Modified Fisher Grade Research Articles

Improved accuracy of delayed cerebral ischemia diagnosis with plasma nitric oxide synthase 3, nicotinamide adenine dinucleotide phosphate, and 8-iso-prostaglandin F2α.

The pathophysiology of delayed cerebral ischemia (DCI) is not fully elucidated. The lack of accurate diagnostic tools increases the probability of delayed diagnosis and timely treatment. The authors assessed the relationship of 8-iso-prostaglandin F2α (F2-IsoP) and oxidative stress biomarkers, nitric oxide synthase 3 (NOS3) and nicotinamide adenine dinucleotide phosphate (NADPH), with DCI after aneurysmal subarachnoid hemorrhage (aSAH). The authors assessed 65 aSAH patients for F2-IsoP, NOS3, and NADPH concentrations using commercial ELISA on days 2, 4, and 6 after aSAH. The authors examined the correlations of plasma F2-IsoP, NOS3, and NADPH concentrations and clinical variables with DCI onset. F2-IsoP, NOS3, and NADPH are important laboratory predictors of DCI. Of the clinical predictors, modified Fisher grade, Hunt and Hess grade, and tobacco smoking were the most significant predictors. In patients with DCI, plasma F2-IsoP and NOS3 concentrations were higher, and NADPH concentrations were lower, than in those without DCI (p < 0.01). Plasma F2-IsoP concentration on day 2, and NADPH and NOS3 concentrations on day 6, correlated with DCI occurrence (p < 0.01). The authors observed decreased antioxidant capacity in patients with DCI, which may be explained by increased F2-IsoP and decreased NADPH. Assessment of F2-IsoP, NOS3, and NADPH may improve the diagnostic accuracy of DCI. Further work is required to determine the role of F2-IsoP, NOS3, and NADPH in clinical practice and DCI pathophysiology.

High levels of blood lipid and glucose predict adverse prognosis in patients with aneurysmal subarachnoid hemorrhage

ObjectiveWe conducted a retrospective study on the prognostic factors of aneurysmal subarachnoid hemorrhage (aSAH) patients in the author's Hospital from January 2019 to May 2023. To discuss the association of the blood lipid and glucose levels of patients with the prognosis of aSAH, and verify that high blood lipid and glucose levels are important factors affecting adverse prognosis. MethodsAll patients with aSAH were collected as the case group, which was divided into two groups according to the modified Rankin Scores (mRS), the good prognosis group (Group A, mRS ＜ 3) and the adverse prognosis group (Group B,mRS ≥3). The clinical data of age, gender, accompanied chronic diseases (hypertension, diabetes), smoking, drinking, Glasgow Coma Scale (GCS), Hunt-Hess (H-H) grade, Modified Fisher grade, total cholesterol (TC) , triglyceride (TG) , high-density cholesterol lipoprotein (HDL-C) , low-density cholesterol lipoprotein (LDL-C) , blood glucose (BG) , responsible aneurysm diameter and location were recorded too. Correlations between blood lipid and glucose levels and Modified Fisher grade were assessed by the Spearman correlation analysis. The receiver operating characteristic (ROC) curve was utilized to evaluate the diagnostic efficacy. The effect of blood lipid and glucose levels on adverse prognosis was analyzed by Logistic regression models. ResultA total of 259 patients with aSAH were enrolled. The average age of all patients is (56.54 ± 10.52) years, including 96 males and 163 females. They were divided into Group A (n = 146) and Group B (n = 113). Univariate analysis results show that age, the levels of TC, TG, LDL-C, and BG were higher in Group B (P < 0.05). Besides, Group B had more severe GCS, H-H grade, and Modified Fisher grade than Group A, and a higher proportion of intracranial aneurysms with larger diameter (P < 0.05). Correlation analysis showed that TC, TG, LDL-C, and BG levels were positively correlated with Modified Fisher grade (P < 0.05) and H-H grade (P < 0.05). Multivariate logistic regression model analysis showed that high level of Modified Fisher grade (OR = 0.079, 95%CI: 0.027–0.230) , high level of H-H grade (OR = 0.204, 95%CI: 0.067–0.622) , TC (OR = 10.711, 95%CI: 2.457–46.700) , LDL-C (OR = 0.178, 95%CI: 0.039–0.823) and BG (OR = 1.273, 95%CI: 1.012–1.602) increased the risk of adverse prognosis. The AUC of “H-H grade”, “Modified Fisher grade”, “TC level”, “LDL-C level” and “BG level” was 0.822, 0.885, 0.860, 0.772, and 0.721, respectively, in the ROC curve. ConclusionModified Fisher grade, H-H grade, TC, LDL-C, and BG levels at admission were independent predictors of adverse prognosis of aSAH. Besides, TC, LDL-C, and BG levels were positively correlated with Modified Fisher grade and Hunt-Hess grade. What's more, high levels of TC, LDL-C, and BG combined with Modified Fisher grade and H-H grade can identify high-risk groups with adverse prognoses in aSAH patients.

Risk Factors for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review of Observational Studies.

Cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) remains one of the leading causes of high mortality and poor outcomes. Understanding the risk factors associated with CV is pivotal to improving patients' outcomes.We conducted an extensive search for analytical observational studies that analyzed the correlation between various variables and the likelihood of CV development among adult patients with SAH (age ≥ 18years). Five scholar databases were used, namely, PubMed, EBSCO, Web of Science, Science Direct, and Google Scholar. Relevant studies published between January 1st, 2016, and August 9th, 2023, were included. The Newcastle-Ottawa Scale was adopted to assess the risk of bias among included observational studies. A total of 33 studies met the inclusion criteria. Of the 24,958 patients with SAH who were identified, 6,761 patients had a subsequent CV (27.1%). Several statistically significant risk factors were reported across the literature. Younger age, female sex, smoking, alcohol intake, modified Fisher grade 3-4, higher Hunt and Hess grading, and the presence of multiple comorbidities (diabetes, hypertension, congestive heart failure, and history of stroke) were among the well-established risk factors for CV. Additionally, leukocytosis was consistently reported to be a significant predictor in multiple studies, providing compelling evidence for its association with CV. Even though single studies reported an association between CV and certain variables, further research is necessary to investigate the implications of these findings. These include arterial tortuosity, hypokalemia, potassium to glucose gradient, hypoalbuminemia, anemia, von Willebrand factor and vascular endothelial growth factor, use of desflurane, and hemodynamic stability. Overall, this systemic review provides a comprehensive summary of the current data that evaluates the potential risk factors for the development of CV after SAH. However, because of data heterogeneity, certain factors require further validation in their correlation with CV development. Larger-scale observational and clinical trials are mandatory to extensively investigate the significant predictors of CV to lay the scientific foundation for improving outcomes in susceptible patients with SAH.

The factors associated with the modified Fisher grade in patients with aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening medical condition with a high fatality and morbidity rate. There was a substantial link between the modified Fisher grade of aSAH and the neurological function deficit. This study aimed to analyze the factors associated with the modified Fisher grade of aSAH using a machine learning approach. A multi-center observational study was conducted. The patients with aSAH were recruited from five tertiary hospitals in China. The volume of hemorrhage in aSAH was measured using the modified Fisher grade scale. The risk factors responsible for the modified Fisher grade of aSAH were analyzed, which include sociodemographic factors, clinical factors, blood index, and ruptured aneurysm characteristics. We built several tree-based machine learning models (XGBoost, CatBoost, LightGBM) for prediction and used grid search to optimize model parameters. To comprehensively evaluate the model, we used Accuracy, Precision, Area Under the Receiver Operating Characteristic Curve (AUROC), Area Under the Precision-Recall Curve (AUPRC), and Brier as evaluation indicators to assess the model performance and select the best model. A total of 888 patients with aSAH were recruited, of whom 305 with modified Fisher grade of 3 and 4. The results show that the XGBoost model has the highest AUROC of 0.772, and the indicators are better than CatBoost and LightGBM. The feature importance graph shows that the top feature variables include platelet, thrombin time, fibrinogen, preadmission systolic blood pressure, activated partial thromboplastin time, and the time interval between the onset of aSAH and the first-time CT examination. The factors responsible for the modified Fisher grade of aSAH were identified, which offered valuable insights for future research and clinical intervention. These risk factors should be controlled in the treatment of unruptured aneurysms, and appropriate treatment can be given if necessary to reduce the risk of severe hemorrhage after aneurysm rupture.

Comparison of scales for the evaluation of aneurysmal subarachnoid haemorrhage: a retrospective cohort study

Background/ObjectivesAneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening event with major complications. Delayed cerebral infarct (DCI) occurs most frequently 7 days after aSAH and can last for a prolonged period. To determine the most predictive radiological scales in grading subarachnoid or ventricular haemorrhage or both for functional outcome at 3 months in a large aSAH population, we conducted a single-centre retrospective study.MethodsA 3-year single-centre retrospective cohort study of 230 patients hospitalised for aSAH was analysed. Initial computed tomography (CT) scans in patients hospitalised for aSAH were blindly assessed using eight grading systems: the Fisher grade, modified Fisher grade, Barrow Neurological Institute scale, Hijdra scale, Intraventricular Haemorrhage (IVH) score, Graeb score and LeRoux score.ResultsOf 200 patients with aSAH who survived to day 7 and were included for DCI analysis, 39% of cases were complicated with DCI. The Hijdra scale was the best predictor for DCI, with a receiver operating characteristic area under the curve (ROCAUC) of 0.80 (95% confidence interval (CI), 0.74–0.85). The IVH score was the most effective grading system for predicting acute hydrocephalus, with a ROCAUC of 0.85 (95% CI, 0.79–0.89). In multivariate analysis, the Hijdra scale was the best predictor of the occurrence of DCI (hazard ratio, 1.18; 95% CI, 1.10–1.25).ConclusionsAlthough these results have yet to be prospectively confirmed, our findings suggest that the Hijdra scale may be a good predictor of DCI and could be useful in daily clinical practice.Clinical relevance statementBetter assessment of subarachnoid haemorrhage patients would allow for better prognostication and management of expectations, as well as referral for appropriate services and helping to appropriate use limited critical care resources.Key PointsAneurysmal subarachnoid haemorrhage is a life-threatening event that causes severe disability and leads to major complications such as delayed cerebral infarction.Accurate assessment of the amount of blood in the subarachnoid spaces on computed tomography with the Hijdra scale can better predict the risk of delayed cerebral infarct.The Hijdra scale could be a good triage tool for subarachnoid haemorrhage patients.

A predictive model in patients with chronic hydrocephalus following aneurysmal subarachnoid hemorrhage: a retrospective cohort study.

Our aim was to develop a nomogram that integrates clinical and radiological data obtained from computed tomography (CT) scans, enabling the prediction of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH). A total of 318 patients diagnosed with subarachnoid hemorrhage (SAH) and admitted to the Department of Neurosurgery at the Affiliated People's Hospital of Jiangsu University between January 2020 and December 2022 were enrolled in our study. We collected clinical characteristics from the hospital's medical record system. To identify risk factors associated with chronic hydrocephalus, we conducted both univariate and LASSO regression models on these clinical characteristics and radiological features, accompanied with penalty parameter adjustments conducted through tenfold cross-validation. All features were then incorporated into multivariate logistic regression analyses. Based on these findings, we developed a clinical-radiological nomogram. To evaluate its discrimination performance, we conducted Receiver Operating Characteristic (ROC) curve analysis and calculated the Area Under the Curve (AUC). Additionally, we employed calibration curves, and utilized Brier scores as an indicator of concordance. Additionally, Decision Curve Analysis (DCA) was performed to determine the clinical utility of our models by estimating net benefits at various threshold probabilities for both training and testing groups. The study included 181 patients, with a determined chronic hydrocephalus prevalence of 17.7%. Univariate logistic regression analysis identified 11 potential risk factors, while LASSO regression identified 7 significant risk factors associated with chronic hydrocephalus. Multivariate logistic regression analysis revealed three independent predictors for chronic hydrocephalus following aSAH: Periventricular white matter changes, External lumbar drainage, and Modified Fisher Grade. A nomogram incorporating these factors accurately predicted the risk of chronic hydrocephalus in both the training and testing cohorts. The AUC values were calculated as 0.810 and 0.811 for each cohort respectively, indicating good discriminative ability of the nomogram model. Calibration curves along with Hosmer-Lemeshow tests demonstrated excellent agreement between predicted probabilities and observed outcomes in both cohorts. Furthermore, Brier scores (0.127 for the training and 0.09 for testing groups) further validated the predictive performance of our nomogram model. The DCA confirmed that this nomogram provides superior net benefit across various risk thresholds when predicting chronic hydrocephalus. The decision curve demonstrated that when an individual's threshold probability ranged from 5 to 62%, this model is more effective in predicting the occurrence of chronic hydrocephalus after aSAH. A clinical-radiological nomogram was developed to combine clinical characteristics and radiological features from CT scans, aiming to enhance the accuracy of predicting chronic hydrocephalus in patients with aSAH. This innovative nomogram shows promising potential in assisting clinicians to create personalized and optimal treatment plans by providing precise predictions of chronic hydrocephalus among aSAH patients.

Racial and Ethnic Differences in Mortality and Functional Outcomes Following Aneurysmal Subarachnoid Hemorrhage.

Ischemic and hemorrhagic stroke incidence tends to be higher among minority racial and ethnic groups. The effect of race and ethnicity following an aneurysmal subarachnoid hemorrhage (aSAH) remains poorly understood. Thus, we aimed to explore the association between race and ethnicity and aSAH outcomes. Single-center retrospective review of patients with aSAH from January 2009 to March 2023. Primary outcome was in-hospital mortality. Secondary outcomes included delayed cerebral ischemia, cerebral infarction, radiographic and symptomatic vasospasm, pulmonary complications, epileptic seizures, external ventricular drain placement, and modified Rankin Scale score at discharge and 3-month follow-up. Associations between race and ethnicity and outcomes were assessed using binary and ordinal regression models, with multivariable models adjusted for significant covariates. A total of 1325 patients with subarachnoid hemorrhage presented to our center. Among them, 443 cases were excluded, and data from 882 patients with radiographically confirmed aSAH were analyzed. Distribution by race and ethnicity was 40.8% (n=360) White, 31.4% (n=277) Hispanic, 22.1% (n=195) Black, and 5.7% (n=50) Asian. Based on Hunt-Hess and modified Fisher grade, aSAH severity was similar among groups (P=0.269 and P=0.469, respectively). In-hospital mortality rates were highest for Asian (14.0%) and Hispanic (11.2%) patients; however, after adjusting for patient sex, age, health insurance, smoking history, alcohol and substance abuse, and aneurysm treatment, the overall likelihood was comparable to White patients. Hispanic patients had higher risks of developing cerebral infarction (adjusted odds ratio, 2.17 [1.20-3.91]) and symptomatic vasospasm (adjusted odds ratio, 1.64 [1.05-2.56]) than White patients and significantly worse discharge modified Rankin Scale scores (adjusted odds ratio, 1.44 [1.05-1.99]). Non-White patients also demonstrated a lower likelihood of 0 to 2 discharge modified Rankin Scale scores (adjusted odds ratio, 0.71 [0.50-0.98]). No significant interactions between race and ethnicity and age or sex were found for in-hospital mortality and functional outcomes. Our study identified significant differences in cerebral infarction and symptomatic vasospasm risk between Hispanic and White patients following aSAH. A higher likelihood of worse functional outcomes at discharge was found among non-White patients. These findings emphasize the need to better understand predisposing risk factors that may influence aSAH outcomes. Efforts toward risk stratification and patient-centered management should be pursued.

Cisternal nicardipine for prevention of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a comparative retrospective cohort study

PurposeIntrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile.MethodsWe performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group).ResultsSeventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group.ConclusionAdministration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies.

Construction and validation of a perioperative concomitant lower extremity deep vein thrombosis line graph model in patients with aneurysmal subarachnoid hemorrhage

BackgroundTo develop and validate a nomogram for predicting the probability of deep venous thrombosis (DVT) in patients with aneurysmal subarachnoid hemorrhage (aSAH) during the perioperative period, using clinical features and readily available biochemical parameters. MethodsThe least absolute shrinkage and selection operator (LASSO) regression technique was employed for data dimensionality reduction and selection of predictive factors. A multivariable logistic regression analysis was conducted to establish a predictive model and nomogram for post-aSAH DVT. The discriminative ability of the model was determined by calculating the area under the curve (AUC). ResultsA total of 358 aSAH patients were included in the study, with an overall incidence of DVT of 20.9%. LASSO regression identified four variables, including age, modified Fisher grade, total length of hospital stay, and anticoagulation therapy, as highly predictive factors for post-aSAH DVT. The patients were randomly divided into a modeling group and a validation group in a 6:4 ratio to construct the nomogram. The AUCs of the modeling and validation groups were 0.8511 (95% CI, 0.7922–0.9099) and 0.8633 (95% CI, 0.7968–0.9298), respectively. ConclusionsThe developed nomogram exhibits good accuracy, discriminative ability, and clinical utility in predicting DVT, aiding clinicians in identifying high-risk individuals and implementing appropriate preventive and treatment measures.

A nomogram for predicting the risk of cerebral vasospasm after neurosurgical clipping in patients with aneurysmal subarachnoid hemorrhage.

Cerebral vasospasm (CVS) is a common complication that occurs after neurosurgical clipping of intracranial aneurysms in patients with aSAH. This complication can lead to clinical deterioration and a poor prognosis. The aim of this study is to explore the risk factors for CVS in aSAH patients who have undergone neurosurgical clipping, develop a nomogram for CVS, and evaluate its performance. Patients with aSAH who underwent neurosurgical clipping in the Department of Neurosurgery from January 2018 to January 2023 were selected as the subjects of this research. The clinical data of these patients were retrospectively analyzed. Logistic multivariate regression analysis was employed to identify the independent risk factors of CVS. A clinical prediction model in the form of a nomogram for CVS was developed using the R programming language and subsequently evaluated for its performance and quality. A total of 156 patients with aSAH were included in the analysis, comprising 109 patients in the training set and 47 patients in the validation set. In the training cohort, 27 patients (24.77%) developed CVS after neurosurgical clipping, while in the validation cohort, 15 patients (31.91%) experienced CVS. Multivariate regression analysis revealed that age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade were independent risk factors for CVS. The nomogram exhibited excellent discriminative performance in both the training set (AUC = 0.885) and the validation set (AUC = 0.906). CVS was a prevalent complication following neurosurgical clipping in patients with aSAH, with a highly intricate pathogenesis and pathophysiological course. Early prediction of CVS represented a significant challenge in clinical practice. In this study, age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade emerged as independent risk factors for CVS. The resulting nomogram demonstrated substantial predictive value.

Clinical value of serum complement component 1q levels in the prognostic analysis of aneurysmal subarachnoid hemorrhage: a prospective cohort study.

To analyze the relationship between serum complement component 1q (C1q) levels and functional prognosis in patients with aneurysmal subarachnoid hemorrhage (aSAH), and to reveal its clinical value. In this prospective cohort study, we collected clinical data of aSAH patients admitted to the Department of Neurosurgery, Hangzhou First People's Hospital from January 2020 to October 2022. Parameters such as serum C1q levels, Hunt-Hess grade, modified Fisher grade, and the modified Rankin scale (mRS) at 3 months were included for evaluation. Patients were grouped based on the occurrence of delayed cerebral ischemia (DCI). Spearman rank correlation test and Kruskal-Wallis rank sum test were used to analyze the correlation between serum C1q levels, disease severity, and prognosis. Potential risk factors affecting prognosis and the occurrence of DCI were screened through Independent sample t-test or Mann-Whitney U test. Variables with significant differences (p < 0.05) were incorporated into a logistic regression model to identify independent risk factors affecting prognosis and DCI occurrence. Serum C1q levels were plotted as a ROC curve for predicting prognosis and DCI, and the area under the curve was calculated. A total of 107 aSAH patients were analyzed. Serum C1q levels positively correlated with Hunt-Hess grade, modified Fisher grade and mRS (all p < 0.001). Significant differences were observed in C1q levels among different Hunt-Hess grade, mFisher grade and mRS (all p < 0.001). Notably, higher serum C1q levels were seen in the poor prognosis group and DCI group, and correlated with worse prognosis (OR = 36.927, 95%CI 2.003-680.711, p = 0.015), and an increased risk for DCI (OR = 17.334, 95%CI 1.161-258.859, p = 0.039). ROC analysis revealed the significant discriminative power of serum C1q levels for poor prognosis (AUC 0.781; 95%CI 0.673-0.888; p < 0.001) and DCI occurrence (AUC 0.763; 95%CI 0.637-0.888; p < 0.001). Higher C1q levels independently predicted a poor prognosis and DCI with equivalent predictive abilities to Hunt-Hess grade and modified Fisher grade (both p < 0.05). High levels of C1q in the blood is an independent risk factor for poor prognosis and the development of DCI in patients with aSAH. This can more objectively and accurately predict functional outcomes and the incidence of DCI. C1q may have a significant role in the mechanism behind DCI after aSAH.

The obesity paradox and ventriculoperitoneal shunting in aneurysmal subarachnoid hemorrhage patients undergoing microsurgical clipping

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) can be devastating. Identifying predisposing factors is paramount in reducing aSAH-related mortality. Obesity’s negative impact on health is well-established. However, the controversial “obesity paradox” in neurosurgery suggests that obesity may confer a survival advantage in SAH. We hypothesized that obesity would have a negative impact on outcomes following surgical clipping in aSAH. MethodsA single-institution retrospective review was performed of aSAH patients undergoing surgical clipping from 2017 to 2021. Demographics and clinically relevant variables were collected. Obesity was defined as body mass index >30. Primary outcome was death or severe disability (mRS 4–6) at last follow-up. Secondary outcome was VPS placement. Multivariable Cox proportional-hazards model identified predictors of poor outcome. Kaplan-Meier curves identified survivorship differences between obese and non-obese patients. ResultsPoor outcome occurred in 11 of 52 total patients (21.2 %). There were no differences in demographics or distribution of Hunt Hess (HH), modified Fisher Grade (mFG), or external ventricular drain (EVD) placement between obese and non-obese patients. On univariate analysis, hypertension, older age, and non-obesity were predictive of poor outcome. On multivariable analysis, only obesity remained significant, suggesting a protective effect from poor outcome (HR 0.45 [0.21–0.95], p = 0.037). VPS placement occurred in 6 (11.5 %) patients for which obesity was not a significant predictor. ConclusionsObesity may have a protective effect against poor outcome following surgical clipping in aSAH. Additionally, obesity does not appear to increase rate of EVD conversion to VPS. Thus, our study suggests that obesity should not preclude patients from open surgical intervention when clinically appropriate.

Cilostazol May Improve Outcomes Even in Patients with Aneurysmal Subarachnoid Hemorrhage Aged 75 Years and Older: Multicenter Cohort Study and Propensity Score–Matched Analyses

The opportunities to treat elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) are increasing globally, but the outcome remains poor. This study seeks to investigate treatment-related factors that can modify functional outcomes in patients with aSAH aged ≥75 years. A total of 202 patients with aSAH aged ≥75 years prospectively enrolled in 9 primary stroke centers from 2013 to 2021 were retrospectively analyzed. Clinical variables including treatments for hydrocephalus, angiographic vasospasm, and delayed cerebral ischemia were compared between patients with good (modified Rankin Scale [mRS] score 0-2) and poor (mRS score 3-6) outcomes at 90 days from onset, followed by multivariate analyses to find independent outcome determinants. A modifiable treatment-related variable was evaluated after propensity score matching with adjustments for age, sex, pre-onset mRS score, aSAH severity, and treatment modality. More than half of patients showed World Federation of Neurological Societies grades IV-V on admission. Univariate analyses showed that advanced age, worse pre-onset mRS score, more severe neurologic status on admission, higher modified Fisher grade on admission computed tomography scans, and acute and chronic hydrocephalus were associated with poor outcomes. In contrast, administration of a phosphodiesterase type III inhibitor, cilostazol, was associated with good outcomes in both univariate (P= 0.036) and multivariate analyses (adjusted odds ratio, 0.305; 95% confidence interval, 0.097-0.955; P= 0.042). Propensity score matching analyses showed that patients treated with cilostazol had better outcomes (P= 0.016) with fewer incidences of delayed cerebral infarction (P= 0.008). Even in patients with aSAH aged ≥75 years, cilostazol administration may lead to better outcomes by suppressing the development of delayed cerebral infarction.

Lower Serum Iron Level Predicts Postoperative Global Cerebral Edema Following Aneurysmal Subarachnoid Hemorrhage.

Iron plays an important role in neuronal injury and edema formation after intracranial hemorrhage. However, the role of serum iron in aneurysmal subarachnoid hemorrhage (aSAH) is yet to be well-established. This study aims to identify whether serum iron could predict postoperative global cerebral edema (GCE) and poor outcome in aSAH. 847 patients' aSAH clinical data were retrospectively collected at the First Affiliated Hospital of Fujian Medical University. Data on demographics, clinical characteristics, and laboratory values were collected and analyzed through univariate and multivariate analyses. Propensity score matching (PSM) analysis was performed to balance the baseline differences between the groups. The incidence of high-grade global cerebral edema (H-GCE) following aSAH was 12.99% (110/847). Serum iron levels [odds ratio (OR) = 1.143; 95% confidence interval (CI), (1.097-1.191); p < 0.001] were associated with the occurrence of H-GCE following aSAH in the univariate analysis. This association remained statistically significant even after adjusting for other variables in the multivariate model, with serum iron having an OR of 1.091 (95% CI, 1.043-1.141; p < 0.001) for GCE. After 1:1 PSM, serum iron levels ≤ 10.7 µmol/L remained a significant independent predictor of GCE (p = 0.002). The receiver operating characteristic (ROC) curve analysis determined that a serum iron cut-off value of ≤ 10.7 µmol/L was optimal for predicting H-GCE [Areas under the ROC curves (AUC) = 0.701, 95% CI, (0.669-0.732), p < 0.001; sensitivity, 67.27%; specificity, 63.77%] in patients with aSAH. Additionally, a trend was observed in which higher Hunt-Hess grades (HH grade) were associated with lower serum iron levels, and higher modified Fisher grades (mFisher grade) were associated with lower serum iron levels. In addition, the serum iron level was also associated with a 3-month functional neurological outcome (p < 0.001). The results of this study indicate that a decreased serum iron level serves as a clinically significant biomarker for the prediction of postoperative GCE and a poor outcome at 3-months in patients with aSAH.

Prognostic value of initial routine laboratory blood tests in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a retrospective cohort study.

Aneurysmal subarachnoid hemorrhage (aSAH) necessitating mechanical ventilation (MV) presents a serious challenge for intensivists. Laboratory blood tests reflect individual physiological and biochemical states, and provide a useful tool for identifying patients with critical condition and stratifying risk levels of death. This study aimed to determine the prognostic role of initial routine laboratory blood tests in these patients. This retrospective cohort study included 190 aSAH patients requiring MV in the neurosurgical intensive care unit from December 2019 to March 2022. Follow-up evaluation was performed in May 2022 via routine outpatient appointment or telephone interview. The primary outcomes were death occurring within 7 days after discharge (short-term mortality) or reported at time of follow-up (long-term mortality). Clinico-demographic and radiological characteristics, initial routine laboratory blood tests (e.g., metabolic panels and arterial blood gas analysis), and treatment were analyzed and compared in relation to mortality. Multivariable logistic and Cox regression analyses, with adjustment of other clinical predictors, were performed to determine independent laboratory test predictors for short- and long-term mortality, respectively. The patients had a median age of 62 years, with a median World Federation of Neurosurgical Societies grade (WFNS) score of 5 and a median modified Fisher grade (mFisher) score of 4. The short- and long-term mortality of this cohort were 60.5% and 65.3%, respectively. Compared with survivors, non-survivors had more severe disease upon admission based on neurological status and imaging features and a shorter disease course, and were more likely to receive conservative treatment. Initial ionized calcium was found to be independently associate with both short-term [adjusted odds ratio (OR): 0.92; 95% confidence interval (CI): 0.86 to 0.99; P=0.020] and long-term mortality [adjusted hazard ratio (HR): 0.95; 95% CI: 0.92 to 0.99; P=0.010], after adjusting for potential confounders. Moreover, the admission glucose level was found to be associated only with short-term mortality (adjusted OR: 1.19; 95% CI: 1.06 to 1.34; P=0.004). Laboratory screening may provide a useful tool for the management of aSAH patients requiring MV in stratifying risk levels for mortality and for better clinical decision-making. Further study is needed to validate the effects of calcium supplementation and glucose-lowering therapy on the outcomes in this disease.

CLINICO-DEMOGRAPHIC PROFILE AND CLINICAL OUTCOME OF YOUNG ADULT PATIENTS WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE ADMITTED IN QUIRINO MEMORIAL MEDICAL CENTER

In patients younger than 40 years old, aneurysmal subarachnoid hemorrhage (aSAH) is an extremely rare condition. Despite the fact that the clinical features of aSAH have been the subject of extensive research in the general population, there is still some debate regarding the formation of aneurysms and their rupture in the young population. Behaviors such as smoking, excessive alcohol consumption, and the use of sympathomimetic medications are all considered risk factors for aSAH. Being female, the existence of an unruptured cerebral aneurysm, a history of hereditary and family history of aSAH, and certain genetic syndromes all contribute to an increased risk of subarachnoid hemorrhage. An ambidirectional cohort study is utilized in the study on thepatients who are from 19-55 years old admitted at Quirino Memorial Medical Center, Quezon City. The respondents are selected using convenience sampling based on the inclusion and exclusion criteria of the study. The result showed that the Hunt and Hess score still play a significant role in determining the prognosis of young patients with ruptured aSAH. In addition, the survivability of patients in this population does not solely depend on the presence of any behavioral and non-modifiable risk factors for aSAH such as the Modified Fisher Grade Score, location, number, and type of aneurysms on radiographic findings but the clinical outcome and long-term functional outcome depend on the interplay of the above-mentioned factors, as well as the clinical condition of the patient on admission and the interventions given.

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.

A dynamic nomogram for predicting unfavorable prognosis after aneurysmal subarachnoid hemorrhage.

The aim of this study was to examine the predictive value of the multiplication of neutrophil and monocyte counts (MNM) in peripheral blood, and develop a new predictive model for the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). This is a retrospective analysis that included 2 separate cohorts of patients undergoing endovascular coiling for aSAH. The training cohort consisted of 687 patients in the First Affiliated Hospital of Shantou University Medical College; the validation cohort consisted of 299 patients from Sun Yat-sen University's Affiliated Jieyang People's Hospital. The training cohort was used to develop 2 models to predict unfavorable prognosis (modified Rankin scale of 3-6 at 3 months): one was based on traditional factors (e.g., age, modified Fisher grade, NIHSS score, and blood glucose), and another model that included traditional factors as well as MNM on admission. In the training cohort, MNM upon admission was independently associated with unfavorable prognosis (odds ratio after adjustment, 1.06; 95% confidence interval [CI], 1.03-1.10). In the validation cohort, the basic model that included only traditional factors had 70.99% sensitivity, 84.36% specificity, and 0.859 (95% CI, 0.817-0.901) area under the receiver operating characteristic curve (AUC). Adding MNM increased model sensitivity (from 70.99% to 76.48%), specificity (from 84.36% to 88.63%), and overall performance (AUC 0.859 [95% CI, 0.817-0.901] to 0.879 [95% CI, 0.841-0.917]). MNM upon admission is associated with unfavorable prognosis in patients undergoing endovascular embolization for aSAH. The nomogram including MNM is a user-friendly tool to help clinicians quickly predict the outcome of patients with aSAH.

FRED Jr stent for acute flow diversion in ruptured cerebral aneurysms arising from small-caliber vessels: a clinical case series.

Treatment of ruptured aneurysms arising from small-caliber (< 2.5 mm) or distal vessels beyond the circle of Willis is considered challenging with all treatment modalities. Recently, the Flow Re-Direction Endoluminal Device Junior (FRED Jr) stent, designed for flow diversion in small arteries, was approved in the United States for the treatment of nonruptured aneurysms. Here, the authors report their experience using this device in the setting of subarachnoid hemorrhage (SAH). Clinical and radiological records of patients sustaining SAH treated with a FRED Jr stent between June 2020 and October 2022 were reviewed. Treatment course, including antiplatelet therapy, external ventricular drain (EVD) management, and vasospasm, and clinical outcomes were analyzed. Angiographic results were assessed according to the O'Kelly-Marotta (OKM) grading scale. Nine patients at a median age of 62 (range 27-75) years were included. The median Hunt and Hess grade was II (IQR I) and the median modified Fisher grade was 4 (IQR 1). Aneurysm morphology types included saccular (6 patients), blister (1 patient), and dissecting (2 patients), and the aneurysms were located at the anterior communicating artery complex (n = 3) at the A2/A3 (n = 3), M2/M3 (n = 1), V4 (n = 1), and P2 (n = 1) arterial segments. All stents were deployed successfully with no intraprocedural complications. Postoperatively, no rebleeding events were encountered. Vasospasm therapy was initiated in 6 patients, and no symptomatic EVD-related hematomas were observed. Postoperative ischemic events were encountered in 2 patients. The median 3-month modified Rankin Scale score was 2 (IQR 1) for the 7 surviving patients, and 3-month radiographic follow-up revealed OKM grade D in 4 of 7 patients. Flow diversion using the FRED Jr stent is feasible as a potential treatment strategy for acutely ruptured aneurysms arising from small-caliber vessels. The complication profile reported in this series is comparable to those of historical microsurgical cohorts, and effective protection was conferred by this treatment modality. Therefore, our small cohort provides a glimpse into a new tool for successfully achieving acute flow diversion for this subset of difficult-to-treat aneurysms.

Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage

Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P= 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P= 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P= 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P= 0.272). Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.