Symptomatic Vasospasm Research Articles

Safety of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage: A retrospective cohort study

ObjectiveTo investigate the safety and efficacy of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients. MethodsOne hundred eleven patients with aSAH admitted between April 2015 and March 2019, were retrospectively evaluated. The early rehabilitation program was introduced in April 2017 to actively promote mobilization and walking training for aSAH patients. Therefore, patients were divided into two groups (The conventional group (n = 55) and the early rehabilitation group (n == 56). Clinical characteristics, mobilization progression, and treatment variables were analyzed. Complications (rebleeding, symptomatic cerebral vasospasm, hydrocephalus, disuse complications,) and a modified Rankin Scale (mRS) at 90 days were compared in two groups. Factors associated with favorable outcomes (mRS≤2) at 90 days were also assessed. ResultsThe early rehabilitation group had a significantly shorter span to first walking (9 vs. 5 days; P = 0.007). The prevalence of complications was not significantly increased in the early rehabilitation group. Approximately 40% of patients in both groups had pneumonia and urinary tract infections but significantly reduced antibiotic-administration days (13 vs. 6 days; P < 0.001). mRS at 90 days also showed significant improvement in the early rehabilitation group (3 vs. 2; P=0.01). Multivariate logistic regression analysis of favorable outcomes associated that the administration of the early rehabilitation program has a significant independent factor (odds ratio, 3.03; 95% confidence interval, 1.1-8.37). ConclusionsEarly rehabilitation for patients with aSAH can be feasible without increasing complication occurrences. The early rehabilitation program with active mobilization and walking training reduced antibiotic use and was associated with improved independence.

Role of Transluminal Balloon Angioplasty for the Treatment of Vasospasm Due to Aneurysmal Subarachnoid Haemorrhage: A Multicentric Indian Experience.

BackgroundAneurysmal Subarachnoid Haemorrhage (aSAH) is a complex and critical neurological condition associated with significant mortality and morbidity. Apart from the initial insult due to the aneurysmal rupture itself, re-bleeding and severe cerebral vasospasm are some of the complications of aSAH that result in overall poor outcomes. Cerebral vasospasm in post-aSAH can result in delayed ischaemic neurological deficits. In the absence of timely interventions, it can lead to grave consequences for the patient. Management of cerebral vasospasm has been evolving over the years to prevent mortality and morbidity in aSAH patients.Materials and methodsDuring 36 months from January 2018 to December 2020, 164 patients were admitted with aSAH in multiple Indian centres. Endovascular methods were used to treat all the aneurysms. Patients were observed for clinically symptomatic cerebral vasospasm. Patients with suspected vasospasm were further evaluated with a transcranial Doppler (TCD), brain computed tomography (CT) or magnetic resonance imaging (MRI) scan. In addition, digital subtraction angiography (DSA) of cerebral vessels was performed to evaluate vasospasm further. Twenty-two patients had clinically and angiographically significant vasospasm, and 20 patients were treated with transluminal balloon angioplasty (TBA).ResultsSatisfactory lumen dilation was achieved in 79 out of the 91 (86.81%) vasospastic segments, namely, distal internal carotid arteries (ICAs) 100%; middle cerebral arteries (MCA) 97.56% (M1=100%, M2=100%, M3=87.5%); vertebral arteries-100%; basilar arteries-100%; anterior cerebral arteries (ACA) 67.64% (A1=75%, A2=57.14%). The mean Modified Rankin Scale (mRS) score at 90 days was 0.75. 17 patients (85%) had an overall good outcome with no new neurological deficits. There were no cases of vessel rupture, dissection or thromboembolic complications.ConclusionTBA is a valuable, safe and effective option for managing clinically significant vasospasm caused by aSAH, adjuvant to medical management.

Current status of perimesencephalic non-aneurysmal subarachnoid hemorrhage.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a distinctive disease, representing SAH centered in perimesencephalic cisterns, with negative angiography findings. In recent years, the number of patients with PNSAH has increased significantly; however, the knowledge of PNSAH is insufficient. Therefore, we performed a review of the literature from a PubMed search and recounted our understanding of PNSAH. In this review, we summarized that current high-resolution computed tomography angiography is an acceptable replacement for digital subtraction angiography to rule out aneurysms in PNSAH with strict criteria. The current hypothesis about the etiology of PNSAH is that there is deep vein rupture from aberrant venous anatomy and increased intracranial venous pressure. PNSAH is associated with mild symptoms and lower rates of hydrocephalus and symptomatic vasospasm. For PNSAH, conservative treatment has been the mainstream treatment. PNSAH has a benign clinical course and an excellent prognosis; in long-term follow-up, re-bleeding and death were uncommon.

Cilostazol Administration for Subarachnoid Hemorrhage: A Meta-analysis of Randomized Controlled Trials.

The efficacy of cilostazol administration to treat subarachnoid hemorrhage remains controversial. We conduct a systematic review and meta-analysis to explore the influence of cilostazol administration on treatment efficacy for subarachnoid hemorrhage. We have searched PubMed, Embase, Web of science, EBSCO, and Cochrane Library databases through July 2020 for randomized controlled trials assessing the effect of cilostazol administration in patients with subarachnoid hemorrhage. This meta-analysis is performed using the random-effect model. Four randomized controlled trials involving 405 patients were included in the meta-analysis. Overall, compared with control group for subarachnoid hemorrhage, cilostazol intervention can significantly reduce symptomatic vasospasm (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.21-0.60; P = 0.0001) and cerebral infarction (OR, 0.40; 95% CI, 0.22-0.73; P = 0.003) and improve no or mild angiographic vasospasm (OR, 2.01; 95% CI, 1.19-3.42; P = 0.01) and an mRS score of 2 or less (OR, 2.70; 95% CI, 1.09-6.71; P = 0.03), but revealed no obvious influence on severe angiographic vasospasm (OR, 0.53; 95% CI, 0.27-1.02; P = 0.06). There were no increase in adverse events (OR, 1.17; 95% CI, 0.54-2.52; P = 0.69), hemorrhagic events (OR, 0.62; 95% CI, 0.06-6.27; P = 0.69), and cardiac events (OR, 2.14; 95% CI, 0.44-10.27; P = 0.34) after the cilostazol intervention than control intervention. Cilostazol treatment may be effective to treat subarachnoid hemorrhage in the terms of symptomatic vasospasm, cerebral infarction, no or mild angiographic vasospasm, and an mRS score of 2 or less.

Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome.

Purpose of ReviewTo summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS).Recent FindingsARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered.SummaryThe management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.

The impact of hormonal dynamics and serum sodium fluctuations on symptomatic vasospasm after subarachnoid hemorrhage

BackgroundSymptomatic vasospasm (SVS) is a major cause of morbidity and mortality in aneurysmal subarachnoid hemorrhage (SAH), and serum sodium frequently decreases before SVS. Serum sodium changes might be regulated by sodium metabolism-related hormones. This multi-institutional prospective cohort study therefore investigated the measurement of sodium metabolism-related hormones to elucidate the pathophysiology of serum sodium changes in SAH. MethodsSAH patients were treated with clipping or coiling from September 2017 to August 2020 at five hospitals. The laboratory data of 133 SAH patients were collected over 14 days and correlations between changes in serum sodium, sodium metabolism-related hormones (plasma adrenocorticotropic hormone (ACTH), serum cortisol, plasma arginine vasopressin (AVP)), and SVS were determined. Serum sodium concentrations were measured every day and serum sodium levels >135 mEq/L were maintained until day 14. ResultsOf the 133 patients, 18 developed SVS within 14 days of subarachnoid hemorrhage onset (SVS group) and 115 did not suffer from SVS (non-SVS group). Circulating AVP, ACTH, and cortisol concentrations were significantly higher on day 1 in the SVS group compared with the non-SVS group. Fluctuations in serum sodium in the SVS group were significantly higher than those in the non-SVS group. There were antiparallel fluctuations in serum sodium and potassium from days 2 to 14. ConclusionsElevated levels of ACTH/cortisol and AVP on day 1 may be predictive markers for the occurrence of SVS. Multiple logistic regression analysis showed that serum sodium fluctuations were associated with SVS occurrence. Serum sodium fluctuations were associated with stress-related hormonal dynamics. (249 words)

Antiplatelet therapy and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

Delayed cerebral ischemia (DCI) is a potentially preventable cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The authors performed a meta-analysis to assess the effect of antiplatelet therapy (APT) on DCI in patients with aSAH. A systematic review of the PubMed and MEDLINE databases was performed. Study inclusion criteria were 1) ≥ 5 aSAH patients; 2) direct comparison between aSAH management with APT and without APT; and 3) reporting of DCI, angiographic, or symptomatic vasospasm rates for patients treated with versus without APT. The primary efficacy outcome was DCI. The outcomes of the APT versus no-APT cohorts were compared. Bias was assessed using the Downs and Black checklist. The overall cohort comprised 2039 patients from 15 studies. DCI occurred less commonly in the APT compared with the no-APT cohort (pooled = 15.9% vs 28.6%; OR 0.47, p < 0.01). Angiographic (pooled = 51.6% vs 68.7%; OR 0.46, p < 0.01) and symptomatic (pooled = 23.6% vs 37.7%; OR 0.51, p = 0.01) vasospasm rates were lower in the APT cohort. In-hospital mortality (pooled = 1.7% vs 4.1%; OR 0.53, p = 0.01) and functional dependence (pooled = 21.0% vs 35.7%; OR 0.53, p < 0.01) rates were also lower in the APT cohort. Bleeding event rates were comparable between the two cohorts. Subgroup analysis of cilostazol monotherapy compared with no APT demonstrated a lower DCI rate in the cilostazol cohort (pooled = 10.6% vs 28.1%; OR 0.31, p < 0.01). Subgroup analysis of surgically treated aneurysms demonstrated a lower DCI rate for the APT cohort (pooled = 18.4% vs 33.9%; OR 0.43, p = 0.02). APT is associated with improved outcomes in aSAH without an increased risk of bleeding events, particularly in patients who underwent surgical aneurysm repair and those treated with cilostazol. Although study heterogeneity is the most significant limitation of the analysis, the findings suggest that APT is worth exploring in patients with aSAH, particularly in a randomized controlled trial setting.

Utility of automated MRI perfusion (RAPID) with or without MR angiography for detection of angiographic vasospasm after aneurysmal subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) is a major etiology of poor neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Although the development of DCI is certainly multifactorial, the presence of vasospasm is strongly correlated with it. Cerebral angiography remains the gold standard for evaluation of vasospasm, though it is not always practical or cost-effective. In this study, the authors assess the utility of automated MRI Perfusion imaging, with or without MR Angiography (MRA), as a confirmatory tool for suspected angiographic vasospasm. All patients admitted to a single institution with aneurysmal subarachnoid hemorrhage between January 2014 and February 2020 and who underwent MR Perfusion imaging with or without MRA for suspected vasospasm no >24 h prior to an angiogram were identified. 43 subjects were identified. 29 of these patients (67%) underwent simultaneous MRA. 25 patients (53%) received intra-arterial treatment for symptomatic vasospasm. The sensitivity, specificity, PPV, and NPV of MR Perfusion were 43%, 82%, 53%, and 75% for any angiographic vasospasm and 57%, 81%, 42%, and 89% for treated vasospasm. The sensitivity, specificity, PPV, and NPV of MR Perfusion in conjunction with MRA were 61%, 81%, 59%, and 82% for any angiographic vasospasm and 62%, 74%, 35%, and 89% for treated vasospasm. The sensitivity, specificity, PPV, and NPV of transcranial Dopplers (TCDs) in these patients were 35%, 93%, 71%, and 75% for angiographic vasospasm and 42%, 90%, 47%, and 88% for treated vasospasm. Automated MR Perfusion imaging demonstrated relatively low sensitivity and PPV for detection of angiographic and treated vasospasm in this subset of patients after aSAH.

Economic and Humanistic Burden of CerebralVasospasm and Its Related Complications after Aneurysmal Subarachnoid Hemorrhage: A Systematic Literature Review.

IntroductionCerebral vasospasm (VSP) is the leading risk factor of neurological deterioration (i.e., delayed cerebral ischemia [DCI] and cerebral infarction) after aneurysmal subarachnoid hemorrhage (aSAH) and a cause of morbidity and mortality. The objective of this systematic literature review is to summarize the economic and humanistic burden of VSP and its related complications after aSAH.MethodsA predefined protocol was designed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Systematic searches were conducted in MEDLINE, Embase, and Cochrane (in January 2021) to identify studies reporting economic and/or humanistic (i.e., health-related quality of life [HRQoL]) outcomes for patients with asymptomatic and symptomatic VSP after aSAH. Related conferences and additional sources were searched manually. Dual screening, data extraction, and qualitative analysis were conducted.ResultsOf 3818 abstracts identified for review, 43 full-text articles representing 42 single studies met the inclusion criteria and were included. Most studies (33) were observational; nine were randomized clinical trials (RCTs). Economic outcomes were reported in 31 studies, and alongside HRQoL outcomes in 4 studies; 7 studies reported HRQoL outcomes only. Forty studies were conducted in single countries, while only 2 RCTs were conducted in multiple countries. Patients diagnosed with VSP or DCI spent between 2.1 and 7.4 days longer in intensive care and between 4.7 and 17 days longer in hospital (total) compared with patients without VSP or DCI. A significantly higher cost burden of US$33,945 (2021 £26,712) was identified for patients with VSP and £9370 (2021 £13,733) for patients with DCI compared with patients without. Patients with DCI were also disadvantaged by being employed for 62 fewer days (during 24-month follow-up), with an estimated mean cost of £3821 (2021 £5600) for days off work. Poor HRQoL was associated with ≥ 1 days with VSP symptoms (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.4–5.3), symptomatic VSP (OR: 1.9, 95% CI: 1.0–3.6), and DCI (OR: 2.3, 95% CI: 1.3–4.2), although this was not consistent across all studies. Symptomatic VSP and DCI were identified as significant risk factors for depressed mood (OR: 2.2, 95% CI: 1.0–4.9) and global cognitive impairment (OR: 2.3) at 12 months, respectively. The severity of VSP was a critical predictor of post-aSAH economic and humanistic burden. Similar trends in economic and humanistic burden were identified in the general aSAH patient population. Study design and patient heterogeneity precluded direct metaanalysis of the results.ConclusionA substantial direct and indirect economic burden is linked to VSP and its related complications after aSAH. Although limited evidence was identified for humanistic burden, these patients seem to suffer from poor HRQoL with long-lasting burden. Overall, there is an urgent need to understand better the concept of “burden of illness” of VSP and its related complications after aSAH.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40120-022-00348-6.

Comparison of Symptomatic Vasospasm after Surgical Clipping and Endovascular Coiling.

Vasospasm, initial neurological damage, rebleeding, and periprocedural complications are associated prognostic factors for clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH). In this study, factors related to delayed ischemic neurological deficit (DIND) are evaluated using data from our institute for the last 18 years. Data from 2001 to 2018 of patients with aneurysmal SAH who underwent surgical clipping (SC) or endovascular coiling (EC) within 7 days of onset were retrospectively analyzed. Cases of mortality within 5 days after treatment were excluded. Multivariate analysis was used to identify the risk factors for DIND. In total, 840 cases of SAH were assessed; among these cases, 384 (45.7%) and 456 (54.3%) were treated with SC and EC, respectively. The frequency of DIND in the EC group was significantly less than that in the SC group (11.8% vs. 17.7%; p = 0.016). In the results of multivariate analysis, internal carotid artery (ICA) aneurysm and hemorrhagic complications were the risk factors for DIND. Cilostazol administration and EC were significant factors for vasospasm prevention after aneurysmal SAH (odds ratio of ICA aneurysm: 1.59, hemorrhagic complications: 1.76, SC: 1.51, and cilostazol administration: 0.51, respectively). Cilostazol administration was also a significant factor in patients who were treated with EC. ICA aneurysm, treatment strategy, hemorrhagic complications, and cilostazol administration were associated with DIND. Oral administration of cilostazol and avoiding hemorrhagic complications were effective in DIND prevention. If both treatments are available for ruptured aneurysms, clinicians should choose EC on the basis of its ability to prevent DIND.

Japanese Subarachnoid Aneurysm Trial of Neurosurgical Clipping versus Endovascular Coiling in 1863 Patients with Ruptured Intracranial Aneurysms.

This is a post hoc multivariate analysis of the modified World Federation of Neurosurgical Societies (WFNS) grading project, multicenter prospective observational study including 38 neurosurgical institutions across Japan. Japan Neurosurgical Society WFNS grading committee conducted a modified WFNS grading project as a nationwide prospective registry study. We investigate the clinical outcome of both surgical and endovascular interventions after aneurysmal subarachnoid hemorrhage (SAH) in Japan. A total of 792 patients received surgical intervention and 417 patients received endovascular treatment. Eight hundred patients were female, and 409 patients were male. The mean age was 61.5 ± 13.7 years. At 3 month follow-up, there was no statistically significant difference in good clinical outcome between surgical (68.2%) and endovascular (60.9%) group (odds ratio, 0.89; 95% confidence interval, 0.68-1.16; p = 0.381). Unfavorable outcome rate was 31.8% (238 patients) in the surgical group and 39.1% (154 patients) in the endovascular group. Male, elderly people, modified Rankin scale condition before onset, high-grade modified WFNS clinical grading scale, intracerebral hematoma, posttreatment normal pressure hydrocephalus, and neurological deficit due to symptomatic vasospasm were risk factors for the clinical outcome. Treatment modality was not a statistical factor for clinical outcomes. Surgical clipping has still a major role in the management of SAH in Japan. The present study was not a randomized controlled study, but clinical outcome is not influenced by treatment modalities.

Symptomatic cerebral vasospasm following posterior fossa hemangioblastoma resection: illustrative case.

BACKGROUNDSymptomatic cerebral vasospasm following posterior fossa intra-axial tumor resection is a rare phenomenon with only seven cases previously reported in the literature. The condition appears distinct to vasospasm following supratentorial tumor resection and extra-axial tumor resection of the posterior fossa. It shares, however, similarities with vasospasm following aneurysmal subarachnoid hemorrhage.OBSERVATIONSThe authors describe their experience with a 23-year-old female who developed delayed symptomatic vasospasm following resection of a left parapontine cerebellar hemangioblastoma. Tumor resection was complicated by rupture of a fragile arterialized vein, resulting in significant hemorrhage. The patient developed several episodes of focal and variably reversible neurological deficit. These clinical signs corresponded with angiographically confirmed vasospasm, which responded to standard therapies for vasospasm post aneurysmal subarachnoid hemorrhage.LESSONSThis case and literature review highlight that symptomatic vasospasm is a rare, potentially highly morbid complication of posterior fossa intra-axial tumor resection. This phenomenon may be related to significant intraoperative or postoperative hemorrhage. Postoperative radiological findings such as high risk modified Fisher scale hemorrhage could alert clinicians to this condition.

Effect of stress-induced hyperglycemia after non-traumatic non-aneurysmal subarachnoid hemorrhage on clinical complications and functional outcomes.

BackgroundDespite having an overall benign course, non‐traumatic non‐aneurysmal subarachnoid hemorrhage (naSAH) is still accompanied by a risk of clinical complications and poor outcomes. Risk factors and mechanisms of complications and poor outcomes after naSAH remain unknown. Our aim was to explore the effect of stress‐induced hyperglycemia (SIH) on complication rates and functional outcomes in naSAH patients.MethodsWe retrospectively reviewed patients with naSAH admitted to our institution between 2013 and 2018. SIH was identified according to previous criterion. Symptomatic vasospasm, delayed cerebral infarction, and hydrocephalus were identified as main complications. Outcomes were reviewed using a modified Rankin Scale (mRS) at discharge, 3 months, and 12 months. A statistical analysis was conducted to reveal the associations of SIH with complications and outcomes.ResultsA total of 244 naSAH patients were included in the cohort with 74 (30.3%) SIH. After adjusting for age, gender, hypertension, Hunt and Hess (HH) grade, modified Fisher Scale (mFS), intraventricular hemorrhage (IVH), and subarachnoid blood distribution, SIH was significantly associated with symptomatic vasospasm (p < 0.001, 12.176 [4.904–30.231]), delayed cerebral infarction (p < 0.001, 12.434 [3.850–40.161]), hydrocephalus (p = 0.008, 5.771 [1.570–21.222]), and poor outcome at 12 months (p = 0.006, 5.506 [1.632–18.581]), whereas the correlation between SIH and poor outcome at discharge (p = 0.064, 2.409 [0.951–6.100]) or 3 months (p = 0.110, 2.029 [0.852–4.833]) was not significant. Incorporation of SIH increased the area under curve (AUC) of ROC in the combined model for predicting symptomatic vasospasm (p = 0.002), delayed cerebral infarction (p = 0.024), hydrocephalus (p = 0.037), and 12‐month poor outcome (p = 0.087).ConclusionsSIH is a significant and independent risk factor for symptomatic vasospasm, delayed cerebral infarction, hydrocephalus, and long‐term poor outcome in naSAH patients. Identifying SIH early after naSAH is important for decision‐making and treatment planning.

Magnesium Levels and Diastolic Blood Pressure (DBP) as a Vasospasm Prediction Metric in Patients With Aneurysmal Subarachnoid Hemorrhage (SAH).

IntroductionVasospasm is a significant cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study is to evaluate a possible link between vasospasm in patients with aneurysmal SAH and magnesium and blood pressure levels.MethodsSubjects were selected based on chart review of patients presenting to a comprehensive stroke center in Southern California with aneurysmal SAH. 27 were included based on the following criteria: patients greater than 18 years of age, aneurysmal SAH, clinically symptomatic vasospasms and at least one diagnostic confirmation - either from a transcranial doppler (TCD) or digital subtraction angiogram (DSA). The following exclusion criteria also applied: 1) incomplete documentation in the medical record; 2) patients <18 years of age; and 3) patients without TCD measurements.ResultsIn an overall analysis of all patients with or without vasospasm, it was found that the presence of vasospasm was significantly correlated with diastolic blood pressures (DBPs) on day of vasospasm with an r value of 0.418 and p<0.001. Average daily DBPs throughout hospital stay were also correlated with vasospasm with an r-value of 0.455 and p<0.001. Changes in magnesium overall were also significantly related to left Lindegaard ratios with an r value of -0.201 and p value of 0.032. Lindegaard ratios were significantly correlated with age with r values of 0.510, p<0.001, and r=-0.482, p<0.001 for left and right, respectively. A change in magnesium was inversely correlated to the left Lindegaard ratio with an n of 31 and p value of 0.014 (r= -0.439) in patients with vasospasm. We also found a lower incidence of vasospasm in patients older than 65.ConclusionMonitoring magnesium and increases in DBP might be effective as a prophylactic adjunct method in patients with SAH in an effort to predict clinical vasospasm.

Vasospasm following low-velocity penetrating pediatric intracranial trauma

BackgroundBB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population.Case presentationHere, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy.ConclusionsThis case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children.

Abstract TP124: Early Neurological Improvement Can Reduce Intensive Care Unit Length Of Stay In Aneurysmal Subarachnoid Hemorrhage

Introduction: Aneurysmal Subarachnoid Hemorrhage (aSAH) is often accompanied by an extended length of stay (LOS) in the intensive care unit (ICU), at tremendous cost to both the hospital system and the patient. We sought to determine predictors for ICU LOS in these patients. Methods: We performed a retrospective study of a cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed in survivors to identify predictors for ICU LOS among factors present on admission and those related to hospital course. Results: In a cohort of 306 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. ICU LOS was longer for survivors (median 19 days, IQR 14-25) than for non-survivors (median 5 days, IQR 2-8; p&lt;0.001). For survivors (n=210), admission-related factors including Hunt and Hess grades 4 or 5 (4 additional days, 95% CI 0.5-7.5; p=0.027), hydrocephalus with external ventricular drain (EVD) requirement (9.2 additional days, 95% CI 5.7-12.8; p&lt;0.001), and coagulopathy (3.2 additional days, 95% CI 0.9-6.2; p=0.03) were associated with longer ICU LOS; however, early neurological improvement (defined as decrease in Hunt and Hess grades within first 3 days of admission) was associated with shorter ICU LOS (5.4 fewer days, 95% CI 2.7-8.5; p=0.001). Among hospital-related factors, symptomatic vasospasm (3.2 additional days, 95% CI 1.9-6.5; p=0.016), pneumonia (5.7 additional days, 95% CI 3.5-9.4; p= 0.001), and laryngeal edema requiring intubation or reintubation (4.3 additional days, 95% CI 0.7-7.8; p&lt;0.001) were associated with prolonged ICU LOS. Laboratory values from the emergency department and past medical history were not predictive for ICU LOS. Conclusion: Admission-related factors and in-hospital complications were more predictive for prolonged ICU LOS than past medical history or any laboratory values on admission. Early neurological improvement was associated with shorter ICU LOS which underscores the importance of early aggressive treatment measures in patients with aSAH.

Extracranial-intracranial bypass in a neonate with multiple ruptured middle cerebral artery aneurysms: illustrative case

BACKGROUNDReports of ruptured neonatal aneurysms are rare in neurosurgical literature. Pediatric aneurysms differ from adult aneurysms, notably in morphology, size, number, and risk of rerupture. Many authors report experience with clipping, citing durability and decreased use of radiation as benefits over endovascular intervention. Few authors report extracranial-to-intracranial bypass because small pediatric vessels make this option challenging. The authors discussed a case of a newborn with multiple ruptured aneurysms, one of the youngest reported cases involving extracranial-intracranial bypass.OBSERVATIONSA 3-week-old baby presented with hemorrhage from multiple complex middle cerebral artery (MCA) aneurysms. Because of young age, endovascular intervention was not possible; therefore, the patient received craniotomy. Upon exploration, clip reconstruction was impossible; the vessel was trapped, and superficial temporal artery (STA)-MCA bypass was performed. The recipient vessel diameter was 0.3 mm. The postoperative course was complicated by seizures as well as symptomatic vasospasm, which was treated with intraarterial verapamil and ventriculostomy. At last follow-up, the patient was developing normally and was ambulatory with minimal deficit.LESSONSThis case, one of the youngest patients reported, highlighted details of pediatric aneurysm management, such as propensity for multiple/fusiform aneurysms and high risk of re-hemorrhage, with significant mortality. The authors recommended aggressive, early intervention in pediatric aneurysms at centers with surgeons familiar with both endovascular intervention and cerebral bypass.

Cilostazol for Aneurysmal Subarachnoid Hemorrhage: An Updated Systematic Review and Meta-Analysis

Background and Purpose: Delayed cerebral ischemia is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Cilostazol, a selective inhibitor of phosphodiesterase 3, was reported to reduce cerebral vasospasm and improve outcomes. We aimed to conduct an updated systematic review and meta-analysis of the efficacy and safety of cilostazol in aSAH. Methods: We systematically searched PubMed, Embase, MEDLINE, and the Cochrane Library for articles published in English with the latest publishing time in August 2020. Articles reporting favorable outcome as the primary outcome and reporting severe angiographic vasospasm (aVS), symptomatic vasospasm (sVS), new cerebral infarction, or mortality as the secondary outcome were included in this review. Furthermore, we examined whether clinical outcomes were associated with the dosage of cilostazol (300 mg/day vs. 100–200 mg/day). Results: Data from 405 patients in 4 randomized controlled trials (RCTs) and 461 patients in 4 observational studies (OSs) were included. In RCT studies, cilostazol was associated with significant favorable outcomes at discharge or 1 month (risk ratio [RR] 1.41, 95% confidence interval [CI] 1.01–1.97, p = 0.04) or 3 or 6 months (RR 1.16, 95% CI 1.05–1.28, p = 0.002). However, in OSs, no significant difference was indicated in favorable outcomes at discharge or 1 month (RR 1.22, 95% CI 0.94–1.60, p = 0.14) nor 3 or 6 months (RR 1.29, 95% CI 0.92–1.81, p = 0.14). The analyses found that cilostazol significantly reduced the incidences of severe aVS (RCT: RR 0.64, 95% CI 0.41–1.01, p = 0.05; OS: RR 0.61, 95% CI 0.43–0.88, p = 0.007), sVS (RCT: RR 0.46, 95% CI 0.31–0.70, p = 0.0002; OS: RR 0.38, 95% CI 0.21–0.68, p = 0.001), and new cerebral infarction (RCT: RR 0.40, 95% CI 0.24–0.67, p = 0.0005; OS: RR 0.38, 95% CI 0.23–0.64, p = 0.0002). However, no significant difference in mortality (RCT: RR 0.86, 95% CI 0.23–3.21, p = 0.82; OS: RR 0.16, 95% CI 0.02–1.24, p = 0.08) was found. In 3 OSs which reported different doses of cilostazol (300 mg/day vs. 100–200 mg/day) for aSAH, the 300-mg/day cilostazol groups showed decreased delayed cerebral infarction (RR 0.27, 95% CI 0.09–0.81, p = 0.02) but no significant difference in shunt-dependent hydrocephalus (RR 0.92, 95% CI 0.33–2.60, p = 0.88) or functional outcomes (RR 1.14, 95% CI 0.74–1.75, p = 0.56) compared with the 100–200 mg/day cilostazol groups. Conclusions: The meta-analyses suggest the credible efficacy and safety of cilostazol in treating aSAH. Furthermore, 300-mg/day cilostazol treatment appeared to be more effective than 100–200 mg/day treatment.

POSA268 Economic and Humanistic Impact of Vasospasm-Related Complications Following Aneurysmal Subarachnoid Hemorrhage; Results of a Systematic Literature Review

Cerebral vasospasm (VSP) is the main risk factor of neurological deterioration (i.e., delayed cerebral ischemia [DCI] and cerebral infarction [CI]) after initial aneurysmal subarachnoid hemorrhage (aSAH) and a cause of mortality and morbidity. To identify and present the economic and humanistic burden of VSP-related complications following aSAH. PRISMA guidelines were followed. Systematic searches were conducted in MEDLINE and EMBASE (January 2021) to identify studies published in English presenting economic outcomes and/or humanistic (quality of life [QoL]) for patients with VSP (asymptomatic and symptomatic) following aSAH. Related conferences and additional sources (HTA databases, clinical trial registries) were manually searched. Dual screening, data extraction and qualitative analysis was conducted. Of 3818 studies identified, 40 met inclusion criteria and were selected. Majority of included studies were retrospective analyses or chart reviews based in US single-center hospitals. Economic outcomes were reported in 32 studies (up to 2 years follow up). 10 studies presented humanistic outcomes (up to 12 years follow up). A consistent finding across the studies was the significantly higher economic burden (hospital-care-resource-use [HCRU], hospital costs) for patients with symptomatic VSP vs patients without, after the first aSAH episode and following subsequent re-admissions (p<0.05). Patients with DCI were less likely to retain their independence at 3 months and return to full employment 24 months after aSAH. Symptomatic VSP was also strongly related to depressed mood and poor QoL at 1 year which seems to persist over the long-term (up to 5 years). There was a persistent effect of VSP severity on greater HRCU [5 extra days], requirement for care, institutionalisation, worst QoL at 3 months and hospital costs over time. A substantial direct and indirect economic burden is linked to VSP-related complications. Although limited evidence was identified for humanistic outcomes, these patients tend to suffer from poor QoL with long-lasting burden.

Initiating Mobilization Is Not Associated with Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Multicenter Case-control Study.

The study aim was to investigate the association between initiating mobilization within 7 days after onset and symptomatic cerebral vasospasm (SCV) in patients with aneurysmal subarachnoid hemorrhage (aSAH). This was a retrospective multicenter case-control study in Japan. Patients with a diagnosis of aSAH who underwent physical therapy with/without occupational therapy were included and categorized into 2 groups according to the presence or absence of SCV. Initiating mobilization was defined as sitting on the bed edge (at least once, with/without assist, regardless of duration) within 7 days after aSAH onset. Cox proportional hazards regression analysis was performed to evaluate the association between initiating mobilization within 7 days after onset and SCV. The analysis included 510 patients. Among all included patients, 57 (11.2%) patients had SCV. In the univariate Cox proportional hazards regression analysis, initiating of mobilization was not associated with SCV (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.45-1.32). In the multivariate analysis, only the modified Fisher scale was significantly associated with SCV (HR = 26.23; 95% CI = 1.21-571.0). Initiating mobilization within 7 days after aSAH onset was not associated with SCV in patients with aSAH.