Low-grade Subarachnoid Hemorrhage Research Articles

Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study

BackgroundSpontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH.MethodsWe retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis.ResultsOf the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode.ConclusionSAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients.

Aneurysm location and clipping versus coiling for development of secondary normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage: Japanese Stroke DataBank.

The present study aimed to investigate aneurysm locations and treatments for ruptured cerebral aneurysms associated with secondary normal-pressure hydrocephalus (sNPH) after subarachnoid hemorrhage (SAH) by using comprehensive data from the Japanese Stroke DataBank. Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients (1482 men, 3211 women) were registered as having had an SAH caused by a ruptured saccular aneurysm. Of them, 1448 patients (438 men and 1010 women; mean age 61.9 ± 13.4 years) who were confirmed to have or not have coexisting acute hydrocephalus and sNPH were included for statistical analyses. Locations of the ruptured aneurysms were subcategorized into 1 of the following 4 groups: middle cerebral artery (MCA; n = 354), anterior communicating artery and anterior cerebral artery (ACA; n = 496), internal carotid artery (ICA; n = 402), and posterior circulation (n = 130). Locations of 66 of the ruptured aneurysms were unknown/unrecorded. Treatments included craniotomy and clipping alone in 1073 patients, endovascular coil embolization alone in 285 patients, and a combination of coiling and clipping in 17 patients. The age-adjusted and multivariate odds ratios from logistic regression analyses were calculated after stratification using the Fisher CT scale to investigate the effects of the hematoma volume of SAH. Acute hydrocephalus was confirmed in 593 patients, and 521 patients developed sNPH. Patients with a ruptured ACA aneurysm had twice the risk for sNPH over those with a ruptured MCA aneurysm. Those with an ACA aneurysm with Fisher Grade 3 SAH had a 9-fold-higher risk for sNPH than those with an MCA aneurysm with Fisher Grade 1 or 2 SAH. Patients with a ruptured posterior circulation aneurysm did not have any significant risk for sNPH. Clipping of the ruptured aneurysm resulted in twice the risk for sNPH over coil embolization alone. Patients with low-grade SAH caused by a ruptured MCA aneurysm had a low risk for the development of sNPH. In contrast, patients with high-grade SAH caused by a ruptured ACA aneurysm had a higher risk for sNPH. Endovascular coiling might confer a lower risk of developing sNPH than microsurgical clipping.

Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Using Cerebral Blood Flow Velocities and Cerebral Autoregulation Assessment.

The risk of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with large cerebral artery vasospasm, but vasospasm is not a strong predictor for DCI. Assessment of cerebral autoregulation with transcranial Doppler (TCD) may improve the prediction of DCI. The aim of this prospective study was to assess the value of TCD-derived variables to be used alone or in combination for prediction of DCI. We included consecutive patients with low-grade aneurysmal SAH within 4 days of aneurysm rupture. Cerebral autoregulation was evaluated using the moving correlation coefficient Mx calculated from spontaneous fluctuations of cerebral blood flow velocities and arterial blood pressure. Transcranial color-coded sonography was performed to assess large artery vasospasm. Thirty patients (19 women and 11 men; mean age ± SD 44.7 ± 12.1 years) were included. Twenty (66.7%) patients had vasospasm. DCI occurred in six (20%) patients after a median delay of 10 days (range 8-13 days). Cerebral autoregulation was impaired at baseline and at day 7 and then returned to normal at day 14. Neither cerebral autoregulation impairment nor large artery vasospasm alone was associated with DCI. In contrast, the combination of large artery vasospasm with worsening impairment of cerebral autoregulation from baseline to day 7 was significantly correlated to subsequent DCI (p = 0.007). Early deterioration of cerebral autoregulation was strongly predictive of DCI in patients with large artery vasospasm after low-grade SAH. Our results suggest that consideration to both cerebral blood flow velocities and cerebral autoregulation may improve the prediction of DCI.

Feasibility, Safety, and Periprocedural Complications Associated With Endovascular Treatment of Selected Ruptured Aneurysms Under Conscious Sedation and Local Anesthesia

Endovascular coil embolization of ruptured aneurysms is performed under general anesthesia at most centers for perceived improved image quality and patient safety. To report the feasibility of and outcomes associated with endovascular treatment of subarachnoid hemorrhage (SAH) patients with ruptured cerebral aneurysms performed under conscious sedation with local anesthetics. Between January 2005 and December 2009, 187 patients with aneurysmal SAH were treated with coil embolization at the authors' hospital. For each patient, procedural details, mode of anesthesia, and clinical and radiographic outcomes were reviewed retrospectively (retrospective case series). A total of 197 coil embolizations were performed: 112 under general anesthesia, 78 under conscious sedation with local anesthetics, and 7 converted from conscious sedation to general anesthesia. None of the patients who presented with Hunt & Hess grade IV or V were treated under conscious sedation. For patients who presented with Hunt & Hess grades I, II, and III, 79.2%, 66.7%, and 32.6% of patients, respectively, underwent successful completion of treatment under conscious sedation. The symptomatic procedural complication rate was 2.5% overall and 2.4% for the conscious sedation group alone. Among the 14 interventions with intraprocedural perforation, 11 were performed under general anesthesia and 3 were performed under conscious sedation. In the authors' experience, conscious sedation with local anesthetics for endovascular treatment of ruptured intracranial aneurysms is feasible and safe in most patients with low-grade SAH. It may allow direct evaluation of the patient's neurological status, potentially leading to earlier detection and response to intraprocedural complications.

クモ膜下出血軽症例における非急性期のFLAIR画像

クモ膜下出血(SAH)に対するFLAIR画像の診断能力は,急性期のみならず亜急性期や慢性期においても有効であるとされる.しかし,非急性期のSAHに関するFLAIR画像の所見については,詳細な報告はほとんどみられない.今回,脳動脈瘤破裂によるクモ膜下出血のうち,6例の軽症のSAHを対象として,非急性期のFLAIR画像の検討を行った.MRIの撮影時期は,頭痛を自覚してから9日〜約1カ月である.FLAIR画像の特徴は,以下の4点であった.(1)動脈瘤周囲や脳底槽では信号変化を認めない,(2)このため動脈瘤の破裂部位の推測は困難である,(3)側脳室後角内の血腫の診断は,periventricular hyperintensityに影響を受け,少量の場合では識別が困難である,(4)円蓋部のSAHは比較的幅広い範囲に軽度から中等度の高信号として描出され,一方シルビウス裂では限局した範囲に,中等度からやや強い高信号として認めた.上記所見は非急性期の軽症SAH症例においても,FLAIR画像は有用な診断方法であることを示している.しかし,その検出感度はCTを上回るものの,急性期と比較すると高くはない.適切な診断には,発症後の時間経過から予測されるSAHの描出範囲やその信号強度を理解するとともに,診断の限界を認識することが重要である.

Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey.

IntroductionAnemia is associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). It remains unclear whether this association can be modified with more aggressive use of red blood cell (RBC) transfusions. The degree to which restrictive thresholds have been adopted in neurocritical care patients remains unknown.MethodsWe performed a survey of North American academic neurointensivists, vascular neurosurgeons and multidisciplinary intensivists who regularly care for patients with SAH to determine hemoglobin (Hb) concentrations which commonly trigger a decision to initiate transfusion. We also assessed minimum and maximum acceptable Hb goals in the context of a clinical trial and how decision-making is influenced by advanced neurological monitoring, clinician characteristics and patient-specific factors.ResultsThe survey was sent to 531 clinicians, of whom 282 (53%) responded. In a hypothetical patient with high-grade SAH (WFNS 4), the mean Hb concentration at which clinicians administered RBCs was 8.19 g/dL (95% CI, 8.07 to 8.30 g/dL). Transfusion practices were comparatively more restrictive in patients with low-grade SAH (mean Hb 7.85 g/dL (95% CI, 7.73 to 7.97 g/dL)) (P < 0.0001) and more liberal in patients with delayed cerebral ischemia (DCI) (mean Hb 8.58 g/dL (95% CI, 8.45 to 8.72 g/dL)) (P < 0.0001). In each setting, there was a broad range of opinions. The majority of respondents expressed a willingness to study a restrictive threshold of ≤8 g/dL (92%) and a liberal goal of ≥10 g/dl (75%); in both cases, the preferred transfusion thresholds were significantly higher for patients with DCI (P < 0.0001). Neurosurgeons expressed higher minimum Hb goals than intensivists, especially for patients with high-grade SAH (β = 0.46, P = 0.003), and were more likely to administer two rather than one unit of RBCs (56% vs. 19%; P < 0.0001). Institutional use of transfusion protocols was associated with more restrictive practices. More senior clinicians preferred higher Hb goals in the context of a clinical trial. Respondents were more likely to transfuse patients with brain tissue oxygen tension values <15 mmHg and lactate-to-pyruvate ratios >40.ConclusionsThere is widespread variation in the use of RBC transfusions in SAH patients. Practices are heavily influenced by the specific dynamic clinical characteristics of patients and may be further modified by clinician specialty and seniority, the use of protocols and advanced neurological monitoring.

Does Brain Swelling Increase Estimated Specific Gravity?

At the acute phase of traumatic brain injury (TBI), brain swelling contributes substantially to the development of secondary neurological lesions. Elucidating the pathophysiology of brain swelling is crucial to improve TBI management. In a previous study, specific gravity (SG) of the noncontused hemisphere, as estimated by computed tomography (CT), was higher in patients with high Marshall CT scores and severe brain swelling. The aim of this study was to investigate the relationship between estimated specific gravity (eSG) and clinical variable suggestive of brain swelling. Retrospective study of data from a prospectively established database. Neurology ICU in a teaching hospital in Paris, France. We studied 20 patients with severe traumatic brain injury (TBI), 20 patients with high-grade subarachnoid hemorrhage (SAH) presenting similar brain-swelling criteria, 20 patients with low-grade SAH, and 20 healthy controls. None. Estimated brain specific gravity was acquired from CT images obtained at ICU admission. eSG was estimated in the overall intracerebral content and in a region-of-interest composed of white matter and the diencephalon. eSG in the region of interest was significantly higher in the TBI patients than in the high-grade SAH patients (1.0350 +/- 0.0041 vs. 1.0310 +/- 0.0019 g/ml, P < 0.05). eSG was similar in the high-grade SAH, low-grade SAH, and control groups. Our findings do not support a causal link between brain swelling and eSG elevation. The eSG increase in severe TBI patients is not due to brain swelling.

Post-operative changes of cerebral circulation and metabolism in the acute stage of low-grade aneurysmal subarachnoid hemorrhage

Objective: Pre- and post-operative cerebral circulation and metabolism were evaluated in patients with low-grade acute aneurysmal subarachnoid hemorrhage (SAH) who underwent early surgery to investigate the effects on brain dysfunction.Methods: Positron emission tomography (PET) was performed to measure the regional cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), oxygen extraction fraction (OEF) and cerebral blood volume in four patients (one male and three females, mean age: 60.3 years) with low-grade SAH within 30 hours of onset. Post-operative PET was performed on the seventh post-operative day. No patient suffered clinical deterioration during the study. Pre-operative PET scans demonstrated significant global reduction of CBF and CMRO2, compared to 16 normal control subjects, and no significant change in OEF. CBF and CMRO2 reduction post-operatively improved to the normal control values. Post-operative OEF was significantly increased compared to the normal control value.Conclusions: Patients with low-grade SAH have impairment of cerebral circulation and metabolism in the acute period, which improves after surgery. Early surgery for low-grade SAH, necessary to avoid rerupture of the aneurysm, did not worsen the impairment of cerebral circulation and metabolism. However, measures to protect the brain from perioperative damage are necessary to achieve the optimum outcome.

Cigarette smoking as a risk factor for recurrence of aneurysms treated by endosaccular occlusion

Aneurysms treated by endovascular coil embolization have been associated with coil compaction, and the rate of recanalization has been reported to be as high as 40%. The authors report the first published evidence of a correlation between aneurysm recanalization correlated with a history of cigarette smoking. The authors conducted a retrospective chart review of all cases involving patients admitted to their institution from January 1, 2003, to December 31, 2003, for treatment of a cerebral aneurysm. Cases in which patients were treated with coil embolization were reviewed for inclusion. Coil compaction was defined as change in the shape of the coil mass. Aneurysm recanalization was defined as an increase in inflow to the aneurysm in comparison with baseline. The incidence of coil compaction and the relationship with cigarette smoking history were compared in patients with and without recurrence. A total of 110 patients qualified for inclusion. The odds ratio (OR) for aneurysm recanalization after endosaccular occlusion with respect to history of cigarette smoking was significant for the entire cohort (OR 4.53, 95% confidence interval [CI] 1.95-10.52) and especially for the female cohort (OR 3.72, 95% CI 1.45-9.54). The male cohort demonstrated a trend toward a direct correlation, but the sample size was not large enough for statistical significance (OR 7.50, 95% CI 1.02-55.00). There was an increased risk of recanalization especially in patients with low-grade subarachnoid hemorrhage who had a history of cigarette smoking. These data suggest a correlation between cigarette smoking and aneurysm recurrence.

The Current Status of Treatment Strategies for Cerebral Aneurysms in Nagoya University and Affiliated Hospitals Based on a Questionnaire Survey

We investigated differences in the treatment strategies for ruptured aneurysms among 26 hospitals affiliated with Nagoya University and any changes in those strategies based on responses to a questionnaire.We also surveyed the data concerning patients with a ruptured aneurysm collected from our affiliated hospitals between 2001 and 2002. In half of the institutes, angiography is performed immediately after an urgent medical examination, there are only five hospitals (20%) which have a basic policy of terminating the angiography within three to six hours after onset. In half of the institutes, the timing of the treatment also depends on the location of the aneurysm. In particular, the treatment for vertebro-basilar aneurysms tends to be done the next day or later. Low-grade subarachnoid hemorrhage (SAH) patients with mild symptoms tended not to be given any sedative drugs (46%), while patients with SAH in some institutes were sedated without informed consent regardless of the severity. The main treatment method for most anterior circulation aneurysms was clipping. Concerning aneurysms located in the posterior circulation and the origin of the ophthalmic artery, clipping and coiling were equally selected. Almost all the hospitals (92%) responded that their treatment strategy had not changed even after the report of the International Subarachnoid Aneurysm Trial (ISAT). There is a great deal of difference in treatment strategies and indications among institutions. In particular, institutions without neuroendovascular interventionists (NETists) frequently persist in the conventional policy, making it urgently necessary to bring NETists up-to-date on the latest advance in endovascular treatment.

Comparison of Magnetic Resonance Imaging Sequences With Computed Tomography to Detect Low-Grade Subarachnoid Hemorrhage

To compare computed tomography (CT) with magnetic resonance imaging (MRI) for the presumptive diagnosis and localization of acute and subacute low-grade subarachnoid hemorrhage (SAH). We consecutively enrolled 45 patients clinically suspected of low-grade SAH, comparing them with a control group. We obtained axial nonenhanced CT scans as well as fluid-attenuated inversion recovery (FLAIR) and T2-weighted gradient echo (T2*) MRI sequences at 1.0 T. Two neuroradiologists scrutinized the presence of blood at 26 different regions in the intracranial subarachnoid space (SAS). Three of 45 patients had normal CT and MRI scans, and SAH was excluded by lumbar puncture. We demonstrated SAH on CT scans in 28 of 42 (66.6%) patients, T2* sequences in 15 of 42 (35.7%) patients, and FLAIR sequences in 42 of 42 (100%) patients. Fluid-attenuated inversion recovery sequences were superior to CT in 16 of the 26 evaluated regions. The FLAIR sequence was superior for presumptive diagnosis and localization of acute and subacute low-grade SAH, representing a potential tool in this setting.