Modified Fisher Scale Research Articles

Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit

ObjetiveIn Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes. MethodsA retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes. ResultsThe modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (−1.579, p: 0.011) and mWFNS (−0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results. ConclusionOur findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a “dual approach” offers advantages in a patient individualized treatment decision protocol in the European context.

Oxygen-Based Autoregulation Indices Associated with Clinical Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage.

Impairment in cerebral autoregulation has been proposed as a potentially targetable factor in patients with aneurysmal subarachnoid hemorrhage (aSAH); however, there are different continuous measures that can be used to calculate the state of autoregulation. In addition, it has previously been proposed that there may be an association of impaired autoregulation with the occurrence of spreading depolarization (SD) events. Study participants with invasive multimodal monitoring and aSAH were enrolled in an observational study. Autoregulation indices were prospectively calculated from this database as a 10s moving correlation coefficient between various cerebral blood flow (CBF) surrogates and mean arterial pressure (MAP). In study participants with subdural electrocorticography (ECoG) monitoring, SD was also scored. Associations between clinical outcomes using the modified Rankin scale and occurrence of either isolated or clustered SD were assessed. A total of 320 study participants were included, 47 of whom also had ECoG SD monitoring. As expected, baseline severity factors, such as modified Fisher scale score and World Federation of Neurosurgical Societies scale grade, were strongly associated with the clinical outcome. SD probability was related to blood pressure in a triphasic pattern, with a linear increase in probability below MAP of ~ 100 mm Hg. Multiple autoregulation indices were available for review based on moving correlations between mean arterial pressure (MAP) and various surrogates of cerebral blood flow (CBF). We calculated the pressure reactivity (PRx) using two different sources for intracranial pressure (ICP). We calculated the oxygen reactivity (ORx) using the partial pressure of brain tissue oxygen (PbtO2) from the Licox probe. We calculated the cerebral blood flow reactivity (CBFRx) using perfusion measurements from the Bowman perfusion probe. Finally, we calculated the cerebral oxygen saturation reactivity (OSRx) using regional cerebral oxygen saturation measured by near-infrared spectroscopy from the INVOS sensors. Only worse ORx and OSRx were associated with worse clinical outcomes. Both ORx and OSRx also were found to increase in the hour prior to SD for both sporadic and clustered SD. Impairment in autoregulation in aSAH is associated with worse clinical outcomes and occurrence of SD when using ORx and OSRx. Impaired autoregulation precedes SD occurrence. Targeting the optimal MAP or cerebral perfusion pressure in patients with aSAH should use ORx and/or OSRx as the input function rather than intracranial pressure.

Rare simultaneous fetal posterior cerebral artery and conventional posterior cerebral artery duplication in a patient with a ruptured posterior communicating artery aneurysm: illustrative case.

The fetal-type posterior cerebral artery (PCA) is defined as a variant anatomy in which the posterior communicating artery (PCOM) is larger than the hypoplastic or aplastic P1 segment of the PCA. The authors present the novel case of a patient with a duplicated right PCA in parallel with fetal-type and conventional PCAs supplying adjacent components of the PCA cerebral territory. A 59-year-old woman presented with a modified Fisher Scale score 4 subarachnoid hemorrhage. A right irregular PCOM aneurysm that measured 9.5 mm × 4.5 mm × 4.5 mm arose from the base of a variant branch supplying a portion of the PCA, rather than a conventional PCOM, and was found on digital subtraction angiography. Following endovascular coil embolization, the patient was discharged home. The fetal-type variant has implications for thromboembolic events. If an embolism occludes the anterior circulation in a patient with a fetal-type PCA, it may result in an infarct in the PCA territory. Awareness of cerebral arterial anatomy, including an atypical collateral supply, informs a treating team's latitude in tolerance of which sites must be preserved and which can be safely sacrificed. https://thejns.org/doi/10.3171/CASE23735.

Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit

ObjetiveIn Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes. MethodsA retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes. ResultsThe modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (−1.579, p: 0.011) and mWFNS (−0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results. ConclusionOur findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a “dual approach” offers advantages in a patient individualized treatment decision protocol in the European context.

Longitudinal change of serum AIM2 levels after aneurysmal subarachnoid hemorrhage and its prognostic significance: a two-center prospective cohort study

Absent in melanoma 2 (AIM2) is implicated in neuroinflammation. Here, we explored the prognostic significance of serum AIM2 in human aneurysmal subarachnoid hemorrhage (aSAH). We conducted a consecutive enrollment of 127 patients, 56 of whom agreed with blood-drawings not only at admission but also at days 1, 2, 3, 5, 7 and 10 days after aSAH. Serum AIM2 levels of patients and 56 healthy controls were measured. Disease severity was assessed using the modified Fisher scale (mFisher) and World Federation of Neurological Surgeons Scale (WFNS). Neurological outcome at poststroke 90 days was evaluated via the modified Rankin Scale (mRS). Univariate analysis and multivariate analysis were sequentially done to ascertain relationship between serum AIM2 levels, severity, delayed cerebral ischemia (DCI) and 90-day poor prognosis (mRS scores of 3–6). Patients, in comparison to controls, had a significant elevation of serum AIM2 levels at admission and at days 1, 2, 3, 5, 7 and 10 days after aSAH, with the highest levels at days 1, 2, 3 and 5. AIM2 levels were independently correlated with WFNS scores and mFisher scores. Significantly higher serum AIM2 levels were detected in patients with a poor prognosis than in those with a good prognosis, as well as in patients with DCI than in those without DCI. Moreover, serum AIM2 levels independently predicted a poor prognosis and DCI, and were linearly correlated with their risks. Using subgroup analysis, there were no significant interactions between serum AIM2 levels and age, gender, hypertension and so on. There were substantially high predictive abilities of serum AIM2 for poor prognosis and DCI under the receiver operating characteristic curve. The combination models of DCI and poor prognosis, in which serum AIM2, WFNS scores and mFisher scores were incorporated, showed higher discriminatory efficiencies than anyone of the preceding three variables. Moreover, the models are delineated using the nomogram, and performed well under the calibration curve and decision curve. Serum AIM2 levels, with a substantial enhancement during early phase after aSAH, are closely related to bleeding severity, poor 90-day prognosis and DCI of patients, substantializing serum AIM2 as a potential prognostic biomarker of aSAH.

Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage

IntroductionSubarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts. MethodsThis study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients’ clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration. ResultsA total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection. ConclusionsThe most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Factores de riesgo para la colocación de derivación ventriculoperitoneal en hidrocefalia secundaria a hemorragia subaracnoidea espontánea

IntroductionSubarachnoid hemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts. Material and methodsThis study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients’ clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analyzed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration. ResultsA total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25,3%. 66,3% of the total of patients with SAH were due to intracranial aneurysm rupture (n=238). 45,3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11,7% (n=28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26,1 days. The mean rate of reoperation of patients after shunt was 17,7%, mostly due to infection. ConclusionsThe most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Clinical Value of Serum Secretoneurin Levels in Prediction of Delayed Cerebral Ischemia and Prognostic Analysis of Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study.

Secretoneurin is a neuropeptide with several neuroprotective properties. Here, we discuss the importance of serum secretoneurin in assessing severity and predicting delayed cerebral ischemia (DCI) and functional outcomes following aneurysmal subarachnoid hemorrhage (aSAH). A prospective cohort study of 167 patients with aSAH and 100 controls was performed to determine serum secretoneurin levels. Severity was reflected by the Hunt-Hess and modified Fisher scores. Prognostic parameters included DCI and poor 6-month prognosis (extended Glasgow outcome scale scores of 1-4). Univariate analysis followed by multivariate analysis was performed to determine the correlation between severity and prognosis. Compared to controls, patients exhibited a marked elevation in serum secretoneurin levels. Serum secretoneurin levels, which were independently correlated with Hunt-Hess scores and modified Fisher scores, independently predicted DCI and bad 6-month prognosis. Serum secretoneurin levels, which were linearly related to the risk of DCI and poor prognosis under a restricted cubic spline, effectively distinguished the risks under the receiver operating characteristic (ROC) curve. Subgroup analysis for prognosis or DCI prediction revealed no substantial interactions between serum secretoneurin levels and other variables, such as age, sex, hypertension, diabetes, alcohol consumption, and cigarette consumption. In addition, the prognosis model, in which serum secretoneurin, Hunt-Hess scale, and modified Fisher scale were merged, was graphically represented by a nomogram and performed well under the calibration, decision, and ROC curves. Serum secretoneurin levels significantly increased after aSAH, which was intimately correlated with disease severity and independently associated with DCI and worse outcomes, indicating that serum secretoneurin may be a potential prognostic biomarker of aSAH.

Abstract 091: Intraventricular milrinone for management of vasospasm following aneurysmal subarachnoid hemorrhage

Introduction Aneurysmal subarachnoid hemorrhage (aSAH) accounts for about 10% of hemorrhagic strokes [1] and holds a high mortality and morbidity rate. [2, 3] Vasospasm is one of the more devastating complications of aSAH. Novel imaging modalities have drastically improved our ability in prompt detection of vasospasm in these patients. However, clinical management of this complication is still debated among experts. [4] Systemic cerebral vasodilators are widely used in aSAH patients, but guidelines for interventional and rescue procedures are not well developed. [5] Methods Here, we report a case of severe vasospasm following aSAH that was successfully treated with intraventricular injection of milrinone through external ventricular drain (EVD) in conjunction to standard therapy. Results A 70‐year‐old man with a history of diabetes, hypertension, and hyperlipidemia was brought to the emergency department after he was found down and unresponsive. He was intubated by EMS on route. Head CT on arrival showed a diffuse subarachnoid hemorrhage, more prominent in the posterior fossa, and grade IV on the modified Fisher scale. An initial DSA showed a ruptured aneurysm in the second segment of the right posterior inferior cerebellar artery, second segment. A right frontal EVD was placed on the second day. Hemodynamic augmentation was achieved with intravenous and intraventricular milrinone. Cerebral arterial patency was evaluated with daily transcranial doppler (TCD). The patient did not show any evidence of vasospasm until day 9 where TCD revealed severe vasospasm in the basilar and bilateral vertebral arteries, as well as mild vasospasm of anterior and middle cerebral arteries. Intraventricular milrinone was injected into the EVD in from day 9 to day 12. Using sterile technique, 4 mL of CSF was removed followed by the injection of 0.87mg (2mL) of milrinone into the EVD via a three way stop cock. EVD was then flushed with 2mL of preservative‐free saline and clamped for 1 hour. This procedure effectively improved vasospasm on serial TCDs and also DSAs (Figure1). The patient underwent several DSA’s on days 10, 14, 19, 20, and 21 with targeted intraarterial milrinone and verapamil injections. His final TCD showed only mild middle cerebral artery and moderate basilar artery vasospasm. At that point, no more intervention was deemed necessary. A ventriculoperitoneal shunt was also placed. CT scan before discharge showed mild improvement in ventricular size and stable SAH blood products. The course of hospitalization was complicated by hyponatremia, atrial fibrillation, and respiratory failure with inability to wean off ventilator, resulting in tracheostomy and gastrostomy tube placement. The patient was discharged in stable condition on day 30 to a rehabilitation center. Conclusion Intraventricular milrinone in addition to standard therapy can be an effective method in treatment of severe vasospasm in aSAH patients.

Comparison of Prognostic Performance between Fisher and Modified Fisher Scales for Patients with Aneurysmal Subarachnoid Hemorrhage

Abstract Objective The present study aims to assess and compare the prognostic value of these two scales for predicting mortality. Method We reviewed 172 patients with aneurysmal subarachnoid hemorrhage, who were followed-up for 6 months. The Fisher and modified Fisher scales were evaluated for the prediction of mortality using logistic regressions. Results The Fisher scale was associated with mortality (odds ratio [OR]: 2; 95% confidence interval [CI]: 1.09–4.05) in the multivariate analysis. The modified Fisher scale was not associated with mortality in the multivariate analysis (OR: 1.39; 95% CI: 0.9–2.29), nor in the univariate analysis (OR: 1.24; 95%CI: 0.87–1.86). There was no significant association between Fisher score and unfavorable functional outcomes (mRS &gt; 2) in the univariate analysis (OR: 1.33; 95%CI: 0.92–1.92), nor in the multivariate analysis (OR: 1.37; 95%CI: 0.92–2.05). There was no significant association between modified Fisher scores and unfavorable functional outcomes in the univariate analysis (OR: 1.16; 95%CI: 0.88–1.52). There was also no significant association in the multivariate analysis (OR: 1.18; 95%CI: 0.88–1.57). Conclusion Only the Fisher scale was associated with mortality. Neither of the two scales was associated with unfavorable functional outcomes (mRS &gt; 2).

Hounsfield unit as a predictor of symptomatic vasospasm and hydrocephalus in good-grade subarachnoid hemorrhage treated with endovascular coiling.

Patients with good-grade subarachnoid hemorrhage (SAH) often expect favorable outcomes; however, several patients may experience secondary neurological deterioration. Hydrocephalus and vasospasm are significant complications affecting SAH prognosis. We aimed to evaluate the relationship between the incidence of symptomatic vasospasm or hydrocephalus and the Hounsfield unit (HU) value of the subarachnoid space on brain computed tomography (CT) in patients with good-grade SAH treated with endovascular coiling. We conducted a retrospective analysis of consecutive initially good-grade pure SAH patients (Hunt-Hess grade I or II, modified Fisher scale I or III) with ruptured anterior circulation aneurysms treated with endovascular coiling in a single tertiary neurosurgical center between January 2010 and December 2019. The HU value within each cisterns of enrolled patients was measured, and after setting an appropriate cutoff value, it was investigated whether it could be a predictor of the occurrence of vasospasm and hydrocephalus. The study included 108 eligible patients (34 males, mean age 60.88±12.26 years): 26 (24.1%) showed symptomatic vasospasm and 31 (28.7%) developed hydrocephalus. Patients with symptomatic vasospasm had a greater proportion of those with Hunt-Hess grade II (77% vs. 51%, P=0.021) and modified Fisher scale III scores (58% vs. 22%, P=0.001). The hydrocephalus group presented an older mean age (65.90 vs. 58.86 years, P=0.006) and a greater proportion of Hunt-Hess grade II (74% vs. 51%, P=0.025) and modified Fisher scale III cases (45% vs. 25%, P=0.037). The mean HU values of the Sylvian cistern (53.23 vs. 43.99, P<0.001) and basal cisterns (47.04 vs. 40.18, P=0.003) were higher in the vasospasm group. In the hydrocephalus group, only the basal cistern HU value was significantly higher (45.60 vs. 40.32, P=0.016). The area under the receiver operating characteristic (ROC) curve to determine the best cut-off HU value for the prediction of patients with symptomatic vasospasm revealed a Sylvian cistern HU value of 50.375 (sensitivity: 0.692, specificity: 0.683) and basal cistern HU value of 44.875 (sensitivity: 0.615, specificity: 0.659). Multivariable logistic analysis showed that age >70 years and Sylvian cistern HU value were independent predictors of any neurological complication at 1 year. The HU value of the subarachnoid space on brain CT can predict vasospasm, hydrocephalus, and long-term prognosis in good-grade SAH patients.

Monocyte Count and Systemic Immune-Inflammation Index Score as Predictors of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage.

Delayed cerebral ischemia (DCI) is a major cause of disability in patients who survive aneurysmal subarachnoid hemorrhage (aSAH). Systemic inflammatory markers, such as peripheral leukocyte count and systemic immune-inflammatory index (SII) score, have been considered predictors of DCI in previous studies. This study aims to investigate which systemic biomarkers are significant predictors of DCI. We conducted a retrospective, observational, single-center study of 170 patients with SAH admitted between May 2018 and March 2022. We analyzed the patients' clinical and laboratory parameters within 1 hour and 3-4 and 5-7 days after admission. The DCI and non-DCI groups were compared. Variables showing statistical significance in the univariate logistic analysis (p<0.05) were entered into a multivariate regression model. Hunt-Hess grade "4-5" at admission, modified Fisher scale grade "3-4" at admission, hydrocephalus, intraventricular hemorrhage, and infection showed statistical significance (p<0.05) on a univariate logistic regression. Lymphocyte and monocyte count at admission, SII scores and C-reactive protein levels on days 3-4, and leukocyte and neutrophil counts on days 5-7 exhibited statistical significance on the univariate logistic regression. Multivariate logistic regression analysis revealed that monocyte count at admission (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.04-2.65; p=0.036) and SII score at days 3-4 (OR, 1.55; 95% CI, 1.02-2.47; p=0.049) were independent predictors of DCI. Monocyte count at admission and SII score 3-4 days after rupture are independent predictors of clinical deterioration caused by DCI after aSAH. Peripheral monocytosis may be the primer for the innate immune reaction, and the SII score at days 3-4 can promptly represent the propagated systemic immune reaction toward DCI.

Aneurysmal Subarachnoid Hemorrhage: Is the Time Until Intervention Related to Minor Disabilities in 6 Months?

Abstract Background Aneurysmal subarachnoid hemorrhages (aSAHs) account for 5% of all strokes, an appalling number when it comes to the second most common cause of death worldwide. The basis of the treatment is clinical support and either endovascular or surgical intervention. The purpose of the present study is to analyze if the time from the onset of the thunderclap headache until treatment intervention is related to the degree of disability after 6 months. Methods In the present prospective observational study, data were collected from all patients (n = 223) admitted to the hospital with a diagnosis of aSAH. Patients whose data were missing or who missed the follow-up after 6 months were excluded. Then, the number of days from the thunderclap headache until the surgical intervention (Delta T) was obtained. The degree of disability was evaluated using standardized scales, Rankin Scale (RS) and Glasgow Outcome Scale (GOS), at the time of discharge as well as 6 months later. Then, the RS and GOS were correlated with Delta T. Results An average of 6.8 days was found from the onset of symptoms to the intervention, the average age was 54 years old, 73% were women and 55% were smokers. The mean Glasgow Coma Scale on admission was 13. The mean score on the Hunt and Hess scale was 2.1. From the radiological point of view, the mean size of the aneurysm was 6 mm, and the modified Fisher Scale was 3.1. Of the total number of patients at the end of the study (n = 78), 50 underwent microsurgical treatment (63%). Rankin scale at discharge was 1.9 and GOS was 4.5, with no statistically significant change at 6 months. Analyzing the data distribution using linear regression, no statistically significant correlation was found between the time until treatment and disability using RS and GOS (p &gt; 0.05). The same results were found even analyzing age subgroups (≤ 45 years old, 45 to 55 years old, 55 to 70 years old, and &gt; 70 years old with a p-value &gt; 0.05). Conclusions The present study suggests that there is no linear correlation between Delta T and disability at 6 months for the population studied. However, more studies are needed to assess whether these findings may be present in other populations, especially with a shorter time from symptoms to intervention, since the greatest risk of rebleeding occurs in the first 3 days after the event.

Suspected medullary washout leading to severe polyuria following delayed cerebral ischemia: a case report

BackgroundDelayed cerebral ischemia is a clinical entity commonly encountered in patients presenting with acute neurological injury and is often complicated by dysnatremias, such as the cerebral salt wasting syndrome. In this case report, we described an exceptional case of polyuria attributed to an initial cerebral salt wasting phenomenon and iatrogenic-induced medullary washout.Case presentationA 53-year-old woman was admitted to our hospital for the management of a Modified Fisher scale grade 4 subarachnoid hemorrhage due to a ruptured posterior communicating aneurysm. She was initially managed with coil embolization and external ventricular drain due to secondary hydrocephalus. Throughout the course of her hospitalization, she developed severe polyuria reaching up to 40L per day. To keep up with the excessive urinary losses and maintain appropriate cerebral perfusion, fluid replacement therapy was adjusted every hour, reaching up to 1.3 L of crystalloid per hour in addition to aminergic support. An initial diagnosis of partial diabetes insipidus, followed by a cerebral salt wasting syndrome was suspected. While the urine output continued to increase, her serum urea concentration progressively decreased to a point of almost being undetectable on day 9. At that time, the presence of an interstitial medulla washout was hypothesized. Various pharmacological and non-pharmacological interventions were progressively introduced to regain normal renal homeostasis, including non-steroidal anti-inflammatory drugs, fludrocortisone, oral urea and high-protein intake. Medications were progressively weaned, and the patient was successfully discharged from the ICU.ConclusionsCerebral salt wasting should be considered in the initial differential diagnosis of a patient presenting with polyuria in the context of acute neurological injury. Early recognition of this entity is critical to quickly implement proper management. However, as shown in this case report, the concomitance of delayed cerebral ischemia may complexify that management.

Predicting vasospasm risk using first presentation aneurysmal subarachnoid hemorrhage volume: A semi-automated CT image segmentation analysis using ITK-SNAP.

Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) is a significant complication associated with poor neurological outcomes. We present a novel, semi-automated pipeline, implemented in the open-source medical imaging analysis software ITK-SNAP, to segment subarachnoid blood volume from initial CT head (CTH) scans and use this to predict future radiological vasospasm. 42 patients were admitted between February 2020 and December 2021 to our tertiary neurosciences center, and whose initial referral CTH scan was used for this retrospective cohort study. Blood load was segmented using a semi-automated random forest classifier and active contour evolution implemented in ITK-SNAP. Clinical data were extracted from electronic healthcare records in order to fit models aimed at predicting radiological vasospasm risk. Semi-automated segmentations demonstrated excellent agreement with manual, expert-derived volumes (mean Dice coefficient = 0.92). Total normalized blood volume, extracted from CTH images at first presentation, was significantly associated with greater odds of later radiological vasospasm, increasing by approximately 7% for each additional cm3 of blood (OR = 1.069, 95% CI: 1.021-1.120; p < .005). Greater blood volume was also significantly associated with vasospasm of a higher Lindegaard ratio, of longer duration, and a greater number of discrete episodes. Total blood volume predicted radiological vasospasm with a greater accuracy as compared to the modified Fisher scale (AUC = 0.86 vs 0.70), and was of independent predictive value. Semi-automated methods provide a plausible pipeline for the segmentation of blood from CT head images in aSAH, and total blood volume is a robust, extendable predictor of radiological vasospasm, outperforming the modified Fisher scale. Greater subarachnoid blood volume significantly increases the odds of subsequent vasospasm, its time course and its severity.

Volume of Aneurysmal Subarachnoid Hematoma Measured Quantitatively by 3D Slicer to Predict Symptomatic Cerebral Vasospasm.

Aneurysmal subarachnoid hemorrhage is strongly associated with symptomatic cerebral vasospasm. This study aims to investigate whether a quantitative measure of aneurysmal subarachnoid hematoma by 3D Slicer is more valuable for vasospasm risk prediction compared with modified Fisher scale and the new scale by Eagles. We performed a retrospective research of Digital Imaging and Communications in Medicine format (DICOM) in aneurysmal patients treated at our institution from 2019 to 2020. Association between vasospasm and hematoma volume by 3D Slicer was explored by univariate and multivariate analyses. Value of risk prediction was compared through area under the receiver operator characteristic curve (AUC) among the modified Fisher scale, the new scale by Eagles, and hematoma volume by 3D Slicer. Hematoma volume by 3D Slicer had a significant relationship with vasospasm both by one-way analysis of variance (ANOVA; F = 19.37, P < 0.001) and a binary logistic regression analysis (odds ratio [OR] = 1.05, P = 0.016). Hematoma volume by 3D Slicer had a significantly higher AUC (0.708; 95% confidence interval [CI]: 0.618-0.798, P < 0.001) than the modified Fisher scale and the new scale by Eagles. The optimal diagnostic threshold for hematoma volume by 3D Slicer was 15.98 ml, and the sensitivity and specificity were 73.5% and 58.6%, respectively. Volume of aneurysmal subarachnoid hematoma measured quantitatively by 3D Slicer can improve the predictive value for symptomatic cerebral vasospasm.

Cerebral Vasospasm After Traumatic Subarachnoid Hemorrhage and Its Risk Factor: Combined Periodic Follow Up of Transcranial Doppler and CT Angiography

Background: Cerebral vasospasm is a prevalent complication in traumatic brain injury (TBI), particularly in cases of traumatic subarachnoid hemorrhage (T-SAH), for which monitoring and treatment policies remain undefined.Methods: A study was conducted on 49 T-SAH patients with multiple traumas to investigate cerebral vasospasm following T-SAH. Participants underwent transcranial doppler (TCD) and brain CT angiography (CTA) upon hospitalization and subsequent follow-up within seven days. Vasospasm was diagnosed through a comprehensive evaluation of TCD, CTA, and symptoms, with risk factors analyzed accordingly. The initial clinical status was assessed using the Glasgow Coma Scale (GCS), modified Fisher scale (mFS), and Hunt-Hess grade (HHG), while examining various factors to identify underlying risks and evaluating overall body damage via the Injury Severity Score (ISS).Results: Cerebral vasospasm was confirmed in 19 out of the total 49 patients, which is 38.8%. Furthermore, the characteristics that had a statistically significant correlation with the vasospasm group were low GCS (p=0.03, odd ratio=0.592) and high ISS (p=0.022, odd ratio=1.124). Moreover, patients with vasospasm exhibited worse prognoses based on the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS).Conclusion: These findings suggest that T-SAH patients with severe initial brain and systemic damage or neurological deficits should undergo active monitoring using modalities such as TCD and CTA, followed by treatment to prevent and manage vasospasm.

Additive prognostic impact of the cerebrospinal fluid arginine/ornithine ratio to established clinical scores in aneurysmal subarachnoid hemorrhage.

Cerebrospinal fluid (CSF) metabolites are increasingly recognized as prognostic factors in aneurysmal subarachnoid hemorrhage (SAH). The CSF arginine/ornithine ratio (Arg/Orn) was shown to predict cerebral vasospasms and clinical outcome in SAH. The additive prognostic value of Arg/Orn over established prognostic scores has not been investigated. CSF Arg/Orn and the established prognostic scores SAH, FRESH, SAH-PDS, HAIR, Rosen-McDonald, Hunt and Hess, WFNS and modified Fisher scale were determined in a prospective cohort of patients with aneurysmal SAH. Logistic regression models to predict a favorable outcome, defined as a modified Rankin Scale score of 0-3 at 3 months follow-up, were constructed for each score, both with and without the addition of Arg/Orn. The impact of Arg/Orn was assessed comparing logistic regression models containing the respective score with and without Arg/Orn with the likelihood ratio chi-squared test. CSF Arg/Orn and clinical scores were determined in 38 SAH patients. Arg/Orn was an independent predictor of clinical outcome when added to established prognostic scores (p < 0.05) with the exception of HAIR (p = 0.078). All models were significantly improved if Arg/Orn was added as a covariable (p < 0.05). The results of this study confirm Arg/Orn as an independent prognostic factor and its addition improves established prognostic models in SAH.

Using a continuous electrocardiographic patch with heart rhythm analysis in the subacute stage of aneurysmal subarachnoid hemorrhage: The feasibility verification

ObjectiveContinuous cardiac monitoring on patients with aneurysmal subarachnoid hemorrhage (aSAH) is difficult out of intensive care unit (ICU) in the subacute stage. Therefore, we verified the feasibility of a novel electrocardiography (ECG) patch device to record long-term heart rhythm. MethodsThe ECG patches were applied on aSAH patients during their stay in general ward. Any types of significant arrythmia were identified, and heart rate variability (HRV) measures were calculated in time and frequency domains. We analyzed the correlation between heart rhythm with Hunt and Hess scale and modified Fisher scale as well as the occurrence of secondary complications. ResultsTwenty-six patients used the devices on median day 6 after aSAH onset, with put on and take down time average as 137 s and 45 s, respectively. Mean record time was 221.7 h, and no adverse event presented within the period. Hunt and Hess II/III subgroup had higher percentage of HRV high frequency band than IV/V subgroup (9.1 % vs 3.5 %, p = 0.043), whereas ultra low frequency band presented more in the later subgroup (50.4 % vs 61.4 %, p = 0.035). The very low frequency percentage significantly decreased (p = 0.025) at an average of 3 days prior to the occurrence of secondary complications compared to the days without complications. ConclusionFor aSAH patients in general ward during subacute stage, the ECG patch is a safe and feasible tool. The correlation of long-term heart rhythm with prognosis is worthy to be investigated on larger sample size using this device in the future.

Circular RNA hsa_circ_0000690 as a potential biomarker for diagnosis and prognosis of intracranial aneurysm: Closely relating to the volume of hemorrhage.

This study aimed to explore circular RNA (circRNA) hsa_circ_0000690 as a potential biomarker for diagnosis and prognosis of intracranial aneurysm (IA) and its relationship with clinical factors and complications of IA. 216 IA patients admitted to the neurosurgery department of our hospital from January 2019 to December 2020 were selected as the experimental group, and 186 healthy volunteers were selected as the control group. The expression of hsa_circ_0000690 in peripheral blood was detected by quantitative real-time PCR, and its diagnostic value was assessed by receiver operating characteristic curve. Relationship between hsa_circ_0000690 and clinical factors of IA was assessed by chi-square test. Nonparametric test was used in univariate analysis, and regression analysis was used in multivariate analysis. Multivariate Cox proportional hazards regression analysis was used to analyze the survival time. CircRNA hsa_circ_0000690 of IA patients was relatively lower than that in the control group (p<.001). The AUC of hsa_circ_0000690 was 0.752, the specificity was 0.780, and sensitivity was 0.620, with diagnostic threshold of 0.0449. In addition, hsa_circ_0000690 expression was correlated with Glasgow Coma Scale, the volume of subarachnoid hemorrhage, modified Fisher scale, Hunt-Hess levels and surgical type. For hydrocephalus and delayed cerebral ischemia, hsa_circ_0000690 was significant in univariate analysis, but nonsignificant in multivariate analysis. For prognosis, hsa_circ_0000690 was significantly associated with modified Rankin Scales after surgery for 3 months, but not associated with survival time. The expression of hsa_circ_0000690 can act as a diagnostic marker for IA and predict the prognosis of 3 months after operation and is closely related to the volume of hemorrhage.