Nontraumatic Subarachnoid Hemorrhage Research Articles

Abstract TMP83: Association Between Hospital Procedural Volumes and Clinical Outcomes For Patients With Non-Traumatic Subarachnoid Hemorrhage

Introduction: Previous studies of patients with non-traumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume-outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke centers (CSC) certification. Methods: The 8,512 SAH discharges in the National Inpatient Sample (NIS) from 2010-11 were analyzed. Logistic regression models were used to evaluate the association between clinical outcomes (in-hospital mortality and the NIS-SAH Outcome Measure (NIS-SOM)) and 3 measures of hospital annual case volume (ACV) (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable clinical outcomes with different volume thresholds were performed. Results: 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2%for in-hospital mortality and 38.6% for poor outcome on the NIS-SOM. The mean (range) of SAH ACV, coiling ACV, and clipping ACV were 30.9 (1-195), 8.7 (0-94), and 6.1 (0-69). Logistic regression demonstrated improved outcomes with increasing ACVs of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/yr. Sensitivity and specificity analyses with different ACV thresholds confirmed the results. Analysis of previously proposed ACV thresholds, including those used as minimum standards for CSC certification, showed that hospitals with more than 35 SAH cases annually had better outcomes compared to hospitals with fewer cases, but some hospitals below this threshold had similar outcomes to those with more cases. The adjusted odds ratio favoring better outcomes with SAH ACV ≥ 35 compared to SAH 20 to 34 was 0.82 for the NIS-SOM (p=0.0054) and 0.80 (p=0.0055) for in-hospital mortality. Conclusions: Outcomes for SAH patients improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

Abstract 65: Intrathecal Nicardipine for Cerebral Vasospasm Post Subarachnoid Hemorrhage - A Single Center Experience

Introduction: Cerebral vasospasm leading to delayed cerebral ischemia (DCI) is one of the most significant factors impacting functional outcome in patients diagnosed with non-traumatic subarachnoid hemorrhage (SAH). Effective treatment in this setting is lacking. We now report a single center retrospective cohort experience with intrathecal (IT) Nicardipine for this indication. Methods: All patients discharged between 2013-2017 diagnosed with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Demographics, risk factors, clinical courses, radiological DCI, and functional outcomes were analyzed. Results: 1,085 patients were admitted with aneurysmal (n=796) or idiopathic (n=289) SAH. The mean age was 54.5±14.1 and 67.7% were women. Low grade hemorrhage (WFNS 1) was found in 42.4%, medium (WFNS 2-3) in 26.9%, and high grade (WFNS 4-5) in 30.7%. Cerebral vasospasm was diagnosed in 36.6% of the patients, and 85.4% of those received IT Nicardipine (n=339). Only 8.4% of all patients required angiography to treat vasospasm. TCD data was available for 159 patients who received IT Nicardipine. Treatment reduced mean velocities in all arteries within one day by 15.4% on average (p<0.01). This reduction was sustained for the duration of treatment. Nineteen patients (1.8%) suffered from bacterial ventriculitis, and no statistically significant correlation was noted between IT treatment and infection (OR 1.06 95%CI[0.42-2.7]). The incidence of radiological DCI, identified by blinded assement of imaging, was 9.4% and clinical DCI was 5.7%. In this cohort, 65.5% had a favorable functional outcome (mRS≤2) at 90 days. Conclusions: In a retrospective analysis, off-label IT Nicardipine is a safe and potentially effective treatment for cerebral vasospasm and prevention of the subsequent cerebral ischemia. Being the largest of its kind, this cohort could serve as a baseline for future clinical trial designs assessing IT Nicardipine safety and efficacy in a prospective, controlled fashion.

Depression after Subarachnoid Hemorrhage: A Systematic Review.

Background and PurposeDepression is common and debilitating illness accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity and time course of depression after SAH, the factors associated with its development and the impact of depression on patients’ quality of life after SAH. MethodsThe PubMed database was searched for studies published in English that recruited at least 40 patients (>18 years old) after SAH who were also diagnosed with depression. ResultsAltogether 55 studies covering 6,327 patients met study entry criteria. The frequency of depression ranged from 0% to 61.7%, with a weighted proportion of 28.1%. Depression remained common even several years after the index SAH. Depression after SAH was associated with female sex, premorbid depression, anxiety, substance use disorders or any psychiatric disorders, and coping styles. Comorbid cognitive impairment, fatigue, and physical disability also increased the risk of depression. Aneurysmal SAH and infarction may be related to depression as well. Depression reduces the quality of life and life satisfaction in patients after SAH. ConclusionsDepression is common after SAH and seems to persist. Further research is needed to clarify its time course and identify the neuroendocrine and neurochemical factors and brain circuits associated with the development of post-SAH depression. Randomized controlled treatment trials targeting SAH-related depression are warranted.

National Trends in the Treatment of Ruptured Cerebral Aneurysms in Korea Using an Age-adjusted Method.

BackgroundTwo primary treatment methods are used for ruptured cerebral aneurysms, surgical clipping and endovascular coiling. In recent decades, endovascular coiling has shown remarkable progress compared to surgical clipping, along with technological developments. The aim of this study was to investigate the recent trends in treatments for ruptured cerebral aneurysms in Korea.MethodsThe data were obtained from the National Health Insurance database. We evaluated the trends in endovascular coiling and surgical clipping for ruptured aneurysms for the period 2000–2017. We obtained the number of prescriptions with International Classification of Diseases, 9th Revision, clinical modification codes related to nontraumatic subarachnoid hemorrhage and prescription codes S4641/4642 for surgical clipping and M1661/1662 for endovascular coiling. The medical expenses for each prescription were also obtained. The primary outcomes included the cumulative number of patients, patient rates per 100,000 people, and the correlation between patient rates and the percentage of the population in each age group.ResultsIn the case of surgical clipping, there were no increasing or decreasing trends in the cumulative number of patients when the population/age group was ignored. When examining the trends in patient rates per 100,000 population at each year in male, there was no increasing or decreasing trend in the number of surgical clippings between the age groups, in spite of a decreasing tendency in the number of surgical clipping in male in their 40s and older than 60. In females, the surgical clipping rates tended to decrease only in patients older than 60 years, but there was no tendency to increase or decrease in the other ages. In contrast, the cumulative number of patients who underwent endovascular coiling for ruptured cerebral aneurysms increased year by year regardless of the population/age group. In both male and female, there was no increasing or decreasing trend only in the group aged 40 or younger and there was an increasing tendency in the rest of the age groups. In the trend of medical expenses, both the cost of surgical clipping and endovascular coiling showed increases. Specifically, the medical expense trend in endovascular coiling increased more rapidly than that for surgical clipping.ConclusionThere was a significant increase in the proportion of patients with ruptured aneurysms undergoing endovascular coiling between 2010 and 2017, whereas the use of surgical clipping decreased. The endovascular coiling was significantly increased in all age groups and surgical clipping was decreased in all age groups, especially in patients under 50 years of age.

Comparative evaluation of the effectiveness of the transdermal therapeutic system with fentanil and gabapentine in head pain therapy

The study was conducted to comparatively evaluate the effectiveness a transdermal therapeutic system with fentanyl and gabapentin in the treatment of headache in patients with non-traumatic subarachnoid hemorrhage. When assessing the intensity of headache in patients, it was found that with severe pain immediately after endovascular occlusion, the use of transdermal fentanyl with dexketoprofen or paracetamol is most acceptable, and the combination of gabapentin with dexketoprofen / paracetamol is better in case of headache in a more delayed period.

Prospective Longitudinal Evaluation of Coagulation with Novel Thromboelastography Technology in Patients After Subarachnoid Hemorrhage: A Pilot Study

There is limited knowledge of whether hypercoagulability is present after subarachnoid hemorrhage (SAH) or about its timing of onset, duration, and severity. To conduct a pilot new-generation thromboelastography (TEG) technology (TEG6s)-based and conventional coagulation test-supported longitudinal assessment of coagulation in patients with SAH. We prospectively enrolled patients with nontraumatic SAH on admission from May 2015 to May 2016. We performed TEG6s measurements and conventional coagulation tests on days 1, 2, 3, 5, 7, 10, and 14 and compared them with TEG6s parameters in healthy volunteers. We studied 14 patients and 72 TEG6s measurements. Of these patients, 10 (71.4%) were admitted to the intensive care unit. Mean age was 57.5 (±14.5) years, Acute Physiology and Chronic Health Evaluation III score 58.2 (±26.6), length of hospital stay was 23 (±11.7) days, and mortality was 14.3%. At baseline, conventional coagulation tests were within normal range. However, TEG6s parameters already showed increased coagulability. Thereafter, alpha angle, reaction time, functional fibrinogen level, and maximum amplitude rapidly and significantly increased (P < 0.01) compared with healthy controls. Ten (71.4%) patients demonstrated a >20% increase in coagulability based on TEG6s parameters from their baseline. Moreover, TEG6s hypercoagulability peaked at day 10 and only showed an initial partial decline towards normal by day 14. Similarly, platelet counts and fibrinogen levels increased over this period (P < 0.01) CONCLUSIONS: Using TEG6s technology, we found significant and progressive hypercoagulability in 70% of patients, with an early dominant contribution from hyperfibrinogenemia and increased fibrin formation and partial contribution from thrombocytosis, beginning on the first day, increasing to peak values by day 10, and then partly declining toward normal by day14.

Incidence of Terson Syndrome in Treated Subarachnoid Hemorrhage in South Korea: a National Health Insurance Database Study

The aim of this study is to investigate the incidence and mortality of Terson syndrome in patients with treated subarachnoid hemorrhage (SAH) in South Korea. In this nationwide, population-based study, we used the National Health Insurance(NHI) database (2011–2015) to identify patients aged ≥18 years. Newly diagnosed non-traumatic SAH, treated using clipping or coil embolization, were identified, and Terson syndrome was defined as newly diagnosed retinal or vitreous hemorrhage within 3 months of SAH diagnosis. We identified 22,864 patients with treated SAH (tSAH), 196 of whom had Terson syndrome, with the cumulative incidence during 5 years of 0.86% (95% CI: 0.74–0.98): 1.10% (95% CI: 0.88–1.33) in men and 0.71% (95% CI, 0.58–0.85) in women. The cumulative incidence of Terson syndrome in patients aged under 40 was higher than in those aged 40 or over (1.41% vs. 0.81%; p = 0.007). The mortality rate of Terson syndrome in patients with tSAH was not different from that in those without Terson syndrome (4.08% vs. 7.30%; p = 0.089). This was the first nationwide epidemiological study of Terson syndrome using a population-based database. The incidence of Terson syndrome in patients with tSAH was higher in those age under 40 than in those aged 40 or over.

Clinical Relevance of Cerebral Small Vessel Diseases.

Clinical Relevance of Cerebral Small Vessel Diseases.

Risk Factors for Dysphagia and the Impact on Outcome After Spontaneous Subarachnoid Hemorrhage

BackgroundDespite the tremendous impact of swallowing disorders on outcome following ischemic stroke, little is known about the incidence of dysphagia after subarachnoid hemorrhage (SAH) and its contribution to hospital complications, length of intensive care unit stay, and functional outcome.MethodsThis is a retrospective analysis of an ongoing prospective cohort study. Swallowing ability was assessed in consecutive non-traumatic SAH patients admitted to our neurological intensive care unit using the Bogenhausen Dysphagia Score (BODS). A BODS > 2 points indicated dysphagia. Functional outcome was assessed 3 months after the SAH using the modified Rankin Scale with a score > 2 defined as poor functional outcome.ResultsTwo-hundred and fifty consecutive SAH patients comprising all clinical severity grades with a median age of 57 years (interquartile range 47–67) were eligible for analysis. Dysphagia was diagnosed in 86 patients (34.4%). Factors independently associated with the development of dysphagia were poor clinical grade on admission (Hunt & Hess grades 4–5), SAH-associated parenchymal hematoma, hydrocephalus, detection of an aneurysm, and prolonged mechanical ventilation (> 48 h). Dysphagia was independently associated with a higher rate of pneumonia (OR = 4.32, 95% CI = 2.35–7.93), blood stream infection (OR = 4.3, 95% CI = 2.0–9.4), longer ICU stay [14 (8–21) days versus 29.5 (23–45) days, p < 0.001], and poor functional outcome after 3 months (OR = 3.10, 95% CI = 1.49–6.39).ConclusionsDysphagia is a frequent complication of non-traumatic SAH and associated with poor functional outcome, infectious complications, and prolonged stay in the intensive care unit. Early identification of high-risk patients is needed to timely stratify individual patients for dysphagia treatment.

Inflammation in delayed ischemia and functional outcomes after subarachnoid hemorrhage

BackgroundInflammatory mechanism has been implicated in delayed cerebral ischemia (DCI) and poor functional outcomes after subarachnoid hemorrhage (SAH). Identification of cytokine patterns associated with inflammation in acute SAH will provide insights into underlying biological processes of DCI and poor outcomes that may be amenable to interventions.MethodsSerum samples were collected from a prospective cohort of 60 patients with acute non-traumatic SAH at four time periods (< 24 h, 24–48 h, 3–5 days, and 6–8 days after SAH) and concentration levels of 41 cytokines were measured by multiplex immunoassay. Logistic regression analysis was used to identify cytokines associated with DCI and poor functional outcomes. Correlation networks were constructed to identify cytokine clusters.ResultsOf the 60 patients enrolled in the study, 14 (23.3%) developed DCI and 16 (26.7%) had poor functional outcomes at 3 months. DCI was associated with increased levels of PDGF-ABBB and CCL5 and decreased levels of IP-10 and MIP-1α. Poor functional outcome was associated with increased levels of IL-6 and MCP-1α. Network analysis identified distinct cytokine clusters associated with DCI and functional outcomes.ConclusionsSerum cytokine patterns in early SAH are associated with poor functional outcomes and DCI. The significant cytokines primarily modulate the inflammatory response. This supports earlier SAH studies linking inflammation and poor outcomes. In particular, this study identifies novel cytokine patterns over time that may indicate impending DCI.

Digital subtraction cerebral angiography after negative computed tomography angiography findings in non-traumatic subarachnoid hemorrhage

BackgroundCT angiography (CTA) is widely used for the detection of vascular lesions in patients with non-traumatic subarachnoid hemorrhage (ntSAH); however, digital subtraction angiography (DSA) remains the gold standard for diagnosis....

One-year prognosis of non-traumatic cortical subarachnoid haemorrhage: a prospective series of 34 patients

IntroductionCortical subarachnoid haemorrhage (cSAH) has multiple aetiologies. No prospective study has reported the long-term progression of the condition. The objective of this study is to describe the clinical and aetiological characteristics of patients with cSAH and to gain insight into prognosis. MethodsWe performed a prospective, observational, multi-centre study. Data on clinical and radiological variables were collected; during a one-year follow-up period, we recorded data on mortality, dependence, rebleeding, and the appearance of dementia. ResultsThe study included 34 patients (mean age, 68.3 years; range, 27–89). The most frequent symptoms were headache and focal neurological deficits, which were frequently transient and recurrent. CT scans returned pathological findings in 28 patients (85%). Brain MRI scans were performed in 30 patients (88%), revealing acute ischaemia in 10 (29%), old haemorrhage in 7 (21%), and superficial siderosis in 2 (6%). Aetiology was identified in 26 patients (76.5%): causes were cerebral amyloid angiopathy in 8, ischaemic stroke in 5, vasculitis in 4, reversible posterior encephalopathy in 2, venous thrombosis in 2, reversible cerebral vasoconstriction syndrome in 2, carotid occlusion in 1, Marfan syndrome in 1, and meningeal carcinomatosis in 1. Three patients died during follow-up (2 due to causes related to the cause of cSAH). Three patients developed dementia, 3 had lobar haemorrhages, and one had a second cSAH. ConclusionsThe most frequent causes of cSAH in our series were cerebral amyloid angiopathy, ischaemic stroke, and vasculitis. This type of haemorrhage has a worse prognosis than other non-aneurysmal cSAH. There are numerous possible causes, and prognosis depends on the aetiology. In elderly patients, intracranial haemorrhage is frequently associated with cognitive impairment.

The Spectrum of Nontraumatic Convexity Subarachnoid Hemorrhage

Background: Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a nonaneurysmal variant that is associated with diverse etiologies. Methods: With IRB approval, we retrospectively reviewed consecutive nontraumatic cSAH from July 1, 2006 to July 1, 2016. Data were abstracted on demographics, medical history, neuroimaging, etiology, and clinical presentation. Results: We identified 94 cases of cSAH. The cases were classified according to the following etiologies: reversible cerebral vasoconstriction syndrome (RCVS) 17 (18%), cerebral amyloid angiopathy (CAA) 15 (16%), posterior reversible encephalopathy syndrome 16 (17%), cerebral venous thrombosis 10 (11%), large artery occlusion 7 (7%), endocarditis 6 (6%), and cryptogenic 25 (27%). Early rebleeding occurred in 9 (10%) patients. Time from initial imaging to CT rebleeding was 40 hours (range, 5-74). CAA was associated with the highest mean age at 75.8 and RCVS the lowest at 47.6 years (P< .0001). Among patients with RCVS, initial vascular imaging was negative in 6 (35%), and repeat imaging documented vasoconstriction at a mean delay of 5 days (range, 3-16). Conclusion: There were significant differences among the subgroups in cSAH, with CAA presenting as older men with transient neurological deficits, and RCVS presenting as younger women with thunderclap headache. Rebleeding was seen in 10% of cSAH patients. One-third of RCVS patients with cSAH required repeat vascular imaging to diagnose vasoconstriction.

The Use of Standardized Management Protocols for Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Systematic Review.

The use of standardized management protocols (SMPs) may improve patient outcomes for some critical care diseases. WhetherSMPs improve outcomes after subarachnoid hemorrhage (SAH) is currently unknown. We aimed to study the effect of SMPs on 6-month mortality and neurologic outcomes following SAH. A systematic review of randomized control trials (RCTs) and observational studies was performed by searching multiple indexing databases from their inception through January 2019. Studies were limited to adult patients (age ≥ 18) with non-traumatic SAH reporting mortality, neurologic outcomes, delayed cerebral ischemia (DCI) and other important complications. Data on patient and SMP characteristics, outcomes and methodologic quality were extracted into a pre-piloted collection form. Methodologic quality of observational studies was assessed using the Newcastle-Ottawa scale, and RCT quality was reported as per the Cochrane risk of bias tool. A total of 11,260 studies were identified, of which 37 (34full-length articles and 3 abstracts) met the criteria for inclusion. Two studies were RCTs and 35were observational. SMPs were divided into four broad domains: management of acute SAH, early brain injury, DCI and general neurocritical care. The most common SMP design was control of DCI, with 22 studies assessing this domain of care. Overall, studies were of low quality; most described single-center case series with small patient sizes. Definitions of key terms and outcome reporting practices varied significantly between studies. DCI and neurologic outcomes in particular were defined inconsistently, leading to significant challenges in their interpretation. Given the substantial heterogeneity in reporting practices between studies, a meta-analysis for 6-month mortality and neurologic outcomes could not be performed, and the effect of SMPs on these measures thus remains inconclusive. Our systematic review highlights the need for large, rigorous RCTs to determine whether providing standardized, best-practice management through the use of a protocol impacts outcomes in critically ill patients with SAH.Trial registration Registration number: CRD42017069173.

Vitamin K Antagonist (Phenprocoumon) and Subarachnoid Hemorrhage: A Single-Center, Matched-Pair Analysis.

Demographic changes are leading to an aging society with a growing number of patients relying on anticoagulation, and vitamin K antagonists (VKA) are still widely used. As mortality and functional outcomes are worse in case of VKA-associated hemorrhagic stroke, phenprocoumon treatment seems to be a negative prognostic factor in case of subarachnoid hemorrhage (SAH). The purpose of this study was to analyze whether phenprocoumon treatment does worsen the outcome after non-traumatic SAH. All patients treated for non-traumatic SAH between January 2007 and December 2016 in our institution were retrospectively analyzed. After exclusion of patients with anticoagulant or antiplatelet treatment other than phenprocoumon, we analyzed 1040 patients. Thirty-three patients (3%) of those were treated with continuous phenprocoumon. In total, 132 out of all 1007 patients without anticoagulant treatment of the remaining patients were matched as control group (ratio = 1:4). Patients with phenprocoumon treatment were significantly older (66.5years vs. 53.9years; p < .0001), and admission status was significantly more often poor (66.7% vs. 41.8%, p = .007) compared to all patients without anticoagulant treatment. Further, bleeding pattern and rates of early hydrocephalus did not differ. Matched-pair analysis revealed a significant higher rate of angio-negative SAH in the study group (p = .001). Overall rates of hemorrhagic or thromboembolic complications did not differ (21.4% vs. 18.8%; NS) but were more often fatal, and 30-day mortality rate was significantly higher in the phenprocoumon group than in patients of the matched-pair control group (33% vs. 24%; p < .001). 30% of the phenprocoumon group and 37% of the matched-pair control group reached favorable outcome. However, poor outcome was strong associated with the reason for phenprocoumon treatment. Patients with phenprocoumon treatment at the time of SAH are significantly older, admission status is worse, and 30-day mortality rates are significantly higher compared to patients without anticoagulant treatment. However, outcome at 6months did not differ to the matched-pair control group but seems to be strongly associated with the underlying cardiovascular disease. Treatment of these patients is challenging and should be performed on an interdisciplinary base in each individual case. Careful decision-making regarding discontinuation and bridging of anticoagulation and close observation is mandatory.

Increasing Frailty Predicts Worse Outcomes and Increased Complications After Angiogram-Negative Subarachnoid Hemorrhages

The effect of frailty on outcomes after angiogram-negative subarachnoid hemorrhages (ANSAH) is currently unknown. We investigated frailty's effects on ANSAH outcomes, including mortality and in-hospital complications. Patients from 2014 to 2018 with non-traumatic subarachnoid hemorrhage and cerebral angiograms with an unidentifiable hemorrhage source were retrospectively reviewed. The cohort was divided into non-frail (modified frailty index [mFI]= 0) and frail (mFI ≥1) groups based on pre-hemorrhage characteristics. Primary outcomes were mortality rate and discharge location. Multivariate logistic regression analyses determined predictors of ANSAH severity and primary endpoints. Receiver operating characteristic curves were used to discriminate risks for primary endpoints comparing mFI, Hunt and Hess and Fisher scores, and age. We included 75 patients with a mean age of 55.4 ± 1.5 years, comprising 42 (56%) women, and 41 (54.7%) with perimesencephalic bleeds. A total of 32 of 75 (42.7%) patients were classified as frail. Frail individuals were 6.2 times less likely to be discharged home (odds ratio [OR]= 0.16; 95% confidence interval [CI]: 0.05-0.5; P= 0.001) and all mortalities occurred in frail patients (12.5% [n= 4 of 32]; P= 0.030). The only independent predictor of mortality was higher mFI (OR= 5.4; 95% CI: 1.5-19.1; P= 0.009), and lower mFI best predicted discharge home (OR= 0.39; 95% CI: 0.17-0.88; P= 0.023). Receiver operating characteristic analysis showed that mFI best predicted both mortality (area under the curve= 0.9718; P= 0.002) and discharge home (area under the curve= 0.7998; P < 0.001). Frail ANSAH patients have poorer outcomes and increased mortality compared with non-frail patients. Although prospective study is needed, this information significantly impacts our understanding of ANSAH outcomes and frailty should be used for prognostication as it was a better predictor than Hunt and Hess or Fisher scores.

Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage.

We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.

Retinal Vessel Analysis (rGA) at the Patient Bed in the Context of Non-traumatic Subarachnoid Haemorrhage

Retinal Vessel Analysis (rGA) at the Patient Bed in the Context of Non-traumatic Subarachnoid Haemorrhage

Epileptic seizures and outcome in different subtypes of subarachnoid haemorrhage – Results of a single-center retrospective analysis

BackgroundSymptomatic epileptic seizures are an important complication in subarachnoid haemorrhage (SAH) with a frequency of 0.9–25% with importance for patient outcome. The majority of previous studies investigated the incidence of symptomatic epileptic seizures after aneurysmatic SAH. Here we compared the seizure incidence and its impact on the outcome between non-aneurysmatic and aneurysmatic SAH. MethodsWe analysed retrospectively 109 consecutive patients with spontaneous, non-traumatic SAH. Patients were divided in three groups (perimesencephalic, non-aneurysmatic and aneurysmatic SAH). All patients received standard-of-care treatment. The occurrence of acute (0–7 days after SAH) and remote symptomatic epileptic seizures (7 days or more after SAH), severity of SAH as well as clinical outcome parameters (modified Rankin scale [mRS]) at discharge and the frequency of in-house complications were assessed. mRS scores were dichotomized in 0–3 vs. 4–6 to stratify for good versus bad outcome. ResultsPerimesencephalic SAH patients did not experience acute seizures whereas non-aneurysmatic and aneurysmatic SAH patients showed acute seizures with similar frequency (9% and 11%, p = 0.23). The frequency of remote symptomatic seizures was similar in all subgroups (12% vs. 9% vs. 7%, p = 0.72). Seizure occurrence was not predictive for a poor outcome (mRS >4; acute seizures: OR 0.35 [95%CI: 0.02–6.96], p = 0.49; remote seizures: OR 1.72 [95%CI: 0.14–20.1], p = 0.67). ConclusionsSeizures are important neurologic complications of SAH of all etiologies. Nevertheless, acute as well as remote symptomatic seizures are unrelated to the short-term outcome. These results should be treated as hypothesis generating and require confirmation.

Fever Burden in Patients With Subarachnoid Hemorrhage and the Increased Use of Antibiotics

Background: Fever occurs in the majority of subarachnoid hemorrhage (SAH) patients. Nearly 50% of SAH patients have noninfectious fevers. Data are lacking describing the effects of fever burden in the SAH patient population. Methods: This was a single-center, retrospective observational cohort study in patients more or equal to 18 years of age with a diagnosis of nontraumatic SAH admitted to an ICU between January 1, 2010 and September 1, 2015. Exclusion criteria were SAH secondary to trauma or admission for more than 48 hours. Temperature measurements, demographic data, and other pertinent information were collected from Day 0 to Day 13. Daily fever burden was calculated for each patient by calculating an area under the curve. Results: A total of 194 subjects were included. The mean study period maximum temperature (Tmax) for all 194 patients was 40.8 ± 0.83°C. The mean overall fever burden for all 194 patients was 89.2 ± 99.59°C h more than 37°C. The overall fever burden peaked on day 5 and declined thereafter. Fever burden, Tmax, and length of stay in the hospital were all significantly associated with receipt of antibiotics. Only Tmax was associated with poor outcome. The 31 patients who had fever but no identified cause of infection received 1000 doses of antibiotics or 32.25 doses per patient. Conclusion: Fever is common in SAH patients and is associated with antibiotic use, infection, vasospasm, and poor outcome. Some SAH patients may receive antibiotics unnecessarily for noninfectious fever. Clinicians should consider using site-specific parameters related to infection rather than systemic symptoms such as fever to evaluate infection in SAH patients.