Subarachnoid Hemorrhage Research Articles

Significant individual variation in cardiac-cycle-linked cerebrospinal fluid production following subarachnoid hemorrhage

BackgroundSpontaneous subarachnoid hemorrhage (SAH) often results in altered cerebrospinal fluid (CSF) flow and secondary hydrocephalus, yet the mechanisms behind these phenomena remain poorly understood. This study aimed to elucidate the impact of SAH on individual CSF flow patterns and their association with secondary hydrocephalus.MethodsIn patients who had experienced SAH, changes in CSF flow were assessed using cardiac-gated phase-contrast magnetic resonance imaging (PC-MRI) at the Sylvian aqueduct and cranio-cervical junction (CCJ). Within these regions of interest, volumetric CSF flow was determined for every pixel and net CSF flow volume and direction calculated. The presence of acute or chronic hydrocephalus was deemed from ventriculomegaly and need of CSF diversion. For comparison, we included healthy subjects and patients examined for different CSF diseases.ResultsTwenty-four SAH patients were enrolled, revealing a heterogeneous array of CSF flow alterations at the Sylvian aqueduct. The cardiac-cycle-linked CSF net flow in Sylvian aqueduct differed from the traditional figures of ventricular CSF production about 0.30–0.40 mL/min. In 15 out of 24 patients (62.5%), net CSF flow was retrograde from the fourth to the third and lateral ventricles, while it was upward at the cranio-cervical junction in 2 out of 2 patients (100%). The diverse CSF flow metrics did not distinguish between individuals with acute or chronic secondary hydrocephalus. In comparison, 4/4 healthy subjects showed antegrade net CSF flow in the Sylvian aqueduct and net upward CSF flow in CCJ. These net CSF flow measures also showed interindividual variability among other patients with CSF diseases.ConclusionsThere is considerable inter-individual variation in net CSF flow rates following SAH. Net CSF flow in the Sylvian aqueduct differs markedly from the traditional ventricular CSF production rates of 0.30–0.40 mL/min in SAH patients, but less so in healthy subjects. Furthermore, the cardiac-cycle-linked net CSF flow rates in Sylvian aqueduct and CCJ suggest an important role of extra-ventricular CSF production.

Door-in-Door-Out Times at Referring Hospitals and Outcomes from Hemorrhagic Stroke

Interhospital transfer is often required in the care of patients with hemorrhagic stroke. Guidelines recommend a door-in-door-out (DIDO) time of ≤120 minutes at the transferring emergency department (ED); however, it is unknown whether DIDO times are related to clinical outcomes of hemorrhagic stroke. Retrospective, observational cohort study using US registry data from Get With The Guidelines-Stroke participating hospitals. Patients include those aged ≥18 years with intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) who were transferred from the ED to a Get With The Guidelines participating receiving hospital from January 1, 2019, to July 31, 2022. The primary outcome was ordinal discharge modified Rankin scale (mRS) score and secondary outcomes included dichotomous discharge mRS, ability to ambulate independently at discharge, and inhospital mortality at the receiving hospital. In all, 19,708 ICH and 7,757 patients with SAH were included. For patients with ICH, an increasing DIDO time was associated with greater odds of mRS 0 to 3 versus 4 to 6 at discharge in the unadjusted analyses (DIDO 91 to 180 minutes, odds ratio [OR] 1.15 [1.04 to 1.27]; DIDO 181 to 270 minutes, OR 1.51 [1.33, 1.71]; DIDO >270 minutes, OR 1.83 [1.58, 2.11]; versus DIDO ≤90 minutes). In the adjusted analyses, no associations were observed. Similar results were seen for mRS at discharge in patients with SAH. In both patients with ICH and SAH, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of inhospital mortality in the unadjusted analyses. After adjustment, the effect sizes of these associations were reduced, with some of the results based on quartiles becoming statistically nonsignificant. These findings suggest that EDs currently expedite the transfer of the sickest patients; however, prospective studies and more granular data are needed to understand the impact of early treatment and timing of transfer for patients with hemorrhagic stroke.

Association between estimated pulse wave velocity and the risk of mortality in patients with subarachnoid hemorrhage: a retrospective cohort study based on the MIMIC database

BackgroundThe estimated pulse wave velocity (ePWV) is a recently developed, simple and useful tool to measure arterial stiffness and to predict long-term cardiovascular mortality. However, the association of ePWV with mortality risk in patients with subarachnoid hemorrhage (SAH) is unclear. Herein, this study aims to assess the potential prediction value of ePWV on short- and long-term mortality of SAH patients.MethodsData of adult patients with no traumatic SAH were extracted from the Medical Information Mart for Intensive Care (MIMIC) III and IV database in this retrospective cohort study. Weighted univariate and multivariable Cox regression analyses were used to explore the associations of ePWV levels with 30-day mortality and 1-year mortality in SAH patients. The evaluation indexes were hazard ratios (HRs) and 95% confidence intervals (CIs). In addition, subgroup analyses of age, the sequential organ failure assessment (SOFA) score, surgery, atrial fibrillation (AF), renal failure (RF), hepatic diseases, chronic obstructive pulmonary disease (COPD), sepsis, hypertension, and diabetes mellitus (DM) were also performed.ResultsAmong 1,481 eligible patients, 339 died within 30 days and 435 died within 1 year. After adjusting for covariates, ePWV ≥ 12.10 was associated with higher risk of both 30-day mortality (HR = 1.77, 95%CI: 1.17–2.67) and 1-year mortality (HR = 1.97, 95%CI: 1.36–2.85), compared to ePWV < 10.12. The receiver operator characteristic (ROC) curves showed that compared to single SOFA score, ePWV combined with SOFA score had a relative superior predictive performance on both 30-day mortality and 1-year mortality, with the area under the curves (AUCs) of 0.740 vs. 0.664 and 0.754 vs. 0.658. This positive relationship between ePWV and mortality risk was also found in age ≥ 65 years old, SOFA score < 2, non-surgery, non-hepatic diseases, non-COPD, non-hypertension, non-DM, and sepsis subgroups.ConclusionBaseline ePWV level may have potential prediction value on short- and long-term mortality in SAH patients. However, the application of ePWV in SAH prognosis needs further clarification.

Essential thrombocythemia complicated by multivessel intracranial dolichoectasia with subarachnoid hemorrhage and recurrent cerebral infarction

BackgroundPatients with essential thrombocythemia (ET) can develop systemic thrombotic and hemorrhagic vascular complications due to increased and dysfunctional platelets.Case presentationWe encountered a 49-year-old Japanese woman with a history of essential ET, cerebral infarction, hypertension, and hyperlipidemia. She had been taking anagrelide (2.5 mg/day) and aspirin (100 mg/day) and had vomited at home. At the time of admission to our hospital, she was in a deep stupor. We thought these symptoms were caused by intracranial hypertension. Head computed tomography showed severe subarachnoid hemorrhage (SAH) at the interhemispheric fissure, hematoma at the corpus callosum, and intraventricular hemorrhages. Digital subtraction angiography demonstrated multiple dilated, stenotic, tortuous intracranial arteries, and a dissecting aneurysm at the right anterior cerebral artery (ACA). The dissecting aneurysm measured 7.7 × 15.5 mm, and a bleb was observed. Our diagnosis was ruptured ACA dissecting aneurysm and diffuse intracranial arterial dolichoectasia (DIADE). We performed stent-assisted coil embolization of the aneurysm. She remained apathetic and manifested unilateral apraxia and alien limb syndrome due to a partial callosal disconnection. Two months thereafter her symptoms gradually improved, her consciousness level and limb function improved, and her modified Rankin scale (mRS) score was 2. However, when we tapered her antiplatelet therapy, she again developed an acute cerebral infarct.ConclusionsThis is the first presentation of a patient with ET complicated by DIADE, both of which can result in ischemic and hemorrhagic vascular complications including SAH. As antithrombotic therapy in patients with DIADE and ET may be associated with higher hemorrhage rates, its effects must be monitored carefully.

Electroencephalographic monitoring in detection and prediction of delayed cerebral ischemia due to non-traumatic subarachnoid hemorrhage

Intensive care of patients with acute non-traumatic subarachnoid hemorrhage primarily relies on diagnostics of delayed cerebral ischemia (DCI). The major difficulty in detecting DCI emerges upon suppression of wakefulness, when clinical assessment of growing neurological deficit becomes complicated. Widely used transcranial dopplerography allows solely to verify a vasospasm development not always leading to DCI exhibiting a multifactorial underlying mechanism. Electroencephalography (EEG) is the only broadly available instrumental tool ensuring a continuous monitoring of cerebral functional status including in subjects at intensive care unit. To date, non-specific EEG parameters pointing at development of acute cerebral injury were identified that provide varying diagnostic and predictive informative value in DCI. We reviewed publications aimed at assessing the data on visual and quantitative EEG parameters such as regional slowing, alpha rhythm spectral power and relative variability, alpha-to-delta power ratio, and detection of epileptiform activity. Having searched international and Russia-wide medical databases, we found only 7 publications quantitatively assessing diagnostic value of EEG monitoring, which showed that for DCI diagnosis its sensitivity ranged from 76% to 100%, and specificity – from 54% to 100%. We also present a clinical case with a 70-year-old female patient who underwent surgery for non-traumatic subarachnoid hemorrhage due to a ruptured aneurysm of the communicating segment of the right internal carotid artery. During the continuous videoEEG monitoring 2 days before clinical deterioration and appearance of ischemic changes in the right cerebral hemisphere on computed tomography scans, an ictal-interictal continuum pattern was noted to emerge. Future studies should be aimed at clarifying and validating the most informative DCI biomarkers including while recording EEG with intracranial electrodes that may contribute to development of automated algorithms for DCI detection.

Prescribed Drug Use and Aneurysmal Subarachnoid Hemorrhage Incidence: A Drug-Wide Association Study.

Prescribed Drug Use and Aneurysmal Subarachnoid Hemorrhage Incidence: A Drug-Wide Association Study.

Twenty Years of Sustained Improvement in Quality of Care and Outcomes for Patients Hospitalized With Stroke or Transient Ischemic Attack: Data From The Get With The Guidelines-Stroke Program.

The Get With The Guidelines-Stroke program is a quality improvement initiative designed to enhance adherence to evidence-based stroke care. Since its inception in 2003, over 2800 hospitals in the United States have participated in the program. We examined patient characteristics, adherence to performance measures, and in-hospital outcomes in patients hospitalized for acute ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack in The Get With The Guidelines-Stroke hospitals from 2003 through 2022. We quantified temporal changes in performance measure adherence and clinical outcomes over time. Performance measure denominators consisted of patients who were eligible, excluding those with contraindications. Over the 20 years of the program, a total of 7837 849 stroke cases (median age 71 years, 51.0% female; 69.2% ischemic strokes, 3.9% SAHs, 11.5% ICHs, and 15.3% TIAs) were entered into the registry. Except for antithrombotics at discharge, in which the baseline performance was >92%, there was sustained improvement in all performance metrics regardless of type of cerebrovascular event (P<0.01 for all). In patients with acute ischemic stroke, large improvements were observed for anticoagulation for atrial fibrillation (55.7% in 2003 to 97.2% in 2022), smoking cessation counseling (44.7%-97.8%), dysphagia screening (53.8%-83.5%), thrombolytic treatment for patients arriving by 3.5 hours, treat by 4.5 hours (15.2%-92.9%), door-to-needle time within 60 minutes (19.0%-75.3%), and endovascular door-to-puncture time within 90 minutes (54.7%-62.8%). Similar improvements were also observed for measures relevant to patients with subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack. Multivariable analysis showed that there was a sustained increase in odds of receiving each performance measure over time, independent of patient and hospital characteristics for each type of cerebrovascular event. After risk adjustment, there were temporal trends that patients were less likely to be discharged to a skilled nursing facility, and, for ischemic stroke only, more likely to be discharged directly home. During the first 20 years, Get With The Guidelines-Stroke participation was associated with sustained improvement in evidence-based care and outcomes for patients with stroke and transient ischemic attack in the United States.

Can the radiomics features of intracranial aneurysms predict the prognosis of aneurysmal subarachnoid hemorrhage?

ObjectivesThis study attempted to determine potential predictors among radiomics features for poor prognosis in aneurysmal subarachnoid hemorrhage (aSAH), develop models for prediction, and verify their predictive power.MethodsIn total, 252 patients with aSAH were included in this study and categorized into favorable and poor outcome groups based on the modified Rankin Scale score 3 months after event. Radiomics features of the ruptured intracranial aneurysm extracted from computed tomography angiography images were selected using least absolute shrinkage and selection operator regression and 10-fold cross-validation. A radiomics score was created by selecting the optimal features. Other risk factors for a poor prognosis were screened using multivariate regression analysis. Three models (clinical, aneurysm, and clinical-aneurysm combined models) were developed. The performance of the models was assessed using receiver operating characteristic (ROC) curves. A clinical-aneurysm combined nomogram was constructed to forecast the risk of poor prognosis in patients with aSAH.ResultsA total of three clinical variables and six radiomics features were shown to have a significant association with poor prognosis in patients with aSAH. In the training cohort, the clinical, aneurysm, and clinical-aneurysm combined models had areas under the ROC curves of 0.846, 0.762, and 0.893, respectively. In the testing cohort, these models had areas under the ROC curves of 0.848, 0.753, and 0.869, respectively.ConclusionThe radiomics characteristics of ruptured intracranial aneurysms are valuable to predict prognosis after aSAH. The clinical-aneurysm combined model exhibited the best among the three models. The clinical-aneurysm combined nomogram is a reliable and effective tool for predicting poor prognosis in patients with aSAH.

Enhancing Th17 cells drainage through meningeal lymphatic vessels alleviate neuroinflammation after subarachnoid hemorrhage

BackgroundSubarachnoid hemorrhage (SAH) is a severe cerebrovascular disorder primarily caused by the rupture of aneurysm, which results in a high mortality rate and consequently imposes a significant burden on society. The occurrence of SAH initiates an immune response that further exacerbates brain damage. The acute inflammatory reaction subsequent to SAH plays a crucial role in determining the prognosis. Th17 cells, a subset of T cells, are related to the brain injury following SAH, and it is unclear how Th17 cells are cleared in the brain. Meningeal lymphatic vessels are a newly discovered intracranial fluid transport system that has been shown to drain large molecules and immune cells to deep cervical lymph nodes. There is limited understanding of the role of the meningeal lymphatic system in SAH. The objective of this research is to explore the impact and underlying mechanism of drainage Th17 cells by meningeal lymphatics on SAH.MethodsTreatments to manipulate meningeal lymphatic function and the CCR7-CCL21 pathway were administered, including laser ablation, injection of VEGF-C geneknockout, and protein injection. Mouse behavior was assessed using the balance beam experiment and the modified Garcia scoring system. Flow cytometry, enzyme-linked immunosorbent assays (ELISA), and immunofluorescence staining were used to study the impact of meningeal lymphatic on SAH drainage. Select patients with unruptured and ruptured aneurysms in our hospital as the control group and the SAH group, with 7 cases in each group. Peripheral blood and cerebrospinal fluid (CSF) samples were assessed by ELISA and flow cytometry.ResultsMice with SAH showed substantial behavioral abnormalities and brain damage in which immune cells accumulated in the brain. Laser ablation of the meningeal lymphatic system or knockout of the CCR7 gene leads to Th17 cell aggregation in the meninges, resulting in a decreased neurological function score and increased levels of inflammatory factors. Injection of VEGF-C or CCL21 protein promotes Th17 cell drainage to lymph nodes, an increased neurological function score, and decreased levels of inflammatory factors. Clinical blood and CSF results showed that inflammatory factors in SAH group were significantly increased. The number of Th17 cells in the SAH group was significantly higher than the control group. Clinical results confirmed Th17 cells aggravated the level of neuroinflammation after SAH.ConclusionThis study shows that improving the drainage of Th17 cells by meningeal lymphatics via the CCR7-CCL21 pathway can reduce brain damage and improve behavior in the SAH mouse model. This could lead to new treatment options for SAH.

Intraoperative visualization of cerebral aneurysms using navigated 3D-ultrasound power-Doppler angiography.

The questions of whether the spatial resolution of navigated 3D-ultrasound (3D-US) power-Doppler angiography imaging rendered by existing 3D-US systems is sufficient for the intraoperative visualization of cerebral aneurysms, and in what percentage of cases, are largely unanswered. A study on this topic is lacking in the literature. From 2015 to 2022, we performed 86 surgeries on 83 aneurysm patients. Navigated 3D-US was used at the discretion of the operating neurosurgeons when available (i.e., not being used during parallel tumor surgeries). Twenty-five aneurysms (15 ruptured) were operated on using 3D-US; 22 aneurysms were located at the middle cerebral artery (MCA). Patient 3D-US power-Doppler angiography images and surgical reports were retrospectively reviewed to assess the intraoperative ultrasound visibility of aneurysms. In 20 patients (80%) the aneurysms were successfully visualized. In five patients (20%), the aneurysms visualization was insufficient or absent. Nineteen of 22 aneurysms (86.4%) were visualized in the MCA aneurysm subgroup. We observed no association between aneurysm visibility and aneurysm size or the presence of subarachnoid hemorrhage. In the subgroup of MCA aneurysms, no association between aneurysm visibility and the presence of subarachnoid hemorrhage was found; a trend toward poor sonographic visibility of smaller aneurysms was observed (p = 0.09). Our initial data show that intraoperative 3D-US power-Doppler angiography, rendered by current navigated 3D-US systems, clearly depicts the majority of aneurysms in the MCA aneurysm subgroup. However, future prospective studies performed on a higher number of aneurysms localized at various anatomic sites are needed to confirm our initial findings and determine their potential clinical relevance.

Predestinative role acidic cerebrospinal fluid on the destiny of central channel in spinal cord following subarachnoid hemorrhage: an experimental study

Predestinative role acidic cerebrospinal fluid on the destiny of central channel in spinal cord following subarachnoid hemorrhage: an experimental study

Atypical Presentation of a Ruptured Anterior Communicating Artery Aneurysm With Subdural, Intraparenchymal, and Subarachnoid Hemorrhage

Atypical Presentation of a Ruptured Anterior Communicating Artery Aneurysm With Subdural, Intraparenchymal, and Subarachnoid Hemorrhage

Brain-targeted ursolic acid nanoparticles for anti-ferroptosis therapy in subarachnoid hemorrhage

BackgroundSubarachnoid hemorrhage (SAH) is a life -threatening cerebrovascular disease, where early brain injury (EBI) stands as a primary contributor to mortality and unfavorable patient outcomes. Neuronal ferroptosis emerges as a key pathological mechanism underlying EBI in SAH. Targeting ferroptosis for therapeutic intervention in SAH holds significant promise as a treatment strategy.MethodsSAH model was induced via intravascular puncture and quantitatively assessed the presence of neuronal ferroptosis in the early phase of SAH using FJC staining, Prussian blue staining, as well as malondialdehyde (MDA) and glutathione (GSH) measurements. Hyaluronic acid-coated ursolic acid nanoparticles (HA-PEG-UA NPs) were prepared using the solvent evaporation method. We investigated the in vivo distribution of HA-PEG-UA NPs in SAH model through IVIS and fluorescence observation, and examined their impact on short-term neurological function and cortical neurological injury. Finally, we assessed the effect of UA on the Nrf-2/SLC7A11/GPX4 axis via Western Blot analysis.ResultsWe successfully developed self-assembled UA NPs with hyaluronic acid to target the increased CD44 expression in the SAH-afflicted brain. The resulting HA-PEG-UA NPs facilitated delivery and enrichment of UA within the SAH-affected region. The targeted delivery of UA to the SAH region can effectively inhibit neuronal ferroptosis, improve neurological deficits, and prognosis in mice. Its mechanism of action is associated with the activation of the Nrf-2/SLC7A11/GPX4 signaling pathway.ConclusionsBrain-targeted HA-PEG-UA NPs was successfully developed and hold the potential to enhance SAH prognosis by limiting neuronal ferroptosis via modulation of the Nrf-2/SLC7A11/GPX4 signal.Graphical

Early mobilization in patients with aneurysmal subarachnoid haemorrhage may im-prove functional status and reduce cerebral vasospasm rate: a systematic review with meta-analysis.

The primary aim of this study was to evaluate the safety and efficacy of early mobilization in patients with aneurysmal subarachnoid haemorrhage. Systematic review with meta-analysis of randomized controlled studies and observational studies. Patients with aneurysmal subarachnoid haemorrhage. PubMed, Embase, CINAHL, Web of Science, Pedro, and the Cochrane Library databases were searched. A systematic review and meta-analysis were performed. Screening and data extraction were performed by 2 independent reviewers. Sixteen studies involving 1,757 patients were included. Meta-analysis of the data estimated that early mobilization improved mRS score at discharge (mean difference -1.39, 95% CI -2.51 to -0.28, I2 = 86%) and at 3 months (mean difference -1.10, 95% CI -1.54 to -0.66, I2 = 7%). Early mobilization was associated with a reduction in cerebral vasospasm rate, both radiological (OR 0.66, 95% CI 0.45 to 0.96, I2 = 7%) and clinical (OR 0.44, 95% CI 0.27 to 0.72, I2 = 8%); 6% of mobilization sessions involved adverse events, mostly haemodynamic changes. This review found moderate-quality evidence supporting the safety and effectiveness of early mobilization in patients with SAH. Further randomized controlled trials are needed to identify the appropriate mobilization strategy and confirm these results.

Global, Regional, and National Burden of Stroke, 1990-2021: A Systematic Analysis for Global Burden of Disease 2021.

This study aims to perform a comprehensive analysis of stroke burden from the Global Burden of Disease 2021. We conducted a comprehensive analysis of the burden, including prevalence, incidence, mortality, and disability-adjusted life year rates, for stroke across 204 countries and regions from 1990 to 2021 using data from the Global Burden of Disease 2021. We calculated the estimated annual percentage change (EAPC) and performed a joinpoint regression analysis to identify the trends. We also explored the association between the stroke burden and sociodemographic index. The age-standardized prevalence, incidence, mortality, and disability-adjusted life year rates for stroke were 1099.310, 141.553, 87.454, and 1886.196 per 100 000 persons in 2021, respectively. The general stroke burden trends declined in EAPC analysis (age-standardized prevalence: EAPC, -0.37; age-standardized incidence: EAPC, -0.99; age-standardized mortality: EAPC, -1.81; and disability-adjusted life year: EAPC, -1.76). However, we found an increasing burden of stroke in East Asia and Southern Sub-Saharan Africa (EAPC >0). The global burdens of intracerebral hemorrhage, subarachnoid hemorrhage, and ischemic stroke showed a similar trend. The stroke, intracerebral hemorrhage, and ischemic stroke burdens were heavier in men than in women, except for that of subarachnoid hemorrhage in women. Our joinpoint regression analysis revealed that the age-standardized burden rates of stroke decreased from 1990 to 2021 (average annual percent change <0), whereas an upward trend was observed between 2019 and 2021 (average annual percent change >0). The burden of stroke was inversely proportional to the sociodemographic index (P<0.05), except in the case of subarachnoid hemorrhage. The actual stroke burden showed an increasing trend for stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and ischemic stroke in 2021 (during the coronavirus pandemic). We found age-standardized rates of stroke burden declining over time, but some areas exhibited a notable increase in the prevalence, incidence, mortality, and disability-adjusted life year rates.

Treatment of Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage Using the Compliant Manually Adjustable Mesh Comaneci.

Background and purpose: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Compliant and noncompliant balloons and manually adjustable mesh may be used in this indication. We describe our initial experience with the Comaneci (Rapid Medical, Yokneam, Israel) in cerebral vasospasm treatment following aSAH. Methods: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Comaneci device for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details, and outcomes were obtained from electronic medical records. Results: Between February 2022 and June 2023, seven consecutive patients underwent CV treatment with the Comaneci. Angioplasty of 37 arterial segments (supraclinoid internal carotid artery, A1, A2, and A3 segments of the anterior cerebral artery and M1 and M2 segments of the middle cerebral artery) was attempted, and 35/37 (95%) were performed. The vessel diameter improved significantly following angioplasty (+64%), while brain hypoperfusion decreased (-45% of the mean T Max). There was no long-term clinical complication, and 6% per-procedural complications occurred. Conclusions: The Comaneci is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device in the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Infectious Endocarditis With Subarachnoid Hemorrhage and Cerebral Infarction in an Atopic Dermatitis Patient During Unsanitary Cupping Therapy

Infectious Endocarditis With Subarachnoid Hemorrhage and Cerebral Infarction in an Atopic Dermatitis Patient During Unsanitary Cupping Therapy

Serum sodium concentration predicting mortality in patients with aneurysmal subarachnoid hemorrhage

BackgroundTo date, inconsistent evidence exists on the role of hypernatremia in patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent surgical clipping. We aimed to investigate the association between serum sodium and mortality in these patients. MethodsA cohort study was performed to include adult patients with aSAH who underwent surgical clipping in a university hospital. The primary outcome was follow-up mortality. Propensity score matching (PSM) was used for matching patients’ baseline characteristics. Net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to assess and compare the reclassification and discrimination capacity of different models. Trends in serum sodium over time were detected by the ordinary least squares model. ResultsOf 618 aSAH patients with surgical clipping during the study period, normal serum sodium was observed in 467 patients (75.6 %), and admission hypernatremia was noted in 151 patients (24.4 %). After adjustment with multivariate regression analysis, patients with hypernatremia had significantly higher odds for follow-up mortality (aOR: 2.86, 95 % CI: 1.54 to 5.30; P = 0.001). PSM analysis observed similar results (aOR: 2.38, 95 % CI: 1.29 to 4.55; P = 0.009). The incorporation of serum sodium during hospitalization markedly enhanced the IDI (P < 0.001) and NRI (P < 0.001) for the prediction of mortality. ConclusionsIn conclusion, the findings from this cohort study of aSAH patients with surgical clipping indicated that serum sodium can be an independent predictive factor of all-cause mortality, and inferior sequelae in aSAH patients. These findings endorsed the importance of managing hypernatremia and monitoring serum sodium in patients with aSAH.

Liberalization of the Systemic Glucose Management is Associated with a Reduced Frequency of Neuroglucopenia in Subarachnoid Hemorrhage Patients: An Observational Cohort Study.

Pathologically low brain glucose levels, referred to as neuroglucopenia, are associated with unfavorable outcomes in neurocritical care patients. We sought to investigate whether an increase in serum glucose levels would be associated with a reduction of neuroglucopenia. In this retrospective analysis of prospectively collected data, we included 55 consecutive patients with spontaneous subarachnoid hemorrhage who underwent cerebral microdialysis (CMD) monitoring. Neuroglucopenia was defined as CMD-glucose levels < 0.7mmol/l. We identified systemic glucose liberalization events, defined as a day with median serum glucose levels < 150mg/dl, followed by a day with median serum glucose levels > 150mg/dl, and compared concentrations of cerebral metabolites between these days. Unfavorable outcome was defined as modified Rankin Scale score ≥ 3 at 3 months after the bleeding. Episodes of neuroglucopenia were more frequent in patients with unfavorable outcome (19.8% [19.3-20.3%] vs. 10.9% [10.4-11.5%], p = 0.007). Sixty-nine systemic glucose liberalization events were identified in 40 patients. Blood glucose levels increased from 141.2 (138.7-143.6) mg/dl to 159.5 (157.0-162.2) mg/dl (p < 0.001), CMD-glucose levels increased from 1.44 (1.39-1.50) mmol/l to 1.68 (1.62-1.75) mmol/l (p = 0.001), and the frequency of neuroglucopenia decreased from 24.7% (22.9-26.5%) to 20.2% (18.7-21.8%) (p = 0.002) during these events. Liberalization was not associated with changes in CMD-lactate, CMD-pyruvate, CMD-lactate-to-pyruvate ratio, CMD-glutamate, or CMD-glycerol. In conclusion, the liberalization of serum glucose concentrations to levels between 150 and 180 mg/dl was associated with a significant reduction of neuroglucopenia.

A case of subarachnoid hemorrhage due to vertebral artery dissection following spontaneous coronary artery dissection on the same day: Clinical image

A woman in her 60s with well-controlled dyslipidemia presented with anterior chest pain. The electrocardiogram, chest radiograph, and echocardiogram were unremarkable; however, cardiac enzymes levels were elevated. Coronary angiography performed after dual antiplatelet therapy revealed spontaneous coronary artery dissection (SCAD). On the same day, the patient complained of mild headache that was initially treated as migraine. Hours later, the patient reported severe headache, followed by a decline in consciousness. Computed tomography of the head showed subarachnoid hemorrhage, while the angiography revealed bilateral vertebral artery dissection. The ruptured right vertebral artery dissecting aneurysm was treated with coil embolization. Despite treatment, the patient died seven days later. Autopsy confirmed dissections of the coronary and vertebral arteries. Although SCAD is rare, it often coexists with extracoronary vascular abnormalities due to systemic arterial fragility. Therefore, consider cerebrovascular disorders and promptly implementing diagnostic and management strategies in patients with SCAD and headaches is necessary.