Post-aneurysmal Subarachnoid Hemorrhage Research Articles

Clustering of serum biomarkers involved in post-aneurysmal subarachnoid hemorrhage (aSAH) complications

Post-aSAH sequela is characterized by the onset of life-threatening complications along with the upregulated underlying inflammation. Cerebral vasospasm (CVS) is one of the most frequent complication after aSAH, which contributes majorly to delayed cerebral ischemia and poor clinical outcome. The objective of this study was to identify the clusters of serum biomarkers that are associated with cerebral vasospasm (CVS) after suffering from aneurysmal subarachnoid hemorrhage (aSAH). In this single-center study, serum concentrations of 10 potential biomarkers, together with clinical and demographic parameters, for 66 aSAH patients were recorded within 24 h after aSAH. The dataset was split into a training set (43 patients) and a validation set. Correlation heatmaps for both datasets were computed. Variables with inconsistent correlations on the two subsets were excluded. Clusters of relevant biomarkers were identified on the complete set, separately for patients who developed post-aSAH CVS and those who did not. Two clusters were found to be specific for patients who suffered from CVS: mitochondrial gene fragments (cytochrome B (Cyt-B), cytochrome C oxidase subunit-1 (Cox-1), displacement loop (D-loop), and IL-23, and the other one, containing IL-6, IL-10, age, and Hunt and Hess score. Clusters of serum biomarkers, analyzed within 24 h of the onset of aSAH, days before the CVS development, are expressed differently in patients suffering from post-aSAH CVS, compared to patients without CVS. This suggests that these biomarkers may be involved in the pathophysiological processes leading to CVS and may be used as its early predictors. These interesting findings are potentially highly relevant for the management of CVS and call for validation on a larger sample of patients.

Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage.

Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18years with aSAH for radiographic vasospasm detection. The DerSimonian-Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR -). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68-91%) and a specificity of 97% (95%CI, 93-98%), while TCD had lower sensitivity 38% (95%CI, 19-62%) and specificity of 91% (95%CI, 87-94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR - for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR - than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR - , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm.

Symptomatic cerebral vasospasm following posterior fossa hemangioblastoma resection: illustrative case.

BACKGROUNDSymptomatic cerebral vasospasm following posterior fossa intra-axial tumor resection is a rare phenomenon with only seven cases previously reported in the literature. The condition appears distinct to vasospasm following supratentorial tumor resection and extra-axial tumor resection of the posterior fossa. It shares, however, similarities with vasospasm following aneurysmal subarachnoid hemorrhage.OBSERVATIONSThe authors describe their experience with a 23-year-old female who developed delayed symptomatic vasospasm following resection of a left parapontine cerebellar hemangioblastoma. Tumor resection was complicated by rupture of a fragile arterialized vein, resulting in significant hemorrhage. The patient developed several episodes of focal and variably reversible neurological deficit. These clinical signs corresponded with angiographically confirmed vasospasm, which responded to standard therapies for vasospasm post aneurysmal subarachnoid hemorrhage.LESSONSThis case and literature review highlight that symptomatic vasospasm is a rare, potentially highly morbid complication of posterior fossa intra-axial tumor resection. This phenomenon may be related to significant intraoperative or postoperative hemorrhage. Postoperative radiological findings such as high risk modified Fisher scale hemorrhage could alert clinicians to this condition.

Evaluation of Intra-Arterial Nimodipine Therapy in Post-Subarachnoid Hemorrhage Refractory Cerebral Vasospasm

Background: Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage. Vasospasm is managed with triple H and vasodilators but sometimes, patients do not respond. Intra-arterial vasodilator infusion has been shown to improve outcome in such patients. In this study, we try to evaluate the efficacy of intra-arterial nimodipine therapy in 43 patients of post-aneurysmal subarachnoid hemorrhage refractory cerebral vasospasm.

Clazosentan for Improvement of Time to Peak Perfusion in Patients with Angiographically Confirmed Severe Vasospasm

Clazosentan, an endothelin-1 receptor antagonist, has been shown to prevent the development of large vessel angiographic vasospasm after aneurysmal subarachnoid hemorrhage. We hypothesized that clazosentan can improve cerebral perfusion for territories affected by angiographically confirmed vasospasm. The REVERSE study (REversal of Vasospasm with clazosEntan post-aneuRysmal Subarachnoid hEmorrhage) was a prospective multicenter open-label pilot study of adult patients with aneurysmal subarachnoid hemorrhage who received intravenous clazosentan after developing moderate to severe angiographic vasospasm. Using the radiographic data from the REVERSE study and additional retrospective radiographic data from our tertiary medical center, we compared the impact of intravenous clazosentan with intraarterial vasodilator therapy (medical standard of care) on vasospasm reversal using time to peak perfusion (TTPP; the time interval between the peak opacification of contrast dye in the main artery supplying an anatomically defined territory and the parenchymal phase when the dye is diffusely present in the brain parenchyma). Both intravenous clazosentan (n = 7 vessels) and intraarterial vasodilator therapy (n = 11 vessels) resulted in a statistically significant improvement in TTPP at 24h post intervention, when compared with the TTPP just prior to intervention for territories with angiographically confirmed severe vasospasm in the proximal arteries at baseline (linear mixed-effect model, p = 0.02). The clazosentan and intraarterial vasodilator therapy groups exhibited no statistically significant interaction term [time x treatment group (medical standard of care vs. clazosentan)] in our model (p = 0.71), suggesting similar temporal course of two therapies. In our small pilot study, intravenous clazosentan administered for at least 24h had an effect comparable with that of intraarterial vasodilator therapy in reversing angiographically confirmed severe vasospasm. Our results may indicate that clazosentan, in an appropriately selected patient cohort, could offer a noninvasive approach for alleviating vasospasm.

Abstract P831: Use of the Neuro-QoL Measures for Assessment of Contributors to Long-Term Quality of Life, Post-Aneurysmal Subarachnoid Hemorrhage

Background: Aneurysmal subarachnoid hemorrhage (aSAH) survivors are at high risk for poor quality of life (QoL). Standard outpatient neurologic assessment may not capture some affective and cognitive factors important for long-term QoL, and reintegration into normal social roles. The purpose of this study is to determine the utility of the Quality of Life in Neurological Disorders (Neuro-QoL) measures for assessment of such factors in nursing practice. Methods: Standard demographic and clinical characteristics were collected on patients &gt;1 year post-aSAH, along with self-report information on seven Neuro-QoL measures (Ability to Participate in Social Roles and Activities [ABL]; Satisfaction with Social Roles and Activities [SATIS]; Cognitive Function [COG]; Depression [DEP]; Anxiety [ANX]; Lower Extremity Function - Mobility [LE] &amp; Upper Extremity Function - Fine Motor [UE]). Scores are T-scores with mean 50(±10). Associations were determined using Spearman correlations or paired t-tests as appropriate. Results: Participants (N=35) were 48.6(±12.5) years, 4.7(±3.6) years post aSAH, 80% female, 65.7% African American, and mean Hunt Hess Grade 2.3(±0.8). Age, race, and gender were not associated with Neuro-QoL outcomes. Our average sample T-scores were: ABL=45.3; SATIS=47.6; COG=44.3; DEP=49.3; ANX=51.3; LE=46.5; UE=46.7. COG was associated with ABL and SATIS ( p &lt;0.02). ANX was associated with ABL ( p =0.02). UE and LE were associated with ABL (r=0.5, p =0.001; r=0.8, p &lt;0.0001, respectively) and SATIS (r=0.5, p =0.005; r=0.8, p &lt;0.0001). Conclusions: The Neuro-QoL measures provide an effective tool for nursing assessment of QoL in post-aSAH. Although physical disability impairs social integration, we also found that cognitive and anxiety symptoms uniquely influenced the ability to integrate into social roles and may reduce overall QoL.

Outcome of Lumbar Drain in Delayed Communicating Hydrocephalus Secondary to Traumatic and Aneurysmal Subarachnoid Hemorrhage

Introduction: Delayed hydrocephalus is one of the common complications in traumatic subarachnoid hemorrhage and post aneurysmal subarachnoid hemorrhage. This study aims to study the role of lumbar drain in its management.&#x0D; Methods: This is a retrospective study of cases of delayed hydrocephalus which were managed with lumbar drain between March 2009 to February 2019. Computed tomogram or Magnetic Resonance Imaging was used in the diagnosis of delayed hydrocephalus and lumbar drain was inserted. A repeat Computed tomogram scan was performed, and the absence of delayed hydrocephalus was the indication for removal.&#x0D; Results: A total of 40 cases of delayed hydrocephalus were managed with lumbar drain during the study period. Traumatic subarachnoid hemorrhage was the cause of delayed hydrocephalus in 16 cases and the remaining 24 cases were due to post aneurysmal subarachnoid hemorrhage. The most common Fischer grade was III in aneurysm and II in trauma. Delayed hydrocephalus occurred within two to four weeks in aneurysm cases and after four weeks in traumatic cases. All aneurysm was managed with clipping whereas craniotomy or decompressive craniectomy was done in traumatic cases. 92.5% of cases improved after lumbar drainage of the hydrocephalus.&#x0D; Conclusion: This study reports the use of lumbar drain to treat delayed post subarachnoid hemorrhage hydrocephalus in a clinically-cost-effective way with minimal complications. Randomized studies to compare methods to treat delayed hydrocephalus will overcome the limitations of this study. Till then lumbar drain remains a safe alternative in communicating delayed hydrocephalus secondary to subarachnoid hemorrhage.

In-Hospital Evolution of Non Operated Aneurysmal Subarachnoid Hemorrhage at the Neurology Unit of Befelatanana University Teaching Hospital, Antananarivo

Subarachnoid hemorrhage is defined as a sudden irruption of blood in subarachnoid spaces. This study aims to determine the profile and in-hospital evolution of patients with post aneurysmal subarachnoid hemorrhage, who did not have surgical treatment in the Neurology Unit of Befelatanana University Hospital, Antananarivo, Madagascar. This study was a descriptive retrospective study within a period of 4 years, from January 1st, 2014 to December 31th, 2017. The study was carried out in hospitalized patients for subarachnoid hemorrhage with aneurysmal origin. We included 52 patients, with an average age of 48 years and a female predominance. They are housewives in majority of cases. 52% of the cases live in urban areas while 77% of cases have high blood pressure. The main clinical manifestation was a sudden headache, and intracranial aneurysm was located at the anterior communicating artery in 52% of cases. All patients benefited from drug treatments in majority of cases. Due to the lack of financial means, 60% had neurological complications. However, in-hospital mortality rate was at 13%. This study helps us to suggest to our patients medical treatment of their subarachnoid hemorrhage during hospitalization because of difficult access to surgery. It also aims to propose surgery outside the acute phase of the disease.

Intra-Arterial Papaverine-Hydrochloride and Transluminal Balloon Angioplasty for Neurointerventional Management of Delayed-Onset Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm

After subarachnoid hemorrhage, delayed onset vasospasm can result in devastating ischemic stroke. The phenomenon of delayed cerebral ischemia (DCI) is not yet fully understood, and the correlation of angiographic vasospasm and cerebral infarction is still unclear. Therefore, we investigated the effect of endovascular treatment on the angiographic response and occurrence of DCI. Eighty patients with subarachnoid hemorrhage and serious cerebral vasospasm underwent endovascular treatment using intra-arterial papaverine-hydrochloride (IAP) or transluminal balloon angioplasty (TBA). The angiographic response and infarction rate were classified using the pre- and postinterventional angiographic images and computed tomography scans. In 90% of patients, vasospasm could be improved. In most cases (78.8%), IAP was used. Retreatment after IAP was necessary in 32.9% of patients but never after TBA. A total of 233 vascular territories were treated in 128 procedures. Angiographic improvement was observed in 66.5% of territories, which was significantly associated with early intervention (P= 0.02), the use of TBA (P= 0.01), and the dose of papaverine-hydrochloride (P= 0.01). DCI occurred in 47.5% of the patients. Territorial infarction was associated with a poor Hunt and Hess grade (P= 0.03), day of aneurysm treatment (P= 0.01), severe vasospasm before (P= 0.02) and after (P= 0.03) treatment, and number of interventions (P= 0.01). However, the infarction rate was independent of the angiographic response. The discrepancy of excellent angiographic results and the high incidence of DCI might stem from an inaccurate or a delayed diagnosis of impending ischemia. In view of the limited time window, optimized peri-interventional management and continuous cerebral multimodality neuromonitoring might be crucial for the ideal timing of endovascular procedures to prevent cerebral infarctions.

Focused Neuro-Otological Review of Superficial Siderosis of the Central Nervous System.

Infratentorial siderosis (iSS) is a progressive degenerative disorder targeting primarily the cerebellum and cranial nerve eighth; therefore, progressive ataxia and its neuro-otological findings are common. Toxicity from hemosiderin involves selectively vulnerable neurons and glia in these posterior fossa structures. Other neurologic findings may be present, though our focus relates to the cochlea-vestibular cerebellar involvement. Radiographic evidence of siderosis may be the result of recurrent, albeit covert bleeding in the subarachnoid space, or the consequence of an overt post-traumatic or aneurysmal subarachnoid hemorrhage (SAH). The radiographic iSS appearance is identical regardless of the SAH cause. A recent study provides compelling evidence to search and correct possible hemorrhage sources in the spinal canal. The removal of residual existing hemosiderin deposits that may potentially cause clinical symptoms remains as a major therapeutic challenge. We reviewed large data sources and identified salient papers that describe the pathogenesis, clinical and neurotologic manifestations, and the radiographic features of iSS. The epidemiology of iSS is unknown. In a recent series, clinically evident iSS was associated with recurrent SAH; by contrast, in a follow-up period ranging from weeks up to 11 years after a monophasic episode of SAH, radiographic siderosis was clinically silent. However, the post-aneurysmal or post-trauma SAH sample size in this single study was small and their observation period relatively short; moreover, the burden of intraneuronal hemosiderin is likely greater with recurrent SAH. There are a few reports of late iSS, several decades after traumatic SAH. A recent report found subjective hearing loss in aneurysmal SAH individuals with radiographic siderosis. Only in recent years, it is safe to perform magnetic resonance imaging (MRI) in post-aneurysmal SAH, because of the introduction of titanium, MRI-compatible aneurysm clips. iSS can be associated with significant neurotologic and cerebellar morbidity; the recurrent SAH variant is frequently clinically symptomatic, has a shorter latency and greater neurotologic disability. In these cases, a thorough search and management of a covert source of bleeding may stop clinical progression. The frequency and clinical course of radiographic iSS after traumatic and post-aneurysmal SAH is largely unknown. Detection of radiographic iSS after trauma or aneurysm bleeding suggests that the slower clinical course could benefit from an effective intervention if it became available. The use of cochlear implants is a valid alternative with advanced hearing impairment.

Remote Primary Intraventricular Haemorrhage in Case of a Ruptur ed MCA Aneurysm

This is the first documented case report of a simultaneous middle cerebral artery (MCA) aneurysmal subarachnoid hemorrhage (aSAH) and remote third ventricular clot. The occurrence of simultaneous subarachnoid hemorrhage and remote hypertensive intracerebral hemorrhage (ICH) is a rare occurrence and has only been reported three previous times in the literature. Intraventricular hemorrhage (IVH) post aneurysmal subarachnoid hemorrhage is common, where peri-ventricular intracerebral clot has ruptured the ependymal lining. However primary intraventricular hemorrhage (PIVH) without associated parenchymal clot is rare. Migration of blood via outlet foramina of the fourth ventricle through CSF pulsation and flow is thought to be the mechanism for this occurrence and would account for small volumes in the subacute setting. Here, we present a case of a 52-year-old woman with a CT demonstrated spontaneous middle cerebral artery (MCA) bifurcation aneurysmal subarachnoid hemorrhage and a large acute third ventricular clot spanning the foramen Monroe.

Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm, Clinical Correlation between the Aneurysm Site and Clinical Vasospasm

Background: Intracranial vasospasm is a common complication following subarachnoid hemorrhage (SAH). The radiographic vasospasm can reach up to 90% of aneurysmal SAH. Materials and Methods: 139 consecutive patients admitted to Cairo University Hospitals from June 2013 to September 2014 with SAH who had been enrolled in a retrospective controlled study were analyzed retrospectively for the occurrence of vasospasm. The data collected from the charts of Cairo University Hospitals were the patient’s demographics, clinical presentation, aneurysm location, treatment modality, and Glasgow Outcome Scale (GOS) scores. We excluded 24 patients with nonaneurysmal SAH, 3 internal carotid artery (ICA) aneurysms, 7 with multiple aneurysms and 4 patients died before treatment. Results: 72 males and 29 females were included in the study, mean age 53.5 ± 11.5 years. Twelve patients had aneurysms located in the vertebral artery group, 24 had middle cerebral artery aneurysms, 11 had pericallosal aneurysms, and 54 patients had anterior communicating artery (ACoA) complex aneurysms. Radiographic vasospasm occurred in 62.4% with the highest incidence (75.9%) at the ACoA complex group. Symptomatic vasospasm occurred in 48.5% with the highest incidence (63%) at the anterior communicating artery complex aneurysm location. The mean GOS at 6 months follow-up was 4.2. The worse GOS was found in the vertebral artery (VA) aneurysm group with a mean of 3.75. Conclusion: Aneurysms of the anterior communicating artery complex group have a greater risk of both radiographic and clinical vasospasm. Also, the worse 6 months follow-up GOS when an aneurysm was located in the VA group.

A pilot study on the impact of dopamine, serotonin, and brain-derived neurotrophic factor genotype on long-term functional outcomes after subarachnoid hemorrhage.

Objectives:Many that survive an aneurysmal subarachnoid hemorrhage experience lasting physical disability, which might be improved by medications with effects on the dopaminergic, serotonergic, and brain-derived neurotrophic factor neurotransmitter systems. But it is not clear which patients are most likely to benefit from these therapies. The purpose of this pilot study was to explore the relationship of genetic polymorphisms in these pathways with 12-month functional outcomes after aneurysmal subarachnoid hemorrhage.Methods:Subjects were recruited at the time of admission as a part of a larger parent study. Genotypes were generated using the Affymetrix genome-wide human single-nucleotide polymorphism array 6.0. Those within dopaminergic, serotonergic, and brain-derived neurotrophic factor pathways were analyzed for associations with functional outcomes at 12 months post aneurysmal subarachnoid hemorrhage using the Glasgow Outcome Scale and the Modified Rankin Scale.Results:The 154 subjects were 55.8 ± 11.3 years old and 74% female; they had Fisher scores of 2.95 ± 0.67, Hunt/Hess scores of 2.66 ± 1.13, and admission Glasgow Coma Scale scores of 12.52 ± 3.79. Single-nucleotide polymorphisms in the serotonin receptor genes 1B and 1E and dopamine receptor D2 were associated with greater disability (odds ratio: 3.88–3.25, confidence interval: 1.01–14.77), while single-nucleotide polymorphisms in the serotonin receptor genes 2A and 2C and dopamine receptor D5 conferred a risk of poor recovery (odds ratio: 3.31–2.32, confidence interval: 1.00–10.80). Single-nucleotide polymorphisms within the same serotonin genes, and within the dopamine receptor gene D2, were associated with greater recovery after aneurysmal subarachnoid hemorrhage (odds ratio: 0.17–0.34, confidence interval: 0.05–0.89).Conclusions:These data demonstrate that there may be an association between genetic factors and functional outcomes post stroke.

Septoplasty: Scepter Balloon Angioplasty for Vasospasm after Aneurysmal Subarachnoid Hemorrhage

Introduction: Balloon angioplasty can be a requisite approach for the treatment of symptomatic and/or severe vasospasm. Dual-lumen microcatheter balloons have multiple potential advantages for this indication including accommodating a 0.014-inch wire and the potential to deliver superselective vasodilators directly via the microcatheter prior to angioplasty. Methods: The authors reviewed a 3-year institutional experience with the Scepter XC balloon (Microvention, Tustin, CA, USA) in the treatment of postaneurysmal subarachnoid hemorrhage vasospasm, focusing on treatment methods, angiographic, and clinical results. Results: Sixty-four vessels were treated in 18 patients. Fifteen cases were performed under intravenous (i.v.) conscious sedation (83%). The mean pretreatment stenosis was 59% (range 40-80), and the mean post-treatment stenosis was 12% (range 0-40). Five vessels in 3 patients were subsequently retreated via angioplasty for recurrent vasospasm (8%). There were no complications related to the passage of the balloon microcatheter or inflation of the balloon such as dissection or vessel rupture. Of 14 patients with delayed cerebral ischemia, 7 had complete symptomatic resolution after treatment, and 3 had significant symptomatic improvement. Four patients did not improve after treatment though 3 already had confirmed infarcts on imaging prior to angiography. Conclusion: The Scepter XC is a safe and effective balloon microcatheter for angioplasty of cerebral vasospasm after subarachnoid hemorrhage, allowing for superselective delivery of a vasodilator. Its ease of deliverability and visibility often allows for the performance of the procedure under i.v. conscious sedation.

Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm

Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed...

Postaneurysmal subarachnoid hemorrhage vasospasm: a review of the incidence of radiographic and clinical vasospasm

Background Vasospasm following ruptured intracranial aneurysms has always been a challenging condition to treat. Objective The aim of this study was to correlate between clinical and radiographic vasospasms after aneurysmal subarachnoid hemorrhage (SAH) and to point out the other important causes of neurological deterioration. Methods This is a retrospective study conducted on 25 consecutive patients between June 2013 and February 2014 who presented with SAH. Altogether there were 18 male and seven female patients with ages ranging from 42 to 65 years. All patients underwent initial four-vessel or computed tomography (CT) angiography. All patients were treated by direct surgical clipping and all of them were operated upon 48-72 h from admission. All patients were assessed clinically and radiologically by CT scan and conventional angiography or CT angiography at day 10 of postbleeding. Results Out of 25 cases with aneurysmal SAH, 20 developed radiographic vasospasm, with only 11 cases developing clinical vasospasm. Conclusion The incidence of radiographic (angiographic) vasospasm was 80%, with only 55% of cases developing clinical vasospasm. Proper evaluation with laboratory tests and neuroimaging should be carried out in all cases to detect the actual cause of neurological deterioration and to start the proper treatment.

Incidence and clinical characteristics of takotsubo cardiomyopathy post-aneurysmal subarachnoid hemorrhage

Takotsubo cardiomyopathy (TCMP), also known as stress-induced cardiomyopathy, broken heart syndrome or apical ballooning syndrome, is an increasingly recognized syndrome characterized by reversible left ventricular (LV) dysfunction, electrocardiographic (ECG) changes and release of myocardial enzymes that mimic myocardial infarction in the absence of obstructive coronary artery disease (CAD) [ [1] Tsuchihashi K. Ueshima K. Uchida T. et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001; 38: 11-18 Abstract Full Text Full Text PDF PubMed Scopus (1333) Google Scholar ], attributed to a surge in catecholamine levels precipitated by an acute physical or emotional stressor [ 2 Pilgrim T.M. Wyss T.R. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol. 2008; 124: 283-292 Abstract Full Text Full Text PDF PubMed Scopus (387) Google Scholar , 3 Wittstein I.S. Thiemann D.R. Lima J.A.C. et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005; 352: 539 Crossref PubMed Scopus (2324) Google Scholar ]. Stress-induced cardiomyopathy following subarachnoid hemorrhage (SAH) has been described primarily in case reports and small case series [ 2 Pilgrim T.M. Wyss T.R. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol. 2008; 124: 283-292 Abstract Full Text Full Text PDF PubMed Scopus (387) Google Scholar , 4 Caretta G. Vizzardi E. Rovetta R. et al. The link between intracranial haemorrhage and cardiogenic shock: a case of takotsubo cardiomyopathy. Acta Cardiol. 2012 Jun; 67: 363-365 PubMed Google Scholar ], but data from larger series are lacking. The aim of this study was to report the incidence and describe the clinical characteristics of patients with non-traumatic SAH and evidence of TCMP.

Proof of Concept: Endogenous Antiangiogenic Factors Predict the Occurrence of Symptomatic Vasospasm Post Subarachnoid Hemorrhage

The pathogenesis of vasospasm (VS) post aneurysmal subarachnoid hemorrhage (SAH) is multifactorial and not completely understood. The authors hypothesize that circulating antiangiogenic factors play an important role in brain injury post SAH and that elevated levels predict the occurrence of symptomatic vasospasm. In this study the authors measured the serum and cerebrospinal fluid (CSF) levels of soluble endoglin (sEng) and soluble fms-like tyrosine kinase 1 (sFlt1) in controls and SAH patients within 48h of the bleed. Patients were prospectively followed and subcategorized into those with (sVS) and without symptomatic vasospasm (no-sVS). Compared to healthy controls, SAH patients had higher CSF levels of sEng (0.037 vs. 0.251ng/ml; P=0.02) and sFlt1 (0.068 vs. 0.679ng/ml; P=0.001). In the subgroup analysis, sVS patients had higher CSF levels of sEng and sFlt1 than no-sVS patients (sEng: 0.380 vs. 0.159ng/ml, P=0.02; sFlt1: 1.277 vs. 0.343ng/ml, P=0.01). The serum levels of sEng and sFlt1 were not statistically different among the different groups. Based on these results the authors conclude that elevated CSF levels of sFlt1 and sEng herald the occurrence of symptomatic VS post SAH.

Outcomes of ventilator-associated pneumonia in aneurysmal subarachnoid hemorrhage patients

Subarachnoid hemorrhage (SAH) from rupture of cerebral aneurysms is associated with significant mortality and morbidity. About 10% to 25% die before reaching hospital, and of those who survive about 40% to 50% develop significant neurological deficits [1]. Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 hours after initiation of mechanical ventilation. About 20% of post-aneurysmal SAH patients are reported to experience VAP [2]. In this trial, we aimed to report the short-term outcomes of VAP. We performed a surveillance analysis on aneurysmal SAH patients who required mechanical ventilation for more than 48 hours.