World Federation Of Neurosurgical Societies Grade Research Articles

Risk factors for cerebral edema following aneurysm clipping in patients with aneurysmal subarachnoid hemorrhage.

To investigate the factors that contribute to the development of cerebral edema after aneurysm clipping in individuals with aneurysmal subarachnoid hemorrhage (aSAH). A total of 232 patients with aSAH caused by rupture and treated with aneurysm clipping were included in the retrospective analysis of clinical data. Postoperatively, the participants were categorized into two groups based on the presence or absence of cerebral edema: a complication group (n=33) and a non-complication group (n=199).A comparison was made between the overall data of the 2 groups. In the complication group, there were higher proportions of patients experiencing recurrent bleeding, aneurysm in the posterior circulation, Fisher grade III-IV, World Federation of Neurosurgical Societies (WFNS) grade II, Hunt-Hess grade III-IV, concomitant hypertension, duration from onset to operation ≥12h, and concomitant hematoma compared to the non-complication group (p<0.05). Cerebral edema after aneurysm clipping was associated with several risk factors including repeated bleeding, aneurysm in the back of the brain, Fisher grade III-IV, WFNS grade II, Hunt-Hess grade III-IV, simultaneous high blood pressure and hematoma, and a duration of at least 12 hours from the start of symptoms to the surgical procedure (p<0.05). In patients with aSAH, the risk of cerebral edema after aneurysm clipping is increased by recurrent bleeding, aneurysm in the posterior circulation, Fisher grade III-IV, WFNS grade II, Hunt-Hess grade III-IV, concomitant hypertension and hematoma, and duration of ≥12h from onset to operation.

Comparison of efficacy between clazosentan and fasudil hydrochloride-based management of vasospasm after subarachnoid hemorrhage focusing on older and WFNS grade V patients: a single-center experience in Japan.

Subarachnoid hemorrhage often leads to poor outcomes owing to vasospasm, even after successful aneurysm treatment. Clazosentan, an endothelin receptor inhibitor, has been proven to be an effective treatment for vasospasms in a Japanese randomized controlled trial. However, its efficacy in older patients (≥ 75 years old) and those with World Federation of Neurosurgical Societies (WFNS) grade V has not been demonstrated. We retrospectively evaluated the efficacy of clazosentan in older patients and those with WFNS grade V, using real-world data. Patients with subarachnoid hemorrhage treated before and after the introduction of clazosentan were retrospectively evaluated. The patients were categorized into two groups (clazosentan era versus pre-clazosentan era), in which vasospasm management and outcomes were compared. Vasospasms were managed with fasudil hydrochloride-based (pre-clazosentan era) or clazosentan-based treatment (clazosentan era). Seventy-eight patients were included in this study: the clazosentan era (n = 32) and pre-clazosentan era (n = 46). Overall, clazosentan significantly reduced clinical vasospasms (clazosentan era: 31.3% versus pre-clazosentan era: 60.9%, p = 0.01), delayed cerebral ischemia (DCI) (9.4% versus 39.1%, p = 0.004), and vasospasm-related morbidity and mortality (M/M) (3.1% versus 19.6%, p = 0.03). In subgroup analysis of older patients or those with WFNS grade V, no significant difference was observed in clinical outcomes, although both DCI and vasospasm-related M/M were lower in the clazosentan era. Clazosentan was more effective than fasudil-based management in preventing DCI and reducing vasospasm-related M/M. Clazosentan could be used safely in older patients and those with WFNS grade V, although clinical outcomes in these patients were comparable to those of conventional treatment.

Textbook Outcomes Among Patients with Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment.

The case fatality rate among patients with aneurysmal subarachnoid hemorrhage (aSAH) has decreased progressively, with numerous patients subjected to contemporary paradigms that minimize the use of agonizing therapeutic processes. The concept of the "Textbook Outcome" (TO), a composite outcome that highlights numerous favorable outcomes, was developed in the context of gastrointestinal tumor surgeries and expeditiously extended across diverse surgical spheres. The aim of this study was to explore the factors hindering the achievement of optimal prognoses in postinterventional aSAH patients, employ textbook outcomes, and establish predictive models. We conducted a retrospective review of data from 1270 aSAH patients who received endovascular treatment between 2012 and 2018. We delineated an exemplary TO within the aSAH domain, characterized by favorable clinical results, minimal complications, and the absence of retreatments. This TO-oriented approach is explained within the manuscript. The findings revealed that preoperative intraventricular hemorrhage (IVH), preoperative Hunt and Hess grade (H&H) ≥ 3, World Federation of Neurosurgical Societies (WFNS) grade ≥ 3, the presence of blebs on the aneurysm, aneurysms situated at branching sites, and non-stent-assisted endovascular intervention were the strongest risk factors for not achieving textbook outcomes (non-"Textbook Outcome" [N-TO]). Decision curve analysis and calibration analyses revealed strong concordance between the predictions of the N-TO nomogram model and the actual observations. Treatment Outcomes hold significant practical value in clinical studies of aSAH patients receiving endovascular treatment. The likelihood of N-TOs was predicted by IVH, H&H grade ≥ 3, WFNS grade ≥ 2, presence o f bleb on the aneurysm, and aneurysms located at branching sites.

Endovascular Treatment for Ruptured Intracranial Aneurysms with Intracerebral Hematoma—Clinical Propriety of Less Invasive Treatment

Endovascular treatment of ruptured intracranial aneurysms (rIAs) accompanied by intracerebral hematoma (ICH) can be challenging because the ICH can be enlarged due to intraoperative anticoagulation during the endovascular procedure. This retrospective study aimed to compare the outcomes of aneurysmal subarachnoid hemorrhage with and without ICH treated by endovascular procedures. We reviewed 62 patients who underwent endovascular treatment of rIAs between January 2015 and April 2023. The patients were divided into 2 groups: those with ICH (group H; n= 13) and those without ICH (group N; n= 49). The patient demographics, aneurysm characteristics, World Federation of Neurosurgical Societies (WFNS) grade, complications (e.g., symptomatic vasospasm, hydrocephalus), and outcomes were assessed stratified by the presence of ICH. In group H, age, sex, complications, WFNS grade, and hematoma volume were also analyzed in relation to the outcomes at discharge. None of these patients required removal of ICH after endovascular treatment of the rIA. We found no significant differences in patient characteristics, aneurysm morphologies, WFNS grade, or overall outcomes between the 2 groups. In contrast, only a poor WFNS grade was significantly associated with poor outcomes (modified Rankin scale score ≥3) in group H (P= 0.04), and the ICH volume was not significantly different between those with good (6.2 ± 5.8 mL) and poor (14.6 ± 10.4 mL) outcomes in group H (P= 0.20). Endovascular treatment without hematoma evacuation did not adversely affect the outcomes of rIAs with ICH when the clinical condition and aneurysm morphology permitted. Surgical invasion might be avoidable with this less-invasive strategy without worsening the outcomes.

The survival and outcome of older patients with primary aneurysmal subarachnoid haemorrhage: a 2-year follow-up, multi-centre, observational study.

The management of older aneurysmal subarachnoid haemorrhage (aSAH) cases is a clinical challenge. This study aimed to analyse the survival and functional outcomes in older aSAH patients (age ≥ 70years) to provide evidence for making treatment decisions for such patients. We performed a 2-year follow-up analysis of the Chinese Multi-Centre Cerebral Aneurysm Database for older patients suffering from aSAH from 2017 to 2020. A survival analysis was used to investigate the mean survival and hazard ratios for death. Binary logarithmic regression was performed to investigate the odds ratio for independent survival and dependent survival. A total of 1,136 consecutive older patients with aSAH were assessed in this study, and 944 patients (83.1%) were followed up. The overall mean survival was 37.79 ± 1.04months. A total of 380 (40.25%) patients died within 2years after aSAH. In survival analysis, the predictors of mortality were older age, intracerebral haemorrhage (ICH) history, Hunt-Hess (H-H) grade, World Federation of Neurosurgical Societies (WFNS) grade and operative treatment decreased the risk of mortality compared to conservative treatment. In binary logarithmic regression, the predictors of dependent survival were hypertension, diabetes, WFNS grade. The risk for 2-year mortality after aSAH increases markedly with older age, ICH history, H-H grade and WFNS grade. Risk factors for 2-year dependent survival were associated with hypertension, diabetes and WFNS grade in older patients with aSAH. Operative treatment markedly decreased mortality but did not significantly decrease the morbidity of dependent survival compared to conservative treatment.

Walk-In Hospital Admission of Patients with Subarachnoid Hemorrhage: Clinical Presentation and Outcome

Neurosurgeons occasionally encounter cases of subarachnoid hemorrhage (SAH) in admitted walk-in patients, termed "walk-in SAH." However, their clinical characteristics have not been fully understood. We thus aimed to investigate several characteristics of patients with walk-in SAH and compare them with those of patients with good-grade SAH who arrived at the hospital by ambulance. Between January 2011 and January 2018, consecutive patients with World Federation of Neurosurgical Societies (WFNS) grades I and II aneurysmal SAH were enrolled. They were dichotomized into walk-in and ambulance groups, and their demographic and disease-related characteristics were compared. Furthermore, predictors associated with unfavorable outcomes were investigated in patients with walk-in SAH. Of 171 patients with WFNS grades I and II SAH, 68 (39.8%) were categorized as walk-in SAH. The mean time for diagnosis in patients with walk-in SAH was significantly longer than that in patients who arrived by ambulance (P<0.01). Multivariate analysis demonstrated that a lower rate of hypertension, high grades on the Barrow Neurological Institute scale, and Early Brain Edema Score were significantly associated with walk-in SAH (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.21-0.91, P=0.03; OR 0.32, 95% CI 0.13-0.76, P=0.007; OR 0.11, 95% CI 0.02-0.51, P<0.0001, respectively). Additionally, severe angiographic vasospasm was a significant predictor of unfavorable outcomes in walk-in SAH (OR 37.7, 95% CI 1.10-1290.90, P=0.04). Patients with walk-in SAH exhibit radiological characteristics associated with a more favorable outcome among patients with good-grade SAH. Therefore, these patients may have a positive prognosis.

Initial Temporal Muscle Thickness and Area: Poor Predictors of Neurological Outcome in Aneurysmal Subarachnoid Hemorrhage in a Central European Patient Cohort.

The temporalis muscle area (TMA) has been proclaimed as a surrogate parameter for estimating skeletal muscle mass. Pilot studies in Asian populations suggested temporal muscle thickness (TMT) and TMA as prognostic factors for neurological outcomes in aneurysmal subarachnoid hemorrhage (aSAH) patients. This study aimed to validate these findings in a larger European patient cohort. We retrospectively analyzed age, sex, aneurysm location, treatment, World Federation of Neurosurgical Societies (WFNS) grade, Fisher score, and modified Rankin Score (mRS) at six months in patients with aSAH. TMT and TMA measurements were obtained from initial native CT scans. Logistic regression with the dichotomized six-month mRS as the outcome incorporating TMT, weighted average of TMT, or TMA as predictors was performed. Of the included 478 patients, 66% were female, the mean age was 56, and 48% of patients had an mRS of three to six after six months. The mean TMT at the level of the Sylvian fissure was 5.9 (±1.7) mm in males and 4.8 (±1.8) mm in females. The mean TMA was 234.5 (±107.9) mm2 in females and 380 (±134.1) mm2 in males. WFNS grade (p < 0.001), Fisher score (p < 0.001), and age (p < 0.05) correlated significantly with the mRS after six months. No correlation was found between mRS after six months and the TMT at the Sylvian fissure (p = 0.3), the weighted average of TMT (p = 0.1), or the TMA (p = 0.1). In this central European patient cohort of 478 individuals, no significant associations were found between TMT/TMA and neurological outcomes following aSAH. Further prospective studies in diverse patient populations are necessary to determine the prognostic value of TMA and TMT in aSAH patients.

Controlling nutritional status score during hospitalization as a predictor of clinical outcome in patients with aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition with high mortality and a high permanent disability rate. In this study, we examined the association of clinical outcome with the Controlling Nutritional Status (CONUT) score during hospitalization in aSAH patients. A single-center, retrospective observational study was conducted at Gifu University Hospital. Patients transported to the emergency room for aSAH and diagnosed with World Federation of Neurosurgical Societies (WFNS) grade III and IV aSAH between April 2004 and March 2021 were enrolled. A logistic regression model was constructed to evaluate the association of the CONUT score with a modified Rankin scale (mRS) ≥ 3 and delayed cerebral ischemia (DCI). 127 patients diagnosed with WFNS grade III and IV aSAH were analyzed. CONUT score was significantly associated with mRS ≥ 3 during hospitalization. The score obtained by subtracting the CONUT score at admission from the maximum CONUT score was significantly associated with mRS ≥ 3 at discharge. Moreover, the score obtained by subtracting the CONUT score at admission from the maximum CONUT score during the first 14 days was significantly associated with DCI within 14 days from admission. These findings indicate that CONUT score during hospitalization may be a useful daily marker for predicting poor outcomes in aSAH patients.

Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage.

Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3days after the onset of symptoms. Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.

Rebleeding following aneurysmal subarachnoid hemorrhage before ‘endovascular first’ treatment: a retrospective case-control study of published scoring systems

BackgroundPre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction...

Factors related to intracerebral haematoma in patients with aneurysmal subarachnoid haemorrhage in Vietnam: a multicentre prospective cohort study

ObjectivesTo investigate the impact of intracerebral haematoma (ICH) on the outcomes and the factors related to an ICH in patients with aneurysmal subarachnoid haemorrhage (aSAH) in a low- and middle-income...

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience.

Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept. All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05. A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001). TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Predictors of Outcomes Six Months after Endovascular Coil Embolization of Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

To identify factors associated with the outcome and prognosis of coil embolization for poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively reviewed 118 patients with World Federation of Neurosurgical Societies (WFNS) grade IV or V subarachnoid hemorrhage at our institute between January 2010 and December 2020. Outcomes were assessed using modified Rankin Scale (mRS) scores at discharge and at six months after aSAH onset. In addition, patient background, aneurysm characteristics, and treatment outcome were compared between patients showing favorable (mRS scores: 0-2) and unfavorable (mRS scores: 3-6) outcomes at six months. Factors for change of mRS during follow-up were explored, and cut off values were calculated for age using the receiver operating characteristic analysis. Endovascular treatment was performed in 51 of the 118 enrolled patients. Data were analyzed for 43 of these patients who underwent coil embolization of ruptured aneurysms and had complete datasets. The mean age was 61.7 years and 24 (55.8%) patients had WFNS grade V aSAH. Coil embolization-related complications were observed in three patients. There were no treatment-related deaths; however, eight patients (18.6%) died at three months. Multivariate analysis showed that the maximum diameter of the aneurysm (p=0.041) and the postoperative dual antiplatelet therapy (DAPT) (p=0.040) were associated with unfavorable and favorable outcomes, respectively. Older age (p=0.033) was independently associated with mRS score deterioration following discharge. Age 72 years and older was the cut off value for mRS deterioration. Aneurysm size and postoperative DAPT might be associated with outcomes at 6 months. Moreover, we identified older age as an independent factor that influences mRS deterioration following discharge; thus, especially in cases of elderly patients over 72 years of age, it is highly likely that long-term care to prevent disuse and regular follow-up on imaging will be necessary.

Validation of the accuracy of the modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading scale for predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage.

Evaluating the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) who may be at risk of poor outcomes using grading systems is one way to make a better decision on treatment for these patients. This study aimed to compare the accuracy of the modified World Federation of Neurosurgical Societies (WFNS), WFNS, and Hunt and Hess (H&H) Grading Scales in predicting the outcomes of patients with aSAH. From August 2019 to June 2021, we conducted a multicenter prospective cohort study on adult patients with aSAH in three central hospitals in Hanoi, Vietnam. The primary outcome was the 90-day poor outcome, measured by a score of 4 (moderately severe disability) to 6 (death) on the modified Rankin Scale (mRS). We calculated the areas under the receiver operator characteristic (ROC) curve (AUROCs) to determine how well the grading scales could predict patient prognosis upon admission. We also used ROC curve analysis to find the best cut-off value for each scale. We compared AUROCs using Z-statistics and compared 90-day mean mRS scores among intergrades using the pairwise multiple-comparison test. Finally, we used logistic regression to identify factors associated with the 90-day poor outcome. Of 415 patients, 32% had a 90-day poor outcome. The modified WFNS (AUROC: 0.839 [95% confidence interval, CI: 0.795-0.883]; cut-off value≥2.50; PAUROC<0.001), WFNS (AUROC: 0.837 [95% CI: 0.793-0.881]; cut-off value≥3.5; PAUROC<0.001), and H&H scales (AUROC: 0.836 [95% CI: 0.791-0.881]; cut-off value≥3.5; PAUROC<0.001) were all good at predicting patient prognosis on day 90th after ictus. However, there were no significant differences between the AUROCs of these scales. Only grades IV and V of the modified WFNS (3.75 [standard deviation, SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), WFNS (3.75 [SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), and H&H scales (2.96 [SD: 2.60] vs 4.97 [SD: 1.87], p<0.001, respectively) showed a significant difference in the 90-day mean mRS scores. In multivariable models, with the same set of confounding variables, the modified WFNS grade of III to V (adjusted odds ratio, AOR: 9.090; 95% CI: 3.494-23.648; P<0.001) was more strongly associated with the increased risk of the 90-day poor outcome compared to the WFNS grade of IV to V (AOR: 6.383; 95% CI: 2.661-15.310; P<0.001) or the H&H grade of IV to V (AOR: 6.146; 95% CI: 2.584-14.620; P<0.001). In this study, the modified WFNS, WFNS, and H&H scales all had good discriminatory abilities for the prognosis of patients with aSAH. Because of the better effect size in predicting poor outcomes, the modified WFNS scale seems preferable to the WFNS and H&H scales.

Postoperative red blood cell distribution width predicts functional outcome in aneurysmal subarachnoid hemorrhage after surgical clipping: A single-center retrospective study.

Red blood cell (RBC) parameters are associated with outcomes following aneurysmal subarachnoid hemorrhage (aSAH), but their predictive value remains uncertain. This study aimed to detect the association between RBC parameters and functional outcome in aSAH patients undergoing surgical clipping. This retrospective observational study included aSAH patients who underwent surgical clipping at Affiliated Hospital of North Sichuan Medical College between August 2016 and September 2019. The functional outcome following aSAH was assessed by modified Rankin Scale (mRS), and mRS 3-6 was defined as poor functional outcome. Out of 187 aSAH patients included (62% female, 51-66 years old), 73 patients had poor functional outcome. Multivariate logistic regression of admission parameters showed that World Federation of Neurosurgical Societies (WFNS) grade (odds ratio [95% CI]: 1.322 [1.023-1.707], p = 0.033) and white blood cell (WBC) (odds ratio [95% CI]: 1.136 [1.044-1.236], p = 0.003) were independently associated with poor functional outcome. In postoperative parameters, RBC distribution width (RDW) (odds ratio [95% CI]: 1.411 [1.095-1.818], p = 0.008), mean platelet volume (MPV, odds ratio [95% CI]: 1.253 [1.012-1.552], p = 0.039) and admission WFNS grade (odds ratio [95% CI]: 1.439 [1.119-1.850], p = 0.005) were independently associated with poor functional outcome. The predictive model including WFNS grade, admission WBC, and postoperative RDW and MPV had significantly higher predictive power compared to WFNS grade alone (0.787 [0.722-0.852] vs. 0.707 [0.630-0.784], p = 0.024). The combination of WFNS grade and WBC on admission showed the highest positive predictive value (75.5%) and postoperative RDW and MPV combined with admission WFNS grade and WBC showed the highest negative predictive value (83.7%). Postoperative RDW is independently associated with poor functional outcome in aSAH patients undergoing surgical clipping. A combined model containing postoperative RDW may help predict good outcome in patients with aSAH after timely aneurysm clipping.

Comparison of Endovascular Therapy for Ruptured Cerebral Aneurysm during Spasm and Nonspasm Period.

Objective Cerebral vasospasm complicates the treatment of aneurysmal subarachnoid hemorrhage, and the optimal timing of surgery for ruptured intracranial aneurysm diagnosed during the cerebral vasospasm period has been a matter of debate. This study aimed to clarify the differences in endovascular treatment outcomes between the timing of intervention during spasm and nonspasm. Methods and Materials We retrospectively reviewed 68 consecutive patients with ruptured cerebral aneurysms who underwent coil embolization between January 2016 and March 2021. Clinical presentations, radiographic findings, and outcomes were retrospectively reviewed and compared between patients who were treated at the time of spasm and nonspasm. Information regarding the following clinical characteristics was collected: age, sex, World Federation of Neurosurgical Societies (WFNS) grade on admission, aneurysm morphology, treatment result, and outcome. We defined from day 4 to day 14 as the timing of spasm, and vasospasm as more than 30% narrowing of the proximal anterior cerebral artery, middle cerebral artery, and internal carotid artery segment during the second examination compared with the first. The chi-squared test or Fisher's exact test were performed to evaluate the covariates for binary categorical dependent variables as appropriate, and nonnormal variables were compared using the Mann-Whitney U test. Results Ten patients (14.7%) underwent coil embolization at the time of vasospasm. Age, sex, WFNS grade, and aneurysm morphology were not different between the spasm and nonspasm groups. Additionally, there were no significant between-group differences in volume embolization ratio, procedure-related complications, occurrence of delayed cerebral ischemia, and outcome at discharge. Conclusion There were no significant between-group differences in treatment results and outcomes between the spasm and nonspasm groups. Endovascular treatment at the time of vasospasm could be the optimal treatment method for ruptured cerebral aneurysms.

In-hospital complication-related risk factors for discharge and 90-day outcomes in patients with aneurysmal subarachnoid hemorrhage after surgical clipping and endovascular coiling: a propensity score-matched analysis.

More than 10 years have passed since the two best-known clinical trials of ruptured aneurysms (International Subarachnoid Aneurysm Trial [ISAT] and Barrow Ruptured Aneurysm Trial [BRAT]) indicated that endovascular coiling (EC) was superior to surgical clipping (SC). However, in recent years, the development of surgical techniques has greatly improved; thus, it is necessary to reanalyze the impact of the differences in treatment modalities on the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). The authors retrospectively reviewed all aSAH patients admitted to their institution between January 2015 and December 2020. The functional outcomes at discharge and 90 days after discharge were assessed using the modified Rankin Scale (mRS). In-hospital complications, hospital charges, and risk factors derived from multivariate logistic regression were analyzed in the SC and EC groups after 1:1 propensity score matching (PSM). The area under the receiver operating characteristic curve was used to calculate each independent predictor's prediction ability between treatment groups. A total of 844 aSAH patients were included. After PSM to control for sex, aneurysm location, Hunt and Hess grade, World Federation of Neurosurgical Societies (WFNS) grade, modified Fisher Scale grade, and current smoking and alcohol abuse status, 329 patients who underwent SC were compared with 329 patients who underwent EC. Patients who underwent SC had higher incidences of unfavorable discharge and 90-day outcomes (46.5% vs 33.1%, p < 0.001; and 19.6% vs 13.8%, p = 0.046, respectively), delayed cerebral ischemia (DCI) (31.3% vs 20.1%, p = 0.001), intracranial infection (20.1% vs 1.2%, p < 0.001), anemia (42.2% vs 17.6%, p < 0.001), hypoproteinemia (46.2% vs 21.6%, p < 0.001), and pneumonia (33.4% vs 24.9%, p = 0.016); but a lower incidence of urinary tract infection (1.2% vs 5.2%, p = 0.004) and lower median hospital charges ($12,285 [IQR $10,399-$15,569] vs $23,656 [IQR $18,816-$30,025], p < 0.001). A positive correlation between the number of in-hospital complications and total hospital charges was indicated in the SC (r = 0.498, p < 0.001) and EC (r = 0.411, p < 0.001) groups. The occurrence of pneumonia and DCI, WFNS grade IV or V, and age were common independent risk factors for unfavorable outcomes at discharge and 90 days after discharge in both treatment modalities. EC shows advantages in discharge and 90-day outcomes, in-hospital complications, and the number of risk factors but increases the economic cost on patients during their hospital stay. Severe in-hospital complications such as pneumonia and DCI may have a long-lasting impact on the prognosis of patients.

Peripheral Leukocytosis and Clinical Outcomes After Aneurysmal Subarachnoid Hemorrhage.

Background: Aneurysmal subarachnoid hemorrhage (SAH) has a high morbidity rate. Following SAH, a powerful systemic inflammatory response ensues contributing to delayed neurological deterioration and outcome. The aim of this study is to investigate if peripheral leukocytosis following SAH impacts clinical outcomes.Methods: This is a retrospective, observational, single tertiary center study of patients with SAH who underwent microsurgical clipping between 2017 and 2020. The study's inclusion criteria were aneurysmal SAH on baseline computerized tomography (CT), age above 18 years, and hospital admission within 72 hours of bleeding. Traumatic SAH, arteriovenous malformations, and mycotic aneurysms were all excluded. On admission, leukocyte counts were recorded. Demographic and clinical variables were compared between the two groups (TLC ≤12,000 and >12,000). The impact of peripheral leukocytes on clinical outcomes in terms of the Glasgow Outcome Score (GOS) was analyzed. Mann-Whitney U test for continuous variable and Fisher exact test or chi-square test for categorical variables were used for calculation of P-value. A P-value of 0.05 or less was considered statistically significant.Results: Among 90 patients who underwent clipping of ruptured aneurysms, 40 (44.4%) were anterior communicating artery (ACOMM) aneurysms, and 21 (23.3%) were middle cerebral artery(MCA), and 16 (17.8%) were posterior communicating artery (PCOMM). Clinically 57 patients (63.3%) had a World Federation of Neurosurgical Societies (WFNS) grade 1, 17 patients (18.9%) had a grade 2, four patients (4.4%) had a grade 3, and two patients (2.2%) had a grade 4. On radiological examination, six patients (6.7%) had fisher grade 1, 23 patients (25.6%) had grade 2, 22 patients (24.4%) had grade 3, and 39 (43.4%) had grade 4 SAH distribution. Clinical results were poor in 30 individuals (33.3 %), but good in 60 patients (66.7 %). On admission leukocytosis (>12,000) was seen among 34 (37.8%). Leukocytosis (>12,000) was associated with poor WFNS grade (>2); however, statistical significance was not seen with clinical outcome in terms of GOS.Conclusion: Poor clinical grade of patients following aneurysmal SAH is associated with peripheral leukocytosis; however, peripheral leukocytosis is not associated with poor outcomes.

Changes in Short-Term Outcomes After Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter, Prospective, Observational Study

The objective of the study was to clarify the prevalence of and factors associated with changes in patients' outcomes between discharge and 3months after the onset of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, the World Federation of Neurosurgical Societies (WFNS) and modified WFNS (mWFNS) scales were compared. The data of curatively treated patients with aSAH, collected prospectively in the mWFNS scale study between January 2010 and December 2012, were analyzed retrospectively. The improvement or decline in the modified Rankin Scale (mRS) scores between discharge and 3months after onset was determined. A multivariable logistic regression analysis was performed to identify factors, such as age and WFNS and mWFNS grades, associated with changes in the outcome. The mRS scores improved in 28.3% and declined in 2.5% of the patients. WFNS and mWFNS grades Ⅱ-V on admission were significantly associated with improved mRS scores at 3months after onset. Older age (age: 65-74years vs. age <65years, odds ratio: 6.59, 95% confidence interval: 1.28-34.01; age ≥75years vs. age <65years, odds ratio: 17.67, 95% confidence interval: 2.11-148.26) and WFNS grade III were significantly associated with a decline in mRS scores at 3months after onset. The optimal timing for postdischarge assessment of outcomes may be at 3months after onset, especially in older patients with aSAH. The mWFNS scale is presumed to more accurately assess the outcomes of patients with aSAH than the WFNS scale, as demonstrated in this study.

Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage

Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associatedwith unfavorable outcomes (odds ratio [OR], 9.54, P= 0.03; OR, 5.37, P= 0.04; OR, 11.80, P= 0.009; OR, 0.14, P= 0.02 and OR, 6.53, P= 0.04, respectively). The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.