Outcome Of Subarachnoid Hemorrhage Research Articles

Imaging predictors of outcome in acute spontaneous subarachnoid hemorrhage: a review of the literature.

Spontaneous subarachnoid hemorrhage (SAH) accounts for about 5% of strokes, but has a very high morbidity and mortality. Many survivors are left with important cognitive impairment and are severely incapacitated. Prediction of complications such as vasospasm and delayed cerebral ischemia, and of clinical outcome after SAH, is challenging. Imaging studies are essential in the initial evaluation of SAH patients and are increasingly relevant in assessing for complications and prognosis. In this article, we reviewed the role of imaging studies in evaluating early brain injury and predicting complications as well as clinical and neuropsychological prognosis after acute SAH.

Neuroglobin as a Novel Biomarker for Predicting Poor Outcomes in Aneurysmal Subarachnoid Hemorrhage

Neuroglobin (Ngb) has a high affinity for oxygen and helps prevent hypoxic-ischemic brain damage. In this study we analyzed the relationship between Ngb levels and clinical outcomes of aneurysmal subarachnoid hemorrhage (aSAH). Serum Ngb levels were measured in 58 patients with aSAH and 27 control individuals using theenzyme-linked immunosorbent assay. To continuously assess aSAH, we measured serum Ngb levels on days 1, 2, 3, 5, and 7 after aSAH. Clinical data were collected using the Hunt and Hess Scale, the Glasgow Coma Scale (GCS), the World Federation of Neurological Surgeons (WFNS) Scale, and the modified Fisher Scale. Clinical outcomes included 6-month mortality and 6-month unfavorable outcomes (modified Rankin Scale (mRS) score of 3-6). Serum Ngb levels increased after aSAH, peaked on day 2, and then gradually decreased. Serum Ngb levels on admission were higher in the patient group than in the control group (7.67 ± 2.56 ng/mL vs. 6.45 ± 0.88 ng/mL, P < 0.05). Multivariate logistic regression analysis indicated that serum Ngb levels on day 2 after aSAH were independently related to 6-month mortality (odds ratio [OR]= 0.265, 95% confidence interval [CI]= 0.094-0.747, P < 0.05) and 6-month unfavorable outcomes (OR= 1.919, 95% CI= 1.158-3.180, P < 0.05), and receiver operating characteristic curve analysis showed that serum Ngb levels on day 2 predicted 6-month mortality and 6-month unfavorable outcomes, with areas under the curve of 0.893 (P < 0.05; 95% CI, 0.812-0.974) and 0.818 (P < 0.05; 95% CI, 0.691-0.954), respectively, based on the best thresholds. Serum Ngb levels on day 2 after aSAH were strongly associated with poor outcomes in aSAH, suggesting that Ngb may be a novel biomarker for predicting poor outcomes in aSAH.

Vasospasm-related complications after subarachnoid hemorrhage: the role of patients’ age and sex

Outcome of aneurysmal subarachnoid hemorrhage (SAH) depends strongly on occurrence of symptomatic vasospasm (SV) leading to delayed cerebral ischemia (DCI). Various demographic, radiographic, and clinical predictors of SV have been reported so far, partially with conflicting results. The aim of this study was to analyze the role of patients' age and sex on SV/DCI risk, especially to identify age and sex-specific risk groups. All patients admitted with acute SAH during a 14-year-period ending in 2016 were eligible for this study. The study endpoints were the following: SV requiring spasmolysis, occurrence of DCI in follow-up computed tomography scans and unfavorable outcome at 6months (modified Rankin scale > 2). Nine hundred ninety-four patients were included in this study. The majority was female (666; 67%). SV, DCI, and unfavorable outcomes were observed in 21.5, 21.8, and 43.6% of the patients, respectively. Younger age (p < 0.001; OR = 1.03 per year decrease) and female sex (p = 0.025; OR = 1.510) were confirmed as independent predictors of SV. Regarding the sex differences, there were three age groups for SV/DCI risk ≤ 54, 55-74, and ≥ 75years. Male patients showed earlier decrease in SV risk (at ≥ 55 vs. ≥ 75years in females). Therefore, SAH females aged between 55 and 74years were at the highest risk for DCI and unfavorable outcome, as compared to younger/older females (p = 0.001, OR = 1.77/p = 0.001, OR = 1.80). In contrast, their male counterparts did not show these risk alterations (p = 0.445/p = 0.822). After acute SAH, female and male patients seem to show different age patterns for the risk of SV and DCI. Females aged between 55 and 74years are at particular risk of vasospasm-related SAH complications, possibly due to onset of menopause. DRKS, Unique identifier: DRKS00008749.

Bexarotene attenuates early brain injury via inhibiting micoglia activation through PPARγ after experimental subarachnoid hemorrhage

Objectives Early brain injury (EBI) is considered to be one of the main causes of poor outcome in subarachnoid hemorrhage (SAH) patients. Bexarotene is an agonist of retinoid X receptor and plays a protective role in central nervous system diseases. However, the exact role of bexarotene in SAH has not been reported. Therefore, the present study was to determine whether bexarotene administration attenuate EBI after SAH in mice and to explore the underlying mechanism.Methods SAH was induced in C57BL/6 mice by endovascular perforation. Bexarotene was administrated intraperitoneally. Neurological score, cell death, microglia activation, and pro-inflammatory cytokines were detected at 24 h after SAH. The expression of PPARγ was measured by Western blot.Results Results showed that bexarotene significantly improved neurological score after SAH. In addition, the number of cell death and activated microglia were significantly reduced by bexarotene administration. Compared with vehicle-treated mice, bexarotene-treated mice showed reduced pro-inflammatory cytokines after SAH. The expression of PPARγ was significantly increased with bexarotene treatment compared with vehicle-treated controls.Discussion The present study demonstrats that bexarotene administration protects against EBI after SAH, inhibiting cell death, attenuating microglia activation, and alleviating neuroinflammation. The underlying mechanism may partially involve the activation of PPARγ.

Delayed Cerebral Ischemia and Vasospasm After Spontaneous Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis

To report clinical outcomes of delayed cerebral ischemia (DCI) and vasospasm in angiogram-negative subarachnoid hemorrhage (SAH) according to hemorrhage patterns, perimesencephalic hemorrhage (PMH) and non-PMH. Online databases from January 1990 to December 2017 were systematically reviewed. A fixed-effects model was used to control heterogeneity. To resolve publication bias, the trim and fill method was used to estimate number of missing studies and adjusted odds ratio (OR). Subgroup analysis of data from studies that defined angiogram-negative subarachnoid hemorrhage by angiography repeated at least twice or computed tomography angiography was performed. Among 24 studies including 2083 patients, 23/985 patients (2.3%) with PMH and 144/1098 patients (13.1%) with non-PMH had DCI, indicating that patients with PMH experienced significantly lower DCI than patients with non-PMH (OR= 0.219; 95% confidence interval [CI], 0.144-0.334). Regarding vasospasm, 99/773 patients (12.8%) with PMH and 231/922 patients (25.1%) with non-PMH exhibited vasospasm, indicating that patients with PMH experienced significantly lower vasospasm than patients with non-PMH (OR= 0.445; 95% CI, 0.337-0.589). Funnel plots show asymmetry indicating possible publication bias. After trimming 10 studies for DCI and 7 for vasospasm, the adjusted ORs remained significant between PMH and lower risks of DCI and vasospasm. Subgroup analysis of 789 patients in 8 studies showed a lower risk of DCI (OR=0.268; 95% CI, 0.151-0.473) and vasospasm (OR= 0.346; 95% CI, 0.221-0.538) in patients with PMH. PMH showed a significantly lower risk of DCI and vasospasm than non-PMH. Clinical outcomes of angiogram-negative subarachnoid hemorrhage, based on meta-analysis of individual patient data, need to be investigated.

Risk Factors for Unfavorable Outcome in Aneurysmal Subarachnoid Hemorrhage Revisited; Odds and Ends.

To evaluate the odds for unfavorable outcome of each risk factor and a combination of them in patients with aneurysmal subarachnoid hemorrhage (SAH) undergoing surgical clipping in Southern Iran. A total of 367 patients who were operated between March 2007 and March 2016 due to aneurysmal SAH were analyzed according to patients' factors, aneurysm characteristics and intra-operative data. Correlation between outcomes of patients measured by modified Rankin Scale at 6-months with each factor were analyzed. Market Basket analysis was also used to identify the odds of unfavorable outcome for combinations of factors. A total of 367 patients, including 199 females and 168 males with a mean age of 47.27± 11.53 years, who underwent operation between March 2007 and March 2016 due to aneurysmal SAH were analyzed. Unlike gender, higher age was associated with unfavorable outcome. Ischemic heart disease, Duration of operation and amount of bleeding were also found to increase the odds of unfavorable outcome (p=0.01, 0.02, 0.04 respectively). DM, Cigarette smoking and opium addiction as well as the location and multiplicity of aneurysms did not have an adverse effect on outcome. (p≥0.05). Among the numerous risk factors presumed to result in unfavorable outcome in aneurysmal SAH, only older age, duration of operation more than 60 minutes, previous known history of ischemic heart disease, poorer clinical grade and intra-operative bleeding more than 500 mL were found to be significant factors.

Prediction of clinical outcome in subacute subarachnoid hemorrhage using diffusion tensor imaging.

Clinical outcome in nontraumatic subarachnoid hemorrhage (SAH) is multifactorial and difficult to predict. Diffusion tensor imaging (DTI) findings are a prognostic marker in some diseases such as traumatic brain injury. The authors hypothesized that DTI parameters measured in the subacute phase of SAH can be associated with a poor clinical outcome. Diffusion tensor imaging was prospectively performed in 54 patients at 8-10 days after nontraumatic SAH. Logistic regression analysis was performed to evaluate the association of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values with a poor clinical outcome (modified Rankin Scale score ≥ 3) at 3 months. At 8-10 days post-SAH, after adjusting for other variables associated with a poor outcome, an increased ADC at the frontal centrum semiovale was associated with a poor prognosis (OR estimate 1.29, 95% CI 1.04-1.60, p = 0.020). Moreover, an increase of 0.1 in the FA value at the corpus callosum at 8-10 days after SAH corresponded to 66% lower odds of having a poor outcome (p = 0.002). Decreased FA and increased ADC values in specific brain regions were independently associated with a poor clinical outcome after SAH. This preliminary exploratory study supports a potential role for DTI in predicting the outcome of SAH.

Aneurysmal Subarachnoid Hemorrhage Mortality After Implementation of Nocturnist Advanced Practice Provider Coverage.

We hypothesized that a nocturnist advanced practice provider (APP) model compared with overnight neurocritical care coverage with general critical care physicians and neurology residents would provide similar patient outcomes, as measured by patient mortality. This study is a retrospective review of healthcare outcomes of aneurysmal subarachnoid hemorrhage (aSAH) patients from 2013 and 2016, after implementation of specialty-trained neurocritical care nocturnist APPs. In 2013, overnight hours were covered by the general intensive care unit team and a junior neurology resident. In 2016, these patients were cared for by APPs overnight. The primary outcome measured was comparison of mortality before and after this change of overnight coverage because the daytime coverage remained similar between years. In 2013, 58 patients were admitted to the neurocritical care unit with aSAH. In 2016, 19 aSAH patients were admitted to the neurocritical care unit. The mean modified Fisher grade was 3.36 in 2013, with 14 of 58 deaths (mortality rate, 24%). In 2016, the mean modified Fisher grade was 3.4. Three patients died (mortality rate, 15.7%). The active nocturnist APP model was associated with an approximately 10% reduction in SAH mortality (P = .54). This supports the hypothesis that APPs can provide noninferior care as the previous model. Further studies are needed to demonstrate the effects of both nocturnist and APP-driven models.

Does the subspecialty of an intensive care unit (ICU) has an impact on outcome in patients suffering from aneurysmal subarachnoid hemorrhage?

We retrospectively compared the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients treated in a neurosurgical ICU (nICU) between 1990 and 2005 with that of patients treated in a general ICU (gICU) between 2005 and 2013 with almost identical treatment strategies. Among other parameters, we registered the initial Hunt and Hess grade, Fisher score, the incidence of vasospasm, and outcome. A multivariate analysis (logistic regression model) was performed to adjust for different variables. In total, 755 patients were included in this study with 456 patients assigned to the nICU and 299 patients to the gICU. Multivariate logistic regression analysis revealed no significant difference between the patient outcome treated in a nICU versus gICU after adjusting for different variables. The outcome of patients after aSAH is not influenced by the type of ICU (gICU versus nICU). The data do not allow claiming that aSAH patients need to be treated in a specialized ICU for obtaining better results. Parameters which might differ from hospital to hospital, especially warranty of neurosurgical expertise on gICU, have the potential to influence the results.

Functional Outcomes and Delayed Cerebral Ischemia Following Nonperimesencephalic Angiogram-Negative Subarachnoid Hemorrhage Similar to Aneurysmal Subarachnoid Hemorrhage

The angiogram-negative subarachnoid hemorrhage (SAH) literature includes patients with perimesencephalic hemorrhage, which is recognized to have a much better outcome than aneurysmal SAH. To evaluate the clinical outcomes of Nonperimesencephalic Angiogram-Negative SAH (NPAN-SAH). A prospective, spontaneous SAH database of 1311 patients that accrued between April 2006 and December 2014 was screened. All patients with NPAN-SAH and 2 consecutive negative cerebral angiograms were included. We identified 191 (11%) from a total of 1311 patients with spontaneous SAH. Amongst angiogram-negative patients, 83 (4.9%) were adjudicated to have NPAN-SAH. Patient characteristics were similar across the groups, except NPAN-SAH patients were more likely to be men and had higher rates of diabetes. In a multivariable logistic regression model, NPAN-SAH patients were less likely to develop vasospasm, after adjusting for Fisher grade, sex, and diabetes (odds ratio [OR]: 0.197, 95% confidence interval [CI; 0.07-0.55], P = .002). In another adjusted model accounting for Hunt and Hess clinical grade, NPAN-SAH patients were also less likely to develop vasospasm (OR: 0.2, 95% CI [0.07-0.57], P = .002). We found no statistical significance between 2 groups for rebleed, developing hydrocephalus, seizures, or delayed cerebral ischemia. NPAN-SAH patients were equally associated with poor functional outcome (modified Rankin scale ≥3; OR: 1.16, 95% CI [0.615-2.20], P = .6420), and death (OR: 1.22, 95% CI [0.362-4.132], P = .7455) compared to aneurysmal SAH. Although the risk of vasospasm may be lower, patients with NPAN-SAH are equally associated with delayed cerebral ischemia, poor outcome, and death as compared to patients with aneurysmal SAH. Furthers studies may be necessary to further clarify these findings.

Incidence and outcome of subarachnoid haemorrhage in the general and emergency department populations in Queensland from 2010 to 2014.

To determine: (i) incidence and outcome of subarachnoid haemorrhage (SAH) in the general population; and (ii) proportions of SAH in both the general ED population and in ED patients presenting with headache. A population-based study in Queensland from January 2010 to December 2014 was conducted. Data were sourced from the Australian Bureau of Statistics, Queensland Hospital Admitted Patient Data Collection linked to the Queensland death registry and ED Information System. Admitted patients with SAH were identified from ICD-10-AM codes. Inter-hospital transfers and repeat admissions for previously diagnosed SAH were excluded. Pre-hospital deaths from SAH were included. ED patients with headache were identified from ICD-10-AM codes and finding 'headache' in the triage free-text entry. The incidence of SAH, in-hospital mortality, proportions of SAH in the general ED population and ED patients with headache were calculated. There were 1975 incident cases of SAH in admitted patients and 294 pre-hospital deaths from SAH. The incidence of SAH was 9.9 (95% confidence interval [CI] 9.5-10.4) per 100 000 person-years. The incidence standardised to the 'World Standard Population' was 7.0 per 100 000 person-years. The in-hospital mortality was 23.8% (95% CI 22.0-25.8%). SAH was found in 1407 (1.9%, 95% CI 1.8-2.0) of ED patients with headache. Overall, there were 2.4 (95% CI 2.3-2.5) SAH per 10 000 of all ED attendances. The incidence of SAH was similar to that previously reported for Australia. One in 50 ED patients with headache had SAH. Ten in 50 000 ED attendances had a SAH. These estimates can assist in the risk assessment for SAH.

Rolipram Attenuates Early Brain Injury Following Experimental Subarachnoid Hemorrhage in Rats: Possibly via Regulating the SIRT1/NF-κB Pathway.

Early brain injury (EBI) is the primary cause of poor outcome in subarachnoid hemorrhage (SAH) patients. Rolipram, a specific phosphodiesterase-4 inhibitor which is traditionally used as an anti-depressant drug, has been recently proven to exert neuroprotective effects in several central nervous system insults. However, the role of rolipram in SAH remains uncertain. The current study was aimed to investigate the role of rolipram in EBI after SAH and explore the potential mechanism. Adult male Sprague-Dawley rats were subjected to an endovascular perforation process to produce an SAH model. Rolipram was injected intraperitoneally at 2h after SAH with a dose of 10mg/kg. We found that rolipram significantly ameliorated brain edema and alleviated neurological dysfunction after SAH. Rolipram treatment remarkably promoted the expression of Sirtuin 1 (SIRT1) while inhibited NF-κB activation. Moreover, rolipram significantly inhibited the activation of microglia as well as down-regulated the expression of pro-inflammatory cytokines TNF-α, IL-1ß, and IL-6. In addition, rolipram increased the expression of protective cytokine IL-10. Furthermore, rolipram significantly alleviated neuronal death after SAH. In conclusion, these data suggested that rolipram exerts neuroprotective effects against EBI after SAH via suppressing neuroinflammation and reducing neuronal loss. The neuroprotective effects of rolipram were associated with regulating the SIRT1/NF-κB pathway. Rolipram could be a novel and promising therapeutic agent for SAH treatment.

Continuous Acetylsalicylic Acid Treatment Does Not Influence Bleeding Pattern or Outcome of Aneurysmal Subarachnoid Hemorrhage: A Matched-Pair Analysis.

Demographic changes are leading to an aging society with a growing number of patients with cardiovascular diseases, relying on antiplatelet drugs like acetylsalicylic acid (ASA). Although antiplatelet agents are suspected to be protective not only in the cardiologic but in the neurovascular field, the alteration of the coagulating process could have a major impact on the course and outcome after rupture of intracranial aneurysms. Between June 1999 and December 2014, 1422 patients were treated for aneurysmal SAH in our institution, 144 (10.1%) with continuous ASA at the time of aneurysm rupture. A matched-pair analysis was performed. The rate of patients with continuous ASA treatment while rupture of the aneurysm is rising significantly (P < 0.01). Those patients were significantly older than patients without ASA (60 vs. 53 years, P < 0.001). ASA-treated patients more often had aneurysmal rebleeding (4.7% vs. 2.3%, P= 0.3) and treatment-related hemorrhagic complications (13.9% vs. 6.2%, P= 0.06). However, rates were not different in microsurgical or endovascular procedures (16.4% vs. 12.2%, P= 0.6). Favorable outcome (Modified Rankin Scale 0-2) was achieved in 49.3% of the ASA group and 52.1% of the control group (P= 0.7). Patients with continuous ASA treatment were significantly older than patients without ASA, but there was no difference in admission status or bleeding pattern. Outcome was not different in the matched-pair analysis. There was no statistical difference in treatment related-complication rates of microsurgical and endovascular procedures. Therefore, ASA use should not influence treatment decision of the ruptured aneurysm.

A subarachnoid haemorrhage-specific outcome tool.

Functional outcome after subarachnoid haemorrhage has traditionally been assessed using scales developed for other neurological conditions. The modified Rankin score and Glasgow Outcome Scale are most commonly used. Employment of these scales in subarachnoid haemorrhage is hampered by well recognized limitations. We set out to develop and validate a new condition-specific subarachnoid haemorrhage outcome tool (SAHOT). Items addressing diverse aspects of the impact of subarachnoid haemorrhage were collected during focus groups involving patients, next-of-kin and multidisciplinary professionals involved in subarachnoid haemorrhage management. After a series of iterative revisions, the resultant questionnaire was applied to patients and their next-of-kin at 1, 3 and 6 months post-subarachnoid haemorrhage. Rasch methodology was used to finalize the structure of the questionnaire and explore the extent to which SAHOT scores met Rasch-based criteria of successful measurement. The SAHOT was further assessed using traditional scale evaluation techniques, and validated in a second separate subarachnoid haemorrhage patient cohort. The final SAHOT included 56 items dealing with cognitive, physical, and behavioural/psychological consequences of subarachnoid haemorrhage. Rasch analysis indicated the scale successfully measured functional outcome post-subarachnoid haemorrhage. Three item scoring categories produced the best scale performance. There was no evidence of differential item functioning between patients and next-of-kin. The SAHOT was found to be acceptable, have good convergent and divergent validity, good discrimination and excellent responsiveness. It was successfully validated in a second subarachnoid haemorrhage patient cohort. The SAHOT offers the first subarachnoid haemorrhage-specific scientifically robust outcome measure with potential utility in neurovascular clinical services and research studies.

Abstract WP268: Associations Between Case Volume and Outcomes in the Subarachnoid Hemorrhage Patients With Clipping or Coiling: J-ASPECT Study

Background: Many studies have reported that high-volume center was associated with the favorable outcomes in subarachnoid hemorrhage (SAH) patients with treatment. However, in Japan, the effect of the case volume of the hospital in SAH patients remains elusive. The aim of this study is to investigate the associations between case volume and outcomes of clipping or coiling using data obtained from the Japanese Diagnosis Procedure Combination [DPC]-based Payment System. Methods: Of the 847 certified training institutions of the Japan Neurosurgical Society, 327 institutions agreed to participate in this DPC discharge database study. Data on patients hospitalized for SAH between April 1, 2012 and March 31, 2013 were obtained from the DPC database. Patients hospitalized because of SAH were identified using International Classification of Diseases-10 diagnosis codes (I60.0-9). The case volumes of clipping and coiling in each hospital were divided into quintiles (Q1-Q4). Odd ratios (ORs) of in-hospital mortality and modified Rankin Scale (mRS) at discharge were estimated after adjustment for age, sex, comorbidities, and SAH severity. The category of Q1 was assigned a reference for OR. Results: A total of 5214 patients with SAH (3624 clipping, 1590 coiling) were analyzed. Mortality was 9.8%, and proportion of discharge mRS3-6 was 44.0%. No significant associations were found between case volume and in-hospital mortality in both the clipping (Q2, Q3, and Q4; OR = 0.97, 0.69, and 0.77; P = 0.902, 0.148, and 0.263) and coiling group (Q2, Q3, and Q4; OR = 0.94, 1.62, and 0.84; P = 0.864, 0.140, and 0.586). No significant associations were found between case volume and discharge mRS3-6 in both the clipping (Q2, Q3, and Q4; OR = 1.28, 1.27, and 1.09; P = 0.194, 0.189, and 0.619) and coiling group (Q2, Q3, and Q4; OR = 0.89, 1.15, and 0.78; P = 0.691, 0.599, and 0.315). Conclusion: In Japan, case volume did not show the correlation with outcomes in SAH patients. This nationwide database study reflects the real-world practice. &lt;!--EndFragment--&gt;

Abstract TP171: Liver Cirrhosis is Associated With an Increased Risk of Aneurysmal Subarachnoid Hemorrhage

Introduction: Cirrhosis has been associated with non-traumatic subarachnoid hemorrhage (SAH). Additionally, cirrhosis appears to contribute to the development of pulmonary vascular abnormalities. We therefore sought to investigate whether cirrhosis is associated specifically with aneurysmal SAH. Methods: We performed a retrospective cohort study using 2009-2015 inpatient and outpatient claims data from a 5% sample of Medicare beneficiaries ≥66 years of age. Our exposure was cirrhosis as defined by a previously validated algorithm using inpatient and outpatient ICD-9- CM diagnosis codes. The outcome of aneurysmal SAH was identified using a validated approach requiring an inpatient ICD-9-CM diagnosis code for non-traumatic subarachnoid hemorrhage, without concomitant diagnosis codes for trauma or rehabilitation. Additionally, to further ensure we were identifying aneurysmal SAH, we required the presence of an ICD-9-CM procedure code reflecting endovascular or surgical treatment of a cerebral aneurysm during the same hospitalization. Patients were censored at the time of death or end of Medicare coverage or on September 30, 2015. We used survival statistics to calculate incidence rates and Cox proportional hazards models to evaluate the association between cirrhosis and aneurysmal SAH after adjustment for demographics, established SAH risk factors, and Charlson comorbidities. Results: We identified 10,658 (0.6%) patients with cirrhosis from among the 1,778,604 beneficiaries in our sample. The mean age of patients with cirrhosis was 73.2 (±6.5) years, and 48% were female. Over a mean of 4.7 (±2.1) years of follow-up, 4,272 patients were hospitalized with aneurysmal SAH. The annual incidence of aneurysmal SAH in patients with cirrhosis was 0.11% (95% confidence interval [CI], 0.08-0.17%) compared to 0.05% (95% CI, 0.05-0.05%) in patients without cirrhosis. After adjustment for demographics, risk factors, and comorbidities, cirrhosis was independently associated with an increased risk of aneurysmal SAH (hazard ratio, 2.3; 95% CI, 1.5-3.4). Conclusions: We found that cirrhosis was associated with aneurysmal SAH among Medicare beneficiaries. Liver cirrhosis may be an independent risk factor for aneurysmal SAH.

Abstract TMP59: Predictors of Readmissions After Aneurysmal Subarachnoid Hemorrhage

Objective: To identify factors associated with readmission after aneurysmal subarachnoid hemorrhage (SAH) using nationally representative data Background: Readmission rate is a common metric linked to hospital compensation and as a proxy to quality of care. Prior studies in SAH have reported higher risk of readmission among those with longer length of stay (LOS) and discharge to skilled nursing facility. These studies were limited by small sample sizes and single-center design. Methods: The Nationwide Readmissions Database is a de-identified national database of readmissions with data on 49% of U.S. admissions in 2013. We used International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index SAH admissions, comorbidities, and outcomes. Unadjusted and adjusted Poisson models were used to identify factors associated with increase readmission rate up to 1 year after discharge. Results: Out of 14464 index admissions for SAH, 8587 (59.4%) were female, average age was 61.2±16.1 years, with an even distribution of socioeconomic status. Among 11035 who survived to discharge, there were 2765 readmissions (25.1%) up to 1 year. In univariate analysis, variables associated with increased readmission rate included age, atrial fibrillation, CHF, diabetes, renal impairment, COPD, tracheostomy, percutaneous endoscopic gastrostomy, discharge not to home, and greater LOS. In multivariable analysis, significant predictors of higher readmission rate included LOS (0.001 greater rate per day increase, 95% CI 0.0001-0.002), CHF (rate ratio [RR] 1.08, 1.02-1.14), diabetes (RR 1.09, 1.05-1.14), renal impairment (RR 1.15, 1.09-1.2), COPD (RR 1.08, 1.02-1.14). Factors associated with lower readmission rate were age (0.0013 lower rate per year increase, -0.003, 0.0001) and discharge home (RR 0.92, 0.88-0.95). Conclusions: In this nationwide database several medical comorbidities were associated with higher readmission rates after SAH, in addition to previously reported variables of discharge disposition and LOS. Given that 1 out of 4 SAH patients are readmitted within the year, prospective studies are warranted on the feasibility and efficacy of interventions tailored to high-risk subgroups.

Development and validation of outcome prediction models for aneurysmal subarachnoid haemorrhage: the SAHIT multinational cohort study

ObjectiveTo develop and validate a set of practical prediction tools that reliably estimate the outcome of subarachnoid haemorrhage from ruptured intracranial aneurysms (SAH).DesignCohort study with logistic regression analysis to combine...

Intraventricular Hemorrhage Caused by Subarachnoid Hemorrhage: Does the Severity Matter?

Aneurysm rupture might be accompanied by intraventricular hemorrhage (IVH), which is associated with poor outcome of subarachnoid hemorrhage (SAH). The aim of this study was to analyze risk factors and clinical impact of IVH severity. A total of 995 consecutive patients with SAH treated at our institution between January 2003 and June 2016 were eligible for this study. Clinical and radiologic findings were correlated with the presence and severity of IVH assessed with the original Graeb score. A total of 487 patients with SAH (48.9%) presented with IVH (mean IVH severity, 5.48 points [±3.5]). IVH severity correlated with poorer initial clinical condition (World Federation of Neurosurgical Societies grade >3; P<0.001), acute hydrocephalus (P= 0.001), and poor outcome at 6 months (modified Rankin Scale score >2; P<0.001). The location of the ruptured aneurysm in the anterior cerebral artery independently predicted the occurrence (P= 0.007) and severity of IVH (P < 0.001). In turn, aneurysm size affected only the severity of IVH (P=0.001) but not its occurrence (P= 0.153). Early complications of SAH occurring within 72 hours after the bleeding event (cerebral infarction [P= 0.043], early mortality [P= 0.001], and primary craniectomy [P= 0.043]) were independently associated with the severity of IVH. Severity of aneurysmal IVH is a strong contributor to initial severity and early complications of SAH. Patients with larger aneurysms, especially located in the anterior cerebral artery, are at particular risk of severe IVH in cases of aneurysm rupture.

Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Sokół B, Wąsik N, Olczyk C, Więckowska B, Juszkat R, Jankowski R. Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness. Phlebological Review. 2018;26(2):36-43. doi:10.5114/pr.2018.81011. APA Sokół, B., Wąsik, N., Olczyk, C., Więckowska, B., Juszkat, R., & Jankowski, R. (2018). Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness. Phlebological Review, 26(2), 36-43. https://doi.org/10.5114/pr.2018.81011 Chicago Sokół, Bartosz, Norbert Wąsik, Catherine Olczyk, Barbara Więckowska, Robert Juszkat, and Roman Jankowski. 2018. "Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness". Phlebological Review 26 (2): 36-43. doi:10.5114/pr.2018.81011. Harvard Sokół, B., Wąsik, N., Olczyk, C., Więckowska, B., Juszkat, R., and Jankowski, R. (2018). Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness. Phlebological Review, 26(2), pp.36-43. https://doi.org/10.5114/pr.2018.81011 MLA Sokół, Bartosz et al. "Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness." Phlebological Review, vol. 26, no. 2, 2018, pp. 36-43. doi:10.5114/pr.2018.81011. Vancouver Sokół B, Wąsik N, Olczyk C, Więckowska B, Juszkat R, Jankowski R. Predictive value of plasma fibrinogen levels for outcome of aneurysmal subarachnoid haemorrhage during the first week of illness. Phlebological Review. 2018;26(2):36-43. doi:10.5114/pr.2018.81011.