Nontraumatic Subarachnoid Hemorrhage Research Articles

Pharmacologic Venous Thromboembolism Prophylaxis in Patients with Nontraumatic Subarachnoid Hemorrhage Requiring an External Ventricular Drain.

Optimal pharmacologic thromboprophylaxis dosing is not well described in patients with subarachnoid hemorrhage (SAH) with an external ventricular drain (EVD). Our patients with SAH with an EVD who receive prophylactic enoxaparin are routinely monitored using timed anti-Xa levels. Our primary study goal was to determine the frequency of venous thromboembolism (VTE) and secondary intracranial hemorrhage (ICH) for this population of patients who received pharmacologic prophylaxis with enoxaparin or unfractionated heparin (UFH). A retrospective chart review was performed for all patients with SAH admitted to the neurocritical care unit at Emory University Hospital between 2012 and 2017. All patients with SAH who required an EVD were included. Of 1,351 patients screened, 868 required an EVD. Of these 868 patients, 627 received enoxaparin, 114 received UFH, and 127 did not receive pharmacologic prophylaxis. VTE occurred in 7.5% of patients in the enoxaparin group, 4.4% in the UFH group (p = 0.32), and 3.2% in the no VTE prophylaxis group (p = 0.08). Secondary ICH occurred in 3.83% of patients in the enoxaparin group, 3.51% in the UFH group (p = 1), and 3.94% in the no VTE prophylaxis group (p = 0.53). As steady-state anti-Xa levels increased from 0.1 units/mL to > 0.3 units/mL, there was a trend toward a lower incidence of VTE. However, no correlation was noted between rising anti-Xa levels and an increased incidence of secondary ICH. When compared, neither enoxaparin nor UFH use was associated with a significantly reduced incidence of VTE or an increased incidence of ICH. In this retrospective study of patients with nontraumatic SAH with an EVD who received enoxaparin or UFH VTE prophylaxis or no VTE prophylaxis, there was no statistically significant difference in the incidence of VTE or secondary ICH. For patients receiving prophylactic enoxaparin, achieving higher steady-state target anti-Xa levels may be associated with a lower incidence of VTE without increasing the risk of secondary ICH.

Electrocardiographic abnormalities are prognostic of the clinical outcomes and mortality of patients with subarachnoid hemorrhages

PurposeWe explored the relationships between electrocardiographic (ECG) abnormalities and the clinical outcomes and mortality of patients with non-traumatic aneurysmal subarachnoid hemorrhages (SAHs). MethodsThis retrospective cohort study enrolled consecutive adult patients who presented to emergency departments with non-traumatic aneurysmal SAHs. We recorded their demographics, clinical characteristics, and ECG findings, and explored the relationships between ECG abnormalities, on the one hand, and 28-day mortality and prognosis, on the other. ResultsWe enrolled 158 patients, 76 females (48.10%) and 82 males (51.90%) of average age 54.70 ± 7.07 years. A total of 107 patients (67.72%) exhibited at least one ECG abnormality, most commonly a T-wave change (n = 54, 34.18%). Such patients evidenced significantly higher Hunt-Hess and Fisher scale scores than those without abnormalities (both p < 0.001). Patients with abnormal ECG findings experienced more unfavorable outcomes and higher mortality than others (both p < 0.001). ECG abnormalities, including PR prolongation, pathological Q waves, QRS widening, left bundle branch blocks, premature ventricular contractions, ST segment changes, and T-wave changes, were more common in non-survivors and patients with Hunt-Hess scores of 4–5 compared to survivors and those with Hunt-Hess scores <4, respectively. Moreover, increased age and presence of abnormal ECG findings were independent predictors of mortality in aneurysmal SAHs. ConclusionsPatients with abnormal ECG findings exhibited unfavorable clinical outcomes and increased mortality rates. Abnormal ECG findings combined with higher Hunt-Hess or Fischer grade scores usefully predict adverse clinical outcomes in and mortality of SAH patients.

Hypothermia on the first day of ICU admission leads to increased in-hospital mortality in patients with subarachnoid hemorrhage

The relationship between early spontaneous hypothermia and adverse clinical outcomes in patients with subarachnoid hemorrhage (SAH) has not been paid much attention. We designed this retrospective cohort study to determine this relationship by analyzing the association between the lowest body temperature (T-lowest) on the first day of ICU admission and in-hospital mortality. In this study, 550 participants with non-traumatic SAH were chosen from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Multivariate Cox regression analysis showed that T-lowest was nonlinearity correlated with in-hospital mortality (HR = 0.72, 95% CI: 0.59–0.86, p < 0.001). We divided the T-lowest into quartile groups. In comparison to reference group Q1 (31.30–36.06 ℃), group Q3 (36.56–36.72 ℃) had a 50% lower risk of death in the hospital (HR: 0.5, 95% CI: 0.28–0.87, p = 0.014). We further confirmed the curve-like relationship between T-lowest and in-hospital mortality using restricted cubic splines. The mortality is lowest when the T-lowest is close to 36.5 °C, and the risk of death is increased when the temperature is lower or higher than that. Our study demonstrates that in-hospital mortality is associated with T-lowest. Patients with non-traumatic SAH are at increased risk of death if their body temperature on the first day of ICU admission is too low.

Rates of operative intervention and in-hospital mortality following subarachnoid hemorrhage in patients with COVID-19.

COVID-19 had massive effects on the healthcare system and multifactorial implications for the management of intensive care unit and cerebrovascular patients. This study aimed to assess the effect of COVID-19 on the outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH). The National Inpatient Sample (NIS) was used to identify patients with nontraumatic SAH (ICD-10 code I60.x). Patients with nonaneurysmal cerebrovascular malformations or traumatic intracranial injuries were excluded. Only patients managed from April to December 2020 were included in the study given the availability of an ICD-10 code for COVID-19. Data on sociodemographic factors, hospital characteristics, comorbidities, NIS SAH Severity Score (NIS-SSS), surgical treatment, and death were acquired. Multivariable analysis was used to assess predictors of both surgical intervention and in-hospital mortality. In total, 6984 patients met the study criteria, 359 (5.1%) of whom had COVID-19. Those with COVID-19 were more likely to be younger and male and had a higher All Patient Refined Diagnosis-Related Groups illness severity subclass, and NIS-SSS. Moreover, patients with COVID-19 were less likely to undergo surgery (10.0% vs 23.6%, OR 0.35, p < 0.0001) and had significantly higher mortality rates (48.2% vs 22.7%, p < 0.0001). When controlling for other variables, COVID-19 was an independent predictor of death (OR 1.67, p = 0.0002). Aneurysm surgery was performed in 1597 patients (317 open and 1280 endovascular procedures). There was no difference between the cohorts positive and negative for COVID-19 in terms of time to surgery or type of surgery. COVID-19 had significant impacts on patients with nontraumatic SAH. Specifically, patients with COVID-19 were significantly less likely to undergo surgery and had higher in-hospital mortality rates; however, for patients who did undergo procedural intervention, there was no significant difference in the type of intervention. Multiple factors, from medical acuity to healthcare system limitations, may contribute to these findings. Further retrospective research is needed to identify both specific causes of lower intervention rates and other potential nonaneurysmal causes of SAH in patients with COVID-19.

Systemic tolerance of intravenous milrinone administration for cerebral vasospasm secondary to non-traumatic subarachnoid hemorrhage

PurposeDelayed cerebral ischemia (DCI) is a severe subarachnoid hemorrhage (SAH) complication, closely related to cerebral vasospasm (CVS). CVS treatment frequently comprises intravenous milrinone, an inotropic and vasodilatory drug. Our objective is to describe milrinone's hemodynamic, respiratory and renal effects when administrated as treatment for CVS. MethodsRetrospective single-center observational study of patients receiving intravenous milrinone for CVS with systemic hemodynamics, oxygenation, renal disorders monitoring. We described these parameters' evolution before and after milrinone initiation (day – 1, baseline, day 1 and day 2), studied treatment cessation causes and assessed neurological outcome at 3–6 months. ResultsNinety-one patients were included. Milrinone initiation led to cardiac output increase (4.5 L/min [3.4–5.2] at baseline vs 6.6 L/min [5.2–7.7] at day 2, p < 0.001), Mean Arterial Pressure decrease (101 mmHg [94–110] at baseline vs 95 mmHg [85–102] at day 2, p = 0.001) norepinephrine treatment requirement increase (32% of patients before milrinone start vs 58% at day 1, p = 0.002) and slight PaO2/FiO2 ratio deterioration (401 [333–406] at baseline vs 348 [307–357] at day 2, p = 0.016). Milrinone was interrupted in 8% of patients. 55% had a favorable outcome. ConclusionIntravenous milrinone for CVS treatment seems associated with significant impact on systemic hemodynamics leading sometimes to treatment discontinuation.

395 A History of Smoking Is Not an Independent Risk Factor for Perioperative Outcomes in Nontraumatic Subarachnoid Hemorrhage

INTRODUCTION: Nontraumatic Subarachnoid Hemorrhage (NSAH) is a rupture leading to blood accumulating in the subarachnoid region. Smoking contributes to vascular pathogenesis which can ultimately end in an aneurysm. Smoking and history of smoking often is a risk factor for complications perioperatively for vascular procedures, however patients receiving treatment for NSAH may have different perioperative outcome profiles. METHODS: Patients with NSAH who underwent neurosurgery were identified using ICD codes (ICD10, I60; ICD9, 430) in the ACS-NSQIP database from 2005-2021. Subjects were stratified into two study groups based on documented prior history of smoking: smokers or non-smokers. Significant preoperative differences were present between groups so a multivariable logistic regression was performed between patients with and without a prior history of smoking. The 30-day perioperative outcomes of patients with a prior history of smoking were compared to that of control. Perioperative outcomes included death, major adverse cardiovascular events (MACE), cardiac complications, stroke, wound complications, renal complications, sepsis, clot formation, pulmonary complications, return to the operating room, operation time greater than four hours, length of stay longer than 7 days, discharge not to home, and bleeding. RESULTS: There were 626 patients with a prior smoking history and 1336 patients with no prior smoking history. We found no significant difference between these two groups across all adverse outcomes analyzed. CONCLUSIONS: This study shows that although history of smoking is commonly a risk factor for vascular diseases and perioperative complications, it is not a risk factor for the perioperative variables analyzed when treating NSAH. Additional research should be done to determine if different procedures to treat NSAH may have different outcomes among smokers.

709 Establishment of an Early ICU De-escalation Pathway Using the Modified Frailty Index Among Angiogram-Negative Subarachnoid Hemorrhage Patients

INTRODUCTION: Angiogram-negative subarachnoid hemorrhage (ANSAH) may have a benign clinical course. Our standard practice is to observe ANSAH patients for a prolonged period in the ICU. Previous work has established frailty as a strong predictor of ANSAH outcomes. METHODS: A retrospective cohort analysis was performed among patients admitted between 2011 and 2022 with non-traumatic subarachnoid hemorrhage and initial angiogram (DCA) negative for source. Primary endpoints were in-hospital complications, discharge home, and length-of-stay (LOS). Cost analysis was performed using hospital charges. RESULTS: 101 patients were included with an average age of 59.7 ±1.2 years, Hunt and Hess score of 2.0 ± 0.1, and 51 (50.5%) with a perimesencephalic hemorrhage distribution. 2 patients had a subsequent DCA showing aneurysmal etiology, both of whom would have been considered high risk. 38 (37.6%) were frail, 38 (37.6%) required an EVD, and 68 (67.3%) were intact on arrival. Multivariate analysis showed that frailty but not age or perimesencephalic distribution predicted the 3 primary endpoints (p &lt; 0.039) while lack of EVD predicted LOS (p = 0.004) and intact neurologic exam predicted discharge home (p = 0.043). Low-risk patients (40/101, 39.6%) had no deaths, significantly reduced odds of any complication (OR 0.14, 95%CI: 0.04-0.44, p &lt; 0.001), increased odds of discharge home (OR 9.98; 95%CI: 2.19-45.46, p &lt; 0.001), and shorter LOS (7.8 ± 0.4 v. 14.7 ± 1.1 days, p &lt; 0.001). Assuming a 6-day ward stay after 1-day of ICU observation, early de-escalation of low-risk ANSAH patients would, on average, save $20,177.70 per patient. CONCLUSIONS: Non-frail ANSAH patients who are neurologically intact and without an EVD are likely to have a benign clinical course and may benefit from early ICU de-escalation.

Cerebral Aneurysm Characteristics and Surgical Outcomes: An In-Depth Analysis of 346 Cases Operated Using Microsurgical Clipping.

This comprehensive study analyzes 346 surgically treated intracranial aneurysms, emphasizing the importance of understanding risk factors and prevalent characteristics in patients. Intracranial aneurysms, primarily of the saccular or berry type, significantly contribute to nontraumatic subarachnoid hemorrhages and demonstrate a rising incidence due to advances in imaging techniques. The study highlights a gender discrepancy in aneurysm occurrence and a higher prevalence in individuals over 30 years old. The research delves into various aspects, including aneurysm localization, diameter, neck dimensions, and rupture status, with a focus on the anterior communicating artery and middle communicating artery as predominant locations. Significant findings include the prevalence of ruptured aneurysms and the impact of arterial hypertension, atherosclerosis, obesity, and diabetes on aneurysm epidemiology. The study also investigates the occurrence of vasospasm, a significant factor in delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage. The utilization of the Glasgow Outcome Scale and other quantification scales aids in understanding the severity and postoperative outcomes of intracranial aneurysms. Challenges such as the incidence of reopenings and postoperative osteomyelitis are addressed, underlining the need for refined protocols and multidisciplinary approaches in treatment. The study's results contribute to the existing knowledge base on intracranial aneurysms, emphasizing the importance of ongoing research and tailored treatment strategies. The comprehensive nature of this analysis, covering preoperative, intraoperative, and postoperative factors, provides valuable insights into the complex interplay of risk factors and clinical outcomes in patients with intracranial aneurysms.

Association between serum creatinine and 30 days all-cause mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: analysis of the MIMIC-IV database.

Serum creatinine is a prognostic marker for various conditions, but its significance of spontaneous subarachnoid hemorrhage is still poorly understood. This study aims to elucidate the correlation between admission serum creatinine (sCr) levels and all-cause mortality within 30 days among individuals affected by non-traumatic subarachnoid hemorrhage (SAH). This cohort study included 672 non-traumatic SAH adults. It utilized data from the MIMIC-IV database from 2008 to 2019. The patients' first-time serum creatinine was recorded. Subsequently, an examination of the 30-day all-cause mortality was conducted. Employing a multiple logistic regression model, a nomogram was constructed, while the association between sCr and 30-day all-cause mortality was evaluated using Kaplan-Meier survival curves. The calibration curve was employed to assess the model's performance, while subgroup analysis was employed to examine the impact of additional complications and medication therapy on outcomes. A total of 672 patients diagnosed with non-traumatic subarachnoid hemorrhage were included in the study. The mortality rate within this timeframe was found to be 24.7%. Multiple logistic regression analysis revealed that sCr served as an independent prognostic indicator for all-cause mortality within 30 days of admission for SAH patients [OR: 2(1.18-3.41); p = 0.01]. A comprehensive model was constructed, incorporating age, sCr, white blood cell count (WBC), glucose, anion gap, and partial thromboplastin time (PTT), resulting in a prediction model with an AUC value of 0.806 (95% CI: 0.768, 0.843), while the AUC for the test set is 0.821 (95% CI: 0.777-0.865). Creatinine emerges as a significant biomarker, closely associated with heightened in-hospital mortality in individuals suffering from SAH.

Triglyceride-glucose index: a novel evaluation tool for all-cause mortality in critically ill hemorrhagic stroke patients-a retrospective analysis of the MIMIC-IV database

BackgroundHemorrhagic stroke (HS), including non-traumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), constitutes a substantial proportion of cerebrovascular incidents, accounting for around 30% of stroke cases. The triglyceride-glucose index (TyG-i) represents a precise insulin resistance (IR) indicator, a crucial metabolic disturbance. Existing literature has demonstrated an association between TyG-i and all-cause mortality (ACM) among individuals suffering from ischemic stroke (IS). Yet, the TyG-i prognostic implications for severe HS patients necessitating intensive care unit (ICU) admission are not clearly understood. Considering the notably elevated mortality and morbidity associated with HS relative to IS, investigating this association is warranted. Our primary aim was to investigate TyG-i and ACM association among critically ill HS patients within an ICU context.MethodsHerein, patients with severe HS were identified by accessing the Medical Information Mart for Intensive Care-IV (MIMIC-IV, version 2.2) database, using the International Classification of Diseases (ICD)-9/10 as diagnostic guidelines. Subsequently, we stratified the subjects into quartiles, relying on their TyG-i scores. Moreover, we measured mortality at ICU, in-hospital, 30 days, 90 days, and 1 year as the outcomes. Cox proportional hazards regression analysis and restricted cubic splines (RCS) were deployed for elucidating the relation between the TyG-i and ACM while utilizing the Kaplan-Meier (K-M) method to estimate survival curves. The findings’ robustness was assessed by conducting subgroup analysis and interaction tests employing likelihood ratio tests.ResultsThe analysis included 1475 patients, with a male predominance of 54.4%. Observed mortality rates in the ICU, hospital, 30 days, 90 days, and 1 year were 7.3%, 10.9%, 13.8%, 19.7%, and 27.3%, respectively. Multivariate Cox regression analysis results manifested that heightened TyG-i was significantly related to ACM at 30 days (adjusted hazard ratio [aHR]: 1.32; 95% confidence interval [CI]: 1.05–1.67; P = 0.020), 90 days (aHR: 1.27; 95% CI: 1.04–1.55; P = 0.019), and 1 year (aHR: 1.22; 95% CI: 1.03–1.44; P = 0.023). The results of RCS analysis demonstrated a progressive elevation in ACM risk with rising TyG-i levels. Interaction tests found no significant effect modification in this relationship.ConclusionIn summary, TyG-i exhibits a significant correlation with ACM among patients enduring critical illness due to HS. This correlation underscores the probable utility of TyG-i as a prognostic tool for stratifying HS patients according to their risk of mortality. Applying TyG-i in clinical settings could enhance therapeutic decision-making and the management of disease trajectories. Additionally, this investigation augments existing research on the linkage between the TyG-i and IS, elucidating the TyG-i’s role in predicting mortality across diverse stroke categories.

Capabilities of Dynamic Magnetic Resonance Angiography in Patients With Cerebral Aneurysms in the Postoperative Period

Introduction: The leading cause of hemorrhagic stroke is a ruptured cerebral aneurysm (CA), accounting for 70%-85% of nontraumatic subarachnoid hemorrhages. The primary goals of CA treatment are to prevent a rupture, thrombosis, or symptoms of mass effect. The main treatment options for intracranial aneurysms are open clipping, flow-diverter device implantation, resection and stenting of aneurysms. Treated aneurysms should be monitored to assess the stability of the occlusion because more than 20% of surgically treated aneurysms are known to recur. Magnetic resonance angiography (MRA) has recently become increasingly attractive for the follow-up of surgically treated CAs because it is noninvasive, does not require hospitalization, and reduces complications associated with the frequent use of cerebral angiography.Objective: To evaluate capabilities of dynamic MRA in postoperative monitoring of patients with CAs.Materials and methods: The study was conducted at the premises of the Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation). In a hospital setting, 38 patients with CAs were examined in the late postoperative period. All the patients underwent magnetic resonance imaging, 3-dimensional time-of-flight (3D-TOF) MRA, and dynamic MRA followed by cerebral angiography. Imaging findings (MRA, dynamic MRA, and cerebral angiography) were evaluated by radiologists, x-ray surgeons, and neurosurgeons. They assessed treated aneurysms according to the Raymond-Roy occlusion classification: complete obliteration (class 1), residual neck (class 2), and residual aneurysm (class 3). Untreated aneurysms in patients with multiple CAs and de novo aneurysms were also assessed, and we looked for other vascular malformations.Results: The study was conducted in the late postoperative period from 6 to 18 months. A total of 38 patients participated in the study; of them 27 were women (age, 32-77 years) and 11 were men (age, 32-65 years). Dynamic MRA detected neck remnants of 4 clipped aneurysms and 2 embolized ones, which was confirmed by cerebral angiography. According to the dynamic MRA results, in case of clipped aneurysms neck remnants were found in the anterior communicating artery (n = 2), internal carotid artery (n = 1), and anterior choroidal artery (n = 1). In case of embolized aneurysms, neck remnants were revealed in the internal carotid artery (n = 1) and basilar artery (n = 1). Dynamic MRA also detected 5 additional aneurysms: 2 internal carotid artery aneurysms, 1 basilar artery aneurysm, 1 anterior cerebral artery aneurysm, and 1 anterior communicating artery aneurysm. These findings coincided with those of cerebral angiography. Based on the results of our study, the sensitivity and specificity of dynamic MRA in detecting CA neck remnants and untreated aneurysms were 100%.Discussion: Dynamic MRA findings are fully consistent with those of cerebral angiography in terms of determining an aneurysm occlusion status during postoperative follow-up. As for evaluation of de novo intracranial aneurysms, dynamic MRA is also superior to noncontrast 3D-TOF MRA in assessment of aneurysm shape and neck detection. Therefore, dynamic MRA can clearly visualize the structure of cerebral vessels mainly due to the effect of blood flow and static tissue contrast, and the principle is mainly the effect of multiphase scanning and accumulation of contrast agent.Conclusions: Dynamic MRA has a number of advantages over cerebral angiography, such as noninvasiveness, high-resolution images of the cerebral arteries, absence of radiation exposure, use of iodinated contrast agent, and absence of artifacts from metal clips or embolic material.

The Impact of Fluid Balance on Acute Kidney Injury in Nontraumatic Subarachnoid Hemorrhage.

Background: Nontraumatic subarachnoid hemorrhage (SAH) can lead to poor neurologic outcomes, particularly when delayed cerebral ischemia (DCI) occurs. Maintenance of euvolemia following SAH is thought to reduce the risk of DCI. However, attempts at maintaining euvolemia often err on the side of hypervolemia. In this study, we assessed the relationship between fluid balance and acute kidney injury (AKI) in SAH patients, assessing hypervolemia versus euvolemia and their impact on AKI. Methods: In a quaternary care center, neuroscience intensive care unit we conducted a retrospective longitudinal analysis in adult patients who suffered a nontraumatic SAH. Results: Out of 139 patients, 15 (10.8%) patients developed an AKI while hospitalized, with 7 stage I, 3 stage II, and 5 stage III injuries. Acute kidney injury patients had higher peak sodium (150.1 mEq/L vs 142.7 mEq/L, 95% confidence interval [CI]: [2.7-12.1 mEq/L]), higher discharge chloride (109.1 mEq/L vs 104.9 mEq/L, 95% CI: [0.7-7.6 mEq/L]), and lower hemoglobin at discharge (9.3 g/dL vs 11.3 g/dL, 95% CI: [1.0-2.9 g/dL]). At 7 days, AKI patients had a fluid balance that was 1.82 L higher (P = .04), and 3.38 L higher at 14 days (P = .02), in comparison to day 3. Acute kidney injury was associated with significant mortality increases. This increase in mortality was found at 30 days from admission with a 9.52-fold increase, and at 60 days with a 6.25-fold increase. As a secondary outcome, vasospasm (19 patients, 13.7%) showed no association with AKI. Conclusions: Acute kidney injury following SAH is correlated with clinically significant hypervolemia, elevated sodium, elevated chloride, decreased urine output, and decreased hemoglobin at discharge-risk factors for all SAH patients. This study further elucidates the harm of hypervolemia and gives greater practical evidence to physicians attempting to balance the dangers of vasospasm and AKI.

The relationship between the level of vitamin D and ruptured intracranial aneurysms among patients with high sun exposure

Non-traumatic subarachnoid hemorrhage (SAH) accounts for 3–5% of acute strokes. Intracranial aneurysm is the most common cause of non-traumatic SAH. Vitamin D influences the cardiovascular system, including the formation and rupture of cerebral aneurysms. To evaluate the serum vitamin D level in patients living in the tropical zone who suffered aneurysmal subarachnoid hemorrhage and its correlation with demographic and neurological characteristics. This is an analytical cross-sectional study to assess the serum level of vitamin D in a study population of 99 patients treated and diagnosed with aSAH in a public hospital in Recife-PE over a period of 12 months. In the study sample, composed of individuals with high sun exposure due to the lifestyle they lead in a tropical region, we observed hypovitaminosis D (85.9%), with a median of 19.9 ng/ml, although the majority of individuals are skin with high concentration of melanin (Fitzpatrick skin type IV and V). In addition, rates of sun exposure are high to all patients (Solar Index 9.03 P50). Most individuals were female (79.8%); there was no statistical difference in solar exposure/solar index between genders. As for the neurological repercussions, there was no statistical relevance in the clinical prognostic scales evaluated. As the sample was composed mainly of individuals whose economic activity is agriculture, the values of solar index found are vastly higher than those of other studies conducted in high latitude regions. In line with the literature review, some aspects were raised with the objective of justifying such findings that go from the base of the poor diet of these individuals, the increase of melanin in the skin and genetic alterations that directs us to possible mechanisms of natural photoprotection to high sun exposure. Thus, we had a vast majority (85%) of hypovitaminosis D, which in fact makes us wonder if there is any influence of calcitriol on vitamin D receptors in vascular walls and in the cardiovascular system as a whole, which influence bleeding events of this nature. As for the neurological repercussions, measured using assessment scales (Glasgow coma scale, WFNS scale, Hunt–Hess and Fisher's tomographic scale) there was no significant difference in the results. As it is only a descriptive study, the causal relationship of the facts cannot be established. However, in a population exposed to high sun exposure and affected by aneurysmal SAH, there is a significant rate of hypovitaminosis D, which supports the hypothesis that vitamin D plays a role in vascular pathologies, such as cerebral aneurysms and SAH.

Delirium and Its Associations with Critical Care Utilizations and Outcomes at the Time of Hospital Discharge in Patients with Acute Brain Injury.

Background and Objectives: We analyzed delirium testing, delirium prevalence, critical care associations outcomes at the time of hospital discharge in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), non-traumatic subarachnoid hemorrhage (SAH), non-traumatic intraparenchymal hemorrhage (IPH), and traumatic brain injury (TBI) admitted to an intensive care unit. Materials and Methods: We examined the frequency of assessment for delirium using the Confusion Assessment Method for the intensive care unit. We assessed delirium testing frequency, associated factors, positive test outcomes, and their correlations with clinical care, including nonpharmacological interventions and pain, agitation, and distress management. Results: Amongst 11,322 patients with ABI, delirium was tested in 8220 (726%). Compared to patients 18-44 years of age, patients 65-79 years (aOR 0.79 [0.69, 0.90]), and those 80 years and older (aOR 0.58 [0.50, 0.68]) were less likely to undergo delirium testing. Compared to English-speaking patients, non-English-speaking patients (aOR 0.73 [0.64, 0.84]) were less likely to undergo delirium testing. Amongst 8220, 2217 (27.2%) tested positive for delirium. For every day in the ICU, the odds of testing positive for delirium increased by 1.11 [0.10, 0.12]. Delirium was highest in those 80 years and older (aOR 3.18 [2.59, 3.90]). Delirium was associated with critical care resource utilization and with significant odds of mortality (aOR 7.26 [6.07, 8.70] at the time of hospital discharge. Conclusions: In conclusion, we find that seven out of ten patients in the neurocritical care unit are tested for delirium, and approximately two out of every five patients test positive for delirium. We demonstrate disparities in delirium testing by age and preferred language, identified high-risk subgroups, and the association between delirium, critical care resource use, complications, discharge GCS, and disposition. Prioritizing equitable testing and diagnosis, especially for elderly and non-English-speaking patients, is crucial for delivering quality care to this vulnerable group.

Abstract WP274: Clinical Outcomes of Vasospasms in Non-Traumatic Subarachnoid Hemorrhage and Racial Disparity in the United States: A 20-year Analysis of the National Inpatient Sample From 2000-2019

Background: Cerebral vasospasm in non-traumatic subarachnoid hemorrhage (SAH) is associated with a high rate of morbidity and mortality. We aimed to analyze the clinical outcome of the cerebral vasospasms and characterize the racial disparities in patients with vasospasms over a 20 year period. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with cerebral vasospasm (ICD-9 435.9, ICD-10 I67.84) in non-traumatic SAH (ICD-9 430, ICD-10 I60). Demographics, comorbidities, and outcomes were identified. Functional outcome was categorized in Excellent, Good and Poor. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of &lt;0.001. All analysis performed in R version 4.1.3. Results: Among a total of 67,670 SAH patients, 34,091 (50.3%) with vasospasms were identified. Mean Age was 53.4±13.5 years. Patients with vasospasms had higher Elixhauser Comorbidity Score (8.47 ± 7.86 vs. 7.70 ± 7.77; p&lt;0.001). Patients with seizures were more likely to be White or Hispanic, and to have systemic inflammatory disease, hyperlipidemia and hypertension (all p&lt;0.001). After propensity matching, vasospasm patients were less likely to experience in-hospital mortality (AOR 0.53; 95%CI: 0.47-0.59), likely to have longer hospital stay (3.55 days, 95%CI:3.03-4.07), and had increased hospital charges ($114,108; 95%CI: $102,527-125,688)(all p&lt;0.001). The vasospasm patients were 62.2% White, 15.4% Black, 13.2% Hispanic, and 3.7% Asian. The Hispanic patients had more likelihood to have an excellent outcome (P=0.003). Conclusions: Approximately 50% of patients with non-traumatic SAH experienced vasospasms while hospitalized. Vasospasm is more likely to occur in hypertension and hyperlipidemia patients and is associated with longer hospital stay but less in-hospital mortality. The Hispanic race may have better odds of having an excellent outcome.

Abstract HUP7: Impact of Social Determinants of Health and Academic Hospital Care on Outcomes After Non-Traumatic Subarachnoid Hemorrhage

Background: Growing evidence shows that SDOH and care setting affect ischemic stroke recovery. Impact on non-traumatic SAH is unclear. We studied SDOH and academic hospital influence on SAH outcomes. Methods: We conducted a retrospective study using data from the GWTG Stroke. All analyses were conducted using the Precision Medicine Platform. Hospitals partaking in this study obtained either human research approval for enrolment without patient consent or an IRB exemption. The exposures of interest were the Social Deprivation Index (SDI), the Adjusted Gross Income (AGI), and academic hospital care status. SDI and AGI were divided into three groups each, and care setting was labeled as academic or non-academic. Measured outcomes were: in-hospital death, length of stay (LOS), and discharge disposition (DD). We used regression with interaction terms to assess SDOH and care setting impact. Results: The study included 146,310 SAH patients (mean age 60, female sex 61%). Higher SDI was associated with longer LOS (unadjusted median days 11.1, 12.1 and 12.8) and worse DD (unadjusted risk 42.4%, 44%, 44.7%) (p &lt; 0.001). Lower AGI was associated with increased in-hospital mortality (15.9%, 15.5%, 15.1%) and worse DD (44.2%, 43.9%, 43.1%) (p &lt; 0.001). Academic hospital care demonstrated lower LOS (7.7±10.9 vs. 13.2±14.8, p &lt; 0.001), reduced in-hospital mortality (13.8% vs. 16%, p &lt; 0.001), and better DD (63.3% vs. 53.2%, p &lt; 0.001). Adjusted multivariate analysis confirmed these findings. In comparison to the first, for the third tertile of the SDI, the odds for having a good outcome discharge were 0.87 (95% CI 0.82-0.92, p &lt; 0.001). Additionally, SDI third tertile was associated with a significant increase in LOS (Beta 2.05; p=0.001). Higher AGI was correlated with reduced mortality (OR 0.90; 95% CI 0.83-0.96, p=0.004). Academic care was linked to lower in-hospital mortality (OR 0.89; 95% CI 0.81-0.98, p=0.029) and improved DD (OR 1.09; 95% CI 1.01-1.17, p=0.002). Interaction analysis revealed that academic care and higher AGI lead to synergistic reductions in LOS and better discharge outcomes (p&lt;0.05). Conclusion: This analysis of GWTG-Stroke highlights the significant independent and synergistic influence of SDOH and academic hospital care on outcomes following SAH

Abstract TP1: Changing Trends in the Epidemiology of Subarachnoid Hemorrhage: A Population-Based Study

Background: There are conflicting data on temporal trends in subarachnoid hemorrhage (SAH) incidence and outcomes. We examined trends from 1993-2020 in a long-running population-based stroke study conducted in the Greater Cincinnati Northern Kentucky (GCNK) region. Methods: Using a well-validated approach, we ascertained all incident nontraumatic SAHs among residents of the GCNK region in the following study periods; July 1993-June 94, calendar years 1999, 2005, 2010, 2015, and 2020. Potential cases were identified by ICD codes, abstracted, and then adjudicated by physicians. Aneurysmal SAH (aSAH) was defined as those with culprit aneurysms; cases with no available vessel imaging were considered aSAH if the hemorrhage volume was “massive” or if the patient died rapidly after onset. Incidence rates were compared over time using linear regression after normalizing to 2010 census demographics. The primary outcome assessed was unadjusted 30-day Case Fatality Rate (CFR), which was available through 2015. Results: We identified 518 SAH cases, of which 372 were aSAH (71.8%). Overall SAH incidence rate was stable over time, ranging from 8-10 cases per 100,000 person-years (Figure Panel A); however, the rate of aSAH showed a statistically significant decline, going from 7.2 cases/100,000 person-years in 1993 to 5.2 cases/100,000 person-years in 2020 (trend P =0.02). There was a nonsignificant increase in nonaneurysmal SAH ( P =0.09 for trend). Overall 30-day CFR declined significantly through 2015 ( P =0.006, Figure Panel B), driven predominantly by a decline in aSAH CFR (from 39.3% to 23.7%, trend P =0.04). Conclusion: We observed a significant decline in the incidence of aSAH from 1993-2020; however, overall SAH incidence was stable in the setting of numerically more nonaneurysmal SAHs. Further study is needed to understand the causes of this trend. 30-Day CFR has significantly improved both for overall SAH and for aSAH.

The Use of Neuromarker NSE, S100-B, GFAP Proteins in the Diagnosis and Treatment of Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage

   The incidence of non-traumatic subarachnoid hemorrhage due to rupture of cerebral aneurysms and subsequent disability motivates the search for predictors of severe course and unfavorable outcome of the disease for early intensive treatment. NSE, S100-B, GFAP markers have proven themselves well for assessing the dynamics of treatment for diseases of the nervous system and detecting neurological nosologies. The use of the above proteins in aneurysmal hemorrhage opens up new perspectives in assessing the clinical status of the patient in the early stages, developing further treatment strategies, as well as helps draw conclusions about the outcome of the disease and possible disability of the patient. The studies collected in the review motivate continued research of the neuromarkers in aneurysmal hemorrhage.

GFAP and UCHL1 in Non-traumatic SAH: The Story thus Far. A Systematic Review of the Literature.

Non-traumatic subarachnoid hemorrhage (SAH) is associated with a high percentage of misdiagnosis and poor prognosis. Biomarkers could be useful in the identification, treatment/management guidance, and outcome improvement of SAH patients. The current systematic review aims to investigate the potential role of biomarkers GFAP (Glial Fibrillary Acidic Protein) and UCH-L1 (Ubiquitin C-Terminal Hydrolase L1) in the diagnosis and prognosis of non-traumatic SAH. A systematic search of PubMed, Scopus, and Web of Science databases was conducted from their inception through February 2023. 17 studies met the inclusion criteria and were included in this review. The vast majority of the included studies (82%) were on GFAP. Most studies used blood and/or CSF samples and incorporated multiple measurements through the initial hospitalization days. The majority of identified studies significantly reported higher levels of GFAP and UCHL1 in SAH patients with poor outcomes. There was notable variation in the specimen type and the timing of sampling. Quantification of GFAP and UCHL1 through the initial days of hospitalization shows promise in the prediction of SAH patient outcomes. Further research is nevertheless warranted to confirm these findings and further clarify the use of the two biomarkers in SAH diagnosis and the prediction of severity and secondary events.

Relationship between baseline bicarbonate and 30-day mortality in patients with non-traumatic subarachnoid hemorrhage.

This study aimed to explore the relationship between baseline bicarbonate levels and 30-day mortality in individuals with non-traumatic subarachnoid hemorrhage (SAH). Patients with non-traumatic SAH were chosen from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The relationship between baseline bicarbonate and 30-day mortality was examined using Cox regression models. Restricted cubic splines were used to test the hypothesis that there was an association between bicarbonate and mortality. With the use of Kaplan-Meier survival curve analysis, we looked deeper into the validity of these correlations. To find subgroups with differences, interaction tests were utilized. This retrospective cohort study consisted of 521 participants in total. Bicarbonate had a negative association with death at 30 days (HR = 0.93, 95%CI: 0.88-0.98, p = 0.004). Next, we divided bicarbonate into quartile groups. In comparison to the reference group Q1 (20 mEq/L), groups Q3 (23-25 mEq/L) and Q4 (26 mEq/L) had adjusted HR values of 0.47 (95%CI: 0.27-0.82, p = 0.007) and 0.56 (95%CI: 0.31-0.99, p = 0.047). No definite conclusions can be derived from this study, since there is no obvious curve link between baseline bicarbonate and 30-day mortality. Patients' 30-day mortality increased statistically significantly (p < 0.001, K-M analysis) in patients with low bicarbonate levels. The relationship between bicarbonate and 30-day mortality remained consistent in the stratified analysis, with no observed interactions. Finally, 30-day mortality was negatively associated with baseline bicarbonate levels. Patients with non-traumatic SAH are more at risk of mortality if their bicarbonate levels are low.