Treatment Of SAH Research Articles

Extensive bilateral anterior and posterior circulation ischemic stroke caused by severe vasospasm (Delayed cerebral ischemia) due to aneurysmal subarachnoid haemorrhage (aSAH) - A case report

Aneurysmal subarachnoid haemorrhage (aSAH) is a disease with high morbidity and mortality even in this modern era. Since treating vasospasm is a challenging task, we emphasize in developing newer aganets for the treatment of vasospasm. In the hyper acute phase, patients with SAH can have catecholamine surge-related arrhythmia, neurogenic pulmonary edema, and irreversible damage to the hypothalamus and brainstem. Delayed cerebral ischemia (DCI) is a serious complication of aneurysmal subarachnoid haemorrhage (aSAH). Though there are many clinical trials to look upon the therapies for DCI and vasospasm in aSAH, none have led to an improvement in outcome of the patient.The prognosis of patients with SAH is grave even with the recent advancements in medical treatments. One of the main cause for this situation, that there are no usable neuroprotective drugs that can be used as soon as SAH is diagnosed. We report a case of ruptured Post Communicating Artery (PCOM) aneurysm with diffuse SAH causing severe vasospasm leading to extensive bilateral anterior and posterior ischemic stroke causing severe morbidity. Since there is no therapeutic breakthrough in treatment of aneurysmal SAH, we emphasize in developing a same.

Abordagem Fisioterapêutica Na Hipertensão Arterial Sistêmica

Hypertension (AH) is a chronic non-communicable disease (NCD) defined by blood pressure levels, in which the benefits of treatment (non-medication and/or medication) outweigh the risks. It is a multifactorial condition, which depends on genetic/epigenetic, environmental and social factors, characterized by persistent elevation of blood pressure (BP), that is, systolic BP (SBP) greater than or equal to 140 mmHg and/or diastolic BP (DBP) greater than or equal to 90 mmHg, measured with the correct technique, on at least two different occasions, in the absence of antihypertensive medication. In 2021, a systematic search of the scientific literature of the main biomedical databases was carried out: Scielo, BVS, MEDLINE and Brazilian Guidelines on Hypertension between the years 2007 to 2021, aiming at the importance of physical therapy as a therapeutic in the control and treatment of SAH. It is evident that even today many difficulties are encountered to establish a 100% effective project for the prevention of SAH, but the role of physical activity in prevention and treatment, light and moderate intensity exercises, from two to three times, is notorious. in the week they were more effective, providing an improvement in the quality of life of these patients.  

α7-Acetylcholine Receptor Signaling Reduces Neuroinflammation After Subarachnoid Hemorrhage in Mice.

Aneurysmal subarachnoid hemorrhage (aSAH) causes a robust inflammatory response which leads worse brain injury and poor outcomes. We investigated if stimulation of nicotinic acetylcholine α7 receptors (α7-AChR) (receptors shown to have anti-inflammatory effects) would reduce inflammation and improve outcomes. To investigate the level of peripheral inflammation after aSAH, inflammatory markers were measured in plasma samples collected in a cohort of aSAH patients. To study the effect of α7-AChR stimulation, SAH was induced in adult mice which were then treated with a α7-AChR agonist, galantamine, or vehicle. A battery of motor and cognitive tests were performed 24h after subarachnoid hemorrhage. Mice were euthanized and tissue collected for analysis of markers of inflammation or activation of α7-AChR-mediated transduction cascades. A separate cohort of mice was allowed to survive for 28days to assess long-term neurological deficits and histological outcome. Microglia cell culture subjected to hemoglobin toxicity was used to assess the effects of α7-AChR agonism. Analysis of eighty-two patient plasma samples confirmed enhanced systemic inflammation after aSAH. α7-AChR agonism reduced neuroinflammation at 24h after SAH in male and female mice, which was associated with improved outcomes. This coincided with JAK2/STAT3 and IRAK-M activity modulations and a robust improvement in neurological/cognitive status that was effectively reversed by interfering with various components of these signaling pathways. Pharmacologic inhibition partially reversed the α7-AChR agonist's benefits, supporting α7-AChR as a target of the agonist's therapeutic effect. The cell culture experiment showed that α7-AChR agonism is directly beneficial to microglia. Our results demonstrate that activation of α7-AChR represents an attractive target for treatment of SAH. Our findings suggest that α7-AChR agonists, and specifically galantamine, might provide therapeutic benefit to aSAH patients.

Craniectomia descompresiva en cirugía de aneurismas. ¿Cuando y cómo realizarla?

Introducción: La Craniectomía Descompresiva es una técnica quirúrgica conocida desde hace más de un siglo, sin embargo, su utilidad ha sido debatida por diferentes neurocirujanos a lo largo de los años. Después del año 1998, la técnica pasó a ser utilizada de forma significativa para una amplia variedad de patologías en las que la hipertensión intracraneal tiene comportamiento refractario. La técnica de descompresión intracraneal aumenta la complacencia, disminuye la presión intracraneal y aumenta la presión de perfusión cerebral con preservación del tejido. Objetivo: Nuestro objetivo es establecer cuándo y cómo realizar la Craniectomía Descompresiva frente a una complicación de la Hemorragia Subaracnóidea Aneurismática o cirugía de aneurismas no rotos. Metodología: Se realizó un universo transversal mediante la revisión de los prontuarios de pacientes sometidos a craniectomia descompresiva debido a la hemorragia subaracnoidea aneurismática o aneurismas no rotos. Los procedimientos se realizaron en el Servicio de Neurocirugía de la Santa Casa de Misericordia de Ribeirão Preto, SP. Resultados: Del año 2010 a 2014, se realizaron 144 craniectomías, siendo 37 por aneurismas (22 rotos); (3%), grado II: 14 casos (64%), grado III: 1 caso (4%), grado II: 7 casos (32%), grado II: 14 casos (64%), grado III: 1 caso (4%); (2%), Fisher 2: 3 casos (14%), Fisher 3: 5 casos (23%), Fisher 4: 8 casos (36%), 15 casos no rotos. La edad media de los pacientes fue de 48 años. 22 casos (60%) sobrevivieron (14 asintomáticos, 4 con déficit, 2 síntomas menores, 2 pérdida de seguimiento); 15 casos (40%) fallecieron. Se produjo 10 casos reoperados, siendo 1 caso el mismo día, 4 casos en el 2º día y 5 casos en el tercer día. De estos, 4 (40%) sobrevivieron y 6 (60%) fallecieron. Complicaciones de las reoperaciones: 1 hidrocefalia, 3 is-quios, 4 hematomas intraparenquimatosos, 2 hipertensiones refractarias. Hunt-Hess y Fisher altos fueron los de peor pronóstico. Las complicaciones que resultaron en craniectomia fueron hematomas, isquemia, edema o asociaciones, asimetría y desviación de la línea media mayor que 0,5 cm. Discusión: El objetivo de la Craniectomía descompresiva es reducir la presión intracraneal, independientemente del factor causal, cuando la PIC se eleva a valores alarmantes. En 1940, Erlich sugirió la realización de Craniectomía Descompresiva para todas las lesiones craneales con coma persistente por más de 24-48 horas. Rowbotham, en 1942, recomendó la técnica para todos los comas traumáticos en que el tratamiento clínico fue ineficaz por 12 horas. Los pacientes con HSA severa a menudo poseen un pronóstico malo, no obstante, sobre la base de los resultadosalentadores de la Craniectomía Descompresiva en el tratamiento de los TCE y AVCi, hay crecientes relatos de la efectividad de la craneiectomía descompresiva en el tratamiento de HSA. Conclusión: Craniectomía Descompresiva reduce la hipertensión intracraneal con disminución de la morbimortalidad. No indicamos craniectomías localizadas por el riesgo de isquemia en los bordes y empeoramiento clínico. La cirugía precoz evoluciona con mejores resultados, menor número de muertes y fortalece la relación médico-paciente. La monitorización de la presión intracraneal (PIC) es fundamental, sobre todo en los casos limítrofes, en los que la decisión sobre la realización de la craniectomía es un desafío en el primer momento.

Abstract WP114: Incidence and Treatment of Unruptured Brain Aneurysms versus SAH in the United States: Trends and Complications over Two Decades

Introduction: Following publication of ISAT in 2002 showing better outcomes with coiling versus clipping of ruptured aneurysms, there was a substantial increase in endovascular management of ruptured aneurysms. This in turn led to coiling becoming the predominant treatment in both SAH and unruptured aneurysms (UA), as well as an overall increase in volume of aneurysms treated in the USA. However, ISAT did not address UA, and it is unclear if real-world practice trends over the past decade justify this change in both practice pattern and volume. Methods: National Inpatient Sample datasets from 1993 to 2015 were obtained and data extracted using ICD-9-CM codes for the diagnosis of UA and SAH, and procedural treatments including clipping and coiling. Age-standardized incidence rates of UA and SAH were estimated. Differences in demographics, hospital characteristics and procedure complications by diagnostic groups were examined, and risk ratios were obtained for factors associated with routine discharge and hospital mortality using poisson regression. Results: From 1993 to 2015, overall treatment of UA significantly increased, yet the incidence of SAH did not change (figure 1). A trend towards increasing procedural complications was noted in SAH, likely related to a concomitant trend observed in increasing patient age and comorbidities. In contrast, recent complication rates of UA repair appeared to plateau or slightly diminish (2011-2015). Clipping of UA remained associated with significantly higher risk ratios for complications when compared with coiling and led to fewer favorable discharges. Conclusion: We conclude that the age-adjusted incidence of SAH in the United States has remained unchanged throughout the past two decades despite a 3-fold increase in treatment of UA. Modern complication rates of clipping and coiling UA appear relatively stable, with clipping demonstrating significantly higher complication rates and less favorable discharges.

A Narrative Review of Adherence to Subarachnoid Hemorrhage Guidelines.

Over the past 2 decades, a large number of guidelines for aneurysmal subarachnoid hemorrhage (aSAH) management have been proposed. The primary aim of these "evidence-based" guidelines is to improve the care of aSAH patients by summarizing and making current knowledge readily available to clinicians. However, an investigation into aSAH guidelines, their changes along time and their successful translation into clinical practice is still lacking.We performed a literature search of historical events and subarachnoid hemorrhage guidelines using the Entrez PubMed NIH, Embase, and Cochrane databases for articles published up to November of 2016. Data were summarized for guidelines on aSAH management and cross-sectional studies of their application. A total of 11 guidelines and 10 cross-sectional studies on aSAH management were analyzed. The use of nimodipine for the treatment of SAH is the only recommendation that remained consistent across guidelines over time (r=0.82; P<0.05). A shift in the definitive treatment for aneurysms from open surgical clipping to endovascular coiling was also noted (r=-0.91; r=0.96; P<0.005). In addition, definitive treatment for aneurysm is being performed earlier. The use of triple-H therapy and the long-term administration of anticonvulsive therapy has decreased. Finally, written protocols for aSAH management were not consistently used across tertiary care institutions (r=-0.46; P=0.43; confidence interval, -0.95 to -0.70).We conclude that guidelines related to the management of patients with SAH have evolved from a consensus-based approach into an evidence-based approach. Nevertheless, the translation into clinical practice is limited, suggesting that personalized approaches to care is inherent, and perhaps necessary for aSAH management.

Anti-TNF-alpha antibody attenuates subarachnoid hemorrhage-induced apoptosis in the hypothalamus by inhibiting the activation of Erk.

BackgroundSubarachnoid hemorrhage (SAH) can induce apoptosis in many regions of the brain including the cortex and hippocampus. However, few studies have focused on apoptosis in the hypothalamus after SAH. Although some antiapoptotic strategies have been developed for SAH, such as anti-tumor necrosis factor-alpha (TNF-α) antibody, the molecular mechanisms underlying this condition have yet to be elucidated. Therefore, the purpose of this study was to evaluate whether SAH could induce apoptosis in the hypothalamus and identify the potential molecular mechanisms underlying the actions of anti-TNF-α antibody, as a therapeutic regimen, upon apoptosis.Materials and methodsSAH was induced in a rat model. Thirty minutes prior to SAH, anti-TNF-α antibody or U0126, an extracellular signal-regulated kinase (Erk) inhibitor, was microinjected into the left lateral cerebral ventricle. In addition, phorbol-12-myristate-13-acetate was injected intraperitoneally immediately after the anti-TNF-α antibody microinjection. Then, real-time polymerase chain reaction, Western blotting and immunohistochemistry were used to detect the expression of caspase-3, bax, bcl-2, phosphorylated Erk (p-Erk) and Erk. Finally, anxiety-like behavior was identified by using open field.ResultsLevels of caspase-3, bax and bcl-2, all showed a temporary rise after SAH in the hypothalamus, indicating the induction of apoptosis in this brain region. Interestingly, we found that the microinjection of anti-TNF-α antibody could selectively block the elevated levels of bax, suggesting the potential role of anti-TNF-α antibody in the inhibition of SAH-induced apoptosis in the hypothalamus. Moreover, we found that Erk activation was necessary for apoptosis after SAH and that the microinfusion of anti-TNF-α antibody could inhibit apoptosis by suppressing the increase of p-Erk in the hypothalamus. Finally, our data indicated that the infusion of anti-TNF-α antibody could improve anxiety-like behavior.ConclusionCollectively, our data demonstrate that anti-TNF-α antibody attenuates apoptosis in the hypothalamus by inhibiting the activation of Erk, which plays an important role in the treatment of SAH.

MANAGEMENT OF HEADACHE IN PATIENTS WITH NON-TRAUMATIC SUBARACHNOID HEMORRHAGE

This review of the literature is devoted to the current state of the problem of management of headache in patients with non-traumatic subarachnoid hemorrhage (NSAH). This pathology is associated with severe and prolonged headache. Despite the huge amount of references on subarachnoid hemorrhage, a little attention is paid to headache in this pathology, so it remains largely unexplored. The article presents data on the epidemiology of the syndrome, possible mechanisms of occurrence, diagnostic methods. Details of the advantages and disadvantages of drugs for anesthesia, available in the arsenal of the clinician at the moment. The results of many previously published studies are diametrically opposed, which does not facilitate the choice of tactics for effective treatment and prevention of complications. The article also identifies the problems, the solution of which, possibly, will lead to an improvement in the results of treatment of SAH and further the quality of life of the patients. The lack of evidance data on the subject suggests that the research is relevant.

State of Practice: Endovascular Treatment of Acute Aneurysmal SAH in Germany.

Acute aneurysmal SAH is a severe disease that requires prompt treatment. Endovascular coiling and neurosurgical clipping are established treatment options. Our intention was to determine the state of current practice in acute aneurysmal SAH treatment in Germany, with emphasis on logistic and temporal aspects. We interviewed 74 German university and nonuniversity hospitals with an anonymous questionnaire comprising 15 questions concerning the practice of treatment and diagnostics of acute aneurysmal SAH at their respective institutions. The response rate was 74% among all institutions (55/74); among university hospitals, 77%; and among nonuniversity hospitals, 72%. The majority of all aneurysms were treated endovascularly (66% of acute aneurysmal SAH, 66% of unruptured aneurysms). Treatment on weekends was provided by 100% of endovascular and 96% of neurosurgical facilities. Average patients with acute aneurysmal SAH were not treated during the night (98%). Seventy percent of endovascular and 78% of neurosurgical treatments were not started later than 8:00 pm. Fifty-three percent of hospitals would not start a same-day diagnostic angiography in acute aneurysmal SAH if treatment was scheduled for the following day. Eighty-two percent of all centers performed DSA after clipping to evaluate the treatment results. Our survey gives a detailed summary of the current practice of endovascular treatment and related topics in acute aneurysmal SAH in Germany and also reveals considerable changes in practice in comparison with older data.

The Role of Fenestration of the Lamina Terminalis on Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Clinical Research.

To compare the beneficial effects of cisternal blood clot evacuation with or without microsurgical fenestration of the lamina terminalis (LT) on symptomatic vasospasm during the course of aneurysmal subarachnoid hemorrhage. This was a clinical, retrospective study that included 72 patients with aneurysmal subarachnoid hemorrhage (aSAH). The patient group that underwent aneurysm clipping with only extensive cisternal drainage of the subarachnoid blood clot was defined as the non fenestrated lamina terminalis group (NonFLT group, n=39). The patient group that underwent aneurysm clipping with extensive cisternal drainage of the subarachnoid blood clot combined with microsurgical fenestration of LT was defined as the fenestrated lamina terminalis group (FLT group, n=33). All patients were operated by the same experienced neurovascular surgeon, the senior author of this article (MEU), and his colleagues. New cerebral infarct development was determined with computed tomography, Glasgow Outcome Score (GOS), clinical vasospasm rate and Hunt-Hess scale (H&H) grade before and after surgery and duration of hospital stay of the patients were assessed and compared. A favorable clinical outcome was obtained from 51.2% of the NonFLT group patients and 72.66% of the FLT group patients. And FLT group patients have better GOS and H&H grade. Clinical vasospasm rate and duration of hospital stay were also significantly reduced in FLT group patients. Wide fenestration of lamina terminalis as a cerebrospinal fluid diversion technique may be very beneficial in the surgical treatment of aneurysmal SAH.

Editorial [(Hot Topic Novel Drug Therapies in the Treatment of SAH) Guest Editors: Surya Karri and Christopher S. Ogilvy

Editorial [(Hot Topic Novel Drug Therapies in the Treatment of SAH) Guest Editors: Surya Karri and Christopher S. Ogilvy

Non-Steroidal Anti-Inflammatory Drugs used as a Treatment Modality in Subarachnoid Hemorrhage

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed therapies worldwide. Meta-analysis data indicate the potential for myocardial infarction, cerebrovascular incident, heart failure, renal failure and arterial hypertension. Here we review the mechanisms of their actions and the potential for therapeutic use in subarachnoid hemorrhage. Searches were performed using PubMed with the search terms "subarachnoid hemorrhage", "NSAID", "treatment", "management", "cerebral aneurysm", and "vasospasm" from 1970 to February, 2012. Articles were also identified through searches of the Cochrane library and searches of the authors' own files. Only papers published in English were reviewed.There are considerably mixed views on the potential impact of NSAIDs on the treatment and prevention of SAH. Whilst theoretically, the potential for positive intervention in the condition is huge, little effect appears to be measurable in clinical practice.

February 10 Highlights

In a decision model that assessed the risks/benefits of screening for new aneurysms after successful treatment of SAH, Wermer et al. showed that complications from preventive treatment outweighed the benefits from preventing new episodes of SAH. Because of the limited data on key factors in the model, is possible that more empirical data may change the balance. see page 369 The accompanying editorial by Brown and Piepgras emphasizes that the model suggests that the overall screening for new aneurysms after SAH does not lead to an increased number of quality-adjusted life years. However, among the factors that had the most marked impact on outcome were the risk of arteriography and treatment—both likely to change with advances in techniques. They also note that where the risk is higher than usual—such as among families with two or more members who previously had a SAH or intracranial aneurysm—“one size does not …

高齢者破裂脳動脈りゅうにおける臨床像および治療方針の検討

Although the treatment of SAH has been much improved recently, the prognosis in elderly patients remains poor due to problems related to the aging. In order to consider future strategy to improve treatment results, it is important to know the character of SAH specific to elderly patients. The clinical features in 65 SAH patients aged between 70 and 88 years, treated between 1997 and 2002, were investigated. The results of clipping in the acute stage were analyzed in relation to tolerability to the active treatments in elderly patients. The effect of operation in the acute stage showed remarkable contrast in each group of clinical condition: in the severe group only 16% in their 70s and 0% in their 80s showed good recovery but in the mild group it was 84% in those in their 70s and 83% in those in their 80s, which was comparable to the outcome in younger patients. The clinical condition in patients with poor outcome was characterized by the presentation of disturbance in higher cortical function, indicating the presence of generalized damage in the brain in elderly patients. SAH in elderly patients is characterized clinically by distinction of 2 groups: one in which the effect of SAH easily resulted in generalized brain damage and the other in which patients could withstand the effect of SAH. The latter group can be treated aggressively. For the former group, treatments consisting of palliative measures such as embolization and meticulous general care are essential.

8.重症例 : 低体温(PS 1 脳動脈瘤の的確な診断と治療)

8.重症例 : 低体温(PS 1 脳動脈瘤の的確な診断と治療)

Magnetic Resonance Imaging following Treatment of Aneurysmal SAH by Neurosurgical Clipping or Endovascular Coiling: Comparison of Parenchymal Damage with Cognitive Outcome

The relative contribution to cognitive outcome of haemorrhage and surgery following aneurysmal subarachnoid haemorrhage has been assessed using a battery of cognitive tests and magnetic resonance imaging one year after the procedure. To tease out the effect of surgery we have used 40 case-matched patients treated with endovascular coiling as controls. Surgery resulted in greater areas of structural damage than endovascular coiling. Both the surgical and the coiled groups were cognitively impaired on a broad range of cognitive tasks. When comparing the coiled and clipped groups there is a trend towards a poorer cognitive outcome amongst the surgically treated patients. Cognitive outcome following aneurysmal subarachnoid haemorrhage is primarily dictated by the haemorrhage. This first comparison of the two techniques, however, suggests that endovascular coiling may be more advantageous than surgery in the treatment of aneurysmal subarachnoid haemorrhage.

Safety of Ventriculostomy Placementin Patients Requiring Heparinization after GDC Treatment of Acute Aneurysmal SAH

Safety of Ventriculostomy Placementin Patients Requiring Heparinization after GDC Treatment of Acute Aneurysmal SAH

Early management of the patient with recent aneurysmal subarachnoid hemorrhage.

Despite its efficacy in preventing rebleeding, the anticipated strong trend in favor of early intracranial surgery has not been achieved. Early intracranial operation remains a useful choice in the management of recent SAH in good-risk patients, but patients must be carefully selected on an individual basis. Many patients will undoubtedly benefit from early surgery but it is not a panacea. Further investigation of surgical treatment in combination with improved preoperative and postoperative medical therapy will be required to ameliorate the outcome of SAH. In particular, the prevention and treatment of cerebral infarction deserves attention. The results of the antifibrinolytic and timing of intracranial surgery studies point to the need for an effective prevention treatment regimen for vasospasm. Further studies about the efficacy of calcium channel blocking drugs in prevention of ischemia after SAH are needed among patients given antifibrinolytic drugs or having early operation. All the advances in treatment are predicated on prompt diagnosis of SAH in good-condition patients. The medical community needs to maintain a high degree of vigilance for the diagnosis of SAH in all patients complaining of a new, unusual or severe headache. Early referral to properly equipped and staffed medical facilities remains a keystone to effective treatment of SAH.

Current-voltage characteristics of surface barrier liquid-junction and metal-junction cells including recombination

A new expression for the current-voltage ($\mathrm{IV}$) characteristic is derived without assuming constant quasi-Fermi-levels in the depletion region of a surface barrier device, nor a constant surface minority-carrier density. Explicit expressions for recombination effects are discussed but are not involved directly in the treatment. However, the effects appear in the gradient of the excess-carrier transfer velocity. This velocity and its gradient can be obtained empirically by matching experimental curves. The expression is shown to match $\mathrm{IV}$ curves from CdSe photoelectrochemical cells and metal---Schottky-barrier cells based on GaAs. Some of the quasi-Fermi-level (QFL) treatment of Sah, Noyce, and Shockley is corrected to show larger QFL variations in $p\ensuremath{-}n$ junctions than previously supposed. The spacing of the minority-carrier QFL from the Fermi level is calculated at the surface for several semiconductors.