Secondary Cerebral Infarction Research Articles

Development and validation of a new model for the early diagnosis of tuberculous meningitis in adults based on simple clinical and laboratory parameters

BackgroundThe differential diagnosis between tuberculous meningitis (TBM) and viral meningitis (VM) or bacterial meningitis (BM) remains challenging in clinical practice, particularly in resource-limited settings. This study aimed to establish a diagnostic model that can accurately and early distinguish TBM from both VM and BM in adults based on simple clinical and laboratory parameters.MethodsPatients diagnosed with TBM or non-TBM (VM or BM) between January 2012 and October 2021 were retrospectively enrolled from the General Hospital (derivation cohort) and Branch Hospital (validation cohort) of Ningxia Medical University. Demographic characteristics, clinical symptoms, concomitant diseases, and cerebrospinal fluid (CSF) parameters were collated. Univariable logistic analysis was performed in the derivation cohort to identify significant variables (P < 0.05). A multivariable logistic regression model was constructed using these variables. We verified the performance including discrimination, calibration, and applicability of the model in both derivation and validation cohorts.ResultsA total of 222 patients (70 TBM and 152 non-TBM [75 BM and 77 VM]) and 100 patients (32 TBM and 68 non-TBM [31 BM and 37 VM]) were enrolled as derivation and validation cohorts, respectively. The multivariable logistic regression model showed that disturbance of consciousness for > 5 days, weight loss > 5% of the original weight within 6 months, CSF lymphocyte ratio > 50%, CSF glucose concentration < 2.2 mmol/L, and secondary cerebral infarction were independently correlated with the diagnosis of TBM (P < 0.05). The nomogram model showed excellent discrimination (area under the curve 0.959 vs. 0.962) and great calibration (P-value in the Hosmer–Lemeshow test 0.128 vs. 0.863) in both derivation and validation cohorts. Clinical decision curve analysis showed that the model had good applicability in clinical practice and may benefit the entire population.ConclusionsThis multivariable diagnostic model may help clinicians in the early discrimination of TBM from VM and BM in adults based on simple clinical and laboratory parameters.

Retrospective study of spontaneous subarachnoid haemorrhage: vasospasm and other complications (Part III)

Background. Acute subarachnoid haemorrhage (SAH) is a dangerous condition: roughly 50% of patients die within 30 days, nearly 25% develop significant neuropsychological and cognitive deficits, about 10% suffer from other complications, and only around 15% recover fully. One of the main causes of mortality is cerebral vasospasm (CVS), a cause of delayed cerebral ischaemia (DCI), which can lead to secondary cerebral infarction. Thus, early detection of CVS is crucial for improving patient outcomes.The aim of this study was to analyse the demographic and clinical (including complications) data of patients diagnosed with SAH, to evaluate the diagnostic methods, and to investigate the prevalence and treatment of complications.Materials and methods. This retrospective study included 102 patients diagnosed with spontaneous SAH, aged at least 18 years, who were treated in the Vilnius University Hospital Santaros Klinikos (VUL SK) in 2014-2017. The obtained VUL SK data were selected by the I60 ICD-10-CM code and depersonalized. Head computerized tomography (CT), CT angiography (CTA), digital subtraction angiography (DSA), transcranial color-coded duplex sonography (TCCS), and magnetic resonance angiography (MRA) were used to evaluate the cerebral arteries.Results. In 102 patients (mean age 58±16 years; 55% female), the most common cause of spontaneous SAH was ruptured aneurysm, the most common arterial sites were the middle cerebral artery (36%), anterior cerebral artery and/or communicating artery (together 33%), and internal carotid artery (20%). In-hospital mortality was as high as 21%. All patients underwent head CT, 78% CTA, 33% DSA, 8% TCCS, and 1% MRA. 71% patients experienced SAH complications: 66% acute, 27% chronic. The most common acute complications were cerebral oedema (34%), rebleeding (29%), and acute ischaemia (23%), the most common chronic complications hydrocephalus (11%), DCI (9%), and CVS (8%).Conclusions. CVS was diagnosed considerably less frequently in this study compared to other studies. While the diagnosis rates of ischaemia and hyponatremia were likewise significantly lower in this study compared to those in others, they are in line with the CVS diagnosis rate. Aside from the CVS and CVS-related complications, all the other SAH complications were roughly within the range of the other studies.

Predictive value of whole-brain CT perfusion combined with ABCD3 score for short-term secondary cerebral infarction after TIA.

To investigate the predictive value of Whole Brain CT Perfusion (WB-CTP) combined with the ABCD3 score in patients with transient ischemic attack (TIA). A total of 336 TIA patients with TIA underwent WB-CTP and ABCD3 score assessment within 48 h of admission. Spearman correlation test was performed to analyze the relationship between the degree of vascular stenosis, relative perfusion values, and ABCD3 score. Logistic regression analysis was used to identify independent risk factors for secondary cerebral infarction. Receiver operating characteristic (ROC) curves were generated to evaluate the predictive value of relative cerebral blood flow (rCBF), degree of vascular stenosis, ABCD3 score, and the WB-CTP-ABCD3 combined model for secondary cerebral infarction after TIA. Calibration curves and H-L tests were used to evaluate the predictive efficacy of the model. Among the 336 TIA patients, 143 showed abnormal perfusion areas and 146 had responsible vessel stenosis. The degree of vascular stenosis, relative time-to-maximum (rTmax), and relative mean transit time (rMTT) were positively correlated with the ABCD3 score, while rCBF and relative cerebral blood volume (rCBV) were negatively correlated with the ABCD3 score. ROC curve analysis identified a cutoff value of 0.8205 for rCBF, with a sensitivity of 84.10% and specificity of 58.10% for distinguishing the cerebral infarction group from the non-cerebral infarction group. Furthermore, rCBF ≤ 0.8205, degree of vascular stenosis, and ABCD3 score > 6 were identified as independent risk factors for secondary cerebral infarction in TIA patients within 90 days in TIA patients. The AUC of the WB-CTP-ABCD3 combined model for predicting secondary cerebral infarction within 90 days was 0.836. The model risk was assessed by plotting calibration curves. The value of p for the H-L goodness of fit test was 0.366 (p > 0.05), which indicated that the difference between the obtained model and the perfect model were statistically insignificant. The combined model of WB-CTP-ABCD3 shows promise as a valuable method for predicting secondary cerebral infarction within 90 days following TIA.

Early-stage serum Stanniocalcin 1 as a predictor of outcome in patients with aneurysmal subarachnoid hemorrhage.

Stanniocalcin-1 (STC1) takes part in anti-inflammatory and anti-oxidative processes, thus demonstrating neuroprotective properties. Early brain injuries associated with initial subarachnoid hemorrhage typically led to secondary cerebral infarction and poor outcomes. This retrospective study aimed to clarify the clinical significance of serum STC1 level in patients with subarachnoid hemorrhage.We collected demographic information, comorbidities, neurological status in detail. All blood samples were collected on admission. Enzyme-linked immunosorbent assay kits were used to detect the serum level of STC1. Spearman analysis was used to explore the relationship between STC1 and clinical severity. Multivariate logistic regression was used to investigate the prognostic role of STC1 in patients with aneurysmal subarachnoid hemorrhage (aSAH). Receiver operating characteristic curve was performed to investigate the power of STC1 in predicting outcome in aSAH patients.Serum STC1 concentration was significantly higher in aSAH patients than in healthy individuals. Serum concentration of STC1 positively correlated with Hunt-Hess grade (r = 0.62, P < .01) and Fisher grade (r = 0.48, P < .01), and negatively correlated with Glasgow Coma Scale on admission (r = −0.45, P < .01). Patients with delayed cerebral ischemia (DCI) had higher level of serum STC1 than those without DCI (13.12 ± 1.44 vs 8.56 ± 0.31, P < .01). Moreover, patients with poor outcome had higher concentration of STC1 than patients with good outcome (11.82 ± 0.62 vs 8.21 ± 0.35,P < 0.01). Results of univariate and multivariate logistic analysis revealed that Hunt-hess III–IV, DCI, and high STC1 level were independent risk factors associated with poor outcome of patients with aSAH. Further analysis revealed that combination of STC1 with Hunt-hess grade was more superior to 2 indicators alone in predicting clinical outcome of aSAH patients.STC1 can be used as a novel biomarker in predicting outcome of patients with aSAH, especially when combined with Hunt-hess grade.

The Clinical Efficacy of Ginkgo biloba Leaf Preparation on Ischemic Stroke: A Systematic Review and Meta-Analysis.

Background Ginkgo biloba leaf preparations (GLPs) are widely used in ischemic stroke, and uncertainty remains regarding their clinical efficacy. To evaluate systematically the clinical efficacy and safety of GLPs in the treatment of ischemic stroke, we examine evidence from randomized controlled trials (RCTs). Methods We examine studies published prior to November 2021 that were found from searching the following sources: PubMed, China National Knowledge Infrastructure (CNKI), WANFANG DATA, Chongqing VIP (CQVIP) databases, and Chinese Biomedical Literature (CBM). We evaluated the quality of the included references according to the Cochrane Manual of Systematic Evaluation and Meta-analysis (MA) performed using RevMan 5.2 software. Results We included a total of 13 RCTs with clinical therapeutic effects, the National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), hemorheology index, and adverse reaction index as evaluation criteria. There were 631 cases in the observation group and 629 cases in the control group. MA results showed the following: NIHSS WMD = −3.89, 95% CI: [−4.22, −3.56], I2 = 19%, P < 0.00001. This index is often used with nerve injury and can also be used to judge the recovery of nerve function. A lower score means less nerve damage and a better chance of recovery. The BI results were WMD = 11.30, 95% CI: [9.83, 12.77], I2 = 7%, P < 0.00001. This index was used to assess patients' ability to take care of themselves, with a higher score indicating a stronger ability to live independently. Clinical effective rate results were WMD = 3.79, 95% CI: [2.49, 5.78], I2 = 0%, P < 0.00001, and this measure can be used to evaluate the effect of treatment clearly and objectively. Hemorheological index results show that plasma viscosity has WMD = −0.16, 95% CI: [−0.20, −0.12], I2 = 40%, P < 0.00001 and fibrinogen (FIB) has WMD = −1.13, 95% CI: [−1.23, −1.04], I2 = 0%, P < 0.00001. Plasma viscosity is mainly related to the amount of fibrinogen, and fibrinogen degradation is an important function of the fibrinolytic system. The imbalance of the fibrinolytic system plays an important role in the pathogenesis of cerebral infarction. Fibrinogen is a risk factor of ischemic cerebrovascular disease. Studies have shown that the infarct size of patients with secondary cerebral infarction after CEREBRAL infarction is correlated with their FIB level. In addition, FIB elevation is also one of the risk factors for early infarction after thrombolysis. Therefore, FIB can be used as a detection index for the prevention of cerebral infarction recurrence adverse reactions. Our MA results for FIB show WMD = 0.81, 95% CI: [0.38, 1.73], I2 = 0%, P = 0.58, and RR < 1. Conclusion The existing clinical evidence shows that GLP has a good therapeutic effect on patients with ischemic stroke and can improve their hemorheology indices. In addition, GLP is shown to be relatively safe.

Het posterieur reversibel encefalopathiesyndroom

Posterior reversible encephalopathy syndrome Being confronted with postoperative complications can be challenging. When a patient shows signs of postoperative neurological deficit, a wide range of possible explanations has to be considered. In this specific case, the diagnosis of posterior reversible encephalopathy syndrome (PRES) was made. PRES is characterised by neurological symptoms (headache, confusion, visual changes, paresis and/or convulsions) and certain findings on cerebral imaging (vasogenic oedema, predominantly in the posterior areas of the brain). It is linked to hypertensive disorders, (pre-)eclampsia, certain auto-immune diseases, the use of immunosuppressive medication and kidney failure. Treatment of the hypertension is crucial, but antiseizure drugs and treatment of the underlying disease may also be necessary. Most patients have a complete recovery within 2 weeks. A small minority, however, experiences residual neurologic deficits resulting from secondary cerebral infarction or haemorrhage.

Ischemia Modified Albumin and miR-126 Play Important Role in Diagnosis of Posterior Circulation Transient Ischemic Attack and Prediction of Secondary Cerebral Infarction

Transient ischemic attack (TIA) is a super warning for cerebral infarction stroke, thus probe of sensitive biomarker for TIA diagnosis and prognosis can contribute to make an optimal intervention plan. This study was conducted to explore the value of ischemic modified albumin (IMA) and microRNA-12miR-126 on the diagnosis of posterior circulation TIA and the prediction of secondary cerebral infarction. This study was conducted as a longitudinal prospective research. The levels of serum IMA and miR-126 at 3h, 6h and 12h after TIA onset were analyzed in 106 patients, then the predictive value of IMA and miR-126 for secondary cerebral infarction were tested. A significant increase of serum IMA and a decrease of miR-126 were observed after TIA onset (P = 0.000),simultaneously a significant negative correlation was found between serum IMA for 3 h and miR-126 for 12 hr=-0.401, P = 0.000. Both IMA and miR-126 were significant associated with the secondary cerebral infarction. Early detection of IMA and miR-126 is of great value in diagnosing posterior circulation TIA and predicting the secondary cerebral infarction.

Perioperative Blood Pressure Control in Carotid Artery Stenosis Patients With Carotid Angioplasty Stenting: A Retrospective Analysis of 173 Cases.

Background: Carotid angioplasty stenting (CAS) is a currently widely used surgical treatment of carotid artery stenosis. However, the influences of the perioperative blood pressure (BP) on patients' prognosis remain unclear.Objective: The present study was designed to explore the effects of different perioperative BP control strategies on CAS patients' prognosis.Methods: One hundred seventy-three consecutive patients admitted between January 2016 and April 2019 were reviewed retrospectively. The outcomes of patients with different systolic BP (<120, 120–130, and >130 mmHg) before CAS and within 24 h after CAS were compared. The primary outcomes were the incidence of secondary cerebral infarction (CI) and intracranial hemorrhage (ICH) after CAS. The secondary outcome was the incidence of unfavorable discharge and in-hospital death. The unfavorable discharge was defined as modified Rankin Scale (mRS) score 3–5 at discharge.Results: There was no significant difference between the incidences of ICH (P = 0.803) and CI (P = 0.410) in patients with different BP before CAS. The patients with post-CAS BP values of >130 mmHg had a 37.67-fold increased risk (95% CI: 6.79–209.01) of ICH compared with others, while no significant difference was observed on the incidence of CI (P = 0.174) among patients with different post-CAS BP values. The patients with post-CAS BP values of >130 mmHg also had a significantly higher incidence of unfavorable discharge (P = 0.002) and in-hospital death (P = 0.001) compared with others.Conclusion: High BP (>130 mmHg) within 24 h after CAS significantly increases the risks of secondary cerebral hemorrhage, unfavorable discharge, and in-hospital death. Thus, the BP should be controlled below 130 mmHg in the first 24 h after CAS.

Routine use of perfusion computed tomography for the detection of delayed cerebral ischemia in unconscious patients after aneurysmal subarachnoid hemorrhage.

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) is difficult to diagnose in unconscious patients, but it is essential for the prognosis. We analyzed the diagnostic value of routinely performed perfusion computed tomography (rPCT) to detect DCI-related hypoperfusion in this subgroup of patients. Retrospective analysis of unconscious aSAH patients who underwent rPCT according to a predefined protocol. We exclusively analyzed PCT examinations in patients who were clinically and functionally asymptomatic with regard to transcranial Doppler ultrasound (TCD) and invasive neuromonitoring at the time of the PCT examination. The perfusion maps were quantitatively evaluated to detect DCI-related hypoperfusion. Possible clinical risk factors for the occurrence of DCI-related hypoperfusion in rPCT imaging were analyzed by multivariate analyses. One hundred thirty-six rPCTs were performed in 55 patients. New onset of DCI-related hypoperfusion was observed in 18% of rPCTs. The positive predictive value of rPCT to detect angiographic CVS was 0.80. Between examination days 6 and 10, the rate of DCI-related hypoperfusion was increased significantly (p < 0.05). After rPCT imaging with proof of DCI-related hypoperfusion, short-term follow-up showed secondary cerebral infarction (SCI) in 38%, compared with 5% for patients with normal perfusion on rPCT. The parameters "high risk phase (examination days 6-10)" and "new onset of DCI-related SCI" were significantly associated with the occurrence of DCI-related hypoperfusion in rPCT. In unconscious and asymptomatic aSAH patients, rPCT identifies DCI-related hypoperfusion in a relevant number of examinations. However, despite timely endovascular rescue therapy, a significant proportion of secondary infarction still occurs in this subgroup.

Study of multimodal monitoring in neurocritical care patients

To explore the significance of multimodal monitoring in the monitoring and treatment of neurocritical care patients. 104 neurocritical care patients admitted to the department of Critical Care Medicine of Fujian Provincial Hospital from March 2019 to January 2020 were enrolled. Patients were randomly assigned into two groups, with 52 in each group. In the routine monitoring treatment group, heart rate, blood pressure, respiratory rate and the changes in consciousness and pupils were monitored after operation. The patients were treated with routine medicine to reduce intracranial pressure (ICP), maintain proper cerebral perfusion pressure (CPP), balance fluid intake and output, and maintain the airway clear. Patients in the multimodal monitoring treatment group were treated with invasive ICP monitoring, ultrasound to assess brain structure, ultrasound to measure optic nerve sheath diameter (ONSD), transcranial color doppler (TCCD), internal jugular venous blood oxygen saturation monitoring, near-infrared spectroscopy (NIRS), non-invasive cerebral blood oxygen saturation monitoring and quantitative electroencephalogram monitoring. According to the monitoring results, the patients were given targeted treatment with the goal of controlling ICP and improving brain metabolism. The length of intensive care unit (ICU) stay, the incidences of neurological complications (secondary cerebral infarction, cerebral hemorrhage, high intracranial pressure, etc.), and the incidences of poor prognosis [6 months after the onset of Glasgow outcome score (GOS) 1 to 3] were compared between the two groups. Spearman rank correlation analysis of the correlation between invasive ICP and the ICP value which was calculated by TCCD. The receiver operating characteristic (ROC) curve of invasive ICP and pulsatility index of middle cerebral artery (PIMCA) were used to predict poor prognosis. The length of ICU stay in the multimodal monitoring treatment group was significantly shorter than that of the routine monitoring treatment group (days: 6.27±3.81 vs. 9.61±5.09, P < 0.01), and the incidence of neurological complications was significantly lower than that in the routine monitoring treatment group (9.62% vs. 25.00%, P < 0.05). In the multimodal monitoring treatment group, 37 cases had a good prognosis and 15 cases had a poor prognosis, while the routine monitoring treatment group had a good prognosis in 27 cases and a poor prognosis in 25 cases. The incidence of poor prognosis in the multimodal monitoring treatment group was lower than that of the routine monitoring treatment group (28.85% vs. 48.08%, P < 0.05). In the multimodal monitoring treatment group, the invasive ICP and PIMCA of patients with good prognosis were significantly lower than those of patients with poor prognosis [invasive ICP (mmHg, 1 mmHg = 0.133 kPa): 16 (12, 17) vs. 22 (20, 24), PIMCA: 0.90±0.33 vs. 1.39±0.58, both P < 0.01]. There was no significant difference in resistance index of the middle cerebral artery (RIMCA) between the good prognosis group and the poor prognosis group (0.63±0.12 vs. 0.66±0.15, P > 0.05). There was a positive correlation between the invasive ICP and the ICP value which was calculated by TCCD (r = 0.767, P < 0.001). ROC curve analysis showed that the area under ROC curve (AUC) of invasive ICP for poor prognosis prediction was 0.906, the best cut-off value was ≥ 18 mmHg, the sensitivity was 86.49%, and the specificity was 86.67%. The AUC of PIMCA for poor prognosis prediction was 0.759, the best cut-off value was ≥ 1.12, the sensitivity was 81.08%, and the specificity was 60.00%. The AUC of invasive ICP was greater than PIMCA (Z = 2.279, P = 0.023). Comprehensive analysis of multimodal monitoring indicators for neurocritical care patients to guide clinical treatment can reduce the length of hospital stay, and reduce the risk of neurosurgery complications and disability; invasive ICP can predict poor prognosis of neurocritical care patients.

Diagnosis and treatment of an elderly patient with secondary cerebral infarction caused by COVID-19

We review the experience with the diagnosis and treatment of secondary cerebral infarction in an elderly patient with coronavirus disease 2019 (COVID-19). COVID-19 has rapid disease progression with a high mortality rate in elderly patients, and physicians should be alert to secondary bacterial infection that may result in coagulation dysfunction and cerebral infarction. Early anti-infection therapy, immune regulation and appropriate anticoagulation intervention may help improve the prognosis of the patients.

The mid/long-term follow-up of endovascular treatment of dissecting aneurysms of the posterior cerebellar artery

Objective To investigate the safety and efficacy of endovascular treatment of dissecting aneurysms of the posterior cerebellar artery (PCA). Methods We retrospectively analyzed 19 consecutive patients with 19 dissecting aneurysms of PCA who underwent endovascular treatment at Department of Neurosurgery, Tangdu Hospital, Air Force Military Medical University between July 2012 and June 2017. Among those, 9 cases received stent-assisted coiling, 2 cases received double stents implanting and 8 cases received occlusion of parent artery. The post-intervention results were evaluated by Raymond Classification. We followed up all cases after discharge by imaging and telephone. Telephone follow-up results were about the clinical outcome and DSA results were evaluated by Raymond Classification. Results All patients in this series were treated successfully. Following initial treatment, there were 11 cases that were graded as class Ⅰ, 5 as class Ⅱ and 3 as class Ⅲ based on Raymond classification. Hemorrhagic event of aneurysmal rupture occurred in 2 cases (1 case with secondary in-stent thrombosis) during treatment and secondary cerebral infarction occurred in 1 case after treatment. All of the 3 cases recovered well at discharge. All cases were followed up for 6-28 months (mean: 13.4±3.1 months). Two patients recovered well based on telephone follow-up. Follow-up imaging results were evaluated by Raymond scale in 17 cases, which reported class Ⅰ in 13 aneurysms, class Ⅱ in 2 aneurysms. The other 2 case with recurrence received second endovascular treatment and had no more recurrence during long-term follow-up. Conclusions The endovascular treatment of dissecting aneurysms of PCA at a single center seems satisfactory and the mid-long term follow-up results are favorable. The endovascular treatment of dissecting aneurysms of PCA seems safe and feasible, which still needs to be confirmed by longer follow-up and controlled studies with larger sample size. Key words: Aneurysm, dissecting; Posterior cerebral artery; Embolization, therapeutic; Follow-up studies; Treatment outcome

Magnesium sulfate in combination with nimodipine for the treatment of subarachnoid hemorrhage: a randomized controlled clinical study

ObjectiveCerebral vasospasm(CVS) after Subarachnoid hemorrhage (SAH) can cause delayed cerebral ischemia,secondary cerebral infarction, and rehemorrhage, which are the leading causes of mutilation and death. Nimodipine has been shown to prevent CVS. Magnesium ion (Mg2+) can competitively inhibit the influx of calcium (Ca2+) and prevent vasospasm. There is evidence that magnesium sulfate can prevent CVS and reduce infarct volume after SAH. In this study, we evaluated the efficacy and safety of intravenous magnesium sulfate combined with oral nimodipine on CVS, delayed cerebral ischemia, secondary cerebral infarction, and rehemorrhage after SAH.MethodsThis is a prospective randomized, double-blind trial of 120 patients with SAH who were recruited between January 2003 and January 2009. These patients were assigned to two groups and received the same basic treatment and symptomatic treatment. In group A, patients received 14 days of intravenous administration of 1400 mL 0.9% normal saline + 40 mL 25% magnesium sulfate, 1 mL/min, once per day, followed 7 days of intravenous administration of 500 mL 0.9% normal saline + 15 mL 25% magnesium sulfate, 1 mL/min, once per day and oral nimodipine, 20 mg once, four times a day, for 21 days. Patients in group B received identical treatment to that in group A, except that 25% magnesium sulfate was replaced by placebo. On day 22 of treatment, incidences of intracranial CVS, delayed cerebral ischemia, secondary cerebral infarction, rehemorrhage, neurologic deficits, and death were assessed and adverse events were monitored.ResultsCVS occurred in 4, 12 patients, lasting for 11.09 ± 5.38, 13.73 ± 6.24 hours, mean velocity (Vm) of 143.2 ± 12.7, 149.6 ± 18.9 cm/s in group A, B; Delayed cerebral ischemia occurred in 3, 10 patients, lasting for 13.16 ± 4.82, 15.57 ± 5.35 hours in group A, B; Secondary cerebral infarction occurred in 2 and 8 patients in groups A and B; Neurologic deficits occurred in3 and 11 patients in groups A and B, All P < 0.05; Rehemorrhage occurred in 4 and 5 patients; Death occurred in 5 and 8 patients in groups A and B, respectively, P >0.05. No obvious adverse events were found in both groups.ConclusionIntravenous magnesium sulfate in combination with oral nimodipine for the treatment of SAH can help reduce the incidences of CVS, delayed cerebral ischemia, secondary cerebral infarction, and neurologic deficits with good safety, but it does not reduce the incidences of rehemorrhage and death.

Clinical evaluation of post-operative cerebral infarction in traumatic epidural haematoma

ABSTRACTBackground: Patients with traumatic epidural haematoma, undergoing the prompt and correct treatment, usually have favourable outcomes. However, secondary cerebral infarction may be life-threatening condition, as it is difficult to be identified before neurological impairment occurs.Objective: To evaluate the clinical data of patients with traumatic EDH and assess potential risk factors for post-operative cerebral infarction.Methods: The clinical data of patients with traumatic EDH were collected and analysed retrospectively.Results: The univariate analysis revealed 10 potential risk factors (the haematoma location, volume, the largest thickness and mid-line shift, basal cisterns compression, traumatic subarachnoid haemorrhage, pupil dilatation, pre-operative Glasgow Coma Scale score, ∆GCS and intraoperative brain pressure) for cerebral infarction with statistically significant difference. Of these factors, haematoma volume and basal cistern compression turned out to be the most significant risk factors through final multivariate logistic regression analysis.Conclusion: The findings of this study can provide predictive factors for development of cerebral infarction and information for clinical decision-making and future studies.

Controlled transient hypercapnia: a novel approach for the treatment of delayed cerebral ischemia after subarachnoid hemorrhage?

The authors undertook this study to investigate whether the physiological mechanism of cerebral blood flow (CBF) regulation by alteration of the arterial partial pressure of carbon dioxide (PaCO₂) can be used to increase CBF after aneurysmal subarachnoid hemorrhage (aSAH). In 6 mechanically ventilated patients with poor-grade aSAH, the PaCO₂ was first decreased to 30 mm Hg by modification of the respiratory rate, then gradually increased to 40, 50 and 60 mm Hg for 15 minutes each setting. Thereafter, the respirator settings were returned to baseline parameters. Intracerebral CBF measurement and brain tissue oxygen saturation (StiO₂), measured by near-infrared spectroscopy (NIRS), were the primary and secondary end points. Intracranial pressure (ICP) was controlled by external ventricular drainage. A total of 60 interventions were performed in 6 patients. CBF decreased to 77% of baseline at a PaCO₂ of 30 mm Hg and increased to 98%, 124%, and 143% at PaCO₂ values of 40, 50, and 60 mm Hg, respectively. Simultaneously, StiO₂ decreased to 94%, then increased to 99%, 105%, and 111% of baseline. A slightly elevated delivery rate of cerebrospinal fluid was noticed under continuous drainage. ICP remained constant. After returning to baseline respirator settings, both CBF and StiO₂ remained elevated and only gradually returned to pre-hypercapnia values without a rebound effect. None of the patients developed secondary cerebral infarction. Gradual hypercapnia was well tolerated by poor-grade SAH patients. Both CBF and StiO₂ reacted with a sustained elevation upon hypercapnia; this elevation outlasted the period of hypercapnia and only slowly returned to normal without a rebound effect. Elevations of ICP were well compensated by continuous CSF drainage. Hypercapnia may yield a therapeutic potential in this state of critical brain perfusion. Clinical trial registration no.: NCT01799525 ( ClinicalTrials.gov ).

The value of perfusion computed tomography in predicting clinically relevant vasospasm in patients with aneurysmal subarachnoid hemorrhage

Delayed cerebral ischemia remains a severe potential complication of aneurysmal subarachnoid hemorrhage (SAH) possibly leading to death and disability. We evaluated a semiquantitative and visual analysis of perfusion computed tomography (PCT) as a predictor of clinically relevant vasospasm (CRV) in patients with aneurysmal SAH. Thirty-eight patients with aneurysmal SAH were analyzed yielding 145 PCT scans. PCT, clinical examination, and transcranial Doppler ultrasound (TCD) were performed on days3, 7, 10, and 14 after hemorrhage. Cerebral blood flow, cerebral blood volume, and time to peak (TTP) were analyzed semiquantitatively using six regions of interest, and visually for signs of cerebral hypoperfusion. CRV was defined as secondary cerebral infarction (CI) seen on cranial computed tomography scans and/or delayed neurological deterioration (DND). CI occurred in 13 (34.2%) and DND in 11 patients (28.9%). With TCD as pretest, TTP had a sensitivity of 90% and a specificity of 72% (cutoff value, 0.963) as predictor for CI. TTP's sensitivity as predictor for DND was 90% with a specificity of 61.1% (cutoff value, 0.983). Visual analysis of TTP showed a negative predictive value of 100% with a positive predictive value of 52%. TTP is a sensitive and specific perfusion parameter in predicting CI in patients with SAH. Its use in the clinical setting may optimize the early treatment of patients at risk for vasospasm before the onset of clinical deterioration, especially when applying TCD as pretest. Further investigation in a larger patient population is required.

Cerebral Blood and CSF Flow Patterns in Patients Diagnosed for Cerebral Venous Thrombosis - An Observational Study

Background and Purpose:Recent studies of the organization of the cerebral venous system in healthy subjects using phase contrast magnetic resonance imaging (PC-MRI) show its structural complexity and inter-individual variations. Our objective was to study the venous blood and CSF flows in cerebral venous thrombosis (CVT).Materials and Methods:PC-MRI sequences were added to brain MRI conventional protocol in 19 patients suspected of CVT, among whom 6 patients had CVT diagnosis confirmed by MR venography. Results were compared with 18 healthy age-matched volunteers (HV).Results:In patients without CVT (NoCVT) confirmed by venography, we found heterogeneous individual venous flows, and variable side dominance in paired veins and sinuses, comparable to those in healthy volunteers. In CVT patients, PC-MRI detected no venous flow in the veins and/or sinuses with thrombosis. Arterial flows were preserved. CSF aqueductal and cervical stroke volumes were increased in a patient with secondary cerebral infarction, and decreased in 4 patients with extended thrombosis in the superior sagittal and transverse sinuses. These results suggest the main role of the venous system in the regulation of the dynamic intracranial equilibrium.Conclusions:CVT produces highly individualized pattern of disturbance in venous blood drainage. Complementary to MRI venography, PC-MRI provides non-invasive data about venous blockage consequences on CSF flow disturbances.

Cerebrovascular manifestations of Behçet’s disease

Behçet’s disease (BD) is a systemic inflammatory disease commonly characterized by oral and genital ulcerations, with skin and eye involvement. Its cause is still unknown, but vasculitis is the major pathologic feature. BD is a rare condition, seen more commonly in Turkey, as well as in Middle Eastern, Mediterranean and Far Eastern countries. Neurological involvement is reported to manifest as brainstem or corticospinal tract syndromes, increased intracranial pressure mostly related to venous sinus thrombosis or aseptic meningitis, isolated behavioral symptoms or isolated headache. This report presents a 34-year-old BD patient with secondary cerebral infarction due to head trauma. The clinical and central nervous system findings of BD are discussed.

Curcumin Attenuates Vascular Inflammation and Cerebral Vasospasm After Subarachnoid Hemorrhage in Mice

Cerebral vasospasm is a major cause of death and disability after subarachnoid hemorrhage (SAH); however, clinical therapies to limit the development of cerebral vasospasm are lacking. Although the causative factors underlying the development of cerebral vasospasm are poorly understood, oxidative stress contributes to disease progression. In the present study, curcumin (150 or 300 mg/kg) protected against the development of cerebral vasospasm and limited secondary cerebral infarction after SAH in mice. The protective effect of curcumin was associated with a significant attenuation of inflammatory gene expression and lipid peroxidation within the cerebral cortex and the middle cerebral artery. Despite the ability of curcumin to limit the development of cerebral vasospasm and secondary infarction, behavioral outcome was not improved, indicating a dissociation between cerebral vasospasm and neurologic outcome. Together, these data indicate a novel role for curcumin as a possible adjunct therapy after SAH, both to prevent the development of cerebral vasospasm and to reduce oxidative brain injury after secondary infarction.

CT perfusion predicts secondary cerebral infarction after aneurysmal subarachnoid hemorrhage

To prospectively assess the diagnostic accuracy of CT perfusion (CTP) and transcranial Doppler sonography (TCD) for the prediction of secondary cerebral infarction (SCI) after aneurysmal subarachnoid hemorrhage (SAH). During 2 weeks after SAH, 38 consecutive patients completed an average of 3.5 CT/CTP and 10.7 TCD examinations at regular intervals as required by the study protocol. SCI was defined as delayed infarction on native CT between 3 and 14 days after SAH and developed in n = 14 patients (n = 24 without SCI). Analysis was based on examination dates before SCI. Common measures of diagnostic accuracy were calculated for qualitative CTP (visual color-map ratings from two blinded observers) and TCD assessments (mean flow velocity >120 cm/s in anterior, middle, and posterior cerebral artery territories). Quantitative measures, which for CTP were obtained from cortical a priori regions of interest corresponding to the vascular territories, were analyzed by binary logistic regression. Time of prediction for SCI by CTP was at a median of 3 days (range 2 to 5 days) before manifestation of complete infarction on native CT. Visual assessment of time-to-peak (TTP) color maps performed best for the prediction of SCI with 0.93 sensitivity (95% CI: 0.7 to 1.0) and 0.67 specificity (95% CI: 0.53 to 0.7). On quantitative analysis, the odds ratio (OR) for 1 second of side-to-side delay in TTP was 1.4 (p = 0.01, Wald chi(2) = 8.57, CI: 1.07 to 1.82). Daily TCD measures were not significantly related to SCI at any time before complete infarction on native CT. Time to peak as indicated by CT perfusion is a sensitive and early predictor of secondary cerebral infarction.