Post Subarachnoid Haemorrhage Research Articles

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.

Consequences and coping strategies six years after a subarachnoid hemorrhage - A qualitative study.

BackgroundAfter a subarachnoid haemorrhage (SAH), continuing impairment is common and may impact the person’s life. There is a lack of knowledge regarding long-term consequences experienced.PurposeTo explore experiences of the care and rehabilitation as well as the consequences and strategies used to cope with everyday life six years post SAH.MethodsAn explorative interview study with a qualitative design. Individual interviews, with open ended questions, using an interview guide were performed with sixteen participants (mean age 63, 8 men, 8 women) six years post SAH. Data was analyzed according to a descriptive thematic analysis, and themes were discovered inductively.ResultsTwo major themes from the analysis, both including four sub-themes, were identified; these themes were consequences of the SAH and coping strategies. Participants were grateful to have survived the SAH and most were satisfied with their acute medical care. If discharged directly from the neurosurgical unit participants can feel abandoned. In contrast, participants who were referred to a rehabilitation clinic felt supported and informed. Cognitive problems, such as impaired memory and mental fatigue, were reported as still present six years post SAH. Coping strategies were; receiving support from family, society, employers, or technical equipment. At work, talking to colleagues and to taking breaks were common. Participants described hiding their symptoms from employers and friends, as well as trying to continue doing tasks in the same manner as prior to the SAH. If this was not possible, some refrained from doing these tasks. They went through a mourning process, fear, and worries.ConclusionsParticipants reported several long-term consequences which impacted on their daily lives post SAH, and different coping strategies were used to cope with these problems. Participants reported lack of awareness regarding the consequences of SAH and stressed the importance of structured multidisciplinary follow-ups, which mostly is missing.

The prevalence of growth hormone deficiency in survivors of subarachnoid haemorrhage: results from a large single centre study

ObjectiveThe variation in reported prevalence of growth hormone deficiency (GHD) post subarachnoid haemorrhage (SAH) is mainly due to methodological heterogeneity. We report on the prevalence of GHD in a large cohort of patients following SAH, when dynamic and confirmatory pituitary hormone testing methods are systematically employed.DesignIn this cross-sectional study, pituitary function was assessed in 100 patients following SAH. Baseline pituitary hormonal profile measurement and glucagon stimulation testing (GST) was carried out in all patients. Isolated GHD was confirmed with an Arginine stimulation test and ACTH deficiency was confirmed with a short synacthen test.ResultsThe prevalence of hypopituitarism in our cohort was 19% and the prevalence of GHD was 14%. There was no association between GHD and the clinical or radiological severity of SAH at presentation, treatment modality, age, or occurrence of vasospasm. There were statistically significant differences in terms of Glasgow Outcome Scale (GOS; p = 0.03) between patients diagnosed with GHD and those without. Significant inverse correlations between GH peak on GST with body mass index (BMI) and waist hip ratio (WHR) was also noted (p < 0.0001 and p < 0.0001 respectively).ConclusionUsing the current testing protocol, the prevalence of GHD detected in our cohort was 14%. It is unclear if the BMI and WHR difference observed is truly due to GHD or confounded by the endocrine tests used in this protocol. There is possibly an association between the development of GHD and worse GOS score. Routine endocrine screening of all SAH survivors with dynamic tests is time consuming and may subject many patients to unnecessary side-effects. Furthermore the degree of clinical benefit derived from growth hormone replacement in this patient group, remains unclear. Increased understanding of the most appropriate testing methodology in this patient group and more importantly which SAH survivors would derive most benefit from GHD screening is required.

Working capacity after a subarachnoid haemorrhage: A six-year follow-up.

Subarachnoid haemorrhage can lead to long-term disabilities. It is a major health issue for the patient and can affect work capacity. The aim of this study was to investigate working capacity after subarachnoid haemorrhage from a long-term perspective, using data from national sick leave records. In addition, factors associated with working capacity were analysed. A retrospective cohort study. A consecutive total sample of 38 working-age participants with first-ever subarachnoid haemorrhage was included. Working capacity of the 30 participants not on early retirement prior to the subarachnoid haemorrhage was analysed. Working capacity was defined as no longer being registered on sick leave or early retirement in the Social Insurance Agency and not being age retired or deceased. Regain of working capacity continued until 2.5 years post-subarachnoid haemorrhage and 73% of the participants were deemed to have working capacity. Functional independence at discharge from hospital, and higher responsiveness at admittance were the main factors associated with an earlier regain of working capacity. Nearly three-quarters of subjects were deemed to have working capacity within 2.5 years post-subarachnoid haemorrhage with a non-self-reported outcome. This information will help to individualize rehabilitation for affected persons.

Effects of iodinated contrast media on a novel model of vasospasm due to subarachnoid hemorrhage (LB504)

Objective: Application of iodinated contrast media (CM) in patients with vasospasm after subarachnoid haemorrhage (SAH) may influence the vascular function of spastic brain vessels, with possible consequences for SAH morbidity and mortality. We developed an in vitro model of vasospasm post SAH to investigate the effects of CM on spontaneous myogenic tone and myogenic response of brain vessels.Methods: We used a model of isolated, pressurized rat superior cerebellar arteries. Coagulated blood was deployed in the chamber of a perfusion myograph to simulate SAH. Either vehicle or iodixanol was applied intraluminally. Vessel diameter was monitored in stable conditions and during controlled changes of intraluminal pressure. The myogenic response was quantified as the change in the diameter after each change in intraluminal pressure.Results: Vessels treated with coagulated blood developed a stronger spontaneous myogenic tone compared to the control groups (65.7% and 62.1% in comparison to 77.8% and 78.6% of initial diameter), as well as a significant decrease of the myogenic response. CM did not worsen the myogenic tone and the myogenic response. However, the myogenic response was significantly less impaired for higher pressure changes in vessels exposed to coagulated blood and CM in comparison to coagulated blood alone. The variability of the myogenic response was decreased in the groups receiving CM.Conclusion: Our in vitro model of cerebral vasospasm reflects the clinical evidence that the autoregulation of cerebral blood flow may be impaired after SAH. CM had no negative influence on vessel spontaneous myogenic tone and myogenic response in this model.

The incidence of hypopituitarism in post interventional subarachnoid haemorrhage (SAH) survivors in a tertiary neurosurgical unit

The incidence of hypopituitarism in post interventional subarachnoid haemorrhage (SAH) survivors in a tertiary neurosurgical unit

Should we ban the use of colloids in patients with head injury?

Dear Editor, We read the recommendations from the ESICM task force on colloid volume therapy in critically ill patients [1]. We express our major concerns over the strong recommendation (grade 1C) not to use synthetic colloids in patients with head injury or intracranial bleeding. Indeed, this statement was based on three clinical studies only [1]. The first was retrospective, and found an association between the risk of death and the use of 6 % hetastarch 450/0.7, a highmolecular-weight hetastarch not used in Europe, in a subgroup of trauma patients with moderate or severe traumatic brain injury. The second study was a post hoc analysis of two randomised controlled trials in patients with aneurismal subarachnoid haemorrhage, and found colloids, i.e., 4 % succinylated gelatin and 6 % pentastarch, as one factor associated with unfavourable neurological outcome at 6 months. The third study was a randomised controlled study in 31 patients with severe traumatic brain injury, and reported no difference in the rate of complications between hydroxyethyl starch solution (HES) 200/0.5 and 6 % HES 130/0.4. In this latter study, 6 % HES 130/0.4 was administered over several days at doses of up to 70 ml/kg/24 h. Based on such limited and heterogeneous data, it appears highly speculative to draw conclusions about the risk of colloids in this population, and we urge that readers consider that an association between variables does not necessarily indicate a causal relation. In addition, two randomised controlled studies must be cited. The first study compared the continuous administration of 6 % HES versus crystalloid solutions over 4 days in 40 patients with acute ischaemic stroke, and found no differences in efficacy or safety between the two groups [2]. Similar findings were reported in a second study comparing 10 % HES 130/0.4 versus crystalloids in 106 patients with acute ischaemic stroke [3]. Further prospective randomised controlled trials are clearly needed to address the issue of how best to optimise fluid resuscitation in this population. This would mitigate the effects of unrecorded confounding factors that may exist in cohort studies even after statistical adjustment. In general, it is difficult to isolate the effects of fluids on neurological outcome independently of their effects on the cardiovascular system. The reasons for myocardial dysfunction are numerous after brain injury, and include pulmonary vasoconstriction centrally mediated by brain damage, associated extra-cranial lesions, and/or large doses of sedatives as part of the treatment of intracranial hypertension. In addition, stress-induced cardiomyopathy does exist in these patients [4]. In this context, fluid overloading may result in severe cardiopulmonary complications regardless of the type of fluid administered. An early goal-directed haemodynamic management to optimise cardiac output and volume status in post-subarachnoid haemorrhage vasospasm was associated with better clinical course and fewer cardiopulmonary complications compared to conventional treatment [5]. In conclusion, it would be more appropriate to recommend the routine monitoring of cardiac function in brain-injured patients rather than recommending any ban on the use of colloids after brain injury.

Cognitive and Functional Outcomes of 5-Year Subarachnoid Haemorrhage Survivors: Comparison to Matched Healthy Controls

Background and Purpose: While neuropsychological deficits have been the focus of research post-subarachnoid haemorrhage (SAH), population-based information on long-term neuropsychological impairment post-SAH are lacking. Neither the profile of long-term neuropsychological deficits nor its relationship to long-term functional outcomes has been established. Methods: This was a cross-sectional population-based study of long-term (5 years) neuropsychological and functional outcomes post-SAH. Participants were 27 five-year survivors of SAH previously enrolled in the Auckland Regional Community Stroke study (2002–2003). Twenty-six age-, gender- and ethnicity-matched controls were used to compare mood, functional (i.e. disability; handicap; quality of life, QoL) and neuropsychological outcomes (i.e. verbal memory, visual memory, executive functioning, language, processing speed and visuoperceptual abilities) of SAH survivors. Results: SAH survivors were more depressed and significantly more impaired in the areas of disability, handicap, and QoL than controls. SAH survivors also had significant cognitive deficits across domains when compared to controls. Depressed mood and baseline functioning were related to worse functional outcomes at 5 years post-SAH. Whilst poor cognitive functioning, particularly in the domains of visual memory and language, impacted long-term functional outcomes of SAH survivors. Conclusions: Five-year SAH survivors have many functional and cognitive deficits compared to matched controls. Language and visual memory emerged as independent factors associated with their current functioning.

Diffusion‐weighted imaging and magnetic resonance spectroscopy findings in a case of neonatal hypoglycaemia

Rachel E Musson MBCHB MRCP, Ruth Batty MBBS MRCP FRCR, Santosh R Mordekar MD MRCP MRCPCH, Iain D Wilkinson PHD ARCP FIPEM, Paul D Griffiths PHD FRCR, Daniel JA Connolly BSC MRCP FRCR 1 Radiology Department, Royal Hallamshire Hospital, Sheffield, UK. 2 Department of Neurology, Sheffield Children's Hospital, Sheffield, UK. 3 Academic Unit of Radiology, University of Sheffield, Sheffield, UK. 4 Radiology Department, Sheffield Children's Hospital, Sheffield, UK. Correspondence to: rachel.musson@sth.nhs.uk

High CSF transforming growth factor β levels after subarachnoid haemorrhage: association with chronic communicating hydrocephalus

Background: Chronic communicating hydrocephalus is a common sequela of subarachnoid haemorrhage and develops when the flow and drainage of CSF are impaired after fibrosis in the subarachnoid space. Released by...

1614 Precocious surgical treatment for post brain aneurism subarachnoid haemorrhage. Service casuistry

1614 Precocious surgical treatment for post brain aneurism subarachnoid haemorrhage. Service casuistry

Editorial Listing

Over the last decade there have been significant changes in the management of patients with aneurysmal subarachnoid haemorrhage (SAH). Many of these changes, such as haemodilutional, hypervolaemic, hypertensive therapy and the use of calcium channel blockers, have been directed at the prevention and treatment of vasospasm. The angiograms of a contemporary series of 56 consecutive surgically treated patients with aneurysmal SAH were examined to compare angiographic vasospasm with that seen in historical studies.The time course of angiographic vasospasm was found to be broadly similar to that reported in previous studies, with onset after day 3 following SAH, maximal narrowing during the second week, and resolution after day 16. The times of peak narrowing and resolution were slightly earlier in previous studies. 30% of patients had clinical vasospasm (delayed neurological deficit for which other causes had been excluded), and these patients had a trend to more severe angiographic narrowing than those without clinical vasospasm, particularly in the second week following SAH. 44 angiograms were performed between days 1–3 post SAH and repeated between days 4–16. 95% of these showed arterial narrowing at the second angiogram. Patients not achieving an independent outcome tended to have had both more clinical vasospasm and more severe angiographic spasm than those achieving independence.It is concluded that angiographic vasospasm remains a common occurrence in the modern era, and continues to be associated with clinical events and a poor outcome.

Aneurysmal subarachnoid haemorrhage – Part 1: Pre-operative nursing management diagnosis, complications and treatment: A composite case study

ABSTRACTPatients who survive an Aneurysmal Subarachnoid Haemorrhage or ASAH describe it as being the worst headache ever, multiplied one hundred-times over. It is a debilitating and life threatening condition, which affects approximately 6.5 people per 100,000 throughout Australia and New Zealand every year (The ACROSS group, 2000). When caring for a patient post Aneurysmal Subarachnoid Haemorrhage or ASAH meticulous monitoring of the patient’s neurological, cardiovascular, hepatic, endocrine, renal, and respiratory functions are vital. Due to both the initial ASAH and its complications such as rebleed, cerebral vasospasm, hydrocephalus, cerebral oedema, seizures as well as adverse reactions to counteract these potential problems. All of, which can cause significant long-term morbidity as well as potential mortality if left, undiagnosed and untreated.The following article presets a composite patient highlighting clinical manifestations of ASAH, its associated complications as well as various methods of detecting, preventing and treating them.

Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch

Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch

Role of single photon emission computed tomography and transcranial doppler ultrasonography in clinical vasospasm

This report presents our experience with Transcranial Doppler (TCD) ultrasonography and Single Photon Emission Computed Tomography (SPECT) in the assessment of patients with aneurysmal subarachnoid haemorrhage (SAH). It was designed to evaluate clinical vasospasm with both TCD and SPECT and determine their diagnostic value.Twenty-eight consecutive patients were examined with both TCD and SPECT, performed within 24 hours of each other. They had a total of 45 TCDs and 46 SPECT scans. Eight patients (29%) developed clinical vasospasm, noted from day 2 to day 11 post subarachnoid haemorrhage; these patients underwent TCDs and SPECT scans when the diagnosis of vasospasm was made. Twenty patients (71%) did not demonstrate clinical vasospasm throughout their hospital stay and underwent TCDs and SPECT scans within the first 2 weeks of their SAH, mostly between day 2 and day 10, the period of greatest risk for vasospasm. TCD and SPECT sensitivity for clinical vasospasm was 100% and 50% respectively, their specificity was only 20% and 60%.TCD sensitivity for symptomatic vasospasm was found to be excellent, whereas SPECT was not found to be as useful. We conclude that TCD is the preferred method in the evaluation of patients with subarachnoid haemorrhage.

Problems with phenytoin administration in neurology/neurosurgery ITU patients receiving enteral feeding

Our objective was to investigate the relationship between phenytoin bioavailability, enteral feeding and serum albumin levels in patients admitted to neurology/neurosurgery ITU, via case studies of three patients . The research was performed at the Walton centre for Neurology and Neurosurgery NHS Trust, Liverpool, England, and our subjects consisted of three cases admitted to ITU (1 status epilepticus, 1 post-trauma and 1 post-subarachnoid haemorrhage (SAH)). Phenytoin levels were assessed in relation to the type of feeding and serum albumin levels. We found evidence of a complex relationship between phenytoin levels, enteral feeding and serum albumin in patients in the neuro ITU setting. We conclude that, in this setting the patient’s phenytoin needs to be closely monitored and treated aggressively to maintain therapeutic levels. They should also be followed up during rehabilitation to avoid toxicity.

Angiographic vasospasm in a contemporary series of patients with aneurysmal subarachnoid haemorrhage

Over the last decade there have been significant changes in the management of patients with aneurysmal subarachnoid haemorrhage (SAH). Many of these changes, such as haemodilutional, hypervolaemic, hypertensive therapy and the use of calcium channel blockers, have been directed at the prevention and treatment of vasospasm. The angiograms of a contemporary series of 56 consecutive surgically treated patients with aneurysmal SAH were examined to compare angiographic vasospasm with that seen in historical studies. The time course of angiographic vasospasm was found to be broadly similar to that reported in previous studies, with onset after day 3 following SAH, maximal narrowing during the second week, and resolution after day 16. The times of peak narrowing and resolution were slightly earlier in previous studies. 30% of patients had clinical vasospasm (delayed neurological deficit for which other causes had been excluded), and these patients had a trend to more severe angiographic narrowing than those without clinical vasospasm, particularly in the second week following SAH. 44 angiograms were performed between days 1-3 post SAH and repeated between days 4-16. 95% of these showed arterial narrowing at the second angiogram. Patients not achieving an independent outcome tended to have had both more clinical vasospasm and more severe angiographic spasm than those achieving independence. It is concluded that angiographic vasospasm remains a common occurrence in the modern era, and continues to be associated with clinical events and a poor outcome.

Effect of spantide, a substance-P antagonist, on cerebral vasospasm in primates.

Experimental SAH in the squirrel monkey induces an angiographically demonstrable late spasm of about 23% at six days post subarachnoid haemorrhage (SAH). The late spasm is associated with a generalized reduction in cerebral blood flow (CBF) of about 30%. Intracisternal administration of the substance P (SP) antagonist spantide two hours and three days post SAH significantly reduces the degree of late spasm and also decreases the degree of CBF reduction. The findings suggest that SP is involved in the development of both angiographical spasm and CBF changes post SAH.

Is vascular angiopathy following intracranial aneurysm rupture immunologically mediated?

Immunofluorescence studies showed the presence of IgM and/or C3 in the endothelium of intracranial aneurysms in 5 out of 6 patients with subarachnoid haemorrhage (SAH). In none of them were the immune deposits found in the gyrus rectus. Cortical tissue of 4 epileptic patients which served as a control give negative results. Serum studies on femoral artery wall used as an antigenic substrate did not reveal circulating antibodies of the IgM or IgG class. Our studies strongly suggest that the IgM and/or C3 immune deposits located in the endothelium of intracranial arteries may play a role in post SAH neurological complications.

Effect of unilateral pre- and postganglionic lesioning of the trigeminal nerve on the development of cerebral vasospasm in the squirrel monkey: angiographic findings.

Bilateral carotid angiography was performed in the squirrel monkey before and after unilateral pre- and postganglionic trigeminal lesioning. A unilateral postganglionic lesion caused a significant constriction of about 27% of the ipsilateral cerebral arteries, while a preganglionic lesion did not change the baseline arterial diameter. Following a subarachnoid haemorrhage (SAH) the degree of vasoconstriction in the animals with a preganglionic lesion did not differ significantly from that seen in controls. In the postganglionically lesioned animals, the vasoconstriction was more pronounced (12% at both 10 min and 6 days post SAH) on the lesioned as compared with the non-lesioned side. At day 6 post SAH the degree of vasoconstriction was 19% more pronounced on the lesioned side in post- as compared with the preganglionically lesioned animals. There was no difference in the degree of spasm on the non-lesioned side between the two groups. The findings indicate that the trigeminal system has both a peripheral and a central function. The peripheral, or axon reflex mechanism, exerts a tonic effect on the cerebral vessels. Following a SAH the axon reflex seems to attenuate cerebral vasospasm.