Subarachnoid Hemorrhage With Multifocal Cerebral Aneurysms in a Patient With Crohn's Disease and Sjögren's Syndrome: A Case Report and Literature Review.

Only a few reports of the association between Crohn's disease (CD) and Sjögren's syndrome (SS) have been documented in the medical literature. Herein, we are presenting a 61-year-old female patient who presented with subarachnoid hemorrhage (SAH). She has a past medical history of primary SS on no active treatment, and CD in remission while on maintenance immunotherapy. She also tested positive for COVID-19. Computed tomography angiography (CTA) brain as well as cerebral angiogram revealed multifocal cerebral aneurysms. Successful coiling was achieved with a cerebral angiogram. This case serves to add to a limited body of reported cases and remind clinicians of the association between SS/CD and cerebral aneurysms. Herein, we review the literature regarding this association and also the effect of immunotherapy and COVID-19 on the progression of cerebral aneurysms.

Cerebral vasospasm after subarachnoid hemorrhage from intracranial aneurysm rupture in SARS-CoV-2 positive patients. A retrospective review from two Bulgarian hospitals

Intracranial aneurysms are acquired lesions resulting from hemodynamic stress on the vascular wall. Their rupture usually presents as a subarachnoid hemorrhage (SAH) with a high mortality rate. Cerebral vasospasm follows, which leads in many cases to delayed brain ischemia and even death. We aimed to explore the relationship between cerebral perfusion and coronavirus disease (COVID-19) in aneurysmal SAH. We analyzed 42 cases that underwent treatment for proven SAH due to ruptured cerebral aneurysms between January 2020 and December 2021. The patients were treated adhering to a standard protocol. The cerebral vasospasm was assessed by measuring the difference in the mean arterial pressure of the carotid artery relative to the internal cerebral artery (Lindegaard's ratio) by transcranial Doppler ultrasound for 12 consecutive days. Twenty-three patients showed no signs of an acute respiratory syndrome associated with COVID-19 but tested positive for the SARS-coronavirus 2 (SARS-CoV-2). The control group included 19 SARS-CoV-2 negative cases. The mean age was 59.7 +/- 8.4 years (range 44-72), with 29 males and 13 females. The mean arterial pressure was without a significant difference of 89.3 +/- 3.3 to 89.7 +/- 3.7 mmHg in SARS-CoV-2 negative to positive patients. When viral infection was evident, we observed a higher Lindegaard's ratio of 2.12 +/- 0.36 than the control, with a value of 1.43 +/- 0.33 (p < 0.01). Thus, brain perfusion was 32.5% better in negative patients. We suggest that SARS-CoV-2 positive patients, without acute COVID-19, are more likely to have worse brain perfusion after SAH from cerebral aneurysm rupture.

Aneurysmal Subarachnoid Hemorrhage during the Shutdown for COVID-19.

The aim was to evaluate hospitalization rates for aneurysmal subarachnoid hemorrhage (SAH) within an interdisciplinary multicenter neurovascular network (NVN) during the shutdown for the COVID-19 pandemic along with its modifiable risk factors. In this multicenter study, admission rates for SAH were compared for the period of the shutdown for the COVID-19 pandemic in Germany (calendar weeks (cw) 12 to 16, 2020), the periods before (cw 6-11) and after the shutdown (cw 17-21 and 22-26, 2020), as well as with the corresponding cw in the years 2015-2019. Data on all-cause and pre-hospital mortality within the area of the NVN were retrieved from the Department of Health, and the responsible emergency medical services. Data on known triggers for systemic inflammation, e.g., respiratory viruses and air pollution, were analyzed. Hospitalizations for SAH decreased during the shutdown period to one-tenth within the multicenter NVN. There was a substantial decrease in acute respiratory illness rates, and of air pollution during the shutdown period. The implementation of public health measures, e.g., contact restrictions and increased personal hygiene during the shutdown, might positively influence modifiable risk factors, e.g., systemic inflammation, leading to a decrease in the incidence of SAH.

Impact of COVID-19 Pandemic on Treatment Management and Clinical Outcome of Aneurysmal Subarachnoid Hemorrhage - A Single-Center Experience.

Background: Previous studies reported decreased volumes of acute stroke admissions during the COVID-19 pandemic. We aimed to examine whether aneurysmal subarachnoid hemorrhage (aSAH) volumes demonstrated similar declines in our department. Furthermore, the impact of the pandemic on disease progression should be analyzed. Methods: We conducted a retrospective study in the neurosurgical department of the university hospital Frankfurt including patients with the diagnosis of aSAH during the first year of the COVID pandemic. One year cumulative volume for aSAH hospitalization procedures was compared to the year before (03/2020 - 02/2021 vs. 03/2019 - 02/2020) and the last 5 pre-COVID-pandemic years (2015-2020). All relevant patient characteristics concerning family history, disease history, clinical condition at admission, active/past COVID-infection, treatment management, complications, and outcome were analyzed. Results: Compared to the 84 hospital admissions during the pre-pandemic years, the number of aSAH hospitalizations (n = 56) declined during the pandemic without reaching significance. No significant difference in the analyzed patient characteristics including clinical condition at onset, treatment, complications, and outcome, between 56 patients with aSAH admitted during the COVID pandemic and the treated patients in the last 5 years in the pre-COVID period were found. In our multivariable analysis, we detected young age (p < 0.05; OR 4.2) and no existence of early hydrocephalus (p < 0.05; OR 0.13) as important factors for a favorable outcome (mRS ≤ 0-2) after aSAH during the COVID pandemic. A past COVID-infection was detected in young patients suffering from aSAH (Age <50years, p < 0.05; OR 10.5) with an increased rate of cerebral vasospasm after aSAH onset (p < 0.05; OR 26). Nevertheless, past COVID-infection did not reach significance as a high-risk factor for unfavorable outcomes. Conclusion: There was a relative decrease in the number of patients with aSAH during the COVID-19 pandemic. Despite the extremely different conditions of hospitalization, there was no impairing significant effect on the treatment and outcome of admitted patients with aSAH. A past COVID infection seemed to be an irrelevant limiting factor concerning favorable outcomes.

Management protocol for emergency aneurysm craniotomy clipping in non-major COVID-19 epidemic areas in Beijing, China.

BACKGROUND: An epidemic of COVID-19 broke out in Wuhan, China, since December 2019. The ordinary medical services were hindered. However, the emergency cases, including aneurysmal subarachnoid hemorrhage (aSAH), still required timely intervention. Thus, it provoked challenges to the routine management protocol. In this study, we summarized our experience in the emergency management of aSAH (Beijing Tiantan Protocol, BTP) in Beijing, China. METHODS: Demographic, clinical, and imaging data of consecutive emergency aSAH patients who underwent craniotomy clipping during the COVID-19 epidemic season were reviewed and compared with the retrospective period last year. Subgroup analysis was further performed to assess the outcomes of different screening results and several detailed protocols. Neurological outcomes were evaluated by the modified Rankin Scale (mRS). RESULTS: A total of 127 aSAH were referred to our emergency department, and 42 (33.1%) underwent craniotomy clipping between January 20, 2020, and March 25, 2020. The incidence of preoperative hospitalized adverse events and the perioperative outcomes were similar (- 0.1, 95% CI - 1.0 to 0.8, P = 0.779) to the retrospective period last year (January 2019-March 2019). After the propensity score matching (PSM), there were still no statistical differences in prognostic parameters between the two groups. Eight (19.0%) of the 42 individuals were initially screened as preliminary undetermined COVID-19 cases, in which 2 of them underwent craniotomy clipping in the negative pressure operating room (OR). The prognosis of patients with varied COVID-19 screening results was similar (F(2, 39) = 0.393, P = 0.678). Since February 28, 12 cases (28.6%) received COVID-19 nucleic acid testing (NAT) upon admission, and all showed negative. The false-negative rate was 0.0%. The preoperative hospitalized adverse events and postoperative prognosis were still similar between patients with and without COVID-19 NAT (- 0.3, 95% CI - 1.4 to 0.9, P = 0.653). CONCLUSIONS: Our emergency surgery management protocol (BTP) is reliable for scheduling emergency aneurysm craniotomy clipping in non-major epidemic areas.