Targeted Temperature Management for Poor Grade Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.

OBJECTIVE: We assessed the effectiveness and safety of target temperature management (TTM) in treating patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). The primary objective was to evaluate the neurological outcome at 3 months. Secondary objectives were to assess mortality, delayed cerebral ischemia, cerebral edema, hydrocephalus, midline shift, and laboratory indicators related to TTM. METHODS: A single-blind, nonrandomized controlled trial was conducted. After admission, patients with poor-grade aSAH (Hunt-Hess scores IV âˆ¼ V) were assigned to a TTM group or a control group in a 1:1 ratio. TTM with core temperatures ranging from 36°C to 37°C was performed immediately and maintained until microclipping or endovascular embolization. Subsequently, rapid induction to 33°C ∼ 35°C was carried out and maintained for 3 to 5 days. Then, the patients underwent slow rewarming to 36°C ∼ 37°C and maintained at that temperature for a minimum of 48 hours. RESULTS: Sixty patients (30 treated with TTM and 30 with standard treatment) were included in the study. At 3 months, a favorable prognosis (modified Rankin scale score 0 to 3) was significantly higher in the TTM group than in the control group (n = 14, 46.7% vs. n = 6, 20.0%, P = 0.028). Adjusted multivariate logistics regression analysis indicated that TTM (odds ratio = 0.20, 95% confidence interval: 0.05-0.77, P = 0.019) reduced the number of unfavorable prognoses 3 months after admission. CONCLUSIONS: This study demonstrated the effectiveness and safety of TTM in patients with poor-grade aSAH, and its implementation improved neurological outcomes. Multicenter randomized controlled studies with a large number of patients are needed to confirm these observations.

A visualized MAC nomogram online predicts the risk of three-month mortality in Chinese elderly aneurysmal subarachnoid hemorrhage patients undergoing endovascular coiling.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage (aSAH) is an aggressive disease with higher mortality rate in the elderly population. Unfortunately, the previous models for predicting clinical prognosis are still not accurate enough. Therefore, we aimed to construct and validate a visualized nomogram model to predict online the 3-month mortality in elderly aSAH patients undergoing endovascular coiling. METHOD: We conducted a retrospective analysis of 209 elderly aSAH patients at People's Hospital of Hunan Province, China. A nomogram was developed based on multivariate logistic regression and forward stepwise regression analysis, then validated using the bootstrap validation method (n = 1000). In addition, the performance of the nomogram was evaluated by various indicators to prove its clinical value. RESULT: Morbid pupillary reflex, age, and using a breathing machine were independent predictors of 3-month mortality. The AUC of the nomogram was 0.901 (95% CI: 0.853-0.950), and the Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (p = 0.4328). Besides, the bootstrap validation method internally validated the nomogram with an area under the curve of the receiver operator characteristic (AUROC) of 0.896 (95% CI: 0.846-0.945). Decision curve analysis (DCA) and clinical impact curve (CIC) indicated the nomogram's excellent clinical utility and applicability. CONCLUSION: An easily applied visualized nomogram model named MAC (morbid pupillary reflex-age-breathing machine) based on three accessible factors has been successfully developed. The MAC nomogram is an accurate and complementary tool to support individualized decision-making and emphasizes that patients with higher risk of mortality may require closer monitoring. Furthermore, a web-based online version of the risk calculator would greatly contribute to the spread of the model in this field.

A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation. Methods: We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA). Results: Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram. Conclusion: We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.

The routing of medical evacuation of patients with ruptures of cerebral aneurysms from remote out-of-the-way rural area.

The patients with aneurysm subarachnoid hemorrhage (aSAH) living in remote, inaccessible, rural areas cannot be provided with urgent neurosurgical care on the spot. They require medical evacuation (ME) to neurosurgical hospital. The purpose of the study was to investigate effect of complex (multi-stage) and simple (one-stage) logistic scheme of ME of patients in acute period of aSAH on the outcome of the disease. The retrospective analysis of results of surgical treatment in 145 patients with aSAH hospitalized in regional vascular center (RVC) in Yakutsk in 2017-2018 was carried out. The subjects were allocated into 3 groups: group 1 - patients from regions of the Republic of Sakha, who underwent ME to the RSC using simple transportation scheme; group 2 - patients from regions of the Republic of Sakha who underwent ME using complex transportation scheme; group 3 (control) - patients hospitalized from territory of Yakutsk. The RVC hospitalized 145 patients. The sanitary aviation delivered 91 (62.8%) patients from districts of the Republic to the RVC. The duration of time from the onset of disease to surgical treatment: in group 1-2 days; in group 2-4 days; in group 3, 2 days (p = 0.018). The frequency of re-rupture of cerebral aneurysm in the group 1 and group 2 did had no statistically significant differences (19,1% and 32.7%) (p = 0.142). Mortality: in group 1 7.1%; in group 2 8.2%; in group 3 7.4% and no statistically significant differences between groups 1 and 2 (p = 1,000), between groups 1 and 3 (p = 1,000) and between groups 2 and 3 (p = 0.886). When applying complex logistic scheme of ME, transportation over considerable distance does not deteriorated course of disease and results of surgical treatment of patients with aSAH in acute period of hemorrhage.

Increase in Brain Volume After Aneurysmal Subarachnoid Hemorrhage Leads to Unfavorable Outcome: A Retrospective Study Quantified by CT Scan.

Background and Purpose: Primary brain swelling occurs in aneurysmal subarachnoid hemorrhage (aSAH) patients. The absence of a dynamic quantitative method restricts further study of primary brain swelling. This study compared differences in the change rate of brain volume (CRBV) between patients with and without primary brain swelling in the early stage of aSAH. Moreover, the relationship between CRBV and clinical outcomes was evaluated. Methods: Patients hospitalized within 24 h after aSAH were included in this retrospective study. Utilizing a qualitative standard established before the study to recognize primary brain swelling through brain CT after aSAH, clinical outcomes after 3 months of SAH were evaluated with a modified Rankin scale (mRS). The brain volume (BV) of each patient was calculated with a semiautomatic threshold algorithm of 3D-slicer, and the change in brain volume (CIBV) was obtained by subtracting the two extreme values (CIBV = BVmax - BVmin). The CRBV was obtained by CIBV/BVmin × 100%. The CRBV values that predicted unfavorable prognoses were estimated. Results: In total, 130 subjects were enrolled in the study. The mean CRBV in the non-swelling group and swelling group were 4.37% (±4.77) and 11.87% (±6.84), respectively (p < 0.05). CRBV was positively correlated with the length of hospital stay, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume (Spearman ρ = 0.334; p < 0.001; Pearson ρ = 0.269, p = 0.002; Pearson ρ = 0.278, p = 0.001; Pearson ρ = 0.233, p = 0.008, respectively). Analysis of variance showed significant differences in CIBV, CRBV, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume among varying modified Fisher scale (mFisher), with higher admission mFisher scale, indicating larger values of these variables. After adjusting for risk factors, the model showed that for every 1% increase in the CRBV, the probability of poor clinical prognosis increased by a factor of 1.236 (95% CI = 1.056-1.446). In the stratified analysis, the odds of worse clinical outcomes increased with increases in the CRBV. Receiver operating characteristic curve analysis showed that HH grade, mFisher scale, and score of CRBV (SCRBV) had diagnostic performance for predicting unfavorable clinical outcomes. Conclusion: Primary brain swelling increases brain volume after aSAH. The CRBV quantified by 3D-Slicer can be used as a volumetric representation of the degree of brain swelling. A larger CRBV in the early stage of aSAH is associated with poor prognosis. The CRBV can be used as a neuroimaging biomarker of early brain injury after bleeding and may be an effective predictor of patients' clinical prognoses.

Elevated Glucose-Potassium Ratio Predicts Preoperative Rebleeding in Patients With Aneurysmal Subarachnoid Hemorrhage.

Introduction: Recent reports revealed that higher serum glucose-potassium ratio (GPR) levels at admission were significantly associated with poor outcomes at 3 months following aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to investigate the association between GPR and the risk of rebleeding following aSAH. Methods: This single-center retrospective study of patients with aSAH was conducted in our hospital between January 2008 and December 2020. Patients meeting the inclusion criteria were divided into the rebleed group and the non-rebleed group. Univariate and multivariate analyses were implemented to assess the association between risk factors of rebleeding and outcomes. Results: A total of 1,367 patients experiencing aSAH, 744 patients who met the entry criteria in the study [mean age (54.89 ± 11.30) years; 60.50% female patients], of whom 45 (6.05%) developed rebleeding. The patients in the rebleed group had significantly higher GPR levels than those of patients without rebleeding [2.13 (1.56-3.20) vs. 1.49 (1.23-1.87); p < 0.001]. Multivariable analysis revealed that higher mFisher grade and GPR were associated with rebleeding [mFisher grade, odds ratios (OR) 0.361, 95% CI 0.166-0.783, p = 0.01; GPR, OR 0.254, 95% CI 0.13-0.495, p < 0.001]. The receiver operating characteristics (ROCs) analysis described that the suitable cut-off value for GPR as a predictor for rebleeding in patients with aSAH was determined as 2.09 (the area under the curve [AUC] was 0.729, 95% CI 0.696-0.761, p < 0.0001; the sensitivity was 53.33%, and the specificity was 83.98%). Pearson correlation analysis showed a significant positive correlation between GPR and mFisher grade, between GPR and Hunt-Hess grade (mFisher grade r = 0.4271, OR 0.1824, 95% CI 0.3665-0.4842, p < 0.001; Hunt-Hess grade r = 0.4248, OR 0.1836, 95% CI 0.3697-0.4854, p < 0.001). The patients in the poor outcome had significantly higher GPR levels than those of patients in the good outcome [1.87 (1.53-2.42) vs. 1.45 (1.20-1.80); p < 0.001]. Multivariable analysis demonstrated that GPR was an independent predictor for poor prognosis. The AUC of GPR was 0.709 (95% CI 0.675-0.741; p < 0.0001) (sensitivity = 77.70%; specificity = 55.54%) for poor prognosis. Conclusion: Higher preoperative serum GPR level was associated with Hunt-Hess grade, mFisher grade, rebleeding, and unfunctional outcome, and that they predicted preoperative rebleeding and the 90-days outcome of non-diabetic patients with aSAH, who had potentially relevant clinical implications in patients with aSAH.

Prevalence of Ruptured Intracranial Aneurysms in a Tertiary Care Hospital of Nepal.

INTRODUCTION: Intracranial aneurysms affect 3-8 percent of the world's population, with ruptured aneurysms being the most common cause of subarachnoid hemorrhage. The sensitivity of Computed Tomography Angiogram in diagnosing intracranial aneurysm is 97%. The aim of our study is to find out the prevalence of ruptured intracranial aneurysms among all the admitted cases encountered in our hospital. METHODS: A descriptive cross-sectional study was done at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences from 2016 to 2018. Convenience sampling method was done. In order to detect the site and size of aneurysms, 16 slice Siemens Computed Tomography with Computed Tomography angiogram was used. Ethical approval was obtained from the Institutional Review Committee at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences. Based on demographic data and computed tomography angiography findings, various morphometric parameters along with demographic parameters were considered for the study. RESULTS: Among 10,856 cases, prevalence of ruptured intracranial aneurysms were found in 42 (0.386%) [Confidence Interval= 0.395 to 0.377]. Among 42 cases, Middle Cerebral Artery aneurysm was present on 16 (39.02%) followed by Anterior Communicating Artery on 14 (34.14%), then Posterior Communicating Artery on 5 (12.19%). The largest neck and dome size were seen in basilar tip aneurysm with size of 11mm and 8mm respectively. The most common type was Fischer grade 4. CONCLUSIONS: The prevalence of ruptured intracranial aneursyms were found to be higher as compared to the other international studies.

Impact of Early Versus Late Intravenous Followed by Oral Nimodipine Treatment on the Occurrence of Delayed Cerebral Ischemia Among Patients With Aneurysm Subarachnoid Hemorrhage.

BACKGROUND: Guidelines for aneurysm subarachnoid hemorrhage (aSAH) management recommend treatment with nimodipine to all patients to reduce delayed cerebral ischemia (DCI) and poor clinical outcome. However, it did not give the most beneficial time to start therapy and route of administration. OBJECTIVES: To compare the DCI occurrence and clinical outcome among aSAH patients who received nimodipine treatment at different times. METHODS: A retrospective cohort study was conducted by collecting data from medical chart reviews between August 30, 2010, and October 31, 2015, at Prasart Neurological Institute, Thailand. Patients were classified into 2 groups by time to receive nimodipine: early group and late group (<96 and >96 hours, respectively). All patients received intravenous (IV) followed by oral nimodipine to complete treatment course. Clinical outcome was graded using the Glasgow Outcome Scale at 21 days. The factors related to DCI were analyzed using multivariate logistic regression. RESULTS: A total of 149 patients were recruited: early (n = 97) and late (n = 52). No difference in baseline characteristics between groups was observed. The occurrence of DCI was not statistically significantly different between groups (early group, 18.60%, vs late group, 20.80%; P = 0.74). The World Federation of Neurosurgical Societies IV to V was associated with DCI occurrence. The proportion of patients with good outcome, poor outcome, or death did not show any difference between groups. CONCLUSIONS AND RELEVANCE: Receiving IV nimodipine 3 to 7 days following oral therapy after bleeding can be the alternative regimen in patients who did not start nimodipine within 96 hours.

The expression of von Willebrand factor and ADAMTS13 in aneurysmal subarachnoid hemorrhage / 中华急诊医学杂志

Objective To study the clinical values of dynamic changes of yon Willebrand factor (vWF) and ADAMTS13 (a disintegrin and metalloprotease with thrombospondin repeats-13 ) in aneurysmal subarachnoid hemorrhage. Methods Twenty-nine patients with aneurysmal subarachnoid hemorrhage admitted to Department of Neurosurgery from April 2010 through April 2011 were enrolled for retrospective study.They could be categorized into 3 sets of grouping:delayed cerebral ischemia group ( DCI group) and non-delayed cerebral ischemia group ( no DCI group ),cerebral vasospasm group ( CVS group ) and no vasospasm group (no CVS group),and good prognosis group and poor prognosis group,and another 20 healthy subjects as control group.All patients were examined with CT,DSA,or/and CTA to identify the intracranial subarachnoid hemorrhage resulted from aneurysm rupture.The exclusion criteria included:(1)the time from onset to admission was longer than 72 hours or patient was in imminent danger of death; (2)patients had surgery,interventiona] or conservative treatment outside the hospital; (3) patients were under the treatment of antiplatelet medicine such as aspirin,clopidogrel,or other anticoagulants such as warfarin,etc ; (4) patients had blood diseases,impaired kidney or liver function,pregnant,or with recent infections.Venous blood were taken one day,4 days and 10 days after SAH to determine plasma concentrations of ADAMTS13 and vWF by using enzyme-linked immunosorbent assay (ELISA). Transcranial Doppler ultrasonography (TCD) was used to measure mean blood flow velocity of middle cerebral artery (VMCA).Glasgow outcome scale (GOS) score was measured before discharge. Data were analyzed by using SPSS version 13.0 software. Results The levels of vWF were significantly higher in DCI group,CVS group and poor prognosis group compared with those in the control group 1 day,4 days and 10 days after SAH.There were differences in vWF between DCI group and no DCI group 1 day and 4 days after SAH ( P ＜ 0.05 ).There were significantly differences in vWF between CVS group and no CVS group,and between good prognosis group and poor prognosis group 4 days and 10 days after SAH ( P ＜ 0.01 ).In DCI group and poor prognosis group,the level of plasma ADAMTS13 was significantly lower 1 day after SAH than that in the normal control group (P ＜0.01) and in the no DCI group (P ＜0.O1 ); and there were no differences in ADAMTS13 between CVS group and no CVS group.Conclusions In the early stage,the increase in plasma vWF and decrease in ADAMTS13 activity are associated with DCI,and the decrease in ADAMTS13 activity can be used to predict the outcome.

Clinical Characteristics of Aneurysm Rupture with the Focus of Hypertension and Smoking as Predisposing Factors

OBJECTIVE: The purpose of this study is to identify risk factors for subarachnoid hemorrhage(SAH) in Korea. METHODS: The clinical record and environmental data of 250 patients who had admitted our hospital between September 2001 and May 2003 were reviewed retrospectively by the neurosurgical nursing practitioners. RESULTS: In this study, the peak age for presentation with ruptured intracranial aneurysm was around 5th decade which is most active period of his or her life. The peak time of aneurysm rupture was from 6 to 12 A.M.(34.8%) and the onset of SAH occurred the most frequently at work(30.4%). The prevalence of hypertension in SAH patients was 42.8%, That of cigarette smoking in men and in women were 81.7% and 15.8% respectively. Hypertension was significantly corrected with the amount of hemorrhage based on Fisher Grading system(P<0.05). The consumption of smoking and the amount of hemorrhage was closely correlated also(P<0.05). CONCLUSION: Hypertension and cigarette smoking may be closely related to aneurysmal SAH. Undoubtedly, they are significantly related to massive, fatal SAH with poor neurologic condition. To prevent reduce aneurysmal SAH, cessation of smoking, anti-hypertensive medication and stress control are most important basic step in promotion of public health.

Electrocardiographic Abnormalities after Subarachnoid Hemorrhage / 대한마취과학회지

BACKGROUND: Electrocardiogram was one of the routine monitorings not only using for preanesthetic assessment but also in the operation room and ICU. Electrocardiographic changes are reported frequently after subarachnoid hemorrhage. Preanesthetic assessment of ECG abnormalities in the patients with subarachnoid hemorrhage is important. The aim of this study was to investigate the functional significance of ECG changes for perioperative assessment of cardiac function. METHODS: For premedication, patients were administered glycopyrrolate 0.2 mg 1 hour prior to induction. Induction was established with pentothal sodium, succinylcholine after precurarization and preoxygenation. N2O/O2 (2:1), isoflurane and pancuronium were administered for maintenance. The monitorings for patients were performed ECG (5 leads), direct atrial pressure, ETCO2, CVP and rectal temperature. RESULTS: ECG abnormalities consisted of T wave abnormalities, ST segment changes, abnormal Q wave, QT interval prolongation, LVH and arrhythmia etc. We analyzed 41 of 108 SAH patients who had ECG abnormalities of neurogenic origin preoperatively. Of these, 46% in T wave, 17% in LVH, 15% in Q wave, 15% in ST segment changes and 7% in the others (CRBBB, PAC, AF) were found. CONCLUSIONS: It is concluded that we found a poor relationship between electrocardiographic changes after subarachnoid hemorrhage and evidences of myocardial dysfunction on the echocardiogram. General anesthesia in the patients of the subarachnoid hemorrhage must not be delayed in the patients with ECG abnormalities of neurogenic origin. A preanesthetic cardiac assessment in the patients with ECG abnormalities of cardiogenic origin must be always performed.