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Objective To investigate the relationship between serum mannan binding lectin(MBL),histi-dine rich glycoprotein(HRG),interleukin(IL)-23/IL-17 inflammatory axis and cerebral vasospasm(CVS)and prognosis in patients with aneurysmal subarachnoid hemorrhage(aSAH)after interventional emboliza-tion.Methods A total of 195 patients with aSAH who underwent interventional embolization treatment in the hospital from March 2019 to February 2022 were selected and were divided into no CVS group(126 cases),mild CVS group(18 cases),moderate CVS group(39 cases),and severe CVS group(12 cases)according to the occurrence and severity of CVS detected by digital subtraction angiography at the 4th postoperative day.The levels of serum MBL,HRG,IL-23 and IL-17 among the four groups before and 3 d after surgery were compared.The patients were followed up for 6 months and divided into good prognosis group(137 cases)and poor prognosis group(58 cases)according to their prognosis.Factors influencing poor prognosis in aSAH pa-tients were analyzed by multivariate Logistic regression model.The predictive value of serum MBL,HRG,IL-23,IL-17 levels and their combined application models for poor prognosis in patients with aSAH was analyzed by receiver operating characteristic(ROC)curve.Results The incidence rate of CVS after interventional em-bolization was 35.38%in 195 patients with aSAH.3 d after surgery,the serum levels of MBL,IL-23 and IL-17 in the mild,moderate,and severe CVS groups were higher than those in the no CVS group,those in the severe CVS group were higher than those in the moderate CVS group,those in the moderate CVS group were higher than those in the mild CVS group(P<0.05).The serum HRG levels in the mild,moderate,and severe CVS groups were lower than those in the non CVS group,those in the severe CVS group were lower than those in the moderate CVS group,those in the moderate CVS group were lower than those in the mild CVS group(P<0.05).3 d after surgery,the levels of serum MBL,IL-23 and IL-17 in the four groups were higher than that before surgery,while the levels of serum HRG were lower than that before surgery(P<0.05).The pro-portions of patients with aneurysm diameter≥6 mm,number of aneurysms>1,surgery time>24 h,Hunt-Hess grade Ⅲ/Ⅳ and postoperative CVS,and serum levels of MBL,IL-23,and IL-17 on the 3rd day after sur-gery in the good prognosis group were lower than those in the poor prognosis group,and serum HRG levels at 3 d after surgery in the good prognosis group were higher than that in the poor prognosis group(P<0.05).Multivariate Logistic regression analysis showed that aneurysm diameter≥6 mm,Hunt-Hess grade Ⅲ/Ⅳ and postoperative CVS,elevated serum levels of MBL,IL-23,and IL-17 and decreased HRG level at 3 d after sur-gery were independent risk factors for poor prognosis in aSAH patients(P<0.05).ROC results showed that serum levels of MBL,HRG,IL-23,and IL-17 at 3 d after surgery had certain predictive power for poor progno-sis in patients with aSAH.The predictive model with the combined application of four indicators had relatively high efficiency(the area under the curve was 0.853).Conclusion Elevated levels of MBL,IL-23,IL-17,and decreased HRG levels in aSAH patients after interventional embolization could increase the risk of CVS and are associated with poor prognosis in aSAH patients after interventional embolization.The above indicators have a certain predictive power for poor prognosis in aSAH patients.

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Objective To investigate the relationship between factors related to the transforming growth factor β(TGF-β)/Aerine-threonine kinase receptors(Smads)signaling pathway and cognitive dysfunction in peripheral blood of patients with aneurysmal subarachnoid hemorrhage(aSAH).Methods The clinical data of 100 patients with aSAH admitted to Chongzuo City People's Hospital from October 2018 to March 2022 were retrospectively selected and grouped according to the patients'Montreal Cognitive Assessment Scale(MoCA)scores,including 54 cases with cognitive dysfunction and 46 cases without cognitive dysfunction.The clinical data,peripheral blood TGF-β,Smad1,Smad3,and Smad7 mRNA expression levels of the two groups were compared.The relationship between pathway-related factors and cognitive dysfunction in patients with aSAH was analyzed in a multifactorial manner.The predictive value of pathway-related factors for cognitive dysfunction in aSAH patients was assessed using the receiver operating characteristic(ROC)curve.Results Peripheral blood TGF-β,Smad1,Smad3,and Smad7 mRNA expression levels were higher in the cognitively impaired group than in the group without cognitive impairment(P<0.05).Multifactorial showed that pathway-related factors were significantly associated with cognitive impairment in patients with aSAH(P<0.05).The ROC showed that the area under the curve(AUC)of pathway-related factors jointly predicted cognitive dysfunction in patients with aSAH was superior to that predicted alone(P<0.05).Conclusion The high expression of factors related to the TGF-β/Smads signaling pathway in the peripheral blood of aSAH patients suggests that this pathway may be associated with cognitive dysfunction in patients.

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Objective To investigate the clinical correlation of Naomai Jiejing decoction with cerebrovascular hemodynamics,thromboelastography(TEG)and rehabilitation outcome in patients with aneurysmal subarachnoid hemorrhage(aSAH).Methods A total of 160 patients with aSAH admitted to Zhongshan Traditional Chinese Medicine Hospital from January 2020 to December 2022 were selected as the study objects,and were divided into study groupand control group according to whether the patients used Naomai Jiejing decoction.The control group was treated with basic therapy combined with nimodipine,the study group was treated with basic therapy combined with nimodipine and Naomai Jiejing decoction(No.1)before surgery,and was treated with basic therapy combined with Nimodipine and naomai Jiejing decoction(No.2)after surgery.Chinese medicine symptom score,cerebrovascular hemodynamics indexes[systolic peak velocity(Vs),mean blood velocity(Vm),end-diastolic peak velocity(Vd),pulsatile index(PI)and resistance index(RI)]and TEG parameters[maximum amplitude(MA),α angle and coagulation index(CI)]were compared between the two groups before and after treatment.Finally,the short-term prognosis of the two groups was evaluated by glasgow prognostic score,and the short-term prognosis of the two groups was compared.Results A total of 160 aS AH patients were included,with 85 in the study group and 75 in the control group.After treatment,the Chinese medicine symptom scores in the study group were significantly lower than those in the control group(P＞0.05).After treatment,the indexes of cerebrovascular hemodynamics in the study group were better than those in the control group(P＜0.05).After treatment,the TEG parameters in the study group were significantly lower than those in the control group(P＜0.05).The overall prognosis of the study group was better than that of the control group,and the proportion of patients with good recovery was significantly higher than that of the control group(P＜0.05).Conclusion Naomai Jiejing decoction has a good treatment effect on aSAH patients,can improve cerebrovascular hemodynamics and TEG parameters,relieve clinical symptoms,and improve the short-term prognosis of patients.

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Background Aneurysmal subarachnoid hemorrhages (aSAHs) account for 5% of all strokes, an appalling number when it comes to the second most common cause of death worldwide. The basis of the treatment is clinical support and either endovascular or surgical intervention. The purpose of the present study is to analyze if the time from the onset of the thunderclap headache until treatment intervention is related to the degree of disability after 6 months. Methods In the present prospective observational study, data were collected from all patients (n » 223) admitted to the hospital with a diagnosis of aSAH. Patients whose data were missing or who missed the follow-up after 6 months were excluded. Then, the number of days from the thunderclap headache until the surgical intervention (Delta T) was obtained. The degree of disability was evaluated using standardized scales, Rankin Scale (RS) and Glasgow Outcome Scale (GOS), at the time of discharge as well as 6 months later. Then, the RS and GOS were correlated with Delta T. Results An average of 6.8 days was found from the onset of symptoms to the intervention, the average age was 54 years old, 73% were women and 55% were smokers. The mean Glasgow Coma Scale on admission was 13. The mean score on the Hunt and Hess scale was 2.1. From the radiological point of view, the mean size of the aneurysm was 6 mm, and the modified Fisher Scale was 3.1. Of the total number of patients at the end of the study (n » 78), 50 underwent microsurgical treatment (63%). Rankin scale at discharge was 1.9 and GOS was 4.5, with no statistically significant change at 6 months. Analyzing the data distribution using linear regression, no statistically significant correlation was found between the time until treatment and disability using RS and GOS (p > 0.05). The same results were found even analyzing age subgroups ( 45 years old, 45 to 55 years old, 55 to 70 years old, and > 70 years old with a p-value > 0.05). Conclusions The present study suggests that there is no linear correlation between Delta T and disability at 6 months for the population studied. However, more studies are needed to assess whether these findings may be present in other populations, especially with a shorter time from symptoms to intervention, since the greatest risk of rebleeding occurs in the first 3 days after the event.

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Objective:To investigate the clinical value of hematoma volume estimated by 3D-Slicer in predicting symptomatic cerebral vasospasm (sCVS) after aneurysmal subarachnoid hemorrhage (aSAH).Methods:CT images on admission of 84 aSAH patients, admitted to our hospital from January 2018 to June 2021, were collected. The hematoma volume of these patients was measured by 3D-Slicer (3D-Slicer hematoma volume). Patients were divided into sCVS group and non-sCVS group according to the occurrence of postoperative sCVS. The differences of 3D-Slicer hematoma volume, Fisher grading scale and modified Fisher grading scale between the two groups were compared by statistical methods, and the independent risk factors for sCVS after aSAH were screened. The differences of 3D-Slicer hematoma volume among patients with different Fisher grading scale or modified Fisher grading scale were compared.Results:There was no significant difference in Fisher grading scale and modified Fisher grading scale between sCVS group and non-SCVS group ( P>0.05), but the 3D-Slicer hematoma volume in sCVS group was significantly larger than that in non-SCVS group ( P<0.05). 3D-Slicer hematoma volume ( OR=1.061, 95%CI: 1.004-1.120, P=0.034) was independent risk factors for sCVS after aSAH. The comparison of 3D-Slicer hematoma volume among patients with different Fisher grading scale or modified Fisher grading scale showed statistical difference ( P<0.05). Conclusion:As compared with Fisher grading scale and modified Fisher grading scale, the hematoma volume measured by 3D-Slicer has more advantage in predicting sCVS after aSAH.

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Objective:To investigate the relations of serum hypoxia inducible factor 2α (HIF-2α) and miR-21 expressions with cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH) after interventional embolization.Methods:One hundred and seventy-four patients with aSAH underwent interventional embolization in our hospital from October 2017 to June 2019 were prospectively selected. DSA examination was performed 4 d after surgery, and severity of cerebral vasospasm was evaluated. Enzyme-linked immunosorbent assay was used to detect the level of serum HIF-2α and reverse transcription-PCR was employed to detect the serum miR-21 expression before and 3 and 7 d after interventional embolization. The clinical data and changes of serum HIF-2α and miR-21 expressions in patients with different degrees of cerebral vasospasm were compared. Correlation analysis was performed to analyze the relation of HIF-2α expression with miR-21 expression 3 and 7 d after interventional embolization. Receiver operating characteristics curve was used to analyze the diagnostic values of serum HIF-2α and miR-21 levels in cerebral vasospasm 3 d after interventional embolization.Results:There were 100 patients without vasospasm, and 20, 38 and 16 patients with mild, moderate and severe cerebral vasospasm, respectively. The serum levels of HIF-2α and miR-21 in patients with mild, moderate and severe cerebral vasospasm increased successively 3 and 7 d after interventional embolization, with significant differences ( P<0.05). Positive correlation was noted between expressions of HIF-2α and miR-21 in serum 3 and 7 d after interventional embolization ( P<0.05). Area under the curve (AUC) of HIF-2α in diagnosis of cerebral vasospasm was 0.748 ( 95%CI: 0.615-0.883, P=0.000) 3 d after interventional embolization. AUC of serum miR-21 level in diagnosis of cerebral vasospasm was 0.715 ( 95%CI: 0.590-0.842, P=0.000). AUC of serum HIF-2α combined with miR-21 in diagnosis of cerebral vasospasm was 0.893 ( 95%CI: 0.792-0.985, P=0.000). When diagnostic critical points of HIF-2α and miR-21 were 82.75 pg/mL and 1.15, the sensitivity, accuracy and negative predictive value of HIF-2α combined with miR-21 in the diagnosis of cerebral vasospasm were higher than those of HIF-2α or miR-21 alone. Conclusion:The expressions of serum HIF-2α and miR-21 in patients with aSAH after interventional embolization can effectively predict the occurrence of cerebral vasospasm, and may be involved in the occurrence and development of cerebral vasospasm.

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@#To explore the effect of early progressive rehabilitation on cognitive functions in patients with aneurysmal subarachnoid hemorrhage（aSAH）.Methods Patients diagnosed aSAH in the hospital from March 2018 to March 2019 were included. Information of the patients were retrospectively collected including personal data，clinical features，imaging data，rehabilitation treatment，and followed up for 3 months. All subjects were divided into two groups，according to Mini-mental state score（MMSE）. The difference of personal data，clinical features，imaging data，rehabilitation treatment were compared between the two groups. After adjusting the confounding factors，the effect of early progressive rehabilitation on cognitive functions of the two groups were analyzed. Results One hundred and twelve patients with aSAH were enrolled，including 27（24.11%）patients with cognitive impairment （MMSE score≤26，cognitive impairment group） and 85（75.89%） patients with normal cognition （MMSE score 27～30，normal group）. The ratio of patients over 65 years old or with poor-grade aneurysmal subarachnoid hemorrhage （Hunt-Hess、modified Fisher scale） in the cognitive impairment group were higher than that in the normal group（P<0.05）. Compared with those patients who were in the normal group，the proportion of front traffic/front loop artery aneurysm and aneurysm diameter<3 mm were significantly higher in the cognitive impairment group（P<0.05）. Compared with patients who were in the interventional embolization group, people who treated with clipping surgery the risk of developing into cognitive dysfunction were decreased（P<0.05）. At the same time，it could reduce the risk of deep vein thrombosis （DVT），but could not reduce the risk of cerebral vasospasm or hydrocephalus. After adjusting confounding factors，patients who treated with early progressive rehabilitation were in a lower risk of cognitive impairment（OR=3.631，95% CI 1.007～13.085）. Conclusions Early progressive rehabilitation could improve the short-term cognitive function of patients with aSAH.

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Objective:To observe the changes of cognitive function, subcortical nuclei volumes, and diffusion kurtosis imaging (DKI) parameters (values of fractional anisotropy [FA], mean diffusivity [MD] and mean kurtosis [MK]) after surgery in patients with aneurysmal subarachnoid hemorrhage (aSAH), and analyze the correlations of cognitive dysfunction with subcortical nuclei volumes and DKI parameters.Methods:A prospective sutdy was conducted;17 patients with aSAH confirmed by surgery in our hospital from September 2019 to June 2020 were selected as patient group, and 16 healthy volunteers whose age, gender, and education level were matched with the patient group were recruited as control group. Neuropsychological tests and MR imaging were performed in the patients 3 months after surgery and the controls right after enrollment. The structural image data of all subjects were post-processed. Bilateral subcortical nuclei volumes and DKI parameters were analyzed. The differences of general clinical data, subcortical nuclei volumes and DKI parameters were compared between the two groups. The correlations of mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) scores with subcortical nuclei volumes and DKI parameters were analyzed.Results:As compared with the control group, the patient group had significantly lower MMSE and MoCA scores, and statistically decreased volumes of ipsilateral hippocampus, ipsilateral thalamus and ipsilateral lentiform nucleus ( P<0.05). The FA values of the contralateral caudate nucleus, bilateral thalamus and bilateral lentiform nucleus and MK values of the ipsilateral hippocampus in the patient group were significantly decreased as compared with those in the control group ( P<0.05); while the MD values of the ipsilateral caudate nucleus in the patient group were significantly increased as compared with those in the control group ( P<0.05). The volume of ipsilateral hippocampus was positively with MoCA scores ( r=0.604, P=0.038); the FA values of contralateral caudate nucleus were negatively correlated with MMSE scores ( r=-0.579, P=0.049). Conclusions:Cognitive dysfunction, atrophy of ipsilateral hippocampus, thalamus and lenticular nucleus, and changes of DKI parameters exist in patients with aSAH after surgery. The changes in ipsilateral hippocampus volume and FA values of caudate nucleus may be related to the postoperative cognitive dysfunction in these patients.

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Objective:To investigate the influencing factors for unfavorable outcome of low-grade aneurysmal subarachnoid hemorrhage (aSAH).Methods:A retrospective study was performed. The clinical data of 273 patients with aSAH of World Federation of Neurosurgery (WNFS) grading I and II, admitted to our hospital from April 2017 to March 2021, were collected. According to modified Rankin scale (mRS) scores 3 months after treatment, these patients were divided into favorable outcome group (mRS scores of 0-2) and unfavorable outcome group (mRS scores of 3-6). Statistical methods were used to analyze the clinical and imaging data differences between the two groups and identify the independent influencing factors for unfavorable outcome. Receiver operating characteristic (ROC) curves were drawn to evaluate the predictive values of different independent factors in unfavorable outcome.Results:Among the 273 patients with low-grade aSAH, 45 patients had unfavorable outcome and 228 patients had favorable outcome. Univariate analysis showed that there was significant difference between the 2 groups in age, Fisher grading distribution, proportions of patients complicated with shunt dependent hydrocephalus, with delayed cerebral ischemia, or with intracranial hemorrhage, and WNFS grading ( P<0.05). Multivariate Logistic regression analysis showed that concurrent shunt dependent hydrocephalus ( OR=5.075, 95%CI: 1.705-15.102, P=0.004), age ( OR=1.090, 95%CI: 1.036-1.147, P=0.004), delayed cerebral ischemia ( OR=8.282, 95%CI: 3.447-19.896, P=0.000), and postoperative intracranial hemorrhage ( OR=8.603, 95%CI: 2.332-31.745, P=0.001) were independent influencing factors for unfavorable outcome. ROC curve analysis showed that the optimal diagnostic threshold of age was 65 years, and the areas under ROC curve for delayed cerebral ischemia and age in predicting unfavorable outcome were 0.733 ( 95%CI: 0.653-0.813, P=0.000) and 0.709 ( 95%CI: 0.622-0.796, P=0.000). Conclusion:Low-grade aSAH patients with age≥65, postoperative shunt dependent hydrocephalus, delayed cerebral ischemia, and intracranial hemorrhage are more likely to have unfavorable outcome; age and complicated delayed cerebral ischemia have certain diagnostic value in low-grade aSAH patients.

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RESUMEN El diagnóstico y el tratamiento de las complicaciones cerebrales de la emergencia hipertensiva constituyen un reto para los médicos de urgencias y terapia intensiva. Mediante una aproximación diagnóstica basada en las diferentes secuencias de las imágenes por resonancia magnética se llega al diagnóstico de encefalopatía hipertensiva, isquemia cerebral, hemorragia intracraneal, hemorragia subaracnoidea aneurismática, síndrome de encefalopatía posterior reversible y a su inmediato tratamiento ajustado a nuestro medio según las últimas guías de práctica clínica de la AHA/ASA (Asociación Americana del Corazón y Asociación Americana de Ataque Cerebrovascular).

SUMMARY The diagnosis and treatment of brain injury in patients with hypertensive emergencies is a challenge for the emergency department and intensive care doctors. The diagnosis of hypertensive encephalopathy, ischemic stroke, intracranial hemorrhage, aneurysmal subarachnoid hemorrhage and posterior reversible encephalopathy syndrome is achieved with different MRI sequences as well as their appropriate treatment according to the last AHA/ASA clinical practice guidelines.

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OBJECTIVE@#To investigate the clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) after surgeries in Yunnan Province.@*METHODS@#We retrospectively analyzed the demographic features, vascular risk factors, severity at admission, and aneurysm locations in 85 patients with aSAH receiving surgical interventions in Yunnan Province. All the patients were treated by aneurysm clipping or coiling and followed up for clinical outcomes and recovery of daily activities evaluated by modified Rankin Scale (mRS) and Activities of Daily Living (ADL) scale, respectively.@*RESULTS@#Thirty-four of the patients (40.0%) underwent aneurysm clipping and 51 (60.0%) underwent aneurysm coiling. During a median follow- up period of 66.23 months (IOR, 12.03 months), 84.7% of the patients had low mRS scores, and 78.8% lived independently. The WFNS grade at admission was significantly correlated with the follow-up mRS scores (95%: 1.48-19.09, =0.011) and ADL (95%: 2.55-28.77, 0.05), but the cost of hospitalization was significantly higher in coiling group than in the clipping group ( < 0.001).@*CONCLUSIONS@#Both aging and a high WFNS grade at admission are associated with a poor prognosis of aSAH, for which aneurysm clipping and coiling have similar long- term outcomes, but for patients with a high WFNS score, aneurysm clipping is favored over coiling in terms of health economics.

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@#Objective　To investigate the relationships between serum microRNA-210 (mir-210),hypoxia inducible factor-1α (HIF-1α) and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH).Methods　Two hundred and sixty patients with aSAH who were diagnosed and treated in the Department of Neurosurgery of our hospital were selected as the study objects.According to the occurrence of DCI after aSAH,they were divided into non DCI group (181 patients) and DCI group (79 patients).The clinical data of the two groups were collected,the levels of serum mir-210 were determined by real-time fluorescent quantitative PCR (qRT-PCR),and the levels of HIF-1α in serum were determined by enzyme-linked immunosorbent assay (ELISA).Results　There were significant differences in aneurysm location,Hunt-Hess grade and Fisher grade between the two groups (P<0.05).The levels of mir-210 and HIF-1α in DCI group were significantly higher than those in non DCI group (P<0.05).Pearson test showed that there was a positive correlation between serum mir-210 level and HIF-1α level in aSAH patients (P<0.05).Multivariate logistic regression analysis showed that Hunt-Hess grade≥3,Fisher grade≥3 and high levels of serum mir-210 and HIF-1α were independent risk factors for DCI after aSAH (P<0.05).ROC curve analysis showed that the area under the curve of DCI after aSAH predicted by serum mir-210 combined with HIF-1α level was higher than that predicted by the two alone,with the sensitivity of 83.33% and the specificity of 94.44%.Conclusions　The levels of mir-210 and HIF-1α in patients with DCI after aSAH are all increased,which can be used as potential indexes to judge the occurrence of DCI after aSAH.

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Objective:To explore the changes of levels of coagulation factors at acute phase (within one week) of aneurysmal subarachnoid hemorrhage (aSAH) and their relations with deep venous thrombosis (DVT).Methods:Two hundred and two aSAH patients (aSAH group), admitted to our hospitals from March 2015 to March 2019, were selected in our study, and these patients were divided into a combined DVT subgroup and a uncombined DVT subgroup according to whether they were combined with DVT on the first and third d of onset. One hundred healthy physical examiners whose age and gender matched with those of aSAH group were selected as control group; one, 3, 5, and 7 d after onset, and one d after enrolling of subjects from the control group, thromboelastogram (TEG) was used to detect the R value of TEG (TEG-R) in all subjects. One, two, 3, 4, 5, 6 and 7 d after onset, color Doppler ultrasonography was used to determine whether aSAH patients had DVT.Results:A total of 73 patients (36.14%) were combined with DVT at acute stage of aSAH; 66 were with asymptomatic thrombosis and 7 with symptomatic thrombosis; 59 were with lower extremity intermuscular vein thrombosis and 14 were with intermuscular vein thrombosis. The incidence of DVT (68/73 [93.2%]) peaked on the 1 st-3 rd d of onset. The TEG-R of patients in aSAH group was statistically lower than that of the control group on the 1 st-3 rd d of onset ( P<0.05); the TEG-R of patients in aSAH group on the 1 st-3 rd d of onset was significantly lower than that on 5 th and 7 th d of onset ( P<0.05). The TEG-R of patients in combined DVT subgroup was significantly lower than that of the uncombined DVT subgroup ( P<0.05). Conclusions:Hyperfunction of coagulation factors at acute stage of aSAH is noted within one-3 d of onset; the incidence of DVT is the highest within 3 d of onset, mainly featured as asymptomatic intermuscular venous thrombosis. Whether or not aSAH would combine with DVT is associated with hyperfunction of coagulation factors.

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Abstract Background: Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. Methods: The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500 mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5 µg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity ≥ 120 cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). Results: The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p < 0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p = 0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p = 0.036, p = 0.012, p = 0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p = 0.012). Conclusions: The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

Resumo Justificativa: A hemorragia subaracnoidea por aneurisma é uma importante causa de morte prematura e de incapacidade em todo o mundo. O sulfato de magnésio mostra um efeito neuroprotetor e reverte o vasoespasmo cerebral. A milrinona também é usada no tratamento de vasoespasmo cerebral. O objetivo do presente estudo foi comparar o efeito profilático do sulfato de magnésio e da milrinona sobre a incidência de vasoespasmo cerebral após hemorragia subaracnoidea. Métodos: O estudo incluiu 90 pacientes com hemorragia subaracnoidea por aneurisma randomicamente distribuídos (randomização simples) em dois grupos: sulfato de magnésio foi administrado em infusão de 500 mg.dia-1 sem dose de ataque durante 21 dias. O Grupo B recebeu milrinona em infusão de 0,5 µg.kg-1·min-1 sem dose de ataque durante 21 dias. O vasoespasmo cerebral foi diagnosticado pela velocidade média do fluxo sanguíneo cerebral na artéria cerebral envolvida (velocidade média do fluxo ≥ 120 cm.s-1), a deterioração neurológica por escala de coma de Glasgow ou angiografia (diminuição do diâmetro da artéria cerebral envolvida > 25%). Resultados: A velocidade média do fluxo sanguíneo cerebral diminuiu significativamente no grupo magnésio em comparação com o grupo milrinona nos dias 7, 14 e 21 (p < 0,001). A incidência de vasoespasmo cerebral diminuiu significativamente com o magnésio em comparação com milrinona (p = 0,007). A escala de coma de Glasgow melhorou significativamente no grupo magnésio em comparação com o grupo milrinona nos dias 7, 14 e 21 (p = 0,036, p = 0,012, p = 0,016, respectivamente). A incidência de hipotensão foi maior com milrinona do que com magnésio (p = 0,012). Conclusões: A incidência de vasoespasmo cerebral após hemorragia subaracnoidea por aneurisma foi significativamente menor e a escala de coma de Glasgow significativamente melhor com magnésio em comparação com milrinona. A milrinona foi associada a uma maior incidência de hipotensão e necessidade de dopamina e norepinefrina em comparação com o magnésio.

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Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

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Objective To explore the application value of short latency somatosensory evoked potentials (SLSEP) as a tool for preoperative assessment of surgical or interventional treatment in patients with severe aneurysmal subarachnoid hemorrhage (aSAH). Methods A prospective observational cohort study was conducted. The patients with severe aSAH with a WFNS grade of Ⅳ or Ⅴ admitted to intensive care unit (ICU) of Beijing Tiantan Hospital of Capital Medical University from November 2016 to April 2017 were enrolled. The patients received SLSEP monitoring within 12 hours after onset, and the monitoring results were classified according to the Judson scale. Meanwhile, the findings on cerebral CT scans at admission were evaluated by the modified Fisher classification. The follow-up was performed at 3 months after aSAH ictus based on the modified Rankin scale (mRS), and a mRS score 0-3 was defined as favorable outcome, 4-6 was defined as unfavorable outcome. For statistical evaluation, demographic, clinical, neuroimaging and SLSEP data were evaluated by univariate analysis to identify the risk factors associated with prognosis;afterwards, those factors were analyzed by multivariate Logistic regression; also the validity was assessed by calculating the respective sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results A total of 41 patients with aSAH were selected, of which 7 were excluded because of the interference of the SLSEP monitoring results, 34 patients with aSAH were enrolled finally. Among them, 21 were classified in the unfavorable outcome group, while the rest (n = 13) were allocated into the favorable outcome group. No significant difference was found in gender, age, body mass index (BMI), time delay from ictus to treatment or the options for therapeutic methods between the two groups. The findings of univariate analysis, however, showed statistically differences in WFNS grade, the modified Fisher scale and Judson scale of SLSEP between the two groups. Yet, the further validity evaluation for these predictors demonstrated that the sensitivity, specificity, PPV and NPV of WFNS grade of Ⅴ and modified Fisher scale of Ⅳ were all less than 85%, whereas the results for SLSEP Judson scale of Ⅲ were much better (sensitivity: 90.5% vs. 71.4% and 71.4%, specificity: 84.6% vs. 69.2% and 76.9%, PPV: 90.5% vs. 79.0% and 83.3%). In the following multivariate Logistic analysis, only Judson scale of Ⅲ was identified to be the independent risk factor for poor outcome [odds ratio (OR) = 45.73, 95% confidence interval (95%CI) = 4.25-499.31, P = 0.002], while the WFNS grade of Ⅴ (OR = 1.14, 95%CI = 0.12-13.06, P = 0.912) and the modified Fisher scale of Ⅳ (OR = 7.22, 95%CI = 0.51-113.20, P = 0.160) were merely associated with poor outcomes without significant independence. Conclusion In comparison with WFNS grade and the modified Fisher scale, SLSEP seems more accurate in the prediction of long-term outcome of severe aSAH prior to surgical or interventional treatment, and thus may be applied as an effective aid in preoperative assessment.

ABSTRACT

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

ABSTRACT

This study aimed to investigate the risk factors related to ventilator-acquired pneumonia (VAP) in aneurysmal subarachnoid hemorrhage (SAH) patients. From January 2011 to December 2015, a single-center retrospective study including 200 SAH patients requiring mechanical ventilation (MV) ≥48 h was performed. The clinical data of these patients were collected and analyzed. The age range of the patients were 41-63 and 72 (36%) were male. The Glasgow coma scale score range was 5-15 and the Simplified Acute Physiology Score II range was 31-52. One hundred and forty-eight (74%) patients had a World Federation of Neurosurgeons (WNFS) score ≥III. Aneurysm was secured with an endovascular coiling procedure in 168 (84%) patients and 94 (47%) patients presented VAP. Male gender (OR=2.25, 95%CI=1.15-4.45), use of mannitol (OR=3.02, 95%CI=1.53-5.94) and enteral feeding above 20 kcal·kg−1·day−1 (OR=2.90, 95%CI=1.26-6.67) after day 7 were independent factors for VAP. Patients with early-onset VAP had a longer duration of sedation (P=0.03), MV (P=0.001) and ICU length of stay (P=0.003) and a worse Glasgow Outcome Scale score (P<0.001), but did not have a higher death rate.

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<p><b>OBJECTIVE</b>We aim to explore the potential association between serum gamma-glutamyl transferase levels and functional outcome after aneurysmal subarachnoid hemorrhage in a Chinese population.</p><p><b>METHODS</b>A total of 386 aneurysmal subarachnoid hemorrhage patients were included in the study from September 2007 to February 2015. Baseline serum gamma-glutamyl transferase levels and 6-month follow-up functional outcomes were determined. A poor outcome was defined as a modified ranking scale score of ⋝ 3. The multivariable logistic model was used to analyze the relationship between serum gamma-glutamyl transferase and clinical outcomes after aneurysmal subarachnoid hemorrhage.</p><p><b>RESULTS</b>The adjusted poor outcome rates of patients with gamma-glutamyl transferase levels of < 30 U/L, 30-50 U/L and ⋝ 50 U/L were 16.7%, 19.6%, and 34.4%, respectively (P < 0.01). The age-sex and multivariable adjusted odds ratios (95% confidence intervals) of poor prognosis comparing the top group (⋝ 50 U/L) with the lowest group (< 30 U/L) were 5.76 (2.74-12.13), 6.64 (2.05-21.52), and 6.36 (1.92-21.02). A significant linear trend existed between gamma-glutamyl transferase level and aneurysmal subarachnoid hemorrhage prognosis. This association was also observed among nondrinkers.</p><p><b>CONCLUSION</b>Patients with higher gamma-glutamyl transferase levels were more likely to have a poor prognosis. Serum gamma-glutamyl transferase can be considered to be an independent predictor of functional outcomes after aneurysmal subarachnoid hemorrhage.</p>

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Objective To investigate the genetic association between endothelin receptor type A(EDNRA)gene polymor-phism and delayed cerebral vasospasm(DCVS)in patients with aneurysmal subarachnoid hemorrhage(aSAH).Methods 133 aSAH patients from January 2015 to January 2017 were recruited to participate in the study.According to whether com-bined with DCVS,they were divided into the DCVS group(78 cases)and the control group(55 cases).Genotype was deter-mined by polymerase chain reaction-restriction fragment length polymorphism combined with DNA direct sequencing tech-nique for the polymorphism of the EDNRA gene.Results Samples of DCVS group and control group both were consistent with Hardy-Weinberg's law of inheritance(χ2=0.295,P=0.863;χ2=0.652,P=0.722).There were significant differ-ences of EDNRA gene rs5335 polymorphism between DCVS group and control group,under allele model(χ2=4.213,P=0.040)and the dominant model(χ2=4.790,P=0.029).However,there was no difference of EDNRA gene polymorphism between DCVS group and control group under recessive model(χ2=1.299,P=0.254).Multivariate Logistic regression a-nalysis showed that allele C was protective factor of DCVS for aSAH patients(OR=0.572,95%CI 0.401~0.872,P=0.021).Conclusion For aSAH patients,EDNRA gene rs5335 polymorphism may closely related to DCVS.