World Federation Of Neurological Surgeons Research Articles

One-year survival of aneurysmal subarachnoid hemorrhage after airplane transatlantic transfer – a monocenter retrospective study

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by commercial airplane (6751 km flight) after being managed according to guidelines. This study describes the characteristics, management and outcomes related to these patients.MethodsRetrospective observational cohort study of 148 patients admitted in intensive care unit for a suspected aSAH and transferred by airplane over a 10-year period (2010–2019).ResultsThe median [interquartile range] age was 53 [45–64] years and 61% were female. On admission, Glasgow coma scale was 15 [13–15], World Federation of Neurological Surgeons (WFNS) grading scale was 1 [1–3] and Fisher scale was 4 [2–4]. External ventricular drainage and mechanical ventilation were performed prior to the flight respectively in 42% and 47% of patients. One-year mortality was 16% over the study period. By COX logistic regression analysis, acute hydrocephalus (hazard ratio [HR] 2.34, 95% confidence interval [CI] 0.98–5.58) prior to airplane transfer, WFNS grading scale on admission (HR 1.53, 95% CI 1.16–2.02) and age (OR 1.03, 95% 1.00–1.07) were associated with one-year mortality.ConclusionWhen necessary, transatlantic air transfer of patients with suspected aSAH after management according to local guidelines seems feasible and safe.

Nimodipine systemic exposure and outcomes following aneurysmal subarachnoid hemorrhage: a pilot prospective observational study (ASH-1 study).

Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH). Guidelines recommend that all patients should receive a fixed-dose nimodipine for 21 days. However, studies reported variability of nimodipine concentrations in aSAH. It is not clear if reduced systemic exposure contributes to worsening outcomes. The aim of this study was to compare nimodipine systemic exposure in those who experienced poor outcomes to those who experienced favorable outcomes. This was a pilot prospective observational study in 30 adult patients admitted to the University of Alberta Hospital with aSAH. Data were collected from the electronic health records following enrollment. Blood samples were collected around one nimodipine 60 mg dose at a steady state, and nimodipine [total, (+)-R and (-)-S enantiomers] plasma concentrations were determined. The poor outcome was defined as a modified Rankin Scale (mRS) score at 90 days of 3-6, while the favorable outcome was an mRS score of 0-2. The correlation between nimodipine concentrations and percent changes in mean arterial pressure (MAP) before and after nimodipine administration was also determined. Furthermore, covariates potentially associated with nimodipine exposure were explored. In total, 20 (69%) participants had favorable outcomes and 9 (31%) had poor outcomes. Following the exclusion of those with delayed presentation (>96 h from aSAH onset), among those presented with the World Federation of Neurological Surgeons (WFNS) grade 3-5, nimodipine median (interquartile range) area under the concentration time curve (AUC0-3h) in those with favorable outcomes were 4-fold higher than in those with poor outcomes [136 (52-192) vs. 33 (23-39) ng.h/mL, respectively, value of p = 0.2]. On the other hand, among those presented with WFNS grade 1-2, nimodipine AUC0-3h in those with favorable outcomes were significantly lower than in those with poor outcomes [30 (28-36) vs. 172 (117-308) ng.h/mL, respectively, value of p = 0.03)]. (+)-R-nimodipine AUC0-3h in those who did not develop vasospasm were 4-fold significantly higher than those who had vasospasm (value of p = 0.047). (-)-S-nimodipine was significantly correlated with percentage MAP reduction. Similar results were obtained when the whole cohort was analyzed. The study was the first to investigate the potential association between nimodipine exposure following oral dosing and outcomes. In addition, it suggests differential effects of nimodipine enantiomers, shedding light on the potential utility of nimodipine enantiomers. Larger studies are needed.

Flow Diverters versus Clipping in the Management of Blister Like Intracranial Aneurysms

Background Blister like aneurysms (BLA) are a rare form of aneurysms contributing to around 0.3 to 1% of all intracranial aneurysms. They are small, broad-based aneurysms usually less than 3 mm in diameter with very thin walls. They are most commonly found along the non-branching points of the supraclinoid portion of the internal carotid artery. It appears as thorn-like protrusions on angiography such as Computed Tomography angiography (CTA) and Digital Subtraction Angiography (DSA) the latter having a higher sensitivity than the former for BLAs albeit more invasive. BLAs may show early aneurysm growth within days to weeks after diagnosis. They have a slight female preponderance and are associated with atherosclerosis although their actual pathophysiology remains elusive. Aim of the Work To compare the degree of occlusion on conventional angiography in BLA patients treated with flow diverters with those treated by microsurgical clipping within one year of intervention. Patients and Methods Most BLAs are diagnosed after an episode of subarachnoid hemorrhage (SAH) and present clinically with a high WFNS score (World Federation of Neurological Surgeons) while the rest of BLAs are diagnosed incidentally on imaging. Due to their unique histology, BLAs are associated with higher rates of rebleed and intraoperative and post-operative rupture. Due to their small size, thin walls and tendency to re-bleed BLA are considered a challenge to both neurosurgeons and neuroradiologists. Results Our search strategy using previously mentioned key wards identified a total of 67 citations. Search was done for studies conducted or published within 2010 to 2020 duration. After removal of duplicate studies, eligibility criteria were applied to the titles of 43 articles with exclusion of non-human population and non-appropriate study design. This yielded 23 studies that underwent full-text analysis, of which 17 did not meet the inclusion criteria of having and lacking of quantitative comparison data. Six studies were included in our systematic review for analysis of population demographics and management outcome with attention to the clinical and radiological outcomes of both microsurgical clipping and flow diversion for treatment of BBAs. Conclusion In our mid-term follow-up study, we saw high occlusion and low retreatment/rerupture rates with good clinical outcomes in the majority of cases. However, dual antiplatelet therapy in the acute ruptured setting can be challenging, and requires special considerations.

Mortality among patients with subarachnoid hemorrhage: a retrospective study

Background & Objective: Subarachnoid hemorrhage (SH) accounts for 50% of hemorrhagic strokes. Few individuals present with ‘thunderclap headaches’, resulting in delayed diagnoses of aneurysmal SH (aSH). We conducted this retrospective study to explore factors for predicting the risk, severity and mortality patterns of aSH and traumatic SH (tSH).
 Methodology: A retrospective study was conducted on 68 SH patients admitted to Intensive Care Units (ICUs) of a Middle East tertiary care hospital. Medical history, demographics, risk factors, outcome and the type of SH were evaluated.
 Results: The mean age of the patients was 47.84 ± 18.24 y, and 38 (55.8%) were males, showing most SH cases occur in middle-age and in males. Majority 59 (86.7%) of the patients presented with risk factors such as trauma (35%), hypertension (37%), anti-thrombotic use (15.25%), alcoholism (3%) and smoking (1.5%). The regression model showed age and risk factors significantly influence the type and severity of SH (P < 0.05). The mortality was significantly higher in those suffering from traumatic SH compared to non-traumatic SH (84.6% versus 10.5%, P < 0.0061).
 Conclusion: Age, male gender and risk factors predispose the type and severity of SH. Mortality rates are higher among traumatic SH in comparison to non-traumatic SH patients.
 Abbreviations: SH - Subarachnoid Hemorrhage; aSH - Aneurysmal Subarachnoid Hemorrhage; tSH - Traumatic Subarachnoid Hemorrhage; WFNS - World Federation of Neurological Surgeons; MRI - Magnetic resonance imaging
 Key words: Subarachnoid hemorrhage; Risk Factors; Severity; Classification; WFNS
 Citation: Sindi AA, Abushoshah I, Bokhary DH, Banser SM, Bedaiwi WH, Bajuneid KM, Algethamy HM. Mortality among patients with subarachnoid hemorrhage: a retrospective study. Anaesth. pain intensive care 2023;27(4):545−552; DOI: 10.35975/apic.v27i4.2161
 Received: February 27, 2023; Reviewed: May 15, 2023; Accepted: May 16, 2023

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel pre- and postoperative risk factors for shunt- dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. A systematic search was conducted using Pubmed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC were reported by greater than 4 studies and could be extracted separately for patients who did or did not develop SDHC. 37 studies were included, comprising 12,667 aSAH patients (SDHC 2,214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH including high World Federation of Neurological Surgeons (WFNS) grades (odds ratio (OR) 2.43), hypertension (OR 1.33), anterior cerebral artery (ACA) (OR 1.36), middle cerebral artery (MCA) (OR 0.65), and vertebrobasilar artery (VBA) (2.21) involvement, decompressive craniectomy (DC) (OR 3.27), delayed cerebral ischemia (DCI) (OR 1.65), and intracerebral hematoma (ICH) (OR 3.91). Several new factors associated with increased odds of developing SDHC following aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of pre- and postoperative prognosticators that may influence how surgeons recognize, treat, and manage aSAH patients at high risk for developing SDHC.

Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry.

Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.

Plasma SPARC Elevation in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage.

Matricellular proteins have been implicated in pathologies after subarachnoid hemorrhage (SAH). To find a new therapeutic molecular target, the present study aimed to clarify the relationships between serially measured plasma levels of a matricellular protein, secreted protein acidic and rich in cysteine (SPARC), and delayed cerebral ischemia (DCI) in 117 consecutive aneurysmal SAH patients with admission World Federation of Neurological Surgeons (WFNS) grades I-III. DCI developed in 25 patients with higher incidences of past history of hypertension and dyslipidemia, preoperative WFNS grade III, modified Fisher grade 4, spinal drainage, and angiographic vasospasm. Plasma SPARC levels were increased after SAH, and significantly higher in patients with than without DCI at days 7-9, and in patients with VASOGRADE-Yellow compared with VASOGRADE-Green at days 1-3 and 7-9. However, there were no relationships between plasma SPARC levels and angiographic vasospasm. Receiver-operating characteristic curves differentiating DCI from no DCI determined the cut-off value of plasma SPARC ≥ 82.1ng/ml at days 7 - 9 (sensitivity, 0.800; specificity, 0.533; and area under the curve, 0.708), which was found to be an independent determinant of DCI development in multivariate analyses. This is the first study to show that SPARC is upregulated in peripheral blood after SAH, and that SPARC may be involved in the development of DCI without angiographic vasospasm in a clinical setting.

Hydrocephalus, cerebral vasospasm, and delayed cerebral ischemia following non-aneurysmatic spontaneous subarachnoid hemorrhages: an underestimated problem

Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27–84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications.

The effects of surgical clipping on the outcomes of patients with ruptured middle cerebral artery aneurysms A multi center study

The objective of the study: To determine the statistical importance of each predicted factor in terms of prognosis for patients with ruptured MCAAs, we focus on those who have had surgical treatment for their aneurysms. Materials and methods: A total of 104 patients with ruptured MCAAs were examined in this retrospective analysis, which covered the years 2018 through 2020 and was conducted by the Neurosurgical Department at MMC Hosptial Mardan , pakistan . Patient characteristics (age, sex, comorbid conditions), aneurysm location (proximal, bifurcation, or distal), aneurysm dome size (small, large, or giant), aneurysm size at the time of surgery (ultra-early, early, or delayed), and Intracerebral Hemorrhage (ICH) volume are all assessed as potential predictors. Mean, standard deviation, covariance, and correlation were determined for each parameter (through the linear regression model). Results: The World Federation of Neurological Surgeons (WFSN) grading system was used to evaluate each patient's clinical status; a score of 5 indicated excellent quality in 37 (35.3%), while a score of 4 indicated a fair rate in the remaining 28 patients.

External validation of the Ruptured Arteriovenous Malformation Grading Scale (RAGS) in a multicenter adult cohort

PurposeWhile Ruptured Arteriovenous Malformation Grading Scale (RAGS) has recently been validated in children, the literature lacks validation on adults exclusively. Therefore, we aimed to determine the validity of RAGS on the external multicenter adult cohort and compare its accuracy with other scales.MethodsA retrospective analysis was performed in five neurosurgical departments to extract patients who presented with the first episode of acute brain arteriovenous malformation (bAVM) rupture between 2012 and 2019. Standard logistic regression and area under the receiver operating curve (AUROC) calculations were performed to determine the value of the following scales: intracerebral hemorrhage (ICH), AVM-associated ICH (AVICH), Spetzler-Martin (SM), Supplemented SM (Supp-SM), Hunt and Hess (HH), Glasgow Coma Scale (GCS), World Federation of Neurological Surgeons (WFNS), and RAGS to predict change in categorical and dichotomized modified Rankin Scale (mRS) across three follow-up periods: within the 6 months, 6 months to 1 year, and above 1 year.ResultsSixty-one individuals with a mean age of 43.6 years were included. The RAGS outperformed other grading scales during all follow-up time frames. It showed AUROC of 0.78, 0.74, and 0.71 at the first 6 months, between 6 and 12 months, and after 12 months of follow-up, respectively, when categorized mRS was applied, while corresponding values were 0.79, 0.76, and 0.73 for dichotomized mRS, respectively.ConclusionThe RAGS constitutes a reliable scale predicting clinical outcomes following bAVM rupture among adults. Furthermore, the RAGS proved its generalizability across medical centers with varying treatment preferences.

Supraorbital eyebrow approach: A single-center experience.

Keyhole neurosurgery is the notion of safely removing brain and skull base lesions through smaller and more precise openings that lessen collateral damage to the surrounding scalp, brain, blood vessels, and nerves. The traditional frontal and pterional approaches require large craniotomies and this predisposes patients to significant and avoidable morbidity. With the growing expectation for minimally invasive surgery, we present our experience with the supraorbital keyhole craniotomy for surgical lesions in the anterior cranial fossa and parasellar regions. We retrospectively analyzed and evaluated all cases of neoplastic, vascular, trauma, and infective pathologies of the anterior fossa and parasellar regions treated using a keyhole approach, the supraorbital eyebrow (SOE) approach from January 2018 to June 2022. Treatment outcomes were evaluated based on pathology. A total of 50 patients underwent a SOE craniotomy during the study period (28 females and 22 males). Their average age ranged from 12 to 86 years, with a mean age of 47.4 years. All patients had anterior skull base and/or anterior frontal lobe pathologies: (23 tumors, 17 ruptured aneurysms, five traumatic frontal hematomas, three extradural empyema, one cerebral cavernous malformation, and one traumatic frontal skull base fracture with dural tear and CSF leak). Gross total tumor resection was achieved in 87% of cases (13 meningiomas of which six were giant, three gliomas, two craniopharyngiomas, and two cerebral metastases). Clip ligation occlusion rate for our aneurysm cases was 100% and intraoperative rerupture was observed in three cases. Mean ICU stay was 2.2 days for the entire series. The overall 30-day mortality rate for our series was 16% (eight deaths). This was highest in the ruptured aneurysm subgroup, with all 5 mortality cases in the aneurysmal subgroup presenting as World Federation of Neurological Surgeons (WFNS) grades ≥ III. 4 of the deaths were in WFNS IV and V patients. The most frequent perioperative complication was transient periorbital swelling which resolved within 7 days. It was observed in 18 of the 50 patients. The next common complications in descending frequency were eyebrow alopecia (three cases), supraorbital hypoesthesia (two cases), CSF leak (two cases), and surgical site infection (one case). There was one approach-related intraoperative complication secondary to carotid injury in a giant meningioma redo case. Conversion to a larger craniotomy was never necessary. Clinical outcome for our cases was evaluated according to the Modified Rankin Scale (mRS) at 3-month postsurgery. A good clinical outcome (mRS ≤ 2) was achieved for 78% of our patients. The SOE approach craniotomy is an effective minimally invasive approach for various pathologies of the anterior cranial base and parasellar regions. With experience, giant tumors and complex vascular pathology can be addressed with this keyhole approach.

The prevalence of cardiac complications and their impact on outcomes in patients with non-traumatic subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a serious condition, and a myocardial injury or dysfunction could contribute to the outcome. We assessed the prevalence and prognostic impact of cardiac involvement in a cohort with SAH. This is a prospective observational multicenter study. We included 192 patients treated for non-traumatic subarachnoid hemorrhage. We performed ECG recordings, echocardiographic examinations, and blood sampling within 24 h of admission and on days 3 and 7 and at 90 days. The primary endpoint was the evidence of cardiac involvement at 90 days, and the secondary endpoint was to examine the prevalence of a myocardial injury or dysfunction. The median age was 54.5 (interquartile range [IQR] 48.0–64.0) years, 44.3% were male and the median World Federation of Neurological Surgeons (WFNS) score was 2 (IQR 1–4). At day 90, 22/125 patients (17.6%) had left ventricular ejection fractions ≤ 50%, and 2/121 patients (1.7%) had evidence of a diastolic dysfunction as defined by mitral peak E-wave velocity by peak eʹ velocity (E/eʹ) > 14. There was no prognostic impact from echocardiographic evidence of cardiac complications on neurological outcomes. The overall prevalence of cardiac dysfunction was modest. We found no demographic or SAH-related factors associated with 90 days cardiac dysfunction.

Neurofilament light chain and S100B serum levels are associated with disease severity and outcome in patients with aneurysmal subarachnoid hemorrhage.

ObjectivesSerum neurofilament light chain (NfL) is a biomarker for neuroaxonal damage, and S100B is a blood marker for cerebral damage. In the present study, we investigated the relationship between serum NfL and S100B levels, severity, and outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH).MethodsWe prospectively recruited aSAH patients and healthy controls between January 2016 and January 2021. Clinical results included mortality and poor outcomes (modified Rankin scale score of 3-6) after 6 months. The ultrasensitive Simoa technique was used to evaluate NfL levels in the blood, and ELISA was used to detect S100B.ResultsA total of 91 patients and 25 healthy controls were included in the study, with a death rate of 15.4%. The group of aSAH patients had significantly higher serum levels of NfL and S100B (P < 0.01). Furthermore, the levels of NfL and S100B increased when the Hunt-Hess, World Federation of Neurological Surgeons (WFNS), and Fisher grades increased (P < 0.01). Serum NfL and S100B levels were linked to poor prognoses and low survival rates. The blood levels of NfL and S100B were found to be an independent predictor related to 6-month mortality in multivariable analysis. Additionally, the areas under the curves for NfL and S100B levels in serum were 0.959 and 0.912, respectively; the clinical diagnostic critical thresholds were 14.275 and 26.54 pg/ml, respectively; sensitivities were 0.947 and 0.921, and specificities were 0.849 and 0.811.ConclusionsThe NfL and S100B values for aSAH patients within 12 days of admission were considerably associated with Hunt-Hess grade, WFNS, and Fisher grade. The higher the grade, the higher the NfL and S100B value, and the poorer the prognosis. Serum NfL and S100B values could be feasible biomarkers to predict the clinical prognosis of patients with aSAH.

Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

BackgroundPatients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. MethodsWe included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H–H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. ResultsWe included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H–H grade IV versus V (aOR 2.9, 95% CI 1.9–4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0–5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6–5.1), and decreased with older age (aOR 0.7, 95% CI 0.5–1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3–0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2–0.8).ConclusionsWe present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.

External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage

PurposeExternal ventricular drains (EVD) are commonly used in aneurysmal subarachnoid hemorrhage (aSAH) patients and can be life-saving by diverting cerebrospinal fluid. However, the overall relationship between EVD use and outcome is poorly understood.MethodsIn an exploratory analysis of an aSAH patient cohort, we examined EVD use in relation to modified Rankin Scale (mRS) at hospital discharge and at 6 months (unfavorable outcome = mRS > 2) using univariable and multivariable analyses.ResultsEVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5–25) vs 11.5 (6.5–18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5–34) vs 13.5 (10.5–27) days, p = 0.015] than men and greater mRS at discharge [4 (3–5) vs 3 (2–3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3–6) vs 2 (2–3), p < 0.001] and at 6 months [4 (2–6) vs 1 (0–2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale.ConclusionIn an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation.

C-Terminal Proarginine Vasopressin is Associated with Disease Outcome and Mortality, but not with Delayed Cerebral Ischemia in Critically Ill Patients with an Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is an important indication for intensive care unit admission and may lead to significant morbidity and mortality. We assessed the ability of C-terminal proarginine vasopressin (CT-proAVP) to predict disease outcome, mortality, and delayed cerebral ischemia (DCI) in critically ill patients with aSAH compared with the World Federation of Neurological Surgeons (WFNS) score and Acute Physiological and Chronic Health Evaluation IV (APACHE IV) model.MethodsC-terminal proarginine vasopressin was collected on admission in this single-center, prospective, observational cohort study. The primary aim was to investigate the relationship between CT-proAVP and poor functional outcome at 1 year (Glasgow Outcome Scale score 1–3) in a multivariable logistic regression model adjusted for WFNS and APACHE IV scores. Secondary aims were mortality and DCI. The multivariable logistic regression model for DCI was also adjusted for the modified Fisher scale.ResultsIn 100 patients, the median CT-proAVP level was 24.9 pmol/L (interquartile range 11.5–53.8); 45 patients had a poor 1-year functional outcome, 19 patients died within 30 days, 25 patients died within 1 year, and DCI occurred in 28 patients. Receiver operating characteristics curves revealed high accuracy for CT-proAVP to identify patients with poor 1-year functional outcome (area under the curve [AUC] 0.84, 95% confidence interval [CI] 0.77–0.92, p < 0.001), 30-day mortality (AUC 0.84, 95% CI 0.76–0.93, p < 0.001), and 1-year mortality (AUC 0.79, 95% CI 0.69–0.89, p < 0.001). CT-proAVP had a low AUC for identifying patients with DCI (AUC 0.67, 95% CI 0.55–0.79, p 0.008). CT-proAVP ≥ 24.9 pmo/L proved to be a significant predictor for poor 1-year functional outcome (odds ratio [OR] 8.04, 95% CI 2.97–21.75, p < 0.001), and CT-proAVP ≥ 29.1 pmol/L and ≥ 27.7 pmol/L were significant predictors for 30-day and 1-year mortality (OR 9.31, 95% CI 1.55–56.07, p 0.015 and OR 5.15, 95% CI 1.48–17.93, p 0.010) in multivariable models with WFNS and APACHE IV scores. CT-proAVP ≥ 29.5 pmol/L was not a significant predictor for DCI in a multivariable model adjusted for the modified Fisher scale (p = 0.061).ConclusionsC-terminal proarginine vasopressin was able to predict poor functional outcome and mortality in critically ill patients with aSAH. Its prognostic ability to predict DCI was low.Trial RegistrationNederlands Trial Register: NTR4118.

263 Neurofilament light chain is a predictor of outcome after aneurysmal subarach- noid haemorrhage

BackgroundThe best predictor of clinical outcome after aneurysmal subarachnoid haemorrhage (aSAH) is the World Federation of Neurological Surgeons (WFNS) score. Yet, this marker of early brain injury only explains 12% of the variance in outcome. Prolonged neurotoxicity via extracellular haemoglobin (Hb) may play a role. Neurofilament light chain (NFL) is released during neuronal damage. We hypothesize that CSF NFL predicts clinical outcome after aSAH and reflects Hb-induced neurotoxicity.MethodsCSF was collected via an external ventricular drain from 44 high-grade aSAH patients over 14 days post-ictus, and via lumbar puncture from 11 non-haemorrhagic, non-inflammatory neurologi- cal control patients. NFL and Hb were measured using enzyme-linked immunosorbent assay and ultra- performance liquid chromatography respectively. Clinical outcome after aSAH was assessed using the modified Rankin Score (mRS).ResultsNFL was higher in aSAH versus control CSF. High CSF NFL and high WFNS independently predicted worse mRS. CSF NFL was a stronger predictor than WFNS. Post-ictus, NFL and Hb CSF concentration gradually increased over two weeks. Maximum CSF NFL was correlated with maximum preceding CSF Hb, but not WFNS.ConclusionThe biomarker NFL is a predictor of clinical outcome after aSAH. NFL concentration likely reflects delayed Hb-induced neurotoxicity rather than early brain injury.pg1p07@soton.ac.uk

Scoring System to Predict Hospital Outcome After Subarachnoid Hemorrhage–Incorporating Systemic Response: The CRIG Score

ObjectivesLocal and systemic proinflammatory and prothrombotic processes after aneurysmal subarachnoid hemorrhage (aSAH) precipitate delayed cerebral ischemia (DCI) and determine clinical outcome. Recent studies using admission and temporal trends of mean platelet volume to platelet count ratio (MPV:PLT) and neutrophil to lymphocyte ratio (NLR) have identified patients developing DCI. We examine if MPV:PLT and NLR along with admission clinical or radiological features can be used to develop a scoring system to predict DCI and in-hospital clinical outcome. Materials and methodsA 7-year retrospective cohort of aSAH patients admitted to a tertiary care medical center was used to study and identify clinical, radiological and laboratory parameters to predict DCI and clinical outcome (good: discharge to home or rehabilitation facility; poor: all other discharge destinations). Using regression analyses a scoring system (Clinical, Radiological, Inflammatory, dysGlycemia, CRIG) was developed. ResultsOf 271 patients, admission clinical grade (World Federation of Neurological Surgeons’ scale), radiological grade (modified Fisher score), NLR and glycated hemoglobin were identified as contributors for CRIG score. CRIGDCI score threshold of 112 and CRIGdischarge 109, respectively predicted DCI and adverse clinical outcome in score development cohort. The same threshold predicted DCI and adverse clinical outcome with 78.1 and 100% sensitivity, 44.0 and 52.2% specificity, and 63.2 and 61.4% accuracy, respectively in the score validation cohort. ConclusionsCRIG is an easily calculable scoring system that incorporates systemic response of aSAH – thus, alluding to its multisystem nature. It can be used at the time of admission to predict DCI and clinical outcome.

Latin American Course in Pediatric Neurosurgery. A unique and different course!

The enduring success of the European Course in Pediatric Neurosurgery, established 36 years ago by Maurice Choux, Concezio Di Rocco, and Karl Hovind, who organized it for the first time in Marseille, France in 1986, has motivated the propagation of similar courses in the Americas and Asia-Pacific regions.&#x0D; This project was strongly encouraged and endorsed by the World Federation of Neurological Surgeons (WFNS), European Society for Pediatric Neurosurgery (ESPN), International Society for Pediatric Neurosurgery (ISPN) and the local pediatric institutions and leaders [1].&#x0D; The aim of this course is to promote the development of pediatric neurosurgery through the education and training of residents and practicing neurosurgeons [2].&#x0D; Designed to cover the major fields in pediatric neurosurgery, the scientific program is divided into annual courses over a 3-year cycle, with each annual course based on a 4-day program divided in morning sessions comprising lectures and case discussions, as well as afternoon sessions with lectures, videos, “hands-on”, and “solve a case” sessions.&#x0D; During the course, a transfer of expertise between teachers, regarded as leading experts in their scientific field, and trainees is actively promoted and encouraged. The atmosphere of this course is informal and the number of trainees is thus limited in order to further promote open discussions and the development of collegiality relationships.&#x0D; An official certificate of completion is awarded to those who attend the full cycle of courses (three parts).&#x0D; The first Latin American Course in Pediatric Neurosurgery (LACPN) was held in Florianopolis, Brazil in March 2004, organized by Helio Machado and Ricardo Santos de Oliveira (3).&#x0D; Following the astonishing success of the first course, the second course moved to Puerto Iguazu, Argentina (2005), and the third to Mangaratiba in Rio de Janeiro, Brazil (2006). The second cycle was held in Natal, Brazil (2007), Cordoba in Argentina (2008), and Campos do Jordao, Brazil (2009). The third cycle started in Pirenopolis, Brazil (2010) and moved to Puerto Vallarta, Mexico (2011), and Buenos Aires (2012). In 2013, we celebrated the tenth anniversary of our LACPN. The course was held in Imbassai, Bahia, Brazil.&#x0D; After a pause, the LACPN restarted the fourth cycle in 2016, in Guaruja, then in 2018 in Lagoa Santa, and 2022 in Fortaleza. This cycle was done entirely in Brazil, and in 2020 the LACPN was recognize as an official course of the Brazilian Society for Pediatric Neurosurgery (SBNPed).&#x0D; Over the past 18 years of LACPC more than 310 different trainees (from Brazil, Argentina, Chile, Colombia, Uruguay, Mexico, Venezuela, Bolivia, Cuba, and others) and 72 faculty invitees (from Brazil, Argentina, Chile, Mexico, USA, France, Italy, Costa Rica, Colombia, Turkish, Singapore, Spain, UK, and Australia) have attended the course.&#x0D; The aim of the course is to have in each of the three regions (Europe, Latin-America, and Asia-Pacific) the same series of lectures and workshops, conducted in the same language, with the same organizational frame.&#x0D; Through the promotion of the course worldwide, we hope to build a common spirit among neurosurgeons with pediatric interests, fostering the development of confidence, collaboration, and progress.&#x0D; The LACPN is unique and different course. The course has ratings of over 80% in scientific programming, enabling an immersion in pediatric neurosurgery.&#x0D; The 5th cycle will begin in 2024 Argentina (Tigres), near Buenos Aires and then in Rio de Janeiro (2026). Be part of LACPN!

Outcome and Factors Associated with Poor-Grade Subarachnoid Hemorrhage: A Longitudinal Study

Aim: To assess the factors which determine the outcome of poor-grade subarachnoid hemorrhage. Study design: A longitudinal study Place and Duration: This study was conducted at Pakistan Surgical Center Islamabad Pakistan from April 2020 to April 2021 Methodology: The current study involved 19 patients who had a poor-grade aneurysmal subarachnoid hemorrhage and their different factors were assessed. The inclusion criteria for the study was a diagnosis of poor grade aneurysmal subarachnoid hemorrhage (grade IV or grade V as defined by World Federation of Neurological Surgeons) at the time of admission, confirmation and grading of aneurysmal subarachnoid hemorrhage by CT scans (Fisher grading system), and the aneurysm’s presence has been further confirmed by four-vessel angiography. Results: The incidence of poor-grade patients among all the patients admitted for aneurysmal subarachnoid hemorrhage was 11.89% in our study. We observed that out of 19 patients, 13 had surgeries, and among that, a good outcome was observed in 53.8% of patients. Whereas the 7 patients who were conservatively treated died. Conclusion: If patients with poor-grade aneurysmal subarachnoid hemorrhage are operated (craniotomy with clipping of aneurysm) on within 3 days, they have a 50% chance of giving rise to favorable outcomes. Keywords: Aneurysmal subarachnoid hemorrhage, Poor grade, Glasgow outcome scale