Cross-sectional survey of preoperative nutritional status of cardiac surgery patients in southwest China / 中华危重病急救医学

Objective:To investigate the preoperative nutritional status of cardiac surgery patients in southwest China, analyze the incidence and characteristics of nutritional risk, and provide basis for establishing a standardized individualized nutritional intervention program for cardiac surgery patients.Methods:A cross-sectional survey was conducted on the nutritional status and intervention status of preoperative patients in cardiac surgery department of 23 general hospitals in Yunnan, Guizhou, Sichuan and Chongqing districts. At 00: 00 on July 7, 2022, the patients aged > 18 years old in cardiac surgery departments of the above hospitals who planned to undergo surgical treatment were enrolled as the survey objects to investigate the nutritional status on July 6, 2022 (the survey date), including basic information (general information, nutrition indicators, etc.), nutrition screening and evaluation (nutrition risk screening and organ support, etc.), nutrition treatment (nutrition supplement methods and prescriptions, etc.) and nutrition awareness of medical staff.Results:The 126 questionnaires were collected, of which 125 were valid (99.2%). ① Basic information: of the 125 patients, 67 patients were male (53.6%) and 58 patients were female (46.4%). The age ranged from 19 years old to 86 years old, with an average of (53.13±14.74) years old. Body mass index (BMI) was (22.21±3.78) kg/m 2. The age and BMI of men were significantly higher than those of women [age (years old): 56.63±13.34 vs. 49.09±15.35, BMI (kg/m 2): 22.74±3.86 vs. 21.59±3.61, both P < 0.05]. Of the 125 patients, 75 had valvular disease and 50 were with non-valvular diseases, which mainly included congenital heart disease [19 cases (15.2%)], aortic dissection [13 cases (10.4%)], coronary heart disease [12 cases (9.6%)], etc. The course of disease was 0.5 hour to 36 years, of which 93 patients (74.4%) were more than 6 months and 32 patients (25.6%) were equal to or less than 6 months. The proportion of female patients with disease duration > 6 months was significantly higher than that of male patients [87.9% (51/58) vs. 62.7% (42/67), P < 0.01]. The basic diseases mainly included hypertension [38 cases (30.4%)], coronary heart disease [12 cases (9.6%)], diabetes [7 cases (5.6%)], chronic obstructive pulmonary disease [COPD, 6 cases (4.8%)], etc. Among 125 patients, total protein (TP) < 60 g/L in 24 cases (19.2%), albumin (Alb) < 40 g/L in 64 cases (51.2%), anemia [male hemoglobin (Hb) < 120 g/L, female Hb < 110 g/L] in 33 cases (26.4%). A total of 60 cases of prealbumin data were collected, of which 23 cases (38.3%) were less than 200 mg/L.② Nutrition screening and assessment: 33.6% of the 125 patients did not undergo routine nutrition screening after admission, including the provincial and municipal tertiary hospitals. Among the 83 patients undergoing nutritional screening, 41 (32.8%) were at nutritional risk. Further analysis of patients with nutritional risk showed that of the 41 patients, 20 were male (48.8%) and 21 were female (51.2%); 27 cases (65.9%) was with valvular diseases and 14 cases (34.1%) was with non-valvular diseases; the course of disease was more than 6 months in 30 cases (73.2%), and ≤ 6 months in 11 cases (26.7%). Statistical comparison of the above 83 patients showed that women, basic disease, long term-valvular disease, anemia, low TP, and low Alb before operation were more prone to innutrition. ③ Nutritional therapy: of the 125 patients, 5 were receiving mechanical ventilation (4.0%) and 2 were using vasoactive drugs (1.6%); there were 5 cases with gastrointestinal dysfunction (4.0%), mainly manifested as abdominal distension, abdominal pain, constipation and diarrhea. One patient was treated with enteral nutrition through gastric tube combined with parenteral nutrition support, 124 patients were fed orally, and an irregular phenomenon of injecting amino acid fat emulsion through peripheral vein in 2 patients. ④ Nutrition awareness of medical staff: 124 (99.2%) of the 125 patients had a nutrition department in their hospital; 71 cases (56.8%) received nutrition education, of which 37 cases (52.1%) were consulted by the nutrition department. Of all the cases, only 38 (30.4%) were consulted by the nutrition department, of which 1 (2.6%) did not receive nutrition education after consultation. Conclusions:At present, the incidence of preoperative malnutrition in patients undergoing cardiac surgery is high in southwest China. The incidence of malnutrition in patients with basic diseases, long term-valvular disease, low TP, low Alb and anemia before operation is higher, and the incidence of malnutrition is hidden in women. The course of disease of women is longer than that of men at the time of treatment, and malnutrition is more likely to occur. The attending physicians should pay attention to the above groups. It is necessary to establish a standardized individualized nutritional intervention program and apply it to actual clinical diagnosis and treatment, so as to ultimately improve the prognosis of patients undergoing cardiac surgery and increase the benefits of patients in treatment.

PRMT8 Attenuates Cerebral Ischemia/Reperfusion Injury via Modulating Microglia Activation and Polarization to Suppress Neuroinflammation by Upregulating Lin28a.

Activation and polarization of microglia are involved in neuroinflammation and regulate ischemic stroke-associated brain injury. Protein arginine methyltransferase 8 functions as a regulatory component of hypoxic stress-induced neuroinflammation. The protective effect of protein arginine methyltransferase 8 (PRMT8) against ischemic stroke-associated brain injury through regulation of microglia activation and polarization was investigated. First, PRMT8 was downregulated in middle cerebral artery occlusion (MCAO)-induced mice and oxygen-glucose deprivation/reoxygenation (OGD/R)-induced SH-SY5Y. Injection with AAV-PRMT8 reduced infarct volumes in MCAO-induced mice. Moreover, injection with AAV-PRMT8 promoted neuronal survival and ameliorated histopathological changes in the brains of MCAO-induced mice. The neuronal apoptosis and neuroinflammation in MCAO-induced mice were suppressed by AAV-PRMT8 injection. Second, PRMT8 overexpression increased cell viability and suppressed the cell apoptosis and inflammation of OGD/R-induced SH-SY5Y. Third, injection with AAV-PRMT8 reduced almost 50% of CD86 + M1 microglia and enhanced about 20% of CD206 + M2 microglia. Furthermore, PRMT8 overexpression attenuated OGD/R-induced M1 phenotype polarization of BV2. Lastly, PRMT8 upregulated Lin28a and loss of Lin28a attenuated PRMT8 overexpression-induced increase in cell viability and decrease in cell apoptosis and inflammation of OGD/R-induced SH-SY5Y. In conclusion, PRMT8 promoted M2 phenotype polarization of microglia and suppressed neuronal apoptosis to ameliorate cerebral ischemia/reperfusion injury through upregulation of Lin28a.

Lin28a attenuates cerebral ischemia/reperfusion injury through regulating Sirt3-induced autophagy.

Cerebral ischemia-reperfusion injury causes damage to local brain tissue and its function, but its specific pathogenesis is still unclear. Autophagy is an important catabolic pathway in eukaryotic cells, which is mainly used to remove damaged intracellular organelles, misfolded long-acting macromolecules and participate in cerebral ischemia-reperfusion injury. Lin28 is a highly conserved RNA-binding protein that plays a role in regulating gene translation, which is important for the growth and maintenance of pluripotent cells. Lin28a has been reported to have a clear protective effect on post-ischemic reperfusion injury of the heart. However, whether Lin28a has an effect on nerve injury after cerebral ischemia-reperfusion needs further study. In this study, we found that the expression of Lin28a was decreased in cerebral ischemia-reperfusion mice model. Upregulation of Lin28a could alleviate the nerve injury caused by ischemia-reperfusion, and promote autophagy of nerve cells. Upregulation of Lin28a reduced nerve cell apoptosis and relieved nerve cell injure induced by oxygen-glucose deprivation/reoxygenation. Lin28a increased the LC3-II levels in nerve cells, suggesting the promotion of autophagy. Mechanism studies indicated that Lin28a promoted autophagy mainly through regulating Sirt3 expression and activating AMPK-mTOR pathway. In conclusion, our study revealed the important role of Lin28a in cerebral ischemia-reperfusion and suggested that Lin28a was a protective factor for cerebral ischemia-induced injury.

lncRNA Mtss1 promotes inflammatory responses and secondary brain injury after intracerebral hemorrhage by targeting miR-709 in mice.

Secondary brain injuries following intracerebral hemorrhage (ICH) are mediated by inflammatory pathway activation. The present study aimed to characterize long noncoding RNAs (lncRNAs) that are differentially expressed in cerebral tissues during ICH pathogenesis and to investigate their pathogenic functions. An ICH mouse model established by collagenase injection was used to obtain differentially expressed lncRNAs for deep sequencing. A cellular inflammation model was established by treating mouse microglia with lipopolysaccharide. Expression of lncRNA and miRNA was assessed by quantitative RT-PCR, and protein abundance was measured by western blot. Cytokine levels in mouse serum and cell culture supernatants were analyzed using enzyme-linked immunosorbent assay. Cerebral injury was evaluated by hematoxylin-eosin and Nissl staining, the ratio of brain dry weight/brain wet weight, and neurobehavior scoring. Ionized calcium-binding adaptor molecule 1 (IBA1) expression in the brain sections was assessed using immunohistochemistry. A total of 3681 lncRNAs were differentially expressed in the brain tissue of the ICH mice group compared with the Sham group. Of these, lncRNA metastasis suppressor-1 (Mtss1) expression was increased. Mtss1 knockdown by siRNA in the cellular model strongly suppressed TIR-domain-containing adapter-inducing interferon-ß (TRIF) expression, P65 phosphorylation, and tumor necrosis factor (TNF)-α and interleukin (IL)-1ß secretion. Mtss1 knockdown in ICH mice inhibited secondary brain injury and decreased IBA1, TNF-α, and IL-1ß. Mtss1 was predicted to bind miR-709, and Mtss1 knockdown elevated miR-709 expression in the cellular inflammation model and ICH mice. High expression of Mtss1 promoted inflammatory brain injuries after ICH by enhancing inflammatory cytokine secretion and targeting miR-709 expression.

Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Risk Factors Affecting Clinical Outcomes in Intracranial Aneurysm Patients in a Multi-Center Study.

Objective: Patients with poor-grade aneurysm subarachnoid hemorrhage (SAH) have commonly been considered to have a poor prognosis. The objective of this study was to investigate the independent risk factors affecting clinical outcomes in intracranial aneurysm patients with poor-grade aneurysm subarachnoid hemorrhage (aSAH) underwent different intervention therapies. Methods: A multicenter observational registry of 324 poor-grade aSAH patients treated at tertiary referral centers from October 2010 to March 2012 were enrolled in this study. The clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. Clinical outcomes were assessed via a modified Rankin Scale at 12 months. Multivariate logistic regression models were used to develop prognostic models. The area under the receiver operator characteristic curves (AUC) and Hosmer-Lemeshow tests were used to assess discrimination and calibration. WAP score was developed to predict risk of poor outcome. Results: Older age, female gender, ventilated breathing status, non-reactive pupil response, pupil dilation, lower GCS score, a WFNS grade of V, intraventricular hemorrhage, a higher Fisher grade, a higher modified Fisher grade, and conservative treatment were calculated to be associated with a relatively poor outcome. Multivariate analyses revealed that older age, lower Glasgow coma scale score (GCS), the absence of pupillary reactivity, higher modified Fisher grade, and conservative treatment were independent predictors of poor outcome, showed good discrimination and calibration. Patients with WFNS grade V, older age and non-reactive pupillary reactivity were predicted to have a poor outcome by WAP risk score. Conclusions: A simple WAP risk score had good discrimination and calibration in the prediction of outcome. The risk score can be easily measured and may complement treatment decision-making.

Intracranial Complex Ruptured Aneurysms Coiled with Overlapping Low-Profile Visualized Intraluminal Support Stents: Another Available Option for Complex Ruptured Intracranial Aneurysms.

BACKGROUND: Overlapping stents represent a new paradigm in endovascular interventions, especially for complex and wide-necked aneurysms. The low-profile visualized intraluminal support (LVIS) device is a new generation of self-expanding braided stents recently introduced in China for stent-assisted coiling of intracranial aneurysms. We report several cases of intracranial aneurysms coiled using overlapping LVIS stents to evaluate its efficacy and safety. METHODS: Patients with ruptured intracranial aneurysms treated with double LVIS stents at our center between November 2014 and May 2016 were reviewed. The clinical data and technical results are presented. RESULTS: Ten patients with 15 aneurysms were treated with double LVIS stents, with a 100% technical success rate. No mortality was observed. Immediate angiographic outcome evaluation showed complete occlusion in 13 aneurysms (86.7%) and neck remnants in 2 aneurysms (13.3%). CONCLUSIONS: Double LVIS stents are safe and effective in the treatment of intracranial aneurysms, especially complex aneurysms.

Comparison of Aggressive Surgical Treatment and Palliative Treatment in Elderly Patients with Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: To compare the current treatment approach in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) and identify the independent predictors of the outcome after aggressive surgical treatment. METHOD: This prospective, multicenter cohort study included 104 poor-grade aneurysmal SAH elderly patients, 60 years or older, treated in our institution from October 2010 to March 2013. Patients were grouped according to three treatment arms. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at baseline and at a 12-month follow-up. Univariate and multivariate analysis were performed using the following factors: sex, age, smoking history, breathing ability, alcohol consumption, cerebral hernia, aneurysm location, aneurysm diameter, WFNS grade, CT Fisher grade, treatment approach, and the timing of the aneurysm surgery. RESULTS: At the 12-month follow-up, patients in the coiling group and clipping group had better prognosis than patients in the palliative treatment group. Univariate analysis confirmed that the treatment approach, WFNS grade, CT Fisher grade, and age are critical factors for neurological outcomes in poor-grade SAH. Multivariate analysis indicated that WFNS grade V, CT Fisher grades 3-5, and palliative treatment were independent predictors of poor prognoses. CONCLUSION: Aggressive surgical treatment improves the prognoses in poor-grade aneurysm elderly patients with SAH. Elderly Patients of WFNS grade IV and CT Fisher grades 1-2 are more likely to have a better outcome.

Posterior fossa brain arteriovenous malformations : Clinical features and outcomes of endovascular embolization, adjuvant microsurgery and radiosurgery.

BACKGROUND: Posterior fossa brain arteriovenous malformations (PFbAVM) are relatively rare brain disorders but have a high risk of hemorrhage. Endovascular embolization to reduce the lesion size before treatment may improve the outcome of PFbAVM. The purposes of this study were to identify risk factors associated with hemorrhage in PFbAVM and to assess clinical outcomes in patients receiving initial endovascular embolization. MATERIAL AND METHODS: From 1999 to 2013 a total of 63 patients with PFbAVMs were treated (31 males and 32 females, 14.1 % of all AVM cases). A retrospective examination of patient demographics, clinical presentation, angiographic features, treatment modalities, complications and outcomes was carried out. The re-hemorrhage rate, obliteration rate and modified Rankin scale (MRS) were used as measures of outcome. RESULTS: Of the 63 PFbAVM patients 54 (85.7 %) exhibited hemorrhage and 15 had confirmed aneurysms. The cerebellar location (P = 0.007) and deep venous drainage (P = 0.012) were independent predictors of hemorrhage in multivariate analyses. The mean estimated devascularization was 46.9 % (range 10-100 %) in the 20 patients (31.7 %) treated by endovascular embolization. The 16 patients with residual niduses were further treated by radiosurgery, microsurgery or embolization. Complete obliteration was attained in 12 patients (67 %) while 2 (5.7 %) were left with persisting neurological deficits and 1 had a re-hemorrhage 3 years later (annual rate of 4.6 %). Favorable outcome (MRS ≤ 2) was obtained in the 20 patients receiving initial endovascular embolization (P = 0.039 versus preoperative MRS). CONCLUSION: Cerebellar location and deep venous drainage are predictors of hemorrhage in PFbAVM. Adjuvant endovascular embolization is useful and safe for PFbAVM prior to microsurgery or radiosurgery.

Multidisciplinary Care of Unruptured Brain Arteriovenous Malformations to Improve Symptomatic Headache and the Onset, Progression, and Outcomes of Unruptured Brain Arteriovenous Malformations.

BACKGROUND: Symptomatic headaches attributed to unruptured brain arteriovenous malformations (ubAVMs) are very common and affect patients' quality life, but multidisciplinary care of ubAVMs to improve symptomatic headache remains unclear. OBJECTIVE: The objective is to identify the features of symptomatic headaches, and to obtain headache outcomes following multidisciplinary care of ubAVMs, as well as provide background on the natural history of ubAVMs. STUDY DESIGN: The features of symptomatic headaches and headache outcomes were analyzed in a large cohort of cases after multidisciplinary care of ubAVMs. We have also provided information on the natural history of ubAVMs. SETTING: This study was conducted at the Department of Neurosurgery of Zhujiang Hospital where 336 patients from 1998 to 2014 were reviewed by a multidiscipline team. Only 124 patients were eligible. METHODS: The demographics, clinical features, imaging features, and headache details of eligible patients were reviewed. An 11-point pain scale score was used to assess symptomatic headaches before, during, and after treatment. The headache outcomes, death or stroke, and adverse functional outcomes (modified Rankin Scale score = 2, mRS = 2) were assessed following multidisciplinary care of ubAVMs. RESULTS: Twenty-three (56.1%) of 41 patients had migraine-like headaches located in occipital lobe (P < 0.001), while forty (63.5%) of 63 patients had tension-type-like headaches located in frontotemporal lobe (P < 0.001). For patients with tension-type-like or all types of headache, headache improvement differed between the multidisciplinary group and medical group (87.8% vs. 31.8%, P < 0.001; 85.7% vs. 40.7%, P < 0.001). The risk of death or stroke did not differ between multidisciplinary group and medical group (P = 0.393), whereas the risk of adverse functional outcome (mRS = 2) differed significantly by long-time follow-up (23.0% vs.10.0%, P = 0.022). LIMITATIONS: This study provides the initial experience to support multidisciplinary care for ubAVMs to improve symptomatic headaches and patients' quality life, but based on the retrospective study with inherent limitations, larger samples and multi-center trials are needed on this interesting issue. CONCLUSIONS: Occipital ubAVM is more likely to present with migraine-like headache, while frontotemporal ubAVM tends to present with tension-type-like headache. The effectiveness of multidisciplinary care for ubAVM to improve headache has been shown, but the natural history of ubAVM patients with headache remains unclear.Key Words: Unruptured brain arteriovenous malformations, headache, headache improvement, natural history.

Stent-assisted coiling versus coiling alone of poor-grade ruptured intracranial aneurysms: a multicenter study.

INTRODUCTION: Endovascular coiling is a valid treatment option for poor-grade ruptured aneurysms. However, little is known about stent-assisted coiling of poor-grade aneurysms. OBJECTIVE: To compare the safety and efficacy of stent-assisted coiling with coiling alone for poor-grade aneurysms. METHODS: Using multicenter data on poor-grade aneurysms, we performed a retrospective analysis of 131 consecutive patients treated with endovascular coiling within 14 days after ictus. Patients were split into two groups: stent-assisted coiling and coiling alone. Baseline characteristics, immediate angiographic results, perioperative complications, and clinical outcomes were compared between the two groups. RESULTS: Twenty-three (17.6%) patients were treated with stent-assisted coiling and 108 (82.4%) with coiling alone. There were no statistically significant differences in patient age, sex, clinical grade, Fisher grade, modified Fisher grade, aneurysm location, and size between the stent-assisted coiling and coiling alone groups. Intraprocedural aneurysm rupture, procedure-related ischemic complication, external ventricular drainage-related hemorrhagic complication, and symptomatic vasospasm did not differ between the two groups. Immediate angiographic results and clinical outcomes at discharge and at 6 and 12 months did not differ between the groups. Aneurysm rebleeding occurred in 4 (17.4%) patients after stent-assisted coiling compared with 2 (1.9%) patients after coiling alone (p<0.007). Multivariate analysis showed that incomplete aneurysm occlusion was independently associated with aneurysm rebleeding (p=0.016), and there was a trend toward aneurysm rebleeding after stent-assisted coiling (p=0.051). CONCLUSIONS: Stent-assisted coiling of poor-grade aneurysms is feasible and safe compared with coiling alone. However, the hemorrhagic complication and aneurysm rebleeding may not be negligible.

Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage.

OBJECTIVE An increasing number of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have received endovascular treatment. Endovascular treatment of poor-grade aSAH, however, is based on single-center retrospective studies, and predictors of long-term outcome have not been well defined. Using results from a multicenter prospective registry, the authors aimed to develop preoperative and postoperative prognostic models to predict poor outcome after endovascular treatment of poor-grade aSAH. METHODS A Multicenter Poor-grade Aneurysm Study (AMPAS) was a prospective and observational registry of consecutive patients with poor-grade aSAH. From October 2010 to March 2012, 366 patients were enrolled in the registry, and 136 patients receiving endovascular treatment were included in this study. Outcome was assessed by modified Rankin Scale (mRS) score at 12 months, and poor outcome was defined as an mRS score of 4, 5, or 6. Prognostic models were developed in multivariate logistic regression models. The area under receiver operating characteristic curves (AUC) was used to assess the model's discriminatory ability, and Hosmer-Lemeshow goodness-of-fit tests were used to assess the calibration. RESULTS At 12 months, 64 patients (47.0%) had a poor outcome: 9 (6.6%) had an mRS score of 4, 6 (4.4%) had an mRS score of 5, and 49 (36.0%) had died. Univariate analyses showed that older age (p = 0.001), female sex (p = 0.044), lower Glasgow Coma Scale score (p < 0.001), a World Federation of Neurosurgical Societies (WFNS) grade of V (p < 0.001), higher Fisher grade (p < 0.001), modified Fisher grade (p < 0.001), and wider neck aneurysm (p = 0.026) were associated with a poor outcome. There was a trend toward a worse outcome in patients with anterior communicating artery aneurysms (p = 0.080) and in those with incompletely occluded aneurysms (p = 0.063). After endovascular treatment, the presence of cerebral infarction (p = 0.039), symptomatic vasospasm (p = 0.039), and pneumonia (p = 0.006) were associated with a poor outcome. Multivariate analyses showed that the preoperative prognostic model including age, a WFNS grade of V, modified Fisher grade, and aneurysm neck size had excellent discrimination with an AUC of 0.86 (95% CI 0.80-0.92, p < 0.001), and a postoperative model that included these predictors as well as postoperative pneumonia had excellent discrimination (AUC = 0.87, 95% CI 0.81-0.93, p < 0.001). Both models had good calibration (p = 0.941 and p = 0.653, respectively). CONCLUSIONS Older age, WFNS Grade V, higher modified Fisher grade, wider neck aneurysm, and postoperative pneumonia were independent predictors of poor outcome after endovascular treatment of poor-grade aSAH. The preoperative model had almost the same discrimination as the postoperative model. Endovascular treatment should be carefully considered in patients with poor-grade aSAH with ruptured wide-neck aneurysms. ▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class I.

MCP-1-mediated activation of microglia promotes white matter lesions and cognitive deficits by chronic cerebral hypoperfusion in mice.

Microglia activation played a vital role in the pathogenesis of white matter lesions (WMLs) by chronic cerebral hypoperfusion. In addition, hypoxia induced up-regulated expression of MCP-1, promotes the activation of microglia. However, the role of MCP-1-mediated microglia activation in chronic cerebral ischemia is still unknown. To explore that, chronic cerebral hypoperfusion model was established by permanent stenosis of bilateral common carotid artery in mice. The activation of microglia and the related signal pathway p38MAPK/PKC in white matter, and working memory of mice were observed. We found that stenosis of common carotid arteries could induce MCP-1-mediated activation of microglia through p38MAPK/PKC pathway and white matter lesions. Taken together, our findings represent a novel mechanism of MCP-1 involved in activation of microglia and provide a novel therapeutical strategy for chronic cerebral hypoperfusion.

Aneurysm rebleeding after poor-grade aneurysmal subarachnoid hemorrhage: Predictors and impact on clinical outcomes.

BACKGROUND: Aneurysm rebleeding is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH) and more often occurs in patients with poor-grade aSAH. Limited data on predictors of rebleeding in these patients are available. OBJECTIVE: To investigate predictors of aneurysm rebleeding after poor-grade aSAH and the association of rebleeding with clinical outcomes. METHODS: A multicenter poor-grade aneurysm study was a prospective and observational registry of consecutive patients who presented with poor-grade aSAH defined as a World Federation of Neurosurgical Societies (WFNS) grade of IV or V. Rebleeding was defined as a new hemorrhage on computed tomography scan. Clinical outcomes were assessed with modified Rankin score. Multivariate logistic regression analyses were used to determine independent predictors of rebleeding and association between the rebleeding and clinical outcomes at 12months. RESULTS: Of the 297 patients included in this study, 30 (10.1%) patients experienced rebleeding. Most rebleeding occurred within 24h after ictus. 22 (73.3%) patients died at discharge. Aneurysm rebleeding was independently associated with poor outcome (odds ratio [OR] 36.37, p<0.001) and associated with mortality (OR 25.03, p<0.001) at 12months. The multivariate analysis showed that a lower Fisher grade (OR 0.49, 95% CI 0.31-0.77; p=0.002), ruptured anterior cerebral artery aneurysms (OR 4.26, 95% CI 1.07-16.90; p=0.039), external ventricular drainage (OR 4.62, 95% CI 1.46-14.59; p=0.009) were independently associated with aneurysm rebleeding. CONCLUSIONS: The outcome of aneurysm rebleeding remains very poor. A lower Fisher grade, ruptured anterior cerebral artery aneurysms, external ventricular drainage were associated with increased risk of rebleeding.

Alterations of caveolin-1 expression in a mouse model of delayed cerebral vasospasm following subarachnoid hemorrhage.

The aim of the present study was to evaluate the expression levels of caveolin-1 in the basilar artery following delayed cerebral vasospasm (DCVS) in a rat model of subarachnoid hemorrhage (SAH), in order to investigate the association between caveolin-1 and DCVS, and its potential as a treatment for DCVS of SAH. A total of 150 Sprague Dawley rats were randomly allocated into blank, saline and SAH groups. The SAH and saline groups were subdivided into days 3, 5, 7 and 14 following the establishment of the model. The murine model of SAH was established by double injection of autologous arterial blood into the cisterna magana and DCVS was detected using Bederson neurological severity scores. Hematoxylin and eosin (HE) staining was used to observe the inner perimeter of the basilar artery pipe and variations in the thickness of the basilar artery wall. Alterations in the levels of caveolin-1 protein in the basilar artery were measured using immunofluorescence and western blot analysis; whereas alterations in the mRNA expression levels of caveolin-1 were detected by reverse transcription-quantitative polymerase chain reaction. In the present study, 15 mice succumbed to SAH-induced DCVS in the day 3 (n=3), 5 (n=5) and 7 (n=2) groups. No mortality was observed in the blank control and saline groups during the process of observation in the SAH group, All mice in the SAH groups exhibited Bederson neurological severity scores ≥1; whereas no neurological impairment was detected in the blank and normal saline groups, demonstrating the success of the model. HE staining was used to assess vasospasm and the results demonstrated that the inner perimeter of the basal artery pipe decreased at day 3 in the SAH group; whereas values peaked in the day 7 group. The thickness of the basal artery wall significantly increased (P<0.05), as compared with the blank and saline groups, in which no significant alterations in the wall thickness and the inner perimeter of the basal artery pipe were detected. As detected by immunofluorescence and western blot analysis, the expression levels of caveolin-1 protein significantly decreased in the day 7 of SAH group, as compared with the blank and saline groups (P<0.01), in which no significant alterations were detected. Caveolin-1 mRNA expression levels significantly increased at the day 7 in the SAH group, as compared with the blank and the saline groups (P<0.01), as detected by RT-qPCR. Furthermore, significant differences were detected at day 14 in the SAH group, as compared with the blank and the saline groups (P>0.05), in which no significant alterations were detected. Therefore, the results of the present study demonstrated that caveolin-1 protein was downregulated in the basilar artery of a rat modeling SAH, which may be associated with DCVS. This suggested that caveolin-1 may be a potential target for the treatment of DCVS.

Sinomenine enhances microglia M2 polarization and attenuates inflammatory injury in intracerebral hemorrhage.

Microglia polarization plays a vital role in brain inflammatory injury following intracerebral hemorrhage (ICH). Previous studies have shown that sinomenine possesses potential immunoregulatory capabilities. However, microglia polarization's exact mechanisms in ICH remain uncertain. Therefore, we examined the role of sinomenine on microglia polarization and brain inflammation following ICH. For the experiment, autologous blood models were constructed in C57/BL6 mice. Markers of classically activated (M1) and alternatively activated (M2) microglia were detected by real-time polymerase chain reaction, immunofluorescence, and flow cytometry. Microglial toxicity was assessed using MTT and FACS assays. In addition, the neurological deficit and cerebral water content of ICH mice were also observed. Sinomenine attenuated M1 markers while promoting M2 markers of microglia. Sinomenine also protected hippocampal neurons from indirect toxicity mediated by ICH-treated microglia. Additionally, administration of sinomenine inhibited matrix metalloproteinase (MMP) 3/9 expression, cerebral water content, and neurological deficit. Therefore, sinomenine protected brain function following ICH, perhaps via M2 microglia phenotype induction and MMP 3/9 inhibition. This result suggests that sinomenine is a promising therapeutical strategy in ICH.

A Multicenter Analysis of Computed Tomography Angiography Alone Versus Digital Subtraction Angiography for the Surgical Treatment of Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased intracranial pressure, and these patients are unstable with a high risk of rebleeding. Computed tomography angiography (CTA) has been proposed as an examination tool for the rapid detection of ruptured aneurysms. We aimed to determine the safety and efficacy of CTA alone for surgical treatment of poor-grade aSAH compared with digital subtraction angiography (DSA). METHODS: We conducted a multicenter retrospective analysis of 144 patients with poor-grade aSAH who underwent surgical treatment for 2 different cohorts. Patients were grouped into CTA alone and DSA groups. Baseline characteristics, postoperative complications, and clinical outcomes at discharge and at last follow-up were compared between the 2 groups. Multivariate logistic regression models were used to assess the association between CTA alone and clinical outcomes after we adjusted for potential confounders. RESULTS: Of the 116 patients included, 42 (36.2%) patents received CTA alone and 74 patients (63.7%), including 12 patients with CTA and DSA and 62 patients with DSA alone, received DSA before surgical treatment. Patients with larger ruptured aneurysms (P = 0.006), aneurysm sizes of larger than 5 mm (P = 0.025), presence of single aneurysms (P = 0.018), and presence of intraventricular hemorrhage (P = 0.019) more often received CTA alone. All ruptured aneurysms were clipped successfully during surgery. There were no statistically significant differences in postoperative complications and clinical outcomes between the 2 groups. CONCLUSIONS: Although CTA alone can be safely and effectively used in most patients requiring surgical treatment, additional DSA may be considered in patients with smaller ruptured aneurysms or in those with multiple aneurysms.

Stent-assisted coiling versus coiling alone of ruptured anterior communicating artery aneurysms: A single-center experience.

OBJECTIVE: Endovascular coiling of anterior communicating artery (ACoA) aneurysms has evolved; however, stent-assisted coiling of ruptured aneurysms remains controversial. We aimed to compare periprocedural complications, angiographic and clinical outcomes after stent-assisted coiling with coiling alone of ruptured ACoA aneurysms. METHODS: We performed a retrospective review of consecutive 222 patients with ruptured ACoA aneurysms treated with endovascular coiling within 7 days after ictus. Patients were grouped into stent-assisted coiling and coiling alone groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups. RESULTS: 63 (28.4%) patients underwent stent-assisted coiling and 159 (71.6%) underwent coiling alone. There were no statistically significant differences in age, sex, clinical grading and Fisher grade. Larger aneurysms (P=0.002) and wider-neck aneurysms (P<0.001) were more often treated with stent-assisted coiling within 72h (P=0.025). Intraprocedural aneurysm rupture occurred in 6 (9.5%) patients treated with stent-assisted coiling compared with in 5 (3.1%) treated with coiling alone (P<0.048). Thrombus formation occurred in 10 (15.9%) patients after stent-assisted coiling compared with 6 (3.8%) after coiling alone (P=0.002). Stent-assisted coiling achieved a lower rate of immediate occlusion than coiling alone (P=0.045). Postoperative complications, clinical outcomes, and follow-up aneurysm occlusion did not significantly differ. CONCLUSIONS: Stent-assisted coiling of ruptured ACoA aneurysms was associated with a higher rate of intraprocedural complications and associated with a lower immediate occlusion rate. However, Postoperative complications and clinical outcomes did not differ. Long-term angiographic results require further study.

Predictors of good functional outcomes and mortality in patients with severe rebleeding after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Aneurysmal rebleeding is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH); however, limited data on severity of rebleeding and outcomes after severe rebleeding are available. We aimed to determine predictors of good outcome and mortality after severe rebleeding. MATERIALS AND METHODS: In a multicenter poor-grade aneurysm study, 60 patients with severe rebleeding, defined as new hemorrhage with poor clinical condition caused by rebleeding, were identified. Good functional outcome was defined as a modified Rankin scale (mRS) of ≤2, and mortality was defined as a mRS of 6. Multivariate logistic analyses were used to determine predictors of good outcome and mortality. RESULTS: Of the 58 patients included in this report, 24 (41.3%) patients experienced rebleeding within 24h after ictus. 42 (72.4%) patients had died at 12 months. The rate of good outcome increased from 5.2% at discharge to 13.8% at 6 months and 19.0% at 12 months. In multivariate analysis, World Federation of Neurosurgical Societies (WFNS) grade IV after rebleeding (P=0.007) and aggressive treatment (P=0.039) were independently associated with good outcome. A higher modified Fisher grade before rebledding (P=0.040), larger aneurysms (P=0.005), and lower Glasgow coma score after rebleeding (P=0.003) were independently associated with increased mortality. CONCLUSIONS: A better clinical condition after rebleeding were independently associated with good outcome and inversely associated with morality after severe rebleeding. Despite high mortality of rebleeding, patients with WFNS grade IV treated with aggressive treatment were more likely to have good outcomes regardless of their condition before rebleeding.

Fistula and Infratentorial Location, Characteristics That Contribute to Cerebral Arteriovenous Malformations, Lead to the Formation of Associated Aneurysms in Patients.

OBJECTIVE: Because the formation of associated aneurysms (AAs) related to the characteristics of cerebral artriovenous malformations (cAVMs) is poorly recognized, the purpose of this study was to identify the responsible characteristics of cAVMs related to the formation of AAs and to identify patients with responsible characteristics related to the formation of AAs through the analysis of the outcomes of these patients after treatment. METHODS: This study was performed to analyze the baseline characteristics of patients with cAVMs and AAs. The recurrent AA and residual size of cAVMs were used to evaluate the outcomes of patients after treatment. At the same time, the ROC curve was measured to gauge the relationship between the residual size of cAVMs and recurrent AAs in eligible patients. RESULTS: Fifty (15.0%) patients with cAVMs and AA were confirmed; these patients had twice the hazard of hemorrhage as patients with only isolated cAVMs. An infratentorial location (P < 0.001) and fistula (P = 0.002) were independent predictors of the formation of AAs. After a mean 22.7 months follow-up, 2 patients developed recurrent AAs, and the annual recurrence rate for patients with responsible characteristics was 17.6%, but for all patients was 7.2%. The ROC curve showed that patients, specifically patients with responsible characteristics, the residual size of the cAVM was closely related to recurrent AA (area = 0.89, 95% confidence interval 0.81-0.97, P = 0.023, cut-off value = 82.5%). CONCLUSIONS: Patients with cAVMs and AA who harbor a fistula or an infratentorial location tend to form AAs. To prevent recurrent AAs and decrease the subsequent risk of hemorrhage, complete obliteration of cAVMs or retrograding over 80% size of cAVMs is recommended.

Influencing factors of immediate angiographic results in intracranial aneurysms patients after endovascular treatment.

The purpose of this study was to analyze influencing factors associated with immediate angiographic results in intracranial aneurysms patients after endovascular treatment (EVT), providing theoretical evidence and guidance for clinical treatment of intracranial aneurysms. Totally 529 patients met the inclusive criteria, consisting of 338 males and 191 females. Gender; age; history of hypertension, diabetes, and smoking; intracranial atherosclerosis; rupture status, size and location, features of aneurysmal neck, shapes; vasospasm; treatment modality; and degree of aneurysm occlusion were all carefully and completely recorded. All data were investigated in univariate and multivariate logistic regression model to determine whether they were correlated with the degree of aneurysm occlusion. According to aneurysm size, aneurysms were classified as micro-miniature, miniature, and large aneurysms. There were 451 narrow-neck aneurysms and 78 wide-neck aneurysms. Totally 417 were regular and 112 were irregular. And 125 were un-ruptured aneurysms; 404 were ruptured aneurysms. The modalities of treatment were as follows: embolization with coil (n = 415), stent-assisted coil embolization (n = 89), and balloon-assisted coil embolization (n = 25). Univariate analysis showed that aneurysm size, feature of aneurysm neck, shape, and rupture status might affect the immediate occlusion after EVT. Multivariate logistic regression analysis indicated that ruptured aneurysm, tiny aneurysm, and wide-neck aneurysm were independent influencing factors of complete occlusion of intracranial aneurysm. Aneurysm rupture status, size, feature of aneurysmal neck, and shape might be the independent influencing factors of immediate angiographic results in intracranial aneurysm patients after EVT. Un-ruptured, micro-miniature, narrow-neck, and regular-shaped aneurysms were more probable to be occluded completely.