common cold in younger patients in whom headache suddenly developed at rest, but symptoms were mild, and the patient was brought to a general practitioner at a clinic by means other than an ambulance on the day after onset or subsequently. Misdiagnosis can be prevented by suspecting subarachnoid hemorrhage and performing imaging examinations; obtaining a detailed medical history is therefore essential.

Pseudoaneurysm formation due to rupture of intracranial aneurysms: Case series and literature review.

Background Intracranial pseudoaneurysm formation due to a ruptured non-traumatic aneurysm is extremely rare. We describe the radiological findings and management of pseudoaneurysms due to ruptured cerebral aneurysms in our case series and previously reported cases. Patients and methods Four additional and 20 reported patients presenting with subarachnoid hemorrhage (SAH) are included. Radiological findings and clinical features of these patients were reviewed. Results In our series, three-dimensional computed tomographic angiography (3D-CTA) and/or angiography showed an irregular- or snowman-shaped cavity extending from the parent artery. The radiological examination additionally revealed delayed filling and retention of contrast medium. These findings were the same as previously reported cases. One patient underwent direct clipping of the true aneurysm. For the other three patients with aneurysms at the basilar and anterior communicating arteries, the true portion of the aneurysm was embolized with platinum coils. During the procedures, care was taken not to insert the coils into the distal pseudoaneurysm portion to prevent rupture. The review of 24 cases revealed that the location of the aneurysms was most frequent in the anterior communicating artery (41.7%), and 86.7% of patients were in a severe stage of SAH (>Grade 3 in WFNS or Hunt & Kosnik grading) implying abundant SAH. Conclusions Pseudoaneurysm formation in SAH after non-traumatic aneurysm rupture is rare. However, in cases with an irregular-shaped aneurysm cavity, pseudoaneurysm formation should be taken into consideration.

Blood Glucose Variability: A Strong Independent Predictor of Neurological Outcomes in Aneurysmal Subarachnoid Hemorrhage.

In patients with aneurysmal subarachnoid hemorrhage (SAH), increased glucose variability (GV) is associated with increased mortality and cerebral infarction; however, there are no reports demonstrating an association between GV and neurological outcome. This study investigated whether GV had an independent effect on neurological outcomes in patients with SAH in the intensive care unit. Consecutive adult patients hospitalized with SAH between January 1, 2009, and May 31, 2015 (N = 122) were retrospectively reviewed. Univariate/multivariate analyses were performed to identify independent predictors of poor neurological outcome. Patients were divided according to the mean glucose level (80-139 vs 140-200 mg/dL) and further subdivided using quartiles (Q) of the standard deviation (SD, representing variability) of the glucose level (Q1, Q2 + 3, and Q4). Unfavorable neurological outcomes occurred in 44.2% of the patients. On multiple regression analysis, age, Hunt and Kosnik grade, SD of glucose (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.02-1.17; P < .01), and minimum blood glucose level (OR, 0.95; 95% CI, 0.91-0.99; P < .01) were significantly associated with unfavorable neurological outcomes. Both groups (mean glucose levels: 80-139 and 140-200 mg/dL groups) had increasing unfavorable neurological outcomes with increasing SD of glucose (Q1, 15.0%; Q2 + 3, 40.0%; Q4, 52.4% and Q1, 44.4%; Q2 + 3, 50%; Q4, 88.9% in the 80-139 and 140-200 mg/dL groups, respectively). Patients with minimum glucose of <90 mg/dL comprised >50% of unfavorable neurological outcome. Increased GV was an independent predictor of unfavorable neurological outcomes in patients with SAH.

Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage

PurposeThe purpose of the study is to evaluate the impact of neurointensivist-managed intensive care unit (NIM-ICU) implementation for patients admitted with aneurysmal subarachnoid hemorrhage (SAH). MethodsThis study retrospectively evaluated 234 patients (mean age, 61.7 years; male, 67) admitted with SAH between January 1, 2001, and March 31, 2014. Neurologic outcomes between patients admitted from January 2001 to December 2006 (intensivist-managed intensive care unit group) and January 2007 to March 2014 (NIM-ICU group) were compared. The primary outcome was the incidence of a good neurologic outcome at discharge (GO; the modified Ranking Scale score: GO, 0-2; poor neurological outcome, 3-6) at discharge. ResultsNeurointensivist-managed intensive care unit was initiated for 151 (64.5%) of 234 patients. Univariate analysis demonstrated significantly better outcomes for NIM-ICU group vs intensivist-managed intensive care unit group (GOs, 58.3% vs 41.0%, respectively, P = .01). Multivariate logistic regression was used to evaluate NIM-ICU efficacy for SAH patients, but NIM-ICU was not significantly associated with GOs (P = .054). Subgroup analysis of patient grading by Hunt and Kosnik grades I to II showed that NIM-ICU implementation was an independent predictor of GOs (odds ratio, 4.54; 95% confidence interval, 1.08-22.17; P = .04). ConclusionNeurointensivist-managed intensive care unit may improve neurologic outcomes in SAH patients with Hunt and Kosnik grades I to II.

歩いて来たSAH

To prevent rebleeding of a subarachnoid hemorrhage (SAH) due to intracranial artery aneurysms, early treatment is indispensable. We investigated such cases at the time of initial diagnosis of walk-in patients in hospitals. The study covered 293 patients with SAH caused by ruptured intracranial artery aneurysms who were hospitalized in our department between 1996 and 2005. The individuals were treated at the Yamagata University between 1996 and 2005. All 293 cases had a sudden onset. In 89 cases (30.3%), the individuals consulted physicians at various medical facilities without the use of ambulances. In 129 of these cases (44%), the individuals presented with headache only, including Hunt & Kosnik (H&K) Grade I: 27 (9.2%) and Grade II: 102 (34.8%). These findings revealed that headache is common in such cases. Moreover, 24 of the 27 (88.9%) cases of H&K Grade I and 65 of 102 (63.7%) cases of Grade II were walk-in patients, and the consultation rate of walk-in patients presenting only a headache was very high. The average number of days that individuals waited before consulting a physician was 2.2 (0–35 days). Of the 89 cases of walk-in patients, 24 were very difficult to diagnose (26.9%). Two cases (both H&K I) were difficult to diagnose even under CT examination, and 22 cases (H&K I: 8, II: 14) were not suspected to be SAH cases, and their CT were not examined. These difficult cases were first diagnosed as follows: common cold, 4; high blood pressure, 2; facial palsy for oculomotor nerve paralysis, 1; and ordinary headache, 17. Of these 24 cases for which a confirmed diagnosis was difficult, upon subsequent visits, 18 were diagnosed as having persistent headache; 5, rerupture of SAH (admitted by ambulance); and 1, symptomatic spasm (admitted by ambulance). The location of aneurysms of the walk-in 89 patients were ICA: 21, MCA: 22, ACA: 34, VBA: 3, and other: 9. The overall results of the walk-in 89 patients were GR: 73 (82%), MD: 9 (10%), SD: 1 (1%), D: 6 (7%). Our investigation indicated that difficulty in making a confirmed diagnosis is not rare when only the symptoms are considered.