Subarachnoid Hemorrhage Research Articles

The serum biomarkers NSE and S100B predict intracranial complications and in-hospital survival in patients undergoing veno-venous ECMO

Neurological complications in patients undergoing veno-venous extracorporeal membrane oxygenation (V-V ECMO) are challenging, with new intracranial pathologies posing a grave risk. We aimed to evaluate the utility of neuron-specific enolase (NSE) and S100B biomarkers for predicting outcomes in new-onset intracranial pathology during V-V ECMO. A retrospective analysis spanning 2013–2021 at a German university hospital was conducted. Cases with electronically available data on NSE and S100B serum levels, new intracranial pathologies (intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], cerebral ischemia, hypoxic-ischemic encephalopathy [HIE]), and survival during or after V-V ECMO were screened. The primary objective was to assess the prognostic value of NSE and S100B for in-hospital survival during V-V ECMO. Secondary objectives included analyzing clinical characteristics, outcome parameters, and biomarker distribution in V-V ECMO patients. Additionally, the prognostic value of NSE and S100B for in-hospital death and occurrence of intracranial pathology was calculated. Among 744 ECMO recipients, 426 underwent V-V ECMO. No significant differences in disease severity or organ failure scores were observed between groups, except for SAPS at discharge, which was higher in patients with new intracranial pathologies. Patients with new intracranial pathologies had lower median survival and higher in-hospital mortality. Weaning success from ECMO was also significantly reduced in these patients. Cut-off values of 58.4 µg/lfor NSE and 1.52 µg/l for S100B were associated with detrimental outcomes, characterized by significantly reduced median survival. A significant difference in maximum serum NSE concentration was found between patients with and without new intracranial pathology. All screened cases with new intracranial pathology had an unfavorable neurological outcome (modified Rankin Score [mRS] > 3) at discharge, with a higher proportion having an mRS of 6 in the high NSE group. The emergence of intracranial pathology during V-V ECMO significantly increases the risk of death. Changes in NSE and S100B levels serve as valuable follow-up parameters for predicting new intracranial pathology and survival during V-V ECMO therapy.

Персональная динамика отношения максимумов спектральных плотностей мощности альфа/дельта ритмов пациентов для оценки времени начала развития отсроченной церебральной ишемии после субарахноидального кровоизлияния

To assess the time of onset of delayed cerebral ischemia after subarachnoid hemorrhage, an approach based on personal dynamics of the ratio of the maximums of spectral densities of alpha/delta electroencephalogram rhythms in the data of long-term electroencephalographic monitoring was proposed and tested on clinical data. In contrast to the currently accepted estimation of the index based on alpha (8–13 Hz) and delta (1–4 Hz) frequency ranges averaged over the frequency ranges of rhythm powers. The proposed method is based on the calculation of the ratio of the maxima of the spectral power density in the frequency bands of alpha and delta rhythms using the calculation of Fourier spectra with a Hamming window of 3 hours. It is shown that the dynamics of the index of the ratio of maxima of spectral power densities of alpha/delta rhythms reflects the dependence of the development of delayed cerebral ischemia on a steady decrease in the index ten times more than in control patients. The results reflecting the interhemispheric asymmetry of the dynamics of the ratio of the maxima of spectral densities of alpha/delta rhythm power in patients with diagnosed delayed ischemia are presented.

Исследование временной динамики маркёров отсроченной церебральной ишемии с помощью вейвлет-спектров электроэнцефалограмм

The paper presents the results of a study of the temporal dynamics of some markers of delayed cerebral ischemia (DCI) identified in delta-range wavelet spectra of electroencephalograms (EEG) using the method of electrical activity analysis. EEG signals of 16 patients treated in the intensive care unit of the N.V. Sklifosovsky Research Institute for Emergency Care after surgery for non-traumatic subarachnoid hemorrhage were analyzed. According to computed tomography data, DCI developed in 6 patients, while DCI did not develop in 10 patients. It was found that the patient sample was heterogeneous, namely, in 10 patients (4 patients with DCI and 6 patients without DCI) of 16, the development of DCI could be predicted with 100% accuracy using the studied markers 48 hours after surgery; in the remaining 6 patients (2 patients with DCI and 4 patients without DCI), the studied markers give contradictory results. In this paper, the dynamics of DCI markers is studied using the first sample of patients. Using the second sample, the reasons why the studied markers may give an incorrect prognosis of DCI development in some patients are discussed. It is shown that the studied DCI markers allow not only the accurate prediction of the development of DCI in some patients but also the tracking of the dynamics of the patient’s condition after surgery.

Anterior choroidal artery aneurysm case series: a clinical decision algorithm for endovascular and surgical treatment using a novel classification system.

Anterior choroidal artery (AChA) aneurysms represent 2-5% of intracranial aneurysms. The proximity of the origin of the AChA to the aneurysm neck poses a risk of thromboembolic complications following treatment. AChA occlusion can result in significant neurological deficits. We present a case-series of patients with AChA aneurysms and their treatment outcomes. We describe how treatment was chosen based on aneurysm and patient-specific factors to minimize risks, enhance efficacy of treatment, and improve patient outcomes. We retrospectively reviewed 27 patients who underwent treatment for AChA aneurysms at a single institution from 2015-2024. Clinical presentation, aneurysm characteristics, procedural details, and follow-up data were collected. Twenty-seven AChA aneurysms (median diameter 2.94mm), were treated in 29 procedures. Treatments included clipping (11 aneurysms), flow diversion (13), or coiling (5). The five coiled aneurysms were ruptured at presentation. Three patients experienced permanent infarction (10.3%), two in the setting of vasospasm after coiling and one after flow diversion in a patient who proved to have resistance to clopidogrel. At a median follow-up of 4.73months (IQR = 1.23-14.03), 25 patients (93%) had favorable functional recovery (mRS 0-2). Patients treated for AChA aneurysms experienced favorable functional outcomes by utilizing surgical and endovascular techniques carefully chosen based on aneurysm and patient-specific factors. Two patients did not achieve independence post-coiling due to disability from their initial subarachnoid hemorrhage. There were no treatment related causes of unfavorable functional outcomes.

Retracted] Limb remote ischemic post‑conditioning reduces injury and improves long‑term behavioral recovery in rats following subarachnoid hemorrhage: Possible involvement of the autophagic process

Retracted] Limb remote ischemic post‑conditioning reduces injury and improves long‑term behavioral recovery in rats following subarachnoid hemorrhage: Possible involvement of the autophagic process

Mechanisms of hydrocephalus after intraventricular haemorrhage: a review.

Intraventricular haemorrhage (IVH) is bleeding within the ventricular system, which in adults is usually mainly secondary to cerebral haemorrhage and subarachnoid haemorrhage. Hydrocephalus is one of the most common complications of intraventricular haemorrhage, which is characterised by an increase in intracranial pressure due to an increased accumulation of cerebrospinal fluid within the ventricular system, and is closely related to the patient's prognosis. Surgical methods such as shunt surgery have been used to treat secondary hydrocephalus in recent years and have been effective in improving the survival and prognosis of patients with hydrocephalus. However, complications such as shunt blockage and intracranial infection are often faced after surgery. Moreover, little is known about the mechanism of hydrocephalus secondary to intraventricular haemorrhage. This review discusses the mechanisms regarding the occurrence of secondary hydrocephalus after intraventricular haemorrhage in adults in terms of blood clot obstruction, altered cerebrospinal fluid dynamics, inflammation, and blood composition.

“Think Beyond Trauma!” Multiple Epidural Hematoma in Sickle Cell Disease: A Conundrum

Epidural hematoma is conventionally thought to occur secondary to trauma. Atraumatic/spontaneous epidural hematoma is of rare occurrence and the etiology spans from dural vascular malformations, neoplasms, and coagulopathy to sinus, middle ear, and orbital infections. Occurrence of atraumatic epidural hematoma in sickle cell disease is rarely reported as opposed to frequent neurological complications, such as ischemic stroke seen in 54% of cases, followed by intracerebral, subarachnoid, intraventricular, or subdural hemorrhages. This study reports the case of an eight-year-old male with Sickle cell disease (SCD). He suffered from fever followed by splenic sequestration and multiple spontaneous epidural hematomas without mass effect and successfully managed with conservative treatment.

Complications of mechanical thrombectomy

Ischemic stroke is the most common cause of disability in adults and an important disease for society; therefore, the prevention, diagnosis, and treatment play an important role. Endovascular mechanical recanalization to reopen large occlusions of the intracerebral vessels has established itself as the gold standard in therapy, which is why knowledge of the most important complications and their management is essential for interventionalists. Intracranial hemorrhages, which include intracerebral and subarachnoid hemorrhages, are dreaded complications that significantly worsen the clinical outcome. Early monitoring and optimal management are therefore essential. Cerebral air embolism is arare but dangerous complication whose prevention is paramount, as treatment options are limited.

Cancer-type somatic mutations in saccular cerebral aneurysms.

Intracranial aneurysms (IAs) are a major cause of subarachnoidal hemorrhage (SAH) which can have a significant morbidity and mortality. The processes underlying the aneurysm development remains unclear. We performed whole exome sequencing of DNA derived from 20 saccular cerebral aneurysms of 20 patients, followed by somatic variant calling. Eleven (55%) of the 20 patients had detectable nonsynonymous somatic mutations and in total, 48 mutations were detected in the aneurysm samples. The mutations were highly enriched in cancer-related genes and 77% were predictably deleterious. A p.Tyr562Asp somatic mutation was detected in the PDGFRB gene; somatic mutations at the same codon have been reported in fusiform cerebral aneurysms. These results widen the concept on the role of somatic mutations in cerebral aneurysms, indicating their possible role in the more common saccular aneurysm, similarly to the rarer fusiform aneurysm.

Clinical Outcomes and Predictors of Poor Prognosis in Non-aneurysmal Subarachnoid Hemorrhage: A 10-Year Cohort Analysis

Clinical Outcomes and Predictors of Poor Prognosis in Non-aneurysmal Subarachnoid Hemorrhage: A 10-Year Cohort Analysis

Small Molecule Myeloperoxidase (MPO) Inhibition Prevents Delayed Cerebral Injury (DCI) After Subarachnoid Hemorrhage (SAH) in a Murine Model.

Delayed cerebral injury (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is a preventable injury that would improve patient outcomes if an effective treatment can be developed. The most common long-term disability in patients with SAH is cognitive dysfunction. Contrary to the common theory that damage from DCI originates solely from ischemia caused by cerebral vasospasm, inflammation has been shown to be an important independent mediator of DCI. Neutrophil infiltration of the meninges is a critical step in developing late spatial memory deficits in a murine model of SAH and may serve as a surrogate marker for disease progression. Importantly, myeloperoxidase (MPO) null mice do not develop meningeal neutrophilia and are protected from spatial memory deficits. In this study, wildtype mice administered a single dose of the MPO inhibitor (MPOi) AZD5904 at peak neutrophil entry day have a higher percentage of neutrophils that remain in the meningeal blood vessel 6days after the hemorrhage suggesting neutrophil extravasation into the meninges is inhibited (79 ± 20 vs. 28 ± 24, p < 0.01). Interestingly, the intraperitoneal route of administration has a larger effect than the intrathecal route suggesting that MPO inhibition is best administered systemically not in the central nervous system. Second, mice administered AZD5904 intraperitoneal for 4 consecutive days starting 2days after the hemorrhage do not develop delayed spatial memory dysfunction (two-way analysis of variance, p > 0.001 F [2, 22] = 10.11). Systemic MPOi prevents neutrophil entry into the meninges and prevents spatial memory dysfunction. MPOi is a promising strategy for translation to patients with aneurysmal SAH.

Modifiable Risk Factors for Subarachnoid Hemorrhage: Narrative Review With an Emphasis on Common Controversies and Epidemiologic Pitfalls.

Given the relatively low incidence, high prehospital death rate, substantial geographical differences, and complex disease origin (combination of genetic and environmental risk factors), epidemiologic research on subarachnoid hemorrhage (SAH) and its risk factors is challenging. In practice, we are more or less forced to exploit compromised study designs and nonrepresentative data in such circumstances where it is almost impossible to gather comprehensive data through an optimal design. For example, hospital-based patient cohorts, administrative data repositories, and short-term population-based studies from small geographical regions are often used to research the incidence, case fatality, and risk factors of SAH, regardless of their inherent and self-evident limitations. Since studies on the epidemiology of SAH focus largely on identifying possible risk factors that could aid in disease diagnostics, treatment, and prevention, we aimed to review recent evidence on modifiable risk factors for SAH. In this context, we also try to explain the methodological reasons behind some of the conflicting results and to discuss the primary strengths and limitations of different study designs used in the field of SAH epidemiology. Based on our findings, smoking, high blood pressure, and possibly low physical activity are the only risk factors with high-quality evidence supporting their causal role in SAH. In addition, since all 3 commonly used study designs in SAH epidemiology, namely, hospital-based, population-based, and administrative register-based studies, have their own strengths and limitations, the most robust risk factor estimates and other epidemiologic measures of SAH can likely be established by combining various overlapping and high-quality sources of information in the future.

The Comparative Effects of Anakinra and Tocilizumab on Inflammation and Cerebral Vasospasm in an Experimental Subarachnoid Hemorrhage Model

Objective: Subarachnoid hemorrhage (SAH) is a life-threatening cerebrovascular condition that triggers a robust inflammatory response and cerebral vasospasm. This study aimed to evaluate the effects of anakinra, an interleukin-1 receptor antagonist, and tocilizumab, an interleukin-6 receptor antagonist, on inflammation and vasospasm in an experimental rat SAH model. Methods: Forty male Sprague Dawley rats (200–250 g) were randomly assigned to five groups: control, SAH, SAH + anakinra (ANA), SAH + tocilizumab (TCZ), and SAH + anakinra + tocilizumab (ANA+TCZ). SAH was induced by injecting non-heparinized arterial blood into the cisterna magna. Treatment groups received anakinra (50 mg/kg twice daily), tocilizumab (8 mg/kg once daily), or their combination for three days. Blood and cerebrospinal fluid (CSF) samples were analyzed for inflammatory markers (IL-1, IL-6, TNF-α, CRP), and histopathological evaluations were conducted to assess vasospasm and apoptosis. Results: SAH significantly increased pro-inflammatory cytokines (IL-1, IL-6, TNF-α, CRP) and fibrinogen levels in serum and CSF while reducing the basilar artery lumen diameter (p &lt; 0.001). Anakinra and tocilizumab treatments significantly reduced inflammatory markers and vasospasm severity compared to the SAH group (p &lt; 0.05). Combination therapy was more effective in reducing inflammation and vasospasm than either treatment alone (p &lt; 0.05). Anakinra showed a stronger effect on IL-1 reduction, while tocilizumab was more effective in lowering IL-6 levels. The ANA+TCZ group exhibited a significant decrease in caspase activity, indicating reduced apoptosis (p &lt; 0.05). Conclusions: Anakinra and tocilizumab effectively mitigated inflammation and vasospasm in an experimental SAH model, with combination therapy showing superior efficacy. These findings suggest that targeting both IL-1 and IL-6 pathways may be a promising therapeutic strategy for managing SAH complications. Further studies are warranted to evaluate long-term outcomes and clinical implications.

Spinal cord-spinal canal disproportion following treatment for syringomyelia associated with Chiari malformation type I: illustrative case.

Chiari malformation type I (CM-I) is a common pediatric neurosurgical condition that is often associated with syringomyelia (SM) and spine deformity. The association of these three conditions is well recognized, but the pathophysiology linking them has yet to be fully elucidated. This case report describes the unusual course of a 13-year-old male with CM-I, a large holocord syrinx, and progressive scoliosis who developed an angiography-negative subarachnoid hemorrhage (SAH) 4 months after successful posterior fossa decompression with duraplasty (PFDD). Notably, his cervical spinal canal diameter was increased relative to normative data. After presenting with SAH, he was treated with a course of lumbar cerebrospinal fluid drainage, which relieved his symptoms, and he had no further incidents. His syrinx responded to PFDD with a dramatic decrease in spinal cord diameter, in contradistinction to his dilated bony spinal canal. He is presently 4 years out from his SAH and doing well clinically. This report describes the first case of nonaneurysmal SAH following PFDD for CM-I and SM and explores a possible link between SM and bony spinal canal diameter. https://thejns.org/doi/10.3171/CASE24272.

Regional dynamic cerebral autoregulation across anterior and posterior circulatory territories: A detailed exploration and its clinical implications.

Cerebral autoregulation (CA) is the mechanism that maintains stable cerebral blood flow (CBF) despite fluctuations in systemic blood pressure, crucial for brain homeostasis. Recent evidence highlights distinct regional variations in CA between the anterior (carotid) and posterior (vertebrobasilar) circulations. Non-invasive neuromonitoring techniques, such as transcranial Doppler, transfer function analysis, and near-infrared spectroscopy, facilitate the dynamic assessment of CBF and autoregulation. Studies indicate a robust autoregulatory capacity in the anterior circulation, characterized by rapid adjustments in vascular resistance. On the contrary, the posterior circulation, mainly supplied by the vertebral arteries, may have a lower autoregulatory capacity. in acute brain injuries such as intracerebral and subarachnoid hemorrhage, and traumatic brain injuries, dynamic CA can be significantly altered in the posterior circulation. Proposed physiological mechanisms of impaired CA in the posterior circulation include: (1) Decreased sympathetic innervation of the vasculature impairing compensatory vasoreactivity; (2) Endothelial dysfunction; (3) Increased cerebral metabolic rate of oxygen consumption within the visual cortex causing CBF-metabolism (i.e., neurovascular) uncoupling; and (4) Impaired blood-brain barrier integrity leading to impaired astrocytic mediated release of vasoactive substances (e.g. nitric oxide, potassium, and calcium ions). Furthermore, more research is needed on the effects of collateral circulation, as well as the circle of Willis variants, such as the fetal-type posterior cerebral artery, on dynamic CA. Improving our understanding of these mechanisms is crucial to improving the diagnosis, prognosis, and management of various cerebrovascular disorders.

Proposal of a predictive score for the occurrence of postoperative cerebral vasospasm: analysis of a large single institution retrospective series and literature review.

Despite being uncommon, postoperative vasospasm (PoVS) present notably high morbidity and mortality rates. Our aim was to identify prognostic factors associated with this condition and introduce a scoring system to improve subsequent clinical and radiological surveillance strategies. We conducted a retrospective analysis of our institutional database covering patients aged over 18 who underwent craniotomic or transsphenoidal surgery for elective tumor removal at the Neurosurgical Unit of our institution between January 2016 and August 2023. A comprehensive search was conducted using the Cochrane Database of Systematic Reviews and PubMed database to identify the most correlated risk factors. Literature review included a final group of 32 studies (52 patients) and identified SAH, vessel encasement or vessel manipulation, hypothalamic disfunction, meningitis, younger age, tumor size > 3 cm, and long operative time as predictive factors for PoVS. Our cohort included 2132 patients, with only 13 individuals (0.61%) presenting PoVS. To predict the occurrence of PoVS, we developed a logistic multivariate regression model that identified thick (defined as Fisher grade ≥ 3) subarachnoid hemorrhage (coeff. 6.7, p < 0.001), intraparenchymal hemorrhage (coeff. 3.44, p < 0.001), lesion located in the parasellar region (coeff. 2.1, p = 0.064), and lesion size ≥ 4 cm (coeff. 2.0, p = 0.069) as potential independent predictors of PoVS. Based on statistical model for these variables was assigned a score: thick SAH 7 points, intraparenchymal hemorrhage 3 points, parasellar lesion site 2 points, and lesion size ≥ 4 cm 2 points. The cumulative scores ranged from 0 to 14. PoVS is a rare complication but its association with significant morbidity and mortality underscores the importance of early identification and treatment. In our study we proposed a stratified risk score to identify high risk patients. However, due to rarity of this condition, our score proposal should be considered as a training set a to be validated in future studies with a multicenter setting.

Neurological Pupil Index and Intracranial Hypertension in Patients With Acute Brain Injury

Invasive intracranial pressure (ICP) is the standard of care in patients with acute brain injury (ABI) with impaired consciousness. The Neurological Pupil Index (NPi) obtained by automated pupillometry is promising for noninvasively estimating ICP. To evaluate the association between repeated NPi and invasive ICP values. This study is a secondary analysis of the Outcome Prognostication of Acute Brain Injury With the Neurological Pupil Index (ORANGE), a multicenter, prospective, observational study of patients with ABI performed from October 1, 2020, to May 31, 2022, with follow-up at 6 months after ABI. The ORANGE study was performed at neurologic intensive care units of tertiary hospitals in Europe and North America. In ORANGE, 514 adult patients receiving mechanical ventilatory support were admitted to the intensive care unit after ABI. Invasive ICP monitoring and automated pupillometry assessment every 4 hours during the first 7 days, considered as a standard of care. Association between ICP and NPi values over time, using bayesian joint models, with linear and logistic mixed-effects longitudinal submodels. The study included 318 adult patients (median [IQR] age, 58 [43-69] years; 187 [58.8%] male) who required intensive care unit admission, intubation, and mechanical ventilatory support due to acute traumatic brain injury (n = 133 [41.8%]), intracerebral hemorrhage (n = 104 [32.7%]), or aneurysmal subarachnoid hemorrhage (n = 81 [25.5%]) and had automatic infrared pupillometry used as part of the standard evaluation practice and ICP monitoring. A total of 8692 ICP measurements were collected, with a median (IQR) of 31 (18-37) evaluations per patient. The median (IQR) NPi and ICP for the study population were 4.1 (3.5-4.5) and 10 (5-14) mm Hg, respectively. In a linear mixed model, the mean change in the NPi value, as a continuous variable, was -0.003 (95% credible interval [CrI], -0.006 to 0.000) for each 1-mm Hg ICP increase. No significant association between ICP and abnormal NPi (<3; odds ratio, 1.01; 95% CrI, 0.99-1.03) or absent NPi (0; odds ratio, 1.03; 95% CrI, 0.99-1.06) was observed. Although an abnormal NPi could indicate brainstem dysfunction, in this large and heterogeneous population of patients, NPi values were not significantly associated overall with ICP values. Repeated NPi measurements may not be a sufficient replacement for invasive monitoring. ClinicalTrials.gov Identifier: NCT04490005.

Liberal or Restrictive Transfusion Strategy in Aneurysmal Subarachnoid Hemorrhage.

The effect of a liberal red-cell transfusion strategy as compared with a restrictive strategy in patients during the critical care period after an aneurysmal subarachnoid hemorrhage is unclear. We randomly assigned critically ill adults with acute aneurysmal subarachnoid hemorrhage and anemia to a liberal strategy (mandatory transfusion at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (optional transfusion at a hemoglobin level of ≤8 g per deciliter). The primary outcome was an unfavorable neurologic outcome, defined as a score of 4 or higher on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 12 months. Secondary outcomes included 12-month functional independence as assessed with the Functional Independence Measure (FIM; scores range from 18 to 126) and quality of life as assessed with the EuroQolfive-dimension, five-level (EQ-5D-5L) utility index (scores range from -0.1 to 0.95) and a visual analogue scale (VAS; scores range from 0 to 100); on each assessment, higher scores indicate better health status or quality of life. A total of 742 patients underwent randomization at 23 centers. The analysis of the primary outcome at 12 months included 725 patients (97.7%). An unfavorable neurologic outcome occurred in 122 of 364 patients (33.5%) in the liberal-strategy group and in 136 of 361 patients (37.7%) in the restrictive-strategy group (risk ratio, 0.88; 95% confidence interval [CI], 0.72 to 1.09; P = 0.22). The mean (±SD) FIM score was 82.8±54.6 in the liberal-strategy group and 79.8±54.5 in the restrictive-strategy group (mean difference, 3.01; 95% CI, -5.49 to 11.51). The mean EQ-5D-5L utility index score was 0.5±0.4 in both groups (mean difference, 0.02; 95% CI, -0.04 to 0.09). The mean VAS score was 52.1±37.5 in the liberal-strategy group and 50±37.1 in the restrictive-strategy group (mean difference, 2.08; 95% CI, -3.76 to 7.93). The incidence of adverse events was similar in the two groups. In patients with aneurysmal subarachnoid hemorrhage and anemia, a liberal transfusion strategy did not result in a lower risk of an unfavorable neurologic outcome at 12 months than a restrictive strategy. (Funded by the Canadian Institutes of Health Research and others; SAHARA ClinicalTrials.gov number, NCT03309579.).

Association between serum phosphate level and mortality of patients with aneurysmal subarachnoid hemorrhage.

Disorders of serum phosphate, including hyperphosphatemia and hypophosphatemia, have been confirmed to be related to the poor prognosis of specific critically ill patients. No study analyzes the relationship between continuous serum phosphate level and mortality from aneurysmal subarachnoid hemorrhage (aSAH). This study was performed to explore this relationship. aSAH patients were divided into four groups based on serum phosphate quartiles. Significant factors discovered in the univariate Cox regression were included in the multivariate Cox regression to explore the independent relationship between serum phosphate and mortality of aSAH. Kaplan-Meier survival analysis was performed to compare the difference in survival between the four groups. The 60-day mortality of overall aSAH patients was 20.7%. The mortality of the group with the 1st quartile (29.4%) and the 4th quartile (24.7%) had higher mortality than others (p = 0.028). Univariate Cox regression showed the 2nd quartile (p = 0.020) and 3rd quartile (p = 0.017) were associated with lower mortality risk than the 1st quartile. Compared with the 1st quartile, the 4th quartile was not associated with lower mortality risk (p = 0.458). After adjusting confounding effects, multivariate Cox regression showed only the 4th quartile was significantly associated with higher mortality risk (p = 0.009) than the 1st quartile. The unadjusted relationship between serum phosphate and mortality of aSAH is U-shaped. While high serum phosphate even within the normal range is independently related to the mortality of aSAH. Low serum phosphate may be just a marker for the severity of aSAH. Evaluating the initial serum phosphate is useful for risk stratification of aSAH.

Risk factor analysis and nomogram model establishment for in-hospital death of elderly patients with surgically treated traumatic acute subdural hematoma.

The purpose of this study was to investigate the risk factors for in-hospital death in elderly patients with surgically treated traumatic acute subdural hematoma (ASDH) and to construct a nomogram model for in-hospital death risk prediction. We analyzed 104 elderly patients who underwent decompressive craniotomy (DC) for isolated traumatic ASDH between May 2013 and May 2021 in our department. Independent factors for in-hospital death were identified via univariate and multivariate logistic regression analyses, and a nomogram model was constructed and validated. The overall in-hospital mortality rate was 58.7% (61/104). Sex (odds ratio [OR] = 11.94), dilated pupils (bilateral vs absent; OR = 194.16) and subarachnoid hemorrhage (SAH) (OR = 16.01) were independent risk factors for in-hospital death. A nomogram model for in-hospital death risk prediction was constructed based on these variables. Statistical analysis revealed that this model had good predictive performance, and receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of the nomogram model was 0.916 (95% confidence interval [CI] = 0.861-0.970). The calibration plot, which compared the predicted effective rate and observed effective rate, revealed the accurate predictive ability of the model. The model was internally validated via 200 bootstrap samples to calculate the discrimination accuracy, and the concordance index was 0.891. Decision curve analysis (DCA) demonstrated that the nomogram was clinically beneficial. The most important risk factors for in-hospital death in elderly patients with surgically treated traumatic ASDH were sex, dilated pupils, and SAH. The nomogram constructed from these data could be a promising and convenient tool to predict in-hospital death risk, but further external validation is needed.