Ruptured Brain Aneurysms Research Articles

Nationwide analysis of hospital-to-hospital transfer in patients with aneurysmal subarachnoid hemorrhage requiring aneurysm repair.

Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association between higher institutional volumes and improved outcomes for aSAH patients has been studied extensively. However, the literature exploring patterns of transfer in this context is sparse. Expansion of the endovascular workforce has raised concerns about the decentralization of care, reduced institutional volumes, and worsened patient outcomes. In this paper, the authors explored various patient and hospital factors associated with the transfer of aSAH patients by using a nationally representative database. The 2013 and 2014 years of the National Inpatient Sample (NIS) were used to define an observational cohort of patients with ruptured brain aneurysms. The initial search identified patients with SAH (ICD-9-CM 430). Those with concomitant codes suggesting trauma or other intracranial vascular abnormalities were excluded. Finally, the patients who had not undergone a subsequent procedure to repair an intracranial aneurysm were excluded. These criteria yielded a cohort of 4373 patients, 1379 of whom had undergone microsurgical clip ligation and 2994 of whom had undergone endovascular repair. The outcome of interest was transfer status, and the NIS data element TRAN_IN was used to define this state. Multiple explanatory variables were identified, including age, sex, primary payer, median household income by zip code, race, hospital size, hospital control, hospital teaching status, and hospital location. These variables were evaluated using descriptive statistics, bivariate correlation analysis, and multivariable logistic regression modeling to determine their relationship with transfer status. Patients with aSAH who were treated in an urban teaching hospital had higher odds of being a transfer (OR 2.15, 95% CI 1.71-2.72) than the patients in urban nonteaching hospitals. White patients were more likely to be transfer patients than were any of the other racial groups (p < 0.0001). Moreover, patients who lived in the highest-income zip codes were less likely to be transferred than the patients in the lowest income quartile (OR 0.78, 95% CI 0.64-0.95). Repair type (clip vs coil) and primary payer were not associated with transfer status. A relatively high percentage of patients with aSAH are transferred between acute care hospitals. Race and income were associated with transfer status. White patients are more likely to be transferred than other races. Patients from zip codes with the highest income transferred at lower rates than those from the lowest income quartile. Transfer patients were preferentially sent to urban teaching hospitals. The modality of aneurysm treatment was not associated with transfer status.

Nonaneurysmal “Pseudo-Subarachnoid Hemorrhage” Computed Tomography Patterns: Challenges in an Acute Decision-Making Heuristics

Acute aneurysmal subarachnoid hemorrhage (SAH) is a medical and neurosurgical emergency from ruptured brain aneurysm. Aneurysmal SAH is identified on brain computed tomography (CT) as increased density of basal cisterns and subarachnoid spaces from acute blood products. Aneurysmal SAH-like pattern on CT appears as an optical illusion effect of hypodense brain parenchyma and/or hyperdense surrounding cerebral cisterns and blood vessels termed as "pseudo-subarachnoid hemorrhage" (pseudo-SAH). We reviewed clinical, laboratory, and radiographic data of all SAH diagnoses between January 2013 and January 2018, and found subsets of nonaneurysmal SAH, originally suspected to be aneurysmal in origin. We performed a National Library of Medicine search methodology using terms "subarachnoid hemorrhage," "pseudo," and "non-aneurysmal subarachnoid hemorrhage" singly and in combination to understand the sensitivity, specificity, and precision of pseudo-SAH. Over 5 years, 230 SAH cases were referred to our tertiary academic center and only 7 (3%) met the definition of pseudo-SAH. Searching the National Library of Medicine using subarachnoid hemorrhage yielded 27,402 results. When subarachnoid hemorrhage and pseudo were combined, this yielded 70 results and sensitivity was 50% (n = 35). Similarly, search precision was relatively low (26%) as only 18 results fit the clinical description similar to the 7 cases discussed in our series. Aneurysmal SAH pattern on CT is distinct from nonaneurysmal and pseudo-SAH patterns. The origin of pseudo-SAH terminology appears mostly tied to comatose cardiac arrest patients with diffuse dark brain Hounsfield units and cerebral edema, and is a potential imaging pitfall in acute medical decision-making.

AVM’s and Aneurysms, Hybrid Brain Vascular Surgery: A Case Report

This review tries to describe in a didactical and practical manner the advantages of a combined approach, showing in two cases that Endovascular Therapy and Microsurgical Brain Surgery, can work together, as the best procedure, trying to save resources, time and complications that occur when both strategies work separately. There are reports in different countries about the combination of therapies. Several years ago, we treated many patients working in a conventional surgical room, with some limitations, but recently we have been working in a hybrid surgical room, making the diagnosis, surgical and endovascular treatment in one step. As we know in vascular diseases, saving time is mandatory, and we have improved our own outcomes in ruptured brain aneurysms, and when embolization and surgical resection has been needed for arteriovenous malformations (AVMs).

Blood Flow Diversion as a Primary Treatment Method for Ruptured Brain Aneurysms-Concerns, Controversy, and Future Directions.

Flow diversion is a novel treatment for brain aneurysms that works by redirecting blood flow away from the aneurysm. Immediately after placement of the stent, blood flow stagnates within the aneurysm dome and it undergoes thrombosis. Over time, a new endothelium develops across the neck, thereby reconstructing the parent vessel and curing the aneurysm. The use of this treatment method for ruptured aneurysms has two specific concerns: 1) risk of hemorrhage from the aneurysm after treatment because of potential delayed aneurysm occlusion; and 2) hemorrhagic complications from antiplatelet use, which is required to prevent thromboembolic complications from the device. In this review, we explore these two concerns based on the emerging published literature. Optimal peri-procedural management of these issues in the neurocritical care setting is vital to improving outcomes. We also identify ongoing clinical trials of flow diversion for the treatment of ruptured aneurysms. Flow diversion is an alternative to clipping or coiling for many ruptured aneurysms and may be potentially more efficacious in certain aneurysm subtypes.

Management of delayed cerebral ischemia after subarachnoid hemorrhage

For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.

WE‐DE‐207A‐04: Advances in Radiological Neuro‐Endovascular Interventional Imaging

WE‐DE‐207A‐04: Advances in Radiological Neuro‐Endovascular Interventional Imaging

WE‐DE‐207A‐02: Advances in Cone Beam CT Anatomical and Functional Imaging in Angio‐Suite to Enable One‐Stop‐Shop Stroke Imaging Workflow

WE‐DE‐207A‐02: Advances in Cone Beam CT Anatomical and Functional Imaging in Angio‐Suite to Enable One‐Stop‐Shop Stroke Imaging Workflow

WE‐DE‐207A‐03: Recent Advances in Devices Used in Neuro‐‐Interventions

WE‐DE‐207A‐03: Recent Advances in Devices Used in Neuro‐‐Interventions

WE‐DE‐207A‐01: Parallels in the Evolution of X‐Ray Angiographic Systems and Devices Used for Minimally Invasive Endovascular Therapy

WE‐DE‐207A‐01: Parallels in the Evolution of X‐Ray Angiographic Systems and Devices Used for Minimally Invasive Endovascular Therapy

WE‐DE‐207A‐00: Advances in Image‐Guided Neurointerventions‐Clinical Pull and Technology Push

WE‐DE‐207A‐00: Advances in Image‐Guided Neurointerventions‐Clinical Pull and Technology Push

Brazilian experience of the influence of endovascular treatment on headache in patients with ruptured intracranial aneurysms.

The characteristics of primary headaches in patients with ruptured brain aneurysm embolization have not been well understood to date. This study was conducted to evaluate the influence of endovascular treatment (EVT) of ruptured intracranial aneurysm (RIA) and the pattern of previous primary headache. We evaluated the pattern of headache in patients who suffered a RIA and EVT within one year before the rupture, and prospectively evaluated the characteristics of headache for up to 12 months after EVT. Sixty patients were evaluated and a questionnaire about headache was applied at the time of admission. These patients were contacted 3, 6 and 12 months after treatment to complete the study by filling out follow-up questionnaire on the headache. Thirty-seven patients had headache before the rupture, 16 with tension-type headache (TTH), 11 with migraine without aura, nine with migraine with aura with and one with non-specific characteristics. There was a significant reduction in the frequency of pain for up to 12 months for patients with TTH (P < 0.001) and migraine without aura (P = 0.012), but there was a reduction in pain intensity over the same period in TTH (P = 0.002), migraine with aura (P = 0.004) and migraine without aura (P < 0.001). There was a reduction of the primary headache after endovascular treatment of ruptured brain aneurysm.

Clinical outcome prediction in aneurysmal subarachnoid hemorrhage - Alterations in brain-body interface.

Background:Brain–body associations are essential in influencing outcome in patients with ruptured brain aneurysms. Thus far, there is scarce literature on such important relationships.Methods:The multicenter Tirilazad database (3551 patients) was used to create this clinical outcome prediction model in order to elucidate significant brain–body associations. Traditional binary logistic regression models were used.Results:Binary logistic regression main effects model included four statistically significant single prognostic variables, namely, neurological grade, age, stroke, and time to surgery. Logistic regression models demonstrated the significance of hypertension and liver disease in development of brain swelling, as well as the negative consequences of seizures in patients with a history of myocardial infarction and post-admission fever worsening neurological outcome.Conclusions:Using the aforementioned results generated from binary logistic regression models, we can identify potential patients who are in the high risk group of neurological deterioration. Specific therapies can be tailored to prevent these detriments, including treatment of hypertension, seizures, early detection and treatment of myocardial infarction, and prevention of hepatic encephalopathy.

Pathophysiologic mechanisms of brain-body associations in ruptured brain aneurysms: A systematic review.

Background:Patients with ruptured brain aneurysms and aneurysmal subarachnoid hemorrhage suffer neurological damage from primary injury of the aneurysm rupture itself, as well as a number of secondary injurious processes that can further worsen the affected individual's neurological state. In addition, other body systems can be affected in a number of brain-body associations.Methods:This systematic review synthesizes prospective and retrospective cohort studies that investigate brain-body associations in patients with ruptured brain aneurysms. The methodologic quality of these studies will be appraised.Results:Six cohort studies were included in this systemic review. The methodologic quality of each study was assessed. They had representative patient populations, clear selection criteria and clear descriptions of study designs. Reproducible study protocols with ethics board approval were present. Clinical results were described in sufficient detail and were applicable to aneurysmal subarachnoid hemorrhage patients in clinical practice. There were few withdrawals from the study. Limitations included small sample sizes and between-study differences in diagnostic tests and clinical outcome endpoints. Several pathophysiologic mechanisms of brain-body associations in ruptured brain aneurysms were clarified through this systematic review. Sympathetic activation of the cardiovascular system in aneurysmal subarachnoid hemorrhage not only triggers the release of atrial and brain natriuretic peptides it can also lead to increased pulmonary venous pressures and permeability causing hydrostatic pulmonary edema. Natriuretic states can herald the onset or worsening of clinical vasospasm as the renin-angiotensin-aldosterone system is activated in a delayed manner.Conclusions:This systematic review synthesizes the most current evidence of underlying mechanisms of brain related associations with body systems in aneurysmal subarachnoid hemorrhage. Results gained from these studies are clinically useful and shed light on how ruptured brain aneurysms affect the cardiopulmonary system. Subsequent neuro-cardio-endocrine responses then interact with other body systems as part of the secondary responses to primary injury.

The analysis of treatment results of brain aneurysms rupture

Introduction. The problem of surgical treatment of brain aneurysms is unsolved, and results of treatment don’t satisfy neurosurgical community. The indications and terms of surgery performing are most discussed.Purpose. To determine main causes of unfavorable outcomes of surgical treatment of patients with brain aneurysms rupture on the base of analysis of our own clinical experience.Materials and methods. The results of treatment of 1099 patients with ruptured brain aneurysms were analyzed. 99 patients died without surgery. Microsurgical approach was used in 706 patients, endovascular — in 294.Results. The cause of death of 50% patients who died without surgery was brain aneurysms re-rupture. Postoperative lethality was 9.0% after microsurgical technique use, and 9.2% — after endovascular one. Lethality when using both methods differed significantly depending on terms after brain aneurysm rupture.Conclusion. In the acute period of brain aneurysm rupture (1–3 days) the surgery has to be performed just in patients without clinical signs of angiospasm. Lethality after endovascular surgery in this period is 2.5 times lower than after microsurgical operations.

Yield of Catheter Angiography After Computed Tomography Negative, Lumbar Puncture Positive Subarachnoid Hemorrhage

Patients suspected of having aneurysmal subarachnoid hemorrhage (SAH) are initially evaluated with noncontrast head computed tomography. If the computed tomography is negative, but clinical concern for SAH is high, a lumbar puncture with cerebrospinal fluid analysis is typically performed. The purpose of this study was to evaluate the accuracy of cerebrospinal fluid xanthochromia and erythrocytosis for aneurysmal SAH. Medical records of all patients who underwent catheter angiography at Barnes Jewish Hospital between July 2002 and April 2012 for clinical suspicion of a ruptured brain aneurysm after a negative computed tomography scan and a lumbar puncture suspicious for SAH were reviewed. The cerebrospinal fluid analysis results, angiographic findings, and outcomes of each case were recorded. Fifty-seven patients were identified. Two angiographic lesions were identified in patients with xanthochromia (2/24 patients, ie, 8.3%), both of which were confirmed to have ruptured. The diagnostic yield in patients with nonclearing erythrocytosis and no xanthochromia was 6.3% (1/16 patients), although this lesion was not considered the source of SAH. Catheter angiography should be performed in patients with computed tomography negative but suspicious lumbar puncture, particularly in the presence of xanthochromia. The benefit of angiography in patients with erythrocytosis only is unclear and deserves future study.

Anaemia and its treatment in neurologically critically ill patients: being reasonable is easy without prospective trials

Most healthy humans have a haemoglobin concentration of 12 to 15 g/dL and most intensivists now transfuse packed red blood cells for haemoglobin <7 g/dL. Higher haemoglobin is associated with improved intermediate and clinical outcomes after subarachnoid hemorrhage (from ruptured brain aneurysm) or neurotrauma. An observational study in a recent issue shows that higher haemoglobin was associated with better functional outcomes in patients with spontaneous intracerebral haemorrhage; few patients received a packed red blood cell transfusion, so it is not known if that treatment is better than the disease. The mechanism of anaemia's purported impact on outcome is unclear, although altered metabolism in brain tissue that is sensitive to reduced oxygen delivery is plausible. These data may intensify the differences of opinion between intensivists: whether neurologic patients are better served by higher haemoglobin and potentially by more packed red blood cell transfusion, or simply need to be studied more in prospective clinical trials, remains unclear.

Ｃｏｉｌ塞栓術 重症大型破裂脳動脈瘤に対する急性期部分塞栓術

The rate of endovascular coiling as a treatment of cerebral aneurysm is increasing in Japan. However, the results are not necessarily favorable in cases of large aneurysms, and retreatment is required in many cases. Based on this, clipping should be initially considered as curative treatment for large cerebral aneurysm. In cases of critical (Hunt & Kosnik Grade 4 or 5), extensively ruptured brain aneurysm, direct surgery in the acute phase is not straightforward, and the outcomes are not always favorable. However, some cases follow favorable courses when they pass the acute phase. In extensively ruptured brain aneurysm, endovascular treatments can be performed in a minimally invasive way, and the risk of rebleeding is surprisingly low even with partial occlusion. We experienced 2 cases of extensively ruptured brain aneurysm, successfully treated with partial occlusion for the aneurysm by interventional radiosurgery performed in the acute phase and surgical clipping in the chronic phase. Clipping after endovascular coiling can be difficult to perform when the coil is not removed and is densely filled. Therefore, it is preferable to perform partial occlusion without filling the neck of the aneurysm with the coil.

Poor Central Nervous System Penetration of Tigecycline in a Patient with Sepsis and Ventriculitis Caused by Multidrug-Resistant Klebsiella Pneumoniae

Objective: To report the use of tigecycline in a case of ventriculitis and concurrent bacteremia. Case Summary: A 57-year-old African American male with a ruptured brain aneurysm was admitted to the intensive care unit after surgical intervention and external ventricular drainage placement. His hospital course was complicated by myocardial infarction, ventilator-associated pneumonia, ventriculitis, and sepsis, with multidrug-resistant (MDR) Klebsiella pneumoniae isolated from multiple sites, including blood and cerebral spinal fluid (CSF). The patient was treated with high doses of intravenous tigecycline and gentamicin along with intrathecal gentamicin. This combination eradicated infections outside the central nervous system (CNS) within 48 hours, but it took approximately 8 days for the CSF culture to become negative. Timed serum and CSF fluid samples were collected to determine CSF penetration of tigecycline on day 12 of therapy. CSF concentrations obtained 30 minutes after the dose and at the end of the dosing interval remained below the detectable limit of 0.05 μg/mL. Discussion: Although CSF tigecycline concentrations may not represent actual CNS tissue concentrations at the site of infection, the low CSF concentrations observed in our case may be responsible for the slow CSF clearance of infection. It was not clear whether gentamicin therapy alone, administered both intravenously and intrathecally, would have achieved the same outcome and cleared the infection from the CNS in this patient. Conclusions: Until additional clinical data are available, tigecycline should not be used for the management of MDR infections associated with the CNS.

ISAT and ISUIA: The Impact on Informed Consent

The International Subarachnoid Aneurysm Trial (ISAT) was a multicenter randomized trial that compared the safety and efficacy of endovascular coil treatment versus surgical clipping for the treatment of ruptured brain aneurysms. To be eligible for enrollment in the ISAT trial, each patient had to be deemed equally suitable for either coiling or clipping. The investigators used the term "clinical equipoise" to describe this balance. This study more than any other has set the playing field for the future of interventional radiology/endovascular neurosurgery politics.

The presence of tandem endothelial nitric oxide synthase gene polymorphisms identifying brain aneurysms more prone to rupture

It is becoming apparent that the presence of certain genetic variations (polymorphisms) may increase the individual's susceptibility to cardiovascular diseases, even in the absence of a family history. We hypothesized that brain aneurysms more prone to rupture may be identified on the basis of an individual's genotype for endothelial nitric oxide synthase (eNOS), a critical vasomodulatory protein found to be increasingly relevant to the pathobiology of aneurysms. Patients' clinical data were recorded prospectively. Genomic DNA was isolated from blood samples obtained from individuals presenting consecutively to the Mayo Clinic with ruptured (58 patients) or unruptured (49 patients) intracranial saccular aneurysms. Using polymerase chain reaction and gene microarray technology, the following eNOS genetic polymorphisms were studied: intron-4 27-base pair variable number of tandem repeats (27 VNTR); promoter single nucleotide polymorphism (T-786C SNP); and exon-7 SNP (G894T SNP). Both groups of patients had similar demographic and clinical characteristics. For all three polymorphisms, variant alleles (p < or = 0.003) and their corresponding genotypes (p < or = 0.006) were found two to four times more frequently in patients with ruptured aneurysms than in patients with unruptured aneurysms. Strikingly, the odds ratio for presenting with a ruptured brain aneurysm among individuals demonstrating the copresence of all three variant alleles was 11.4 (95% confidence interval 1.7-75.9, p = 0.004). The authors have uniquely identified a set of tandem eNOS gene variations whose presence can be used to identify patients with aneurysms likely to rupture. We believe that if this finding is reproducible in a large multicenter study, in addition to known anatomical factors a rapid and cost-effective screening tool will become available to clinicians as a genetic aid to predict the risks of rupture in patients presenting with unruptured intracranial aneurysms.