Setting Of Aneurysmal Subarachnoid Hemorrhage Research Articles

Frailty in aneurysmal subarachnoid hemorrhage: the risk analysis index.

Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research. Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2. 42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001). The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors.

Missing a Blood Blister-Like Aneurysm in the Setting of Aneurysmal Subarachnoid Hemorrhage in a Patient Harboring Multiple Aneurysms.

HomeStrokeAhead of PrintMissing a Blood Blister-Like Aneurysm in the Setting of Aneurysmal Subarachnoid Hemorrhage in a Patient Harboring Multiple Aneurysms No AccessCase ReportRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessCase ReportRequest AccessMissing a Blood Blister-Like Aneurysm in the Setting of Aneurysmal Subarachnoid Hemorrhage in a Patient Harboring Multiple Aneurysms Beate Kranawetter, Mohammad Hazaymeh, Dorothee Mielke, Veit Rohde and Tammam Abboud Beate KranawetterBeate Kranawetter Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen. Search for more papers by this author , Mohammad HazaymehMohammad Hazaymeh Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen. Search for more papers by this author , Dorothee MielkeDorothee Mielke https://orcid.org/0000-0002-1462-4864 Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen. Search for more papers by this author , Veit RohdeVeit Rohde Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen. Search for more papers by this author and Tammam AbboudTammam Abboud Correspondence to: Tammam Abboud, MD, Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen, Robert-Koch Straße 40, 37075 Göttingen. Email E-mail Address: [email protected] https://orcid.org/0000-0003-4379-6961 Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen. Search for more papers by this author Originally published14 Jun 2023https://doi.org/10.1161/STROKEAHA.123.042997Stroke. 2023;0FootnotesFor Sources of Funding and Disclosures, see page XXX.Correspondence to: Tammam Abboud, MD, Department of Neurosurgery, University Medical Center Göttingen, Georg-August University Göttingen, Robert-Koch Straße 40, 37075 Göttingen. Email tammam.[email protected]uni-goettingen.de Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.123.042997PMID: 37313741 Originally publishedJune 14, 2023 Keywordsruptured aneurysmsubarachnoid hemorrhagemiddle agedaneurysmangiography, digital subtractionPDF download Advertisement SubjectsAneurysm

Vasospasm following brain tumor resection in children: institutional experience and systematic review.

Delayed cerebral ischemia (DCI) associated with vasospasm is well described in the setting of aneurysmal subarachnoid hemorrhage (SAH). In addition, DCI is very infrequently encountered in patients who have undergone resection of a brain tumor with unclear pathophysiology. The occurrence of DCI in the pediatric population is exceedingly rare, and outcomes in this population have, to the authors' knowledge, never been systematically reviewed. Therefore, the authors present what is to their knowledge the largest series of pediatric patients with this complication and systematically reviewed the literature for individual participant data. The authors conducted a retrospective review of 172 sellar and suprasellar tumors in pediatric patients who underwent surgery at the Montreal Children's Hospital between 1999 and 2017 to identify cases of vasospasm occurring after tumor resection. Descriptive statistics, including patient characteristics, intraoperative and postoperative findings, and outcome status, were collected. A systematic review was also conducted using three databases (PubMed, Web of Science, Embase) to identify reported cases available in the literature of vasospasm after tumor resection in children and collect individual participant data on these patients for further analysis. Six patients treated at Montreal Children's Hospital were identified, with an average age of 9.5 years (range 6-15 years). The prevalence of vasospasm after tumor resection was 3.5% (6/172). Vasospasm in all 6 patients occurred after craniotomy was performed to treat a suprasellar tumor. The average interval from surgery to symptoms was 3.25 days (range 12 hours-10 days). The most common tumor etiology was craniopharyngioma, seen in 4 cases. Extensive tumor encasement of blood vessels requiring significant operative manipulation was described in all 6 patients. A rapid decrease in serum sodium (exceeding 12 mEq/L/24 hrs or below 135 mEq/L) was seen in 4 patients. On final follow-up, 3 patients were left with significant disability, and all patients had persistent deficits. A systematic review of the literature revealed a total of 10 other patients whose characteristics and treatment were compared with those of the 6 patients treated at Montreal Children's Hospital. Vasospasm after tumor resection in children and youth is likely a rare entity, with a prevalence of 3.5% in this case series. Suprasellar tumor location (particularly craniopharyngioma tumor etiology), significant encasement of blood vessels by the tumor, and postoperative hyponatremia may be predictive factors. Outcome is poor, with most patients having significant persistent neurological deficits.

Effects of hyperoxemia on aneurysmal subarachnoid hemorrhage outcomes: a systematic review and meta-analysis.

In recent years, hyperoxemia in the intensive care unit has received attention as potentially contributing to negative outcomes in the setting of cardiac arrest, ischemic stroke, and traumatic brain injury. The authors sought to evaluate whether hyperoxemia contributes to worse outcomes in the setting of aneurysmal subarachnoid hemorrhage (aSAH) and to summarize suggested pathophysiological mechanisms. A systematic literature review was conducted without date restrictions on the PubMed and Web of Science databases on September 15, 2021. All studies that assessed the relationship between patients treated for aSAH and hyperoxemia were eligible independent of the criteria used to define hyperoxemia. All nonclinical studies and studies that did not report outcome data specific to patients with aSAH were excluded. A total of 102 records were found and screened, resulting in assessment of 10 full-text studies, of which 7 met eligibility criteria. Risk of bias was assessed using the Downs and Black checklist. A meta-analysis on the pooled 2602 patients was performed, and forest plots were constructed. Additionally, a review of the literature was performed to summarize available data regarding the pathophysiology of hyperoxemia. The included studies demonstrated an association between hyperoxemia and increased morbidity and mortality following aSAH. The criteria used to determine hyperoxemia varied among studies. Pooling of univariate data showed hyperoxemia to be associated with poor neurological outcome (OR 2.26, 95% CI 1.66-3.07; p < 0.001), delayed cerebral ischemia (DCI) (OR 1.91, 95% CI 1.31-2.78; p < 0.001), and increased incidence of poor neurological outcome or mortality as a combined endpoint (OR 2.36, 95% CI 1.87-2.97; p < 0.001). Pooling of multivariable effect sizes showed the same relationship for poor neurological outcome (OR 1.28, 95% CI 1.07-1.55; p = 0.01) and poor neurological outcome and mortality as a combined endpoint (OR 1.17, 95% CI 1.11-1.23; p < 0.001). Additionally, review of preclinical studies underlined the contribution of oxidative stress due to hyperoxemia to acute secondary brain injury and DCI. Reported outcomes from the available studies have indicated that hyperoxemia is associated with worse neurological outcome, mortality, and DCI. These findings provide a general guideline toward avoiding hyperoxemia in the acute setting of aSAH. Further studies are needed to determine the optimal ventilation and oxygenation parameters for acute management of this patient population.

Anisocoria Correlates With Injury Severity and Outcomes After Blunt Traumatic Brain Injury.

BACKGROUND: Automated infrared pupillometry (AIP) has been shown to be helpful in the setting of aneurysmal subarachnoid hemorrhage and stroke as an indicator of imminent irreversible brain injury. We postulated that the early detection of pupillary dysfunction after light stimulation using AIP may be useful in patients with traumatic brain injury (TBI). METHODS: We performed a retrospective review of the Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care database, a prospectively populated multicenter registry of patients who had AIP measurements taken during their intensive care unit admission. The primary eligibility criterion was a diagnosis of blunt TBI. Ordinal logistic modeling was used to explore the association between anisocoria and daily Glasgow Coma Scale scores and discharge modified Rankin Scale scores from the intensive care unit and from the hospital. RESULTS: Among 118 subjects in the who met inclusion, there were 6187 pupillometer readings. Of these, anisocoria in ambient light was present in 12.8%, and that after light stimulation was present in 9.8%. Anisocoria after light stimulation was associated with worse injury severity (odds ratio [OR], 0.26 [95% confidence interval (CI), 0.14-0.46]), lower discharge Glasgow Coma Scale scores (OR, 0.28 [95% CI, 0.17-0.45]), and lower discharge modified Rankin Scale scores (OR, 0.28 [95% CI, 0.17-0.47]). Anisocoria in ambient light showed a similar but weaker association. CONCLUSION: Anisocoria correlates with injury severity and with patient outcomes after blunt TBI. Anisocoria after light stimulation seems to be a stronger predictor than does anisocoria in ambient light. These findings represent continued efforts to understand pupillary changes in the setting of TBI.

Diagnostic accuracy of shuttle CT angiography (CTA) and helical CTA in the diagnosis of vasospasm

PurposeTo evaluate the diagnostic accuracy of computed tomography angiography (CTA) acquired with shuttle technique (CTAs) and helical CTA (CTAh) for vasospasm, using digital subtraction angiography (DSA) obtained within 24 h as reference standard. MethodsThirty-six patients with suspected vasospasm in the setting of aneurysmal subarachnoid hemorrhage (ASAH, 30/36) or acute inflammatory/infectious conditions (6/36) who underwent CTAs (17/36) or CTAh (19/36) followed by DSA within 24 h were identified retrospectively. Presence of vasospasm in the proximal cerebral arterial segments was assessed qualitatively and semi-quantitatively on CTA and subsequent DSA. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Inter-rater variability was assessed using Cohen's kappa. ResultsOn CTAs, 35% of patients had low and 65% had high vasospasm burden. On CTAh, 37% had low and 63% had high vasospasm burden. ROC analysis demonstrated an AUC of 0.87 for CTAs (95%CI 0.67–1.00, p = 0.015) and 0.88 for CTAh (0.72–1.00, p = 0.028). Cohen's kappa was 0.843 (95%CI 0.548–1.000). Thresholding with Youden's J index, CTAs had a sensitivity of 85.71% (95%CI 48.69 to 99.27) and specificity of 66.67% (35.42 to 87.94). CTAh had sensitivity of 100% (56.55 to 100.00) and specificity of 78.57% (52.41 to 92.43). ConclusionCTAs and CTAh yielded similar sensitivity, specificity, and AUC values on ROC analysis for the detection of vasospasm using DSA as reference standard. Our findings suggest that CTAs is a promising alternative to CTAh especially in patients requiring serial imaging, given its potential advantages of decreased radiation exposure, contrast dose, and cost-effectiveness.

The Woven EndoBridge device for ruptured intracranial aneurysms: international multicenter experience and updated meta-analysis.

The Woven EndoBridge (WEB) can be used to treat wide-necked aneurysms without antiplatelet medications, suggesting it may have advantages in the setting of aneurysmal subarachnoid hemorrhage (aSAH). The goal was assessment of safety and efficacy of WEB in aSAH given the delayed nature of aneurysmal thrombosis. An international retrospective analysis of patients with aSAH treated with WEB was conducted at 7 tertiary centers from 2016 to 2020. Outcomes included rates of rebleeding, retreatment, complications, and complete occlusion. Furthermore, a systematic review and meta-analysis was conducted from 2011 to 2020 assessing the same outcomes. All pooled event rates were calculated using a random effect model. Consecutive patients with aSAH harbored 25 aneurysms that were treated with 29 WEB devices. The mean age was 53years, and 65% were female. Zero experienced rebleeding, 2 were retreated, 2 experienced complications, 16 were completely occluded at 3months, and 21 were completed occluded at 9-12months. Meta-analysis of 309 WEB treatments for aSAH from 7 case series revealed 2.5% (95% CI 1-5%) had rebleeding, 9% (95% CI 4-17%) were retreated, 17% (95% CI 10-30%) had complications, and 61% (95% CI 51-71%) were completely occluded at 3-6months. WEB embolization in the setting of aSAH provides similar protection against rebleeding with comparable retreatment rates to traditional approaches. However, there is a higher rate of incomplete radiographic occlusion and operative complications compared to WEB embolization of unruptured aneurysms. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH.

Enantioselective assay of nimodipine in human plasma using liquid chromatography-tandem mass spectrometry.

Nimodipine is a dihydropyridine calcium channel blocker that exhibits higher selectivity toward cerebral blood vessels compared with other members of the same class. It has been shown to improve outcomes and prevent delayed cerebral ischemia in the setting of aneurysmal subarachnoid hemorrhage, a life-threatening brain bleed. Nimodipine is a chiral compound and it is marketed as a racemic mixture of (+)-R and (-)-S enantiomers. (-)-S-Nimodipine is approximately twice as potent a vasorelaxant as the racemic mixture and is more rapidly eliminated than the (+)-R counterpart following oral dosing. Few analytical procedures have been reported to determine nimodipine enantiomers in biological samples; however, the reported methods were time-consuming, involved multistep extraction procedures and required large sample volumes. Herein, we present an LC-MS/MS method for quantifying nimodipine enantiomers in human plasma using a small sample volume (0.3 ml) and a single liquid-liquid extraction step. The peak area ratios were linear over the tested concentration ranges (1.5-75 ng/ml) with r2 > 0.99. The intraday CV and percentage error were within ±14% while the interday values were within ±13%, making this analytical method feasible for research purposes and pharmacokinetic studies.

Spreading Depolarizations and Subarachnoid Hemorrhage.

Cortical spreading depolarizations (SD) are strongly associated with worse tissue injury and clinical outcomes in the setting of aneurysmal subarachnoid hemorrhage (SAH). Animal studies have suggested a causal relationship, and new therapies to target SDs are starting to be tested in clinical studies. A recent set of single-center randomized trials assessed the effect of the phosphodiesterase inhibitor cilostazol in patients with SAH. Cilostazol led to improved functional outcomes and SD-related metrics in treated patients through a putative mechanism of improved cerebral blood flow. Another promising therapeutic approach includes attempts to block SDs with, for example, the NMDA receptor antagonist ketamine. SDs have emerged not only as a therapeutic target but also as a potentially useful biomarker for brain injury following SAH. Additional clinical and preclinical experimental work is greatly needed to assess the generalizability of existing therapeutic trials and to better delineate the relationship between SDs, SAH, and functional outcome.

Does Nimodipine Interruption due to High Catecholamine Doses Lead to a Greater Incidence of Delayed Cerebral Ischemia in the Setting of Aneurysmal Subarachnoid Hemorrhage?

Current guidelines recommend the administration of nimodipine for the prevention of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). However, nimodipine can lead to significant drops in mean arterial pressure and cerebral perfusion pressure. Catecholamines are then used to maintain them while nimodipine is reduced and/or held. There is no evidence that nimodipine retains its neuroprotective effect at lower doses. We aimed to investigate the role of nimodipine interruption in the setting of aSAH and its possible impact on the incidence of DCI. We performed a retrospective analysis in patients with aSAH admitted to our center from January 2012 to October 2015. Nimodipine prophylaxis duration and dosage and the incidence of DCI were recorded. Bivariate correlation with Spearman's rho (ρ) and ordinal regression analyses were performed. A total of 170 patients were included in the study. Of these, 165 (97.1%) received nimodipine prophylaxis starting on day 0. Nimodipine was interrupted in 85 of 165 (51.5%), whereas dose was reduced in 47 of 165 (28.5%); full dose was received by only 33 of 165 (20%). DCI was observed in 85 of 170 (50%). Nimodipine interruption correlated in a statistically significant way with a greater incidence of DCI (ρ= 0.431, P < 0.001); receiving full doses of nimodipine showed a statistically significant inverse correlation to DCI (ρ= -0.273, P < 0.001). Ordinal regression analysis revealed nimodipine interruption as a statistically significant independent predictor of DCI (odds ratio 0.194; 95% confidence interval 0.079-0.474, P < 0.001). Our analysis reveals a greater incidence of DCI in patients with aSAH when nimodipine is interrupted.

Demographic and clinical predictors of multiple intracranial aneurysms in patients with subarachnoid hemorrhage

OBJECTIVE Pathophysiological differences that underlie the development and subsequent growth of multiple aneurysms may exist. In this study, the authors assessed the factors associated with the occurrence of multiple aneurysms in patients presenting with aneurysmal subarachnoid hemorrhage (SAH). METHODS Consecutive patients presenting with aneurysmal SAH between 1996 and 2012 were prospectively enrolled in the Subarachnoid Hemorrhage Outcome Project. Patients harboring 1, 2, or 3 or more aneurysms were stratified into groups, and the clinical and radiological characteristics of each group were compared using multivariate logistic regression. RESULTS Of 1277 patients with ruptured intracranial aneurysms, 890 had 1 aneurysm, 267 had 2 aneurysms, and 120 had 3 or more aneurysms. On multinomial regression using the single-aneurysm cohort as base case, risk factors for patients presenting with 2 aneurysms were female sex (relative risk ratio [RRR] 1.80, p < 0.001), higher body mass index (BMI) (RRR 1.02, p = 0.003), more years of smoking (RRR = 1.01, p = 0.004), and black race (RRR 1.83, p = 0.001). The risk factors for patients presenting with 3 or more aneurysms were female sex (RRR 3.10, p < 0.001), higher BMI (RRR 1.03, p < 0.001), aneurysm in the posterior circulation (RRR 2.59, p < 0.001), and black race (RRR 2.15, p = 0.001). Female sex, longer smoking history, aneurysms in the posterior circulation, BMI, and black race were independently associated with the development of multiple aneurysms in our adjusted multivariate multinomial model. CONCLUSIONS Significant demographic and clinical differences are found between patients presenting with single and multiple aneurysms in the setting of aneurysmal SAH. These predictors of multiple aneurysms likely reflect a predisposition toward inflammation and endothelial injury.

The effect of fenestration of the lamina terminalis on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (FISH)

Background:Shunt-dependent hydrocephalus (SDH) is a well-known sequela following aneurysmal hemorrhage, adversely affecting the outcome after securing ruptured aneurysm. Fenestration of lamina terminalis (FLT) creates an anterior ventriculostomy, facilitates cerebrospinal fluid circulation and clot clearance in the basal cistern. However, controversy exists over whether microsurgical FLT during aneurysm repair can decrease the incidence of SDH.Aims:The study is designed to determine the efficacy of lamina terminalis fenestration on the reduction of SDH after aneurysm clipping.Methods/Design:A total of 288 patients who meet the inclusion criteria will be randomized into single aneurysm clipping or aneurysm clipping plus FLT in the Department of Neurosurgery, West China Hospital. Follow-up was performed 1, 3, 6, and 12 months after aneurysm clipping. The primary outcome is the incidence of SDH and the secondary outcomes include cerebral vasospasm, functional outcome evaluated by the modified Rankin Scale and Extended Glasgow Outcome Scale, and mortality.Discussion:The FISH trial is a large randomized, parallel controlled clinical trial to define the therapeutic value of FLT, the results of which will help to guide the surgical procedure and resolve the long-puzzled debate in the neurosurgical community.Conclusions:This protocol will determine the efficacy of FLT in the setting of aneurysmal subarachnoid hemorrhage.Trial registration identifier:http://www.chictr.org.cn/edit.aspx?pid=15691&htm=4Chinese Clinical Trial Registry:ChiCTR-INR-16009249.

Acute Renal Failure in Aneurysmal Subarachnoid Hemorrhage: Nationwide Analysis of Hospitalizations in the United States

Medical complications in the setting of aneurysmal subarachnoid hemorrhage (aSAH) are common and associated with poor prognosis. We analyzed the incidence, risk factors, and short-term outcomes associated with acute renal failure (ARF) in aSAH. We queried discharge records from all patients admitted to U.S. hospitals between 2002 and 2011 toidentify primary diagnoses of aSAH and secondary diagnoses of ARF. The effect of demographics, hospital characteristics, and pre-existing comorbidity on ARF occurrence and the impact of ARF occurrence on length of stay (LOS), in-hospital costs, moderate to severe disability, and in-hospital mortality were explored in both bivariate and multivariable analyses. The incidence of ARF in patients hospitalized for aSAH (N= 260,885) was 4.0% and increased from 2.1% in 2002 to 5.7% in 2011 (P < 0.0001). The strongest predictors of ARF in multivariable analysis were fluid and electrolyte disorder (odds ratio [OR], 3.24; 95% confidence interval [CI], 3.07-3.42), coagulopathy (OR, 2.43; 95% CI, 2.25-2.63), HIV (OR, 2.42; 95% CI, 1.79-3.27), and diabetes (OR, 2.37; 95% CI, 2.08-2.69). ARF onset in aSAH increased the mean length of stay by 7.2 days and mean total costs by $28,813 (all P < 0.0001). After adjusting for confounding factors, patients with ARF had increased likelihood of moderate to severe disability (OR, 2.03; 95% CI, 1.89-2.19) and in-hospital death (OR, 2.14; 95% CI, 2.03-2.26). The burden of ARF in hospitalized patients with aSAH has increased in the past decade and is detrimental to patient outcomes and healthcare costs. The identification of patient-centered risk factors may allow for close surveillance of high-risk patients.

Safety and efficacy of a new prophylactic tirofiban protocol without oral intraoperative antiplatelet therapy for endovascular treatment of ruptured intracranial aneurysms

BackgroundCoil embolization of intracranial aneurysms is being increasingly used; however, thromboembolic events have become a major periprocedural complication.ObjectiveTo determine the safety and efficacy of prophylactic tirofiban in patients with ruptured...

Significance of routine cerebrospinal fluid analysis in subarachnoid hemorrhage.

The aim of this paper was to determine the diagnostic value of cerebrospinal fluid (CSF) analysis in the setting of aneurysmal subarachnoid hemorrhage (aSAH), hypothesizing that CSF analysis is only critical in confirming suspected infection and may be useful in predicting and/or detecting delayed cerebral ischemia (DCI). Retrospective review of consecutive adult patients diagnosed with aSAH from 1/2000 to 12/2013 at Mayo Clinic, Rochester, MN, USA with cerebral aneurysm(s) identified by vascular imaging, and CSF drawn within 14 days of the date of hemorrhage. We identified 741 patients during the study period, 167 met inclusion criteria and 356 samples were collected. First Median CSF samples were taken 5 (4-8) days postbleed. Multiple samples were taken in 94 (54.5%) patients and the mean number of samples per patient was 2.1. Ventriculitis, confirmed by growth of organism from CSF culture was present in 2 (1.2%) patients and one patient (0.6%) developed meningitis. CSF WBC count remained elevated throughout the 14 days, even when corrected for red blood cell count (RBC). Peak CSF RBCs occurred 2-4 days post bleed, and then gradually normalized. Maximum CSF RBCs did not correlate with modified Fisher grades (P=0.422). Delayed cerebral ischemia (DCI) was present in 86 (51.5%) patients and there was no difference in the CSF profile of patients with DCI compared with those without. Routine CSF sampling for cell count and chemistry in the setting of temporary diversion following aSAH appears to have little clinical benefit beyond the evaluation for infection.

Neuro-ophthalmic Assessment in Unruptured Intracranial Aneurysms

ith increased use of noninvasive imaging of the brain, there has been an increased detection of W incidental, unruptured intracranial aneurysms (UIAs) (1). Unlike in the setting of aneurysmal subarachnoid hemorrhage (SAH), when a patient can present with significant neurologic impairment, a patient seen in the outpatient clinic with a UIA may have no symptoms at all. Management strategies for UIAs must balance the prevention of lifethreatening SAH with the potential morbidity and mortality of the aneurysm treatment itself, whether by surgical or endovascular means. In contrast, a patient presenting with cranial nerve palsy from a UIA, such as an oculomotor nerve palsy resulting from local compressive effect of an ipsilateral posterior communicating artery aneurysm, is a classic neurosurgical emergency where we recommend expedited repair of the aneurysm, even in the face of seemingly contradictory evidence from prospective studies suggesting that symptoms are not necessarily associated with UIA rupture (10). Several studies have sought to develop scoring systems for rupture risk or rupture plus treatment risk (2, 3).

Clinical outcomes after neurogenic stress induced cardiomyopathy in aneurysmal sub-arachnoid hemorrhage: A prospective cohort study

IntroductionNeurogenic stress cardiomyopathy (NCM) has been associated with poor outcomes in the setting of aneurysmal subarachnoid hemorrhage (aSAH). Much less is known regarding recovery of cardiac function. The aim of this prospective cohort study was to study the rate of early cardiac recovery after NCM and the potential effect of NCM on short term functional recovery. A secondary aim sought to determine whether certain biomarkers may be associated with the development of NCM. MethodsPatients with confirmed aSAH between November 2012 and October 2013 were prospectively enrolled and received echocardiograms within 48h of admission. Ejection fraction (%) and regional wall motion abnormality score index (RWMI) were noted. All patients with confirmed aSAH had a troponin and BNP level drawn on admission. Patients with confirmed NCM received a follow up echocardiogram 7–21 days after the initial echocardiogram. Clinical follow up at 3 months evaluated mortality, mRS and mBI scores. Results63 patients with confirmed aSAH were enrolled. In this cohort 11 (17%) patients were confirmed to have NCM. The NCM group had higher in-hospital mortality [n=4(36.4%)] compared to the non-NCM group [n=5(9.6%)] (p=.021). At 3 months the development of NCM was associated with an unfavorable mRS (p=0.042) and mBI (p=0.005). Both an elevated BNP (>100pg/mL) and elevated troponin (>0.3mg/dL) were associated with the development of NCM. Follow-up echocardiograms were performed within 21 days of admission on 8 patients with NCM. An abnormal RWMI of 1.5 or higher was present in 5(71%) patients. ConclusionNCM is a frequent complication associated with aSAH. The onset of the disease occurs early in the course of aSAH and an elevated BNP and troponin may be associated with the onset of NCM. Cardiac function often remains impaired during the acute recovery phase potentially impeding resuscitation during this period. The routine use of short term follow-up echocardiography may be recommended.

Leptin as a marker for severity and prognosis of aneurysmal subarachnoid hemorrhage

Leptin has been identified as a plasma marker for outcomes in traumatic brain injury and intracerebral hemorrhage. We further investigated whether leptin might serve as a marker for severity and prognosis in aneurysmal subarachnoid hemorrhage. One hundred and eight consecutive patients and 108 sex and age – matched healthy subjects were recruited. Plasma leptin levels were measured by enzyme-linked immunosorbent assay. Clinical severity was assessed using World Federation of Neurological Surgeons score and Fisher score. Mortality and poor long-term outcome (Glasgow outcome scale scores of 1–3) at 6 months were recorded. Plasma leptin levels on admission were substantially higher in patients than in healthy controls, and were significantly associated with the clinical severity. There was also a significant association between leptin levels and clinical outcomes at 6 months in multivariate logistic regression analysis. Using receiver operating characteristic curves, we calculated areas under the curve for clinical outcomes at 6 months. The predictive performance of leptin was similar to, but did not obviously improve those of World Federation of Neurological Surgeons score and Fisher score. Thus, leptin may indicate clinical severity of the initial bleeding and also have prognostic value for clinical outcomes in aneurysmal subarachnoid hemorrhage and may therefore help in guiding treatment decisions in the setting of aneurysmal subarachnoid hemorrhage.

Invasive and Noninvasive Multimodal Bedside Monitoring in Subarachnoid Hemorrhage: A Review of Techniques and Available Data

Delayed-cerebral ischemia is a major cause of morbidity and mortality in the setting of aneurysmal subarachnoid hemorrhage. Despite extensive research efforts and a breadth of collective clinical experience, accurate diagnosis of vasospasm remains difficult, and effective treatment options are limited. Classically, diagnosis has focused on imaging assessment of the cerebral vasculature. Recently, invasive and noninvasive bedside techniques designed to characterize relevant hemodynamic and metabolic alterations have gained substantial attention. Such modalities include microdialysis, brain tissue oxygenation, jugular bulb oximetry, thermal diffusion cerebral blood flow, and near-infrared spectroscopy. This paper reviews these modalities and examines data pertinent to the diagnosis and management of cerebral vasospasm.

Copeptin in aneurysmal subarachnoid hemorrhage

Copeptin is a peptide derived from pre-provasospression along with arginine vasospressin. In the setting of aneurysmal subarachnoid hemorrhage (SAH), elevated serum copeptin levels correlate with vasospasm, inpatient mortality, mortality at 1 year, and poor functional outcome at 1 year. The potential role of serum copeptin levels in the management of patients with aneurysmal SAH is promising and should be explored further.