Severe Aneurysmal Subarachnoid Hemorrhage Research Articles

The effect of green channel for stroke patients on treatment of severe aneurysmal subarachnoid hemorrhage

PurposeTo explore the effect of green channel for stroke patients on the treatment of severe aneurysmal subarachnoid hemorrhage. MethodsThis is a retrospective case-control study. The clinical data of patients with severe aneurysmal subarachnoid hemorrhage admitted to the emergency department of our hospital from January 2015 to June 2022 were retrospectively analyzed. Patients diagnosed with subarachnoid hemorrhage, confirmed intracranial aneurysm by preoperative CT angiography or digital subtraction, graded Hunt-Hess grade III, IV, and V, < 72 h from the onset to the time of consultation received surgical treatment in our hospital were included in this study. Patients with serious underlying diseases, such as heart, liver, kidney diseases, or malignant tumors, traumatic subarachnoid hemorrhage, previous history of cerebral hemorrhage, and incomplete data were excluded. The control group included patients with severe aneurysmal subarachnoid hemorrhage admitted from January 2015 to December 2018 before the establishment of the green channel for stroke patients, and the observation group included patients with severe aneurysmal subarachnoid hemorrhage admitted from January 2019 to June 2022 after the establishment of the green channel. The control group received routine treatment in the emergency department; the observation group received improved treatment of green channel for stroke patients. Gender, age, Hunt-Hess grade on admission, modified Rankin scale (mRS) on admission, aneurysm location, aneurysm size and whether accompanied by intracerebral hemorrhage, the time from onset to emergency department, the time from emergency department to vascular diagnostic examination, the time from onset to surgery, the time from emergency department to surgery, the time from hospital admission to surgery, length of hospital stay, complications, treatment effect were analyzed and compared between the 2 groups. SPSS 23.0 software was utilized to conduct comparisons between the 2 groups. The t-test, Chi-square test, or Mann-Whitney U test was chosen based on the data type. Statistical significance was established when p < 0.05. ResultsA total of 71 patients were included in this study, of whom 37 were in the control group and 34 were in the observation group. There were no statistical differences in age, gender, Hunt-Hess grade, mRS scores, aneurysm location, aneurysm size, intracerebral hemorrhage, the time from onset to emergency department, length of hospital stay, complications between the observation group and the control group (all p > 0.05). The time (min) from visit to vascular diagnostic test (60.50 vs. 120.00, p = 0.027), the time (min) from onset to surgery (1792.00 vs. 2868.00, p = 0.023), the time (min) from emergency department to surgery (1568.50 vs. 2778.00, p = 0.016), the time (min) from hospital admission to surgery (1188.50 vs. 2708.00, p = 0.043), all of them were shorter in the observation group than those in the control group. The relative values of admission and 7-day postoperative mRS scores and the relative values of admission and discharge mRS scores ≥ 2 were used as the criteria for determining better efficacy, and the treatment effect was better than that in the control group, and the differences were statistically significant (admission to 7 days postoperative mRS score ≥ 2, 17 (50.0 %) vs. 8 (21.6 %), p = 0.012; admission to discharge mRS score ≥ 2, 19 (55.9 %) vs. 11 (29.7 %), p = 0.026). ConclusionThe green channel for stroke patients with severe aneurysmal subarachnoid hemorrhage can effectively shorten the time from arrival at the emergency department to vascular diagnostic examination and the time from the emergency department to surgery, and achieve a better therapeutic effect, which is worth popularizing and applying.

Effect of Intrathecal Urokinase Infusion on Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) causes serious neurological complications, despite surgical clipping of the aneurysm. Intrathecal urokinase (UK) infusion has been shown to effectively prevent symptomatic vasospasm in patients who have undergone endovascular obliteration of the ruptured aneurysms. To investigate whether intrathecal UK infusion can prevent symptomatic vasospasm in patients undergoing surgical or endovascular treatment. A total of 90 patients with severe aneurysmal SAH were enrolled and assigned to a surgical neck clipping (n= 56) or an endovascular coil embolization (n= 34) groups. After treatment, UK infusion from the lumbar drain was repeated in 32 patients in the surgical neck clipping group (group B) and all in the endovascular coil embolization group (group C) until complete resolution of the SAH was observed on computed tomography. The remaining 24 of the surgical neck clipping group, without UK infusion, were assigned to group A. Symptomatic vasospasm occurred in 7 (29.2%) patients in group A, 2 (6.3%) in group B, and none in group C (group A vs. group B [P=0.02]; group B vs. group C [P=0.14]). Excellent clinical outcomes (modified Rankin score, 0 or 1) were observed in 37.5%, 59.4%, and 76.5% of patients in group A, B, and C, respectively (group A vs. group B [P=0.11]). Clearance of SAH via intrathecal UK infusion significantly reduced symptomatic vasospasm in patients in both UK groups, resulting in better clinical outcomes.

Balanced volatile sedation with isoflurane in critically ill patients with aneurysmal subarachnoid hemorrhage - a retrospective observational study.

In patients with severe aneurysmal subarachnoid hemorrhage (SAH) deep sedation is often used early in the course of the disease in order to control brain edema formation and thus intracranial hypertension. However, some patients do not reach an adequate sedation depth despite high doses of common intravenous sedatives. Balanced sedation protocols incorporating low-dose volatile isoflurane administration might improve insufficient sedation depth in these patients. We retrospectively analyzed ICU patients with severe aneurysmal SAH who received isoflurane in addition to intravenous anesthetics in order to improve insufficient sedation depth. Routinely recorded data from neuromonitoring, laboratory and hemodynamic parameters were compared before and up to 6 days after initiation of isoflurane. Sedation depth measured using the bispectral index improved in thirty-six SAH patients (-15.16; p = 0.005) who received additional isoflurane for a mean period of 9.73 ± 7.56 days. Initiation of isoflurane sedation caused a decline in mean arterial pressure (-4.67 mmHg; p = 0.014) and cerebral perfusion pressure (-4.21 mmHg; p = 0.013) which had to be balanced by increased doses of vasopressors. Patients required increased minute ventilation in order to adjust for the increase in PaCO2 (+2.90 mmHg; p < 0.001). We did not detect significant increases in mean intracranial pressure. However, isoflurane therapy had to be terminated prematurely in 25% of the patients after a median of 30 h due to episodes of intracranial hypertension or refractory hypercapnia. A balanced sedation protocol including isoflurane is feasible for SAH patients experiencing inadequately shallow sedation. However, therapy should be restricted to patients without impaired lung function, hemodynamic instability and impending intracranial hypertension.

Retracted: High-Quality Nursing Combined with the Whole-Course Responsibility Nursing Intervention Reduces the Incidence of Complications in Severe Aneurysmal Subarachnoid Hemorrhage.

[This retracts the article DOI: 10.1155/2022/3252718.].

More is less: Effect of ICF-based early progressive mobilization on severe aneurysmal subarachnoid hemorrhage in the NICU.

Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that occurs due to a ruptured intracranial aneurysm. Although advanced therapies have been applied to treat aSAH, patients still suffer from functional impairment leading to prolonged stays in the NICU. The effect of early progressive mobilization as an intervention implemented in the ICU setting for critically ill patients remains unclear. This retrospective study evaluated ICF-based early progressive mobilization's validity, safety, and feasibility in severe aSAH patients. Sixty-eight patients with aSAH with Hunt-Hess grades III-IV were included. They were divided into two groups-progressive mobilization and passive movement. Patients in the progressive mobilization group received progressive ICF-based mobilization intervention, and those in the passive movement group received passive joint movement training. The incidence of pneumonia, duration of mechanical ventilation, length of NICU stay, and incidence of deep vein thrombosis were evaluated for validity. In contrast, the incidence of cerebral vasospasm, abnormally high ICP, and other safety events were assessed for safety. We also described the feasibility of the early mobilization initiation time and the rate of participation at each level for patients in the progressive mobilization group. The results showed that the incidence of pneumonia, duration of mechanical ventilation, and length of NICU stay were significantly lower among patients in the progressive mobilization group than in the passive movement group (P = 0.031, P = 0.004, P = 0.012), but the incidence of deep vein thrombosis did not significantly differ between the two groups. Regarding safety, patients in the progressive mobilization group had a lower incidence of cerebral vasospasm than those in the passive movement group. Considering the effect of an external ventricular drain on cerebral vasospasm (P = 0.015), we further analyzed those patients in the progressive mobilization group who had a lower incidence of cerebral vasospasm in patients who did not have an external ventricular drain (P = 0.011). Although we found 2 events of abnormally increased intracranial pressure in the progressive mobilization group, there was no abnormal decrease in cerebral perfusion pressure in the 2 events. In addition, among other safety events, there was no difference in the occurrence of adverse events between the two groups (P = 0.073), but the number of potential adverse events was higher in the progressive mobilization group (P = 0.001). Regarding feasibility, patients in the progressive mobilization group were commonly initiated 72 h after admission to the NICU, and 47.06% were in the third level of the mobilization protocol. We conclude that the ICF-based early progressive mobilization protocol is an effective and feasible intervention tool. For validity, more mobilization interventions might lead to less pneumonia, duration of mechanical ventilation and length of stay for patients with severe aSAH in the NICU, Moreover, it is necessary to pay attention over potential adverse events (especially line problems), although we did not find serious safety events.

High-Quality Nursing Combined with the Whole-Course Responsibility Nursing Intervention Reduces the Incidence of Complications in Severe Aneurysmal Subarachnoid Hemorrhage.

Objective The aim of this study is to study the influence of whole-course responsibility nursing combined with high-quality nursing intervention on the level of life and complications of severe aneurysmal subarachnoid hemorrhage patients with postoperative coma. Methods From December 2018 to December 2020, 90 severe aneurysmal subarachnoid hemorrhage patients with postoperative coma were selected and were divided into two groups, the experimental group and the control group, with 45 cases in each group. The control group adopted conventional nursing care, and the experimental group received whole-course responsibility nursing combined with high-quality nursing intervention. The nursing effect, degree of coma, coma recovery, and incidence of complications between all groups were compared. Results Compared with the control group, the experimental group yielded more favorable achievement in terms of the nursing effect (P < 0.05). Superior levels of the Glasgow Coma Scale (GCS) score, Coma Recovery Scale-Revised (CRS-R) score, GQOLI-74 score, and BI score of the experimental group were obtained and compared with the control group (all P < 0.05). The experimental group witnessed a lower complication rate, as compared to the other group (P < 0.05). Conclusion The whole-course responsibility nursing combined with high-quality nursing intervention is applied to severe aneurysmal subarachnoid hemorrhage patients with postoperative coma, which can substantially optimize the nursing efficiency, improve the degree of coma, help recover consciousness, ameliorate the mental state and the quality of life, and reduce the incidence of complications, which is worthy of clinical application.

Clinical Value and Prognosis of C Reactive Protein to Lymphocyte Ratio in Severe Aneurysmal Subarachnoid Hemorrhage.

ObjectiveTo investigate the relationship between CLR and disease severity and clinical prognosis of aSAH.MethodsThe authors retrospectively analyzed the clinical data of 221 patients with aSAH, who were admitted to the intensive care unit from January 2017 to December 2020. The indicators of inflammatory factors in the first blood routine examination within 48 h of bleeding were obtained. The prognosis was evaluated by mRS score at discharge, mRS>2 was a poor outcome. Through the receiver operating characteristic (ROC) curve, the area under the curve was calculated and the predicted values of inflammatory factors (CLR, CRP, WBC, and neutrophils) were compared. Univariate and multivariable logistic regression analyses were used to evaluate the relationship between CLR and the clinical prognosis of patients. ROC curve analysis was performed to determine the optimal cut-off threshold, sensitivity, and specificity of CLR in predicting prognosis at admission.ResultsAccording to the mRS score at discharge, 139 (62.90%) patients were classified with poor outcomes (mRS>2). The inflammatory factor with the best predictive value was CLR, which had an optimal cut-off threshold of 10.81 and an area under the ROC curve of 0.840 (95%CI.788–0.892, P < 0.001). Multivariable Logistic regression analysis showed that the Modified Fisher grade, Hunt-Hess grade, and CLR at admission were independent risk factors for poor outcomes of patients with aSAH (P < 0.05). According to Hunt-Hess grade, patients were divided into a mild group (Hunt-Hess ≤ 3) and a severe group (Hunt-Hess > 3), and the CLR value was significantly higher in severe patients with aSAH than in mild patients. The optimal cut-off threshold of CLR in the severe group was 6.87, and the area under the ROC curve was 0.838 (95% CI.752–0.925, P < 0.001).ConclusionsThe CLR value at the admission of patients with aSAH was significantly associated with Hunt-Hess grade, The higher Hunt-Hess grade, the higher the CL R-value, and the worse the prognosis. Early CLR value can be considered as a feasible biomarker to predict the clinical prognosis of patients with aSAH.

The effect of step-wised protocol on critical care management of severe aneurysmal subarachnoid hemorrhage

Abstract To explore the critical care treatment and clinical outcome of patients with severe aneurysmal subarachnoid hemorrhage (SaSAH), and to provide clinical evidence for the treatment of patients with SaSAH. 160 patients with SaSAH of Hunt and Hess (H&H) grade III or above in the neurosurgical critical care unit at ourospital between June 2016 and June 2018 were enrolled in this study. Patients were treated with brain protective bundle based on step-wised protocol under multimodal monitoring and followed up for 3 months. The incidence of various clinical complications and the clinical prognosis after discharge were statistically analyzed. Furthermore, it carried on the correlation analysis to the risk factors and the prognosis. In 160 patients with SaSAH, 127 patients had responsible aneurysms located in the anterior circulation, and the other 33 patients were located in the posterior circulation. 70 patients (43.8%) underwent transcranial clipping, 81 patients (50.6%) underwent endovascular embolization and 9 patients (5.6%) did not intervene. Patients with IV and V grades of Glasgow Outcome Scale (GOS) were considered good recovery, and those with grade I, II and III were poor prognosis. The 30-day good prognosis rate was 41.3% (66/160) and the poor prognosis rate was 58.7% (94/160). Multivariate logistic regression analysis showed that the Hunt & Hess classification correlated well with prognosis (OR: 4.367,95% CI, 2.254-8.460, P < 0.001). The clinical prognosis of patients with SaSAH is still poor. In particular, under the critical care of neurosurgery, the application of brain protective bundle based on step-wised protocol under multimodal monitoring might improve the clinical prognosis of patients with SaSAH.

Detrimental effects of intrahospital transport on cerebral metabolism in patients suffering severe aneurysmal subarachnoid hemorrhage.

Intrahospital transport for CT scans is routinely performed for neurosurgical patients. Particularly in the sedated and mechanically ventilated patient, intracranial hypertension and blood pressure fluctuations that might impair cerebral perfusion are frequently observed during these interventions. This study quantifies the impact of intrahospital patient transport on multimodality monitoring measurements, with a particular focus on cerebral metabolism. Forty intrahospital transports in 20 consecutive patients suffering severe aneurysmal subarachnoid hemorrhage (SAH) under continuous intracranial pressure (ICP), brain tissue oxygen tension (pbtO2), and cerebral microdialysis monitoring were prospectively included. Changes in multimodality neuromonitoring data during intrahospital transport to the CT scanner and the subsequent 10 hours were evaluated using linear mixed models. Furthermore, the impact of risk factors at transportation, such as cerebral vasospasm, cerebral hypoxia (pbtO2 < 15 mm Hg), metabolic crisis (lactate-pyruvate ratio [LPR] > 40), and transport duration on cerebral metabolism, was analyzed. During the transport, the mean ICP significantly increased from 7.1 ± 3.9 mm Hg to 13.5 ± 6.0 mm Hg (p < 0.001). The ICP exceeded 20 mm Hg in 92.5% of patients; pbtO2 showed a parallel rise from 23.1 ± 13.3 mm Hg to 28.5 ± 23.6 mm Hg (p = 0.02) due to an increase in the fraction of inspired oxygen during the transport. Both ICP and pbtO2 returned to baseline values thereafter. Cerebral glycerol significantly increased from 71.0 ± 54.9 µmol/L to 75.3 ± 56.0 µmol/L during the transport (p = 0.01) and remained elevated for the following 9 hours. In contrast, cerebral pyruvate and lactate levels were stable during the transport but showed a significant secondary increase 1-8 hours and 2-9 hours, respectively, thereafter (p < 0.05). However, the LPR remained stable over the entire observation period. Patients with extended transport duration (more than 25 minutes) were found to have significantly higher levels of cerebral pyruvate and lactate as well as lower glutamate concentrations in the posttransport period. Intrahospital transport and horizontal positioning during CT scans induce immediate intracranial hypertension and an increase in cerebral glycerol, suggesting neuronal injury. Afterward, sustained impairment of neuronal metabolism for several hours could be observed, which might increase the risk of secondary ischemic events. Therefore, intrahospital transport for neuroradiological imaging should be strongly reconsidered and only indicated if the expected benefit of imaging results outweighs the risks of transportation.

Interleukin 6 in cerebrospinal fluid is a biomarker for delayed cerebral ischemia (DCI) related infarctions after aneurysmal subarachnoid hemorrhage

Interleukin 6 (IL-6) is a prominent proinflammatory cytokine and has been discussed as a potential biomarker for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage. In the present study we have analyzed the time course of serum and cerebrospinal fluid (CSF) IL-6 levels in 82 patients with severe aneurysmal subarachnoid hemorrhage (SAH) requiring external ventricular drains in correlation to angiographic vasospasm, delayed cerebral ischemia, secondary infarctions and other clinical parameters. We observed much higher daily mean IL-6 levels (but also large interindividual variations) in the CSF than the serum of the patients with a peak between days 4 and 14 including a maximum on day 5 after SAH. Individual CSF peak levels correlated significantly with DCI (mean day 4–14 peak, DCI: 26,291 ± 24,159 pg/ml vs. no DCI: 16,184 ± 13,163 pg/ml; P = 0.023). Importantly, CSF IL-6 levels differed significantly between cases with DCI and infarctions and patients with DCI and no infarction (mean day 4–14 peak, DCI with infarction: 37,209 ± 26,951 pg/ml vs. DCI, no infarction: 15,123 ± 11,239 pg/ml; P = 0.003), while findings in the latter patient group were similar to cases with no vasospasm (mean day 4–14 peak, DCI, no infarction: 15,123 ± 11,239 vs. no DCI: 15,840 ± 12,979; P = 0.873). Together, these data support a potential role for elevated CSF IL-6 levels as a biomarker for DCI with infarction rather than for DCI in general. This fits well with a growing body of evidence linking neuroinflammation to ischemia and infarction, but (together with the large interindividual variations observed) limits the diagnostic usefulness of CSF IL-6 levels in SAH patients.

Risk Factors for Prognosis in Elderly Patients with Severe Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study.

To investigate the risk factors affecting the prognosis of elderly patients with severe aneurysmal subarachnoid hemorrhage (aSAH). Forty-nine elderly patients with severe aSAH (Hunt and Hess [H-H] grade III-V) were enrolled in this retrospective study. Follow-up was conducted with patients 30days after discharge using the Glasgow Outcome Scale (GOS), on which scores of 1-3 indicated a poor outcome (n = 32) and scores of 4-5 indicated a good outcome (n = 17). The patients' general information (gender, age, presence of hypertension, diabetes, or coronary atherosclerotic heart disease, location of ruptured aneurysm, and H-H grade) and complications (cerebral vasospasm, new cerebral infarction, pulmonary infection, liver dysfunction, hypoalbuminemia, anemia, and electrolyte disturbance) were recorded, and comparison between the different outcome groups was undertaken. Univariate analysis was used to analyze the factors associated with different outcomes, and multivariate logistic regression analysis was used to determine the factors that lead to poor outcomes. The incidence of all complications increased in patients with higher H-H grades, but without statistical significance (P > 0.05). There was no statistically significant difference between the two outcome (poor and good) groups in general information and complications (all P > 0.05), with the exception of different H-H grades (P < 0.05). H-H grade was a statistically significant risk factor for poor outcomes in elderly patients with severe aSAH (OR 11.627, 95% CI 2.475-55.556, P = 0.002). H-H grade is an independent factor related to the prognosis of elderly patients with severe aSAH.

The Impact of Intra-Arterial Papaverine-Hydrochloride on Cerebral Metabolism and Oxygenation for Treatment of Delayed-Onset Post-Subarachnoid Hemorrhage Vasospasm

Delayed posthemorrhagic vasospasm remains among the major complications after aneurysmal subarachnoid hemorrhage (SAH) and can result in devastating ischemic strokes. As rescue therapy, neurointerventional procedures are used for selective vasodilatation. To investigate the effects of intra-arterial papaverine-hydrochloride on cerebral metabolism and oxygenation. A total of 10 consecutive patients, suffering from severe aneurysmal SAH were prospectively included. Patients were under continuous multimodality neuromonitoring and required intra-arterial papaverine-hydrochloride for vasospasm unresponsive to hypertensive therapy. Cerebral metabolism (microdialysis), brain tissue oxygen tension (ptiO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were analyzed for a period of 12 h following intervention. A median dose of 125 mg papaverine-hydrochloride was administered ipsilateral to the multimodality probe. Angiographic improvement of cerebral vasospasm was observed in 80% of patients. During intervention, a significant elevation of ICP (13.7±5.2 mmHg) and the lactate-pyruvate ratio (LPR) (54.2±15.5) was observed, whereas a decrease in cerebral glucose (0.9±0.5 mmol/L) occurred. Within an hour, an increase of cerebral lactate (5.0±2.0 mmol/L) and glycerol (104.4±89.8 μmol/L) as well as a decrease of glucose (0.9±0.4 mmol/L) were measured. In 2 to 5 h after treatment, the LPR significantly decreased (pretreatment: 39.3±15.3, to lowest 30.5±6.7). Cerebral pyruvate levels increased in 1 to 10 h (pretreatment: 100.1± 33.1 μmol/L, to highest 141.4±33.7 μmol/L) after intervention. No significant changes in ptiO2 or CPP occurred. The initial detrimental effects of the endovascular procedure itself were outweighed by an improved cerebral metabolism within 10 h thereafter. As the effect was very limited, repeated interventions or continuous application should be considered.

P3708Prognostic significance of electrocardiographic changes after subarachnoid hemorrhage

Abstract Background and purpose Many reports have examined electrocardiographic (ECG) changes after subarachnoid hemorrhage from long ago; however, there are few reports on the prognosis of patients who have an ECG abnormality. Therefore, in this study, the prognoses of patients with subarachnoid hemorrhage showing abnormal ECG findings were retrospectively analyzed. Methods Over 30 months from January 2014 to June 2016, 199 patients (mean age, 61.1±17.0 years; 46.7% male) admitted with a subarachnoid hemorrhage (SAH) were enrolled. To assess the mechanism underlying abnormal ECG in the SAH, predictor variables, such as demographics (age, sex, and body surface area), hemodynamics (heart rate and systolic blood pressure), blood biochemical results, neurological assessments (Glasgow Coma Scale), and computed tomography (CT) severity classification (World Federation of Neurosurgical Societies classification) were recorded. The subarachnoid hemorrhage was classified into either the cerebral aneurysm rupture group (N=132) or traumatic subarachnoid hemorrhage group (N=67) and analyzed. Results In the cerebral aneurysm rupture group, the QT prolongation was significantly increased compared with the traumatic subarachnoid hemorrhage group (424.8±87.7 ms vs. 400.5±95.8 ms, P&lt;0.05). There was a correlation between consciousness level (Glasgow Coma Scale) on admission and QT prolongation, and significant QT prolongation was observed in critical patients (Pearson's correlation coefficient test P=0.04). ST changes correlated with CT classification severity (WFNS classification), and the most severe group (WFNS Grade 5) showed significant ST changes. On admission, the cerebral aneurysm rupture group and 97.0% in the traumatic subarachnoid hemorrhage group. Conclusions Significantly prolonged QT and ST changes are noted in patients with severe aneurysmal subarachnoid hemorrhage. The cause of the ECG abnormality in subarachnoid hemorrhage patients is not yet understood. A small number of experimental animal models have shown that electrocardiogram abnormalities associated with subarachnoid hemorrhage develop in the brain stem, and an autonomic nerve abnormality may also be involved. A D-dimer is positively correlated with both aneurysm trauma and traumatic subarachnoid hemorrhage and may be used for auxiliary diagnosis of a subarachnoid hemorrhage.

Inhalational Isoflurane Sedation in Patients with Decompressive Craniectomy Suffering from Severe Subarachnoid Hemorrhage: A Case Series

Abstract Background Severe aneurysmal subarachnoid hemorrhage (SAH) may lead to the necessity of decompressive craniectomy (DC) to treat refractory elevated intracranial pressure (ICP). In some patients, adequate deep sedation, as one part of conservative treatment, cannot be achieved. Recent investigations suggest that inhalative sedation might not be as detrimental as considered before, and therefore a treatment option. Materials and Methods A retrospective analysis of seven patients was performed who suffered from aneurysmal SAH (Hunt-Hess grade 3–5, Fisher's score 3) and underwent DC due to a critically elevated ICP. In these patients, the target sedation level could not be achieved even with high doses of intravenous sedatives. Thus, the sedative regimen was switched to inhaled anesthesia with isoflurane. Mean arterial pressure (MAP), ICP, cerebral perfusion pressure (CPP), levels of vasopressors, and respiratory parameters were analyzed. Results Deep sedation (Richmond Agitation-Sedation Scale [RASS] −5, mean–fractional end-expiratory gas concentration [mean-Fet] 0.78%) was rapidly achieved in all patients after commencing general anesthesia with isoflurane. ICP remained stable when comparing 1 hour before the onset of isoflurane sedation (1) with 6 (2), and 12 hours (3) after commencing isoflurane anesthesia (mean ICP [1] 13.83 mm Hg; [2] 12.57 mm Hg; [3] 11.14 mm Hg). The mean duration of application was 9 (± 4) days. CPP could be maintained above 70 mm Hg without the need for extended vasopressor usage. Conclusion In a setting of severe SAH and critically elevated ICP with the need for aggressive multimodal therapy, isoflurane was safely applied in those patients. Our sedation goal was rapidly achieved and critical rise in ICP was not observed. Further investigations are required to demonstrate that inhaled anesthesia with isoflurane can be a promising alternative option, as this drug has better controllable pharmacokinetics, no clinically relevant accumulation of the drug itself, and potential neuroprotective effects (so far reported in different animal models).

Nitric Oxide-Based Treatment of Poor-Grade Patients After Severe Aneurysmal Subarachnoid Hemorrhage

BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) require close treatment in neuro intensive care units (NICUs). The treatments available to counteract secondary deterioration and delayed ischemic events remain restricted; moreover, available neuro-monitoring of comatose patients is undependable. In comatose patients, clinical signs are hidden, and timing interventions to prevent the evolution of a perfusion disorder in response to fixed ischemic brain damage remain a challenge for NICU teams. Consequently, comatose patients often suffer secondary brain infarctions. The outcomes for long-term intubated patients w/wo pupil dilatation are the worst, with only 10% surviving. We previously added two nitroxide (NO) donors to the standard treatment: continuous intravenous administration of Molsidomine in patients with mild-to-moderate aSAH and, if required as a supplement, intraventricular boluses of sodium nitroprusside (SNP) in high-risk patients to overcome the so-called NO-sink effect, which leads to vasospasm and perfusion disorders. NO boluses were guided by clinical status and promptly reversed recurrent episodes of delayed ischemic neurological deficit. In this study, we tried to translate this concept, the initiation of intraventricular NO application on top of continuous Molsidomine infusion, from awake to comatose patients who lack neurological–clinical monitoring but are primarily monitored using frequently applied transcranial Doppler (TCD).MethodsIn this observational, retrospective, nonrandomized feasibility study, 18 consecutive aSAH comatose/intubated patients (Hunt and Hess IV/V with/without pupil dilatation) whose poor clinical status precluded clinical monitoring received standard neuro-intensive care, frequent TCD monitoring, continuous intravenous Molsidomine plus intraventricular SNP boluses after TCD-confirmed macrospasm during the daytime and on a fixed nighttime schedule.ResultsVery likely associated with the application of SNP, which is a matter of further investigation, vasospasm-related TCD findings promptly and reliably reversed or substantially weakened (p < 0.0001) afterward. Delayed cerebral ischemia (DCI) occurred only during loose, low-dose or interrupted treatment (17% vs. an estimated 65% with secondary infarctions) in 17 responders. However, despite their worse initial condition, 29.4% of the responders survived (expected 10%) and four achieved Glasgow Outcome Scale Extended (GOSE) 8–6, modified Rankin Scale (mRS) 0–1 or National Institutes of Health Stroke Scale (NIHSS) 0–2.ConclusionsEven in comatose/intubated patients, TCD-guided dual-compartment administration of NO donors probably could reverse macrospasm and seems to be feasible. The number of DCI was much lower than expected in this specific subgroup, indicating that this treatment possibly provides a positive impact on outcomes. A randomized trial should verify or falsify our results.

Prognostic value of high-sensitivity troponin T in aneurysmal subarachnoid hemorrhage: a prospective observational study

ABSTRACTObjective: To evaluate the prognostic value of high-sensitivity troponin (hsT) in severe aneurysmal subarachnoid hemorrhage (aSAH).Methods: This prospective non-interventional study was performed at a surgical intensive care unit (ICU) from 2012 to 2015. Consecutive patients who had severe aSAH were included. A modified Rankin Scale score ≥ 4 or death within 3 months defined a poor outcome. hsT levels were measured at ICU admission and 72 hours following symptom onset.Results: A total of 137 patients were analyzed. The median hsT level was 29 ng/L (range: 7–4485). The best threshold level of hsT for predicting a poor outcome was 22 ng/L. At this threshold, the sensitivity was 71% (95% confidence interval [CI]: 58%-81%) and the specificity was 58% (95%CI: 46%-70%). The area under the ROC curve was 0.61 (95%CI: 0.52–0.71). Based on a multivariate analysis, the independent factors for a poor neurological prognosis were a World Federation of Neurologic Surgeons (WFNS) score ≥ 4 (odds ratio [OR]: 2.61; 95%CI: 1.04–6.56) and an hsT level > 22 ng/L (OR: 2.80; 95%CI: 1.18–6.64).Conclusion: In patients with severe aSAH, with regard for the severity of disease (assessed by the WFNS score), an hsT level > 22 ng/L at ICU admission was associated with poor outcomes.

Osteopontin in the Cerebrospinal Fluid of Patients with Severe Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. In SAH patients, plasma osteopontin (OPN) has been shown to independently predict poor outcome. The aim of the study is to investigate, in a selected population with severe SAH, OPN time course in cerebrospinal fluid (CSF) and plasma during the first week after aneurism rupture, and OPN prognostic value. We included 44 patients with the following criteria: (1) age 18 and 80 years, (2) diagnosis of SAH from cerebral aneurysm rupture, (3) insertion of external ventricular drain. Plasma and CSF were sampled at day 1, 4, and 8. OPN levels, in CSF and plasma, displayed a weak correlation on day 1 and were higher, in CSF, in all time points. Only in poor prognosis patients, OPN levels in CSF significantly increased at day 4 and day 8. Plasma OPN at day 1 and 4 was predictor of poor outcome. In conclusion, plasma and CSF OPN displays a weak correlation, on day 1. The higher levels of OPN found in the CSF compared to plasma, suggest OPN production within the CNS after SAH. Furthermore, plasma OPN, at day 1 and 4, seems to be an independent predictor of poor outcome.

Effect of premorbid hypertension control on outcome of patients with aneurysmal subarachnoid hemorrhage.

Hypertension is common in patients with aneurysmal subarachnoid hemorrhage (SAH). However, it is still unclear whether premorbid antihypertensive therapy can help to reduce the risk of severe aneurysmal bleeding. Therefore, this study aims to assess the effect of premorbid hypertension control on outcome of patients with aneurysmal SAH. We retrospectively reviewed the clinical data of patients with intracranial aneurysms admitted to our institution from February 2012 to December 2017. Based on premorbid hypertension history and use of antihypertensive agents, all patients with aneurysmal SAH were divided into antihypertensive group and uncontrolled group. Patient characteristics, imaging features, clinical complication, and outcome were analyzed between the two groups. A total of 348 patients with ruptured aneurysms were included in this study. Compared to those with premorbid controlled hypertension, patients with premorbid uncontrolled hypertension presented worse clinical grade, with more severe aneurysmal SAH and more frequent intracerebral hematoma. Patients receiving a treatment for ACEI type or ARB type of drugs in the antihypertensive group suffered from less amount of aneurysmal bleeding, while patients with grade 3 hypertension in the uncontrolled group suffered from more amount of aneurysmal bleeding. Patients with premorbid controlled hypertension had a lower incidence of rebleeding, hydrocephalus, and cerebral vasospasm, and had a lower rate of disability and mortality. Premorbid hypertension control is associated with favorable clinical outcome of patients with aneurysmal SAH. Besides, the ACEI type or ARB type of antihypertensive agents is associated with the less amount of bleeding after aneurysm rupture.

Low-Dose versus Therapeutic Range Intravenous Unfractionated Heparin Prophylaxis in the Treatment of Patients with Severe Aneurysmal Subarachnoid Hemorrhage After Aneurysm Occlusion

While prophylaxis with intravenous unfractionated heparin (UFH) can effectively prevent venous thromboembolism (VTE) during the neurocritical care of patients with severe aneurysmal subarachnoid hemorrhage (aSAH), the risk for intracranial bleeding complications might increase. Owing to this therapeutic dilemma, the UFH administration regimen in this critical patient population remains highly controversial. We performed a retrospective analysis of patients with severe aSAH (Fisher grade 3-4) receiving either low-dose (activated partial thromboplastin time [aPTT] <40 seconds) or therapeutic range (aPTT 50-60 seconds) UFH during intensive care unit (ICU) treatment after complete surgical/endovascular aneurysm occlusion. The primary outcome was the rate of bleeding/VTE complications and the investigation of potential risk factors. This study series comprised 410 patients with aneurysmal SAH (aSAH), with a mean age of 54.7 ± 12.6 years, a male:female ratio of 1:2.2, and aSAH-associated intracerebral hemorrhage (ICH) in 33.2%. After complete aneurysm occlusion, 112 patients (27.3%) received therapeutic dose UFH and 298 patients (72.7%) received low-dose UFH. VTE events occurred in 5.4% of the low-dose UFH cohort and in 6.3% of the therapeutic dose UFH cohort, with no significant differences in the rate and severity of VTE events. However, an increase in initial SAH-associated ICH was significantly (P= 0.007) more frequent in the therapeutic dose cohort (18.8% vs. 3.4%). Heparin-induced thrombocytopenia (HIT) was the sole risk factor for VTE (P < 0.001), and both an aPTT ≥50 seconds under UFH administration (P= 0.007) and the initial presence of SAH-associated ICH (P= 0.035) were significant risk factors for intracranial bleeding complications. Even in high-risk neurocritical patients with severe SAH and prolonged ICU treatment, low-dose UFH-administration for VTE prophylaxis is equally effective as therapeutic UFH administration and carries a lower risk of bleeding complications.

Use of somatosensory evoked potentials for preoperative assessment in patients with severe aneurysmal subarachnoid hemorrhage before surgical or interventional treatment: a prospective observational cohort study

To explore the application value of short latency somatosensory evoked potentials (SLSEP) as a tool for preoperative assessment of surgical or interventional treatment in patients with severe aneurysmal subarachnoid hemorrhage (aSAH). A prospective observational cohort study was conducted. The patients with severe aSAH with a WFNS grade of IV or V admitted to intensive care unit (ICU) of Beijing Tiantan Hospital of Capital Medical University from November 2016 to April 2017 were enrolled. The patients received SLSEP monitoring within 12 hours after onset, and the monitoring results were classified according to the Judson scale. Meanwhile, the findings on cerebral CT scans at admission were evaluated by the modified Fisher classification. The follow-up was performed at 3 months after aSAH ictus based on the modified Rankin scale (mRS), and a mRS score 0-3 was defined as favorable outcome, 4-6 was defined as unfavorable outcome. For statistical evaluation, demographic, clinical, neuroimaging and SLSEP data were evaluated by univariate analysis to identify the risk factors associated with prognosis; afterwards, those factors were analyzed by multivariate Logistic regression; also the validity was assessed by calculating the respective sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). A total of 41 patients with aSAH were selected, of which 7 were excluded because of the interference of the SLSEP monitoring results, 34 patients with aSAH were enrolled finally. Among them, 21 were classified in the unfavorable outcome group, while the rest (n = 13) were allocated into the favorable outcome group. No significant difference was found in gender, age, body mass index (BMI), time delay from ictus to treatment or the options for therapeutic methods between the two groups. The findings of univariate analysis, however, showed statistically differences in WFNS grade, the modified Fisher scale and Judson scale of SLSEP between the two groups. Yet, the further validity evaluation for these predictors demonstrated that the sensitivity, specificity, PPV and NPV of WFNS grade of V and modified Fisher scale of IV were all less than 85%, whereas the results for SLSEP Judson scale of III were much better (sensitivity: 90.5% vs. 71.4% and 71.4%, specificity: 84.6% vs. 69.2% and 76.9%, PPV: 90.5% vs. 79.0% and 83.3%). In the following multivariate Logistic analysis, only Judson scale of III was identified to be the independent risk factor for poor outcome [odds ratio (OR) = 45.73, 95% confidence interval (95%CI) = 4.25-499.31, P = 0.002], while the WFNS grade of V (OR = 1.14, 95%CI = 0.12-13.06, P = 0.912) and the modified Fisher scale of IV (OR = 7.22, 95%CI = 0.51-113.20, P = 0.160) were merely associated with poor outcomes without significant independence. In comparison with WFNS grade and the modified Fisher scale, SLSEP seems more accurate in the prediction of long-term outcome of severe aSAH prior to surgical or interventional treatment, and thus may be applied as an effective aid in preoperative assessment.