Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion.
Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (≥14 days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography.
Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence on the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not correlate with the development of shunt-dependent chronic hydrocephalus.
Hydrocephalus after aneurysmal SAH seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.
Subarachnoid hemorrhage; Ventriculoperitoneal shunt; Chronic hydrocephalus; Related factor
OBJECTIVE—To investigate prospectively the
proportion of patients actually operated on early in units that aim at
surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH)
and what is the main current determinant of poor outcome.
METHODS—A prospective analysis of all SAH
patients admitted during a one year period at three neurosurgical units
that aim at early surgery. The following clinical details were
recorded: age, sex, date of SAH, date of admission to the neurosurgical
centre, whether a patient was referred by a regional hospital or a
general practitioner, Glasgow coma scale and grade of SAH (World
Federation of Neurological Surgeons (WFNS) score) on admission at the
neurosurgical unit, results of CT and CSF examination, the presence of
an aneurysm on angiography, details of treatment with nimodipine or
antifibrinolytic agents, and the date of surgery to clip the aneurysm.
At follow up at three months, the patients' clinical outcome was
determined with the Glasgow outcome scale and in cases of poor outcome
the cause for this was recorded.
RESULTS—The proportion of patients that was
operated on early—that is, within three days after SAH—was 55%.
Thirty seven of all 102admitted patients had a poor outcome.
Rebleeding and the initial bleeding were the main causes of this in
35% and 32% respectively of all patients with poor outcome.
CONCLUSIONS—In neurosurgical units with what has
been termed "modern management" including early surgery, about half
of the patients are operated on early. Rebleeding is still the major
cause of poor outcome.
Grading of patients with aneurysmal subarachnoid hemorrhage (aSAH) is often confounded by seizure, hydrocephalus or sedation and the prediction of prognosis remains difficult. Recently, copeptin has been identified as a serum marker for outcomes in acute ischemic stroke and intracerebral hemorrhage (ICH). We investigated whether copeptin might serve as a marker for severity and prognosis in aSAH.
Eighteen consecutive patients with aSAH had plasma copeptin levels measured with a validated chemiluminescence sandwich immunoassay. The primary endpoint was the association of copeptin levels at admission with the World Federation of Neurological Surgeons (WFNS) grade score after resuscitation. Levels of copeptin were compared across clinical and radiological scores as well as between patients with ICH, intraventricular hemorrhage, hydrocephalus, vasospasm and ischemia.
Copeptin levels were significantly associated with the severity of aSAH measured by WFNS grade (P = 0.006), the amount of subarachnoid blood (P = 0.03) and the occurrence of ICH (P = 0.02). There was also a trend between copeptin levels and functional clinical outcome at 6-months (P = 0.054). No other clinical outcomes showed any statistically significant association.
Copeptin may indicate clinical severity of the initial bleeding and may therefore help in guiding treatment decisions in the setting of aSAH. These initial results show that copeptin might also have prognostic value for clinical outcome in aSAH.
To evaluate the role of lumbar drainage in the prevention of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by coil embolization in good-grade patients.
One-hundred-thirty consecutive patients with aneurysmal subarachnoid hemorrhage in good-grade patients (Hunt & Hess grades I-III), who were treated by coil embolization between August 2004 and April 2010 were retrospectively evaluated. Poor-grade patients (Hunt & Hess grades IV and V), a history of head trauma preceding the development of headache, negative angiograms, primary subarachnoid hemorrhage (SAH), and loss to follow-up were excluded from the study. We assessed the effects on lumbar drainage on the risk of shunt-dependent hydrocephalus related to coil embolization in patients with ruptured intracranial aneurysms.
One-hundred-twenty-six patients (96.9%) did not develop shunt-dependent hydrocephalus. The 2 patients (1.5%) who developed acute hydrocephalus treated with temporary external ventricular drainage did not require permanent shunt diversion. Overall, 4 patients (3.1%) required permanent shunt diversion; acute hydrocephalus developed in 2 patients (50%). There was no morbidity or mortality amongst the patients who underwent a permanent shunt procedure.
Coil embolization of ruptured intracranial aneurysms may be associated with a lower risk for developing shunt-dependent hydrocephalus, possibly by active management of lumbar drainage, which may reflect less damage for cisternal anatomy than surgical clipping. Coil embolization might have an effect the long-term outcome and decision-making for ruptured intracranial aneurysms.
Coil embolization; Hydrocephalus; Lumbar drainage; Shunt
The amount of hemorrhage observed on a brain computed tomography scan, or a patient's Fisher grade (FG), is a powerful risk factor for development of shunt dependent hydrocephlaus (SDHC). However, the influence of treatment modality (clipping versus coiling) on the rate of SDHC development has not been thoroughly investigated. Therefore, we compared the risk of SDHC in both treatment groups according to the amount of subarachnoid hemorrhage (SAH).
We retrospectively reviewed 839 patients with aneurysmal SAH for a 5-year-period. Incidence of chronic SDHC was analyzed using each treatment modality according to the FG system. In addition, other well known risk factors for SDHC were also evaluated.
According to our data, Hunt-Hess grade, FG, acute hydrocephalus, and intraventricular hemorrhage were significant risk factors for development of chronic SDHC. Coiling group showed lower incidence of SDHC in FG 2 patients, and clipping groups revealed a significantly lower rate in FG 4 patients.
Based on our data, treatment modality might have an influence on the incidence of SDHC. In FG 4 patients, the clipping group showed lower incidence of SDHC, and the coiling group showed lower incidence in FG 2 patients. We suggest that these findings could be a considerable factor when deciding on a treatment modality for aneurysmal SAH patients, particularly when the ruptured aneurysm can be occluded by either clipping or coiling.
Shunt dependent hydrocephalus; Fisher grading system; Subarachnoid hemorrhage
Recently, it was reported that fenestration of the lamina terminalis (LT) may reduce the incidence of shunt-dependent hydrocephalus in aneurysmal subarachnoid hemorrhage (SAH). The authors investigated the efficacy of the LT opening on the incidence of shunt-dependent hydrocephalus in the ruptured anterior communicating artery (ACoA) aneurysms. The data of 71-ruptured ACoA aneurysm patients who underwent aneurysmal clipping in acute stage were reviewed retrospectively. Group I (n=36) included the patients with microsurgical fenestration of LT during surgery, Group II (n=35) consisted of patients in whom fenestration of LT was not feasible. The rate of shunt-dependent hydrocephalus was compared between two groups by logistic regression to control for confounding factors. Ventriculo-peritoneal shunts were performed after aneurysmal obliteration in 18 patients (25.4%). The conversion rates from acute hydrocephalus on admission to chronic hydrocephalus in each group were 29.6% (Group I) and 58.8% (Group II), respectively. However, there was no significant correlation between the microsurgical fenestration and the rate of occurrence of shunt-dependent hydrocephalus (p>0.05). Surgeons should carefully decide the concomitant use of LT fenestration during surgery for the ruptured ACoA aneurysms because of the microsurgical fenestration of LT can play a negative role in reducing the incidence of chronic hydrocephalus.
Hydrocephalus; Chronic; Ventriculostomy; Hypothalamus; Lamina Terminalis; Intracranial Aneurysm; Anterior Communicating Artery; Circle of Willis; Subarachnoid Hemorrhage
Acute hydrocephalus (HCP) after aneurysmal subarachnoid hemorrhage (SAH) often persists. Our previous study described factors that singly and combined in a formula correlate with permanent CSF diversion. We now aimed to determine whether the same parameters are applicable at an institution with different HCP management practice.
We reviewed records of 181 consecutive patients who presented with SAH and received an external ventricular drain (EVD) for acute HCP. After exclusion and inclusion criteria were met, 71 patients were analyzed. Data included admission Fisher and Hunt and Hess grades, aneurysm location, treatment modality, ventricle size, CSF cell counts and protein levels, length of stay (LOS) in the hospital, and the presence of craniectomy. Outcome measures were: (1) initial EVD challenge outcome; (2) shunting within 3 months; and (3) LOS.
Shunting correlated with Hunt and Hess grade, CSF protein, and the presence of craniectomy. The formula derived in our previous study demonstrated a weaker correlation with initial EVD challenge failure. Several parameters that correlated with shunting in the previous study were instead associated with LOS in this study.
The decision to shunt depends on management choices in the context of a disease process that may improve over time. Based on the treatment strategy, the shunting rate may be lowered but LOS increased. Markers of disease severity in patients with HCP after SAH correlate with both shunt placement and LOS. This is the first study to directly evaluate the effect of different practice styles on the shunting rate. Differences in HCP management practices should inform the design of prospective studies.
External ventricular drain; hydrocephalus; subarachnoid hemorrhage; shunt
Many previous studies have shown that electrocardiographic (ECG) changes occur patients with subarachnoid hemorrhage (SAH). This study was designed to identify the frequency, influencing factors, and outcome of clinically significant cardiac arrhythmias after SAH.
We retrospectively analyzed clinical data of 122 patients including ECG finding, age, sex, the Hunt-Hess grade, the Fisher's grade, the history of hypertension, peak blood pressure and heart rate, location of aneurysm, Glasgow Outcome Scale (GOS) score, the days of admission to the intensive care unit, the presence of symptomatic vasospasm.
Of 122 SAH patients, 50% (n = 61) had a verified clinically significant arrhythmia. There were no statistically significant independent factors associated with clinically significant arrhythmia in multivariate analysis. Although adjustments for the effects of age, Hunt-Hess grade, and the presence of symptomatic vasospasm on death were made, clinically significant arrhythmias were still independently predictive of death (no arrhythmia versus arrhythmia, 11.5% versus 27.9%, adjusted odds ratio [OR] 3.524, 95% confidence interval [CI] 1.229-10.100, p = 0.019) and poor outcome (GOS ≤ 2, 13.1% versus 29.5%, adjusted OR 3.202, 95% CI 1.174-8.732, p= 0.023).
Clinically significant arrhythmias after SAH are associated with a high mortality rate, and serious cardiac and neurological comorbidity. Patients with an abnormal ECG on admission should undergo close cardiac monitoring, and the presence of rhythm disturbances should prompt aggressive measures to treat myocardial infarction (MI), maintain a normal cardiac rhythm, and minimize the presence of autonomic stress.
Arrhythmia; Death; Subarachnoid hemorrhage
Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH.
Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ≥70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ≥70 years of age).
Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (≥70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus.
In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.
Aneurysmal subarachnoid hemorrhage; Acute hydrocephalus; Shunt-dependent chronic hydrocephalus; Old age; Intraventricular hemorrhage
Background and Purpose
Electrocardiographic (ECG) abnormalities are common after subarachnoid hemorrhage (SAH) but their significance remains uncertain. The aim of this study was to determine whether any specific ECG abnormalities are independently associated with adverse neurological outcomes.
This was a sub-study of the Intraoperative Hypothermia Aneurysm Surgery Trial, which was designed to determine whether intraoperative hypothermia would improve neurological outcome in SAH patients undergoing aneurysm surgery. The outcome was the 3 month Glasgow Outcome Score (GOS), treated as both a categorical measure [GOS 1 (good outcome) to 5 (death)] and dichotomously (mortality/GOS 5 vs GOS 1−4.). The predictor variables were pre-operative ECG characteristics, including heart rate (HR), corrected QT interval, and ST and T wave abnormalities. Univariate logistic regression was performed to screen for significant ECG variables, which were then tested for associations with the outcome by multivariate logistic regression, adjusting for clinical covariates.
The study included 588 patients, of which 31 (5%) died. There was a significant, non-linear association between heart rate and mortality such that lowest quartile (≤60 bpm, odds ratio [OR] 6.5, P=0.027) and highest quartile (>80 bpm, OR 8.8, P=0.006) were associated with higher risk. There was also a significant association between non-specific ST and T wave abnormalities (NSSTTWA) and mortality (OR 3.1, P=0.031).
Bradycardia, relative tachycardia, and NSSTTWA are strongly and independently associated with 3 month mortality after SAH. Further research should be performed to determine whether or not there is a causal relationship between cardiac dysfunction and neurological outcome after SAH.
Subarachnoid hemorrhage; electrocardiography; bradycardia
Electrolyte disturbances are frequently observed during the acute and subacute period after subarachnoid hemorrhage (SAH) that may potentially worsen the therapeutic outcomes. This study was aimed to determine the pattern of electrolyte disturbance in the acute and subacute phase after SAH and their potential impacts on the long term outcome of the patients.
A total of 53 patients were prospectively enrolled in the study. A standard and uniform medical care was performed for all patients. The serum levels of electrolytes (Sodium, Potassium and Magnesium) were measured on admission, 3-5, and 7-10 days after SAH. Radiographic intensity of hemorrhage (Fisher’s scale), and the clinical grading (WFNS grade) were documented in the first visit. The outcomes were evaluated using Glasgow outcome scale (GOS) at 3 months after discharge.
Hyponatremia was the most common electrolyte imbalance among the patients but did not worsen the outcome. Although less common, hypernatremia in the subacute phase was significantly associated with poor outcome. Both hypokalemia and hypomagnesemia were predictive of poor outcomes.
Because electrolyte abnormalities can adversely affect the outcome, the serum levels of electrolytes should be closely monitored with serial measurements and treated properly in patients with aneurysmal SAH.
Subarachnoid hemorrhage, Aneurysm, Electrolyte imbalance, Outcome
Patients with good-grade subarachnoid hemorrhage (SAH) are those without initial neurological deficit. However, they can die or present severe deficit due to secondary insult leading to brain ischemia. After SAH, in a known context of energy crisis, vasospasm, hydrocephalus and intracranial hypertension contribute to unfavorable outcome. Lumbar puncture (LP) is sometimes performed in an attempt to reduce intracranial pressure (ICP) and release headaches. We hypothesize that in good-grade SAH patients, a 20-ml LP releases headaches, reduces ICP and improves cerebral blood flow (CBF) as measured with O15 PET scan.
Six good-grade (WFNS grade 1or 2) SAH patients (mean age 48 years, 2 women, 4 men) were prospectively included. All aneurysms (4 anterior communicating artery and 2 right middle cerebral artery) were coiled at day 1. Patients were managed according to our local protocol. LP was performed for severe headache (VAS >7) despite maximal painkiller treatment. Patients were included when the LP was clinically needed. The 20-ml LP was done in the PET scan (mean delay between SAH and LP: 3.5 days). LP allows hydrostatic measurement of ICP. Arterial blood pressure (ABP) was noninvasively gauged with photoplethysmography. Every signal was monitored and analyzed off-line. Regional CBF (rCBF) was measured semiquantitatively with O15 PET before and after LP. Then we calculated the difference between baseline and post-LP condition for each area: positive value means augmentation of rCBF after the LP, negative value means reduction of rCBF. Individual descriptive analysis of CBF was first performed for each patient; then a statistical group analysis was done with SPM for all voxels using t statistics converted to Z scores (p < 0.01, Z score >3.2).
A 20-ml LP yielded a reduction in pain (–4), a drop in ICP (24.3 ± 12.5 to 6.9 ± 4.7 mm Hg), but no change in ABP. Descriptive and statistical image analysis showed a heterogeneous and biphasic change in cerebral hemodynamics: rCBF was not kept constant and either augmented or decreased after the drop in ICP. Hence, cerebrovascular reactivity was spatially heterogeneous within the brain. rCBF seems to augment in the brain region roughly close to the bleed and to be reduced in the rest of the brain, with a rough plane of symmetry.
In good-grade SAH, LP releases headaches and lowers ICP. LP and the drop in ICP have a heterogeneous and biphasic effect on rCBF, suggesting that cerebrovascular reactivity is not spatially homogeneous within the brain.
Subarachnoid hemorrhage; Cerebral blood flow; Lumbar puncture; Intracranial pressure; PET scanner
External cerebrospinal fluid (CSF) drainage is an effective method to remove massive subarachnoid hemorrhage (SAH), but carries the risk of meningitis and shunt-dependent hydrocephalus. This study investigated whether postoperative cisternal CSF drainage affects the incidence of cerebral vasospasm and clinical outcome in patients with thin SAH. Seventy-eight patients with thin SAH, 22 men and 56 women aged from 17 to 73 years (mean 51.2 years), underwent surgical repair for ruptured anterior circulation aneurysm. Patients were divided into groups with (38 patients) and without (40 patients) postoperative cisternal CSF drainage, and the incidences of angiographical and symptomatic vasospasm, shunt-dependent hydrocephalus, meningitis, and the clinical outcome were compared. The incidences of angiographical vasospasm (31.6% vs 50.0%), symptomatic vasospasm (7.9% vs 12.5%), shunt-dependent hydrocephalus (5.3% vs 0%), and meningitis (2.6% vs 0%) did not differ between patients with and without cisternal CSF drainage. All patients in both groups resulted in good recovery. Postoperative cisternal CSF drainage does not affect the incidence of cerebral vasospasm or the clinical outcome in patients with thin SAH.
subarachnoid hemorrhage; cerebrospinal fluid drainage; cerebral vasospasm; meningitis; hydrocephalus; ruptured intracranial aneurysm
We investigated the role of acute-stage diffusion-weighted images (DWIs) for predicting outcome of poor-grade subarachnoid hemorrhage (SAH). This study included 38 patients with poor-grade SAH who underwent DWI within 24 h after onset. DWI findings were divided into three groups on the basis of lesion area: none (N), spotty (S, ≦10 mm2), or areal (A, >10 mm2). We evaluated the correlation between preoperative DWI findings and clinical outcome, and the characteristics of DWI abnormalities. DWI abnormalities were revealed in 81.6% of cases (group S 34.2% group A 47.3%). All patients in groups N and S and 73.3% of patients in group A were treated radically. For those patients without rerupture, favorable outcomes were achieved in 100% of group N, 53.8% of group S, and 0% of group A. Abnormal lesions on initial DWI, which resulted in permanent lesions, showed a mean apparent diffusion coefficient ratio to the control value of 0.71, which was significantly lower than 0.95 observed in reversible lesions (P<0.01). We recommend radical treatment for even poor-grade SAH as long as the preoperative DWI shows no or only spotty lesions. DWI may provide an objective means to estimate the outcome of poor-grade SAH.
aneurysm; apparent diffusion coefficient; diffusion; magnetic resonance imaging; outcome; subarachnoid hemorrhage
Numerous studies have compared the characteristics of familial intracranial aneurysms with those of non-familial aneurysms. To better understand familial subarachnoid hemorrhage (SAH), we studied a series of patients with SAH who had at least one first-degree relative with SAH, and compared our results with those of previous studies.
We identified patients treated for SAH at our hospital between January 1993 and October 2006 and analyzed those patients with one or more first-degree relatives with SAH. We retrospectively collected data from patients with a family history and searched for patients who had relatives with aneurysms or who had been treated at other hospitals for SAH.
We identified 12 patients from six families with at least two first-degree relatives with SAH. All patients had affected first-degree relatives; in five families, they were siblings. The mean age at the time of rupture was 49.75 years; in four families, the age difference was within 5 years. In five patients (42%), the aneurysm was located in the middle cerebral artery. Only one patient had an aneurysm in the anterior communicating artery.
In agreement with previous studies, our results showed that familial aneurysms, in comparison with non-familiar aneurysms, ruptured at a younger age and smaller size, had a high incidence in the middle cerebral artery, and were underrepresented in the anterior communicating artery. Interestingly, the age at the time of rupture was similar between relatives. Screening should be considered in the fifth or sixth decade for those who have a sibling with SAH.
Subarachnoid hemorrhage; Familial; Aneurysm; Screening
The aim of this study is to investigate the clinical outcomes of surgery and coiling and analyze the predicting factors affecting the clinical outcomes of ruptured posterior inferior cerebellar artery (PICA) aneurysms.
During the last 15 years, 20 consecutive patients with ruptured PICA aneurysms were treated and these patients were included in this study. The Fisher's exact test was used for the statistical significance of Glasgow Outcome Scale (GOS) according to initial Hunt-Hess (H-H) grade, treatment modalities, and the presence of acute hydrocephalus.
Eleven (55%) and nine (45%) patients were treated with surgical clipping and endovascular treatment, respectively. Among 20 patients, thirteen (65.0%) patients had good outcomes (GOS 4 or 5). There was the statistical significance between initial poor H-H grade, the presence of acute hydrocephalus and poor GOS.
In our study, we suggest that initial H-H grade and the presence of acute hydrocephalus may affect the clinical outcome rather than treatment modalities in the ruptured PICA aneurysms.
Aneurysm; Endovascular treatment; Posterior inferior cerebellar artery; Subarachnoid hemorrhage; Surgical clipping
Aneurysmal subarachnoid hemorrhage (SAH) is a hemorrhagic stroke subtype with a poor recovery profile. Cerebral vasospasm (CV), a narrowing of the cerebral vasculature, significantly contributes to the poor recovery profile. Variation in the endothelial nitric oxide (NO) synthase (eNOS) gene has been implicated in CV and outcome after SAH. The purpose of this project was to explore the potential association between three eNOS tagging single nucleotide polymorphisms (SNPs) and recovery from SAH. We included 195 subjects with a diagnosis of SAH and DNA and 6-month outcome data available but without pre-existing neurologic disease/deficit. Genotyping was performed using an ABI Prism® 7000 Sequence Detection System and TaqMan® assays. CV was verified by cerebral angiogram independently read by a neurosurgeon on 118 subjects. Modified Rankin Scores (MRS) and Glasgow Outcome Scale (GOS) scores were collected 6 months post hemorrhage. Data were analyzed using descriptive statistics, ANOVA and chi-square analysis as appropriate. The sample was primarily female (n = 147; 75.4%) and Caucasian (n = 178; 91.3%) with a mean age of 54.6 years. Of the subjects with CV data, 56 (47.5%) developed CV within 14 days of SAH. None of the SNPs individually were associated with CV presence; however, a combination of the three variant SNPs was significantly associated with CV (p = .017). Only one SNP (RS1799983, variant allele) was associated with worse 6-month GOS scores (p < .001) and MRS (p < .001). These data indicate that the eNOS gene plays a role in the response to SAH, which may be explained by an influence on CV.
Subarachnoid hemorrhage; cerebral vasospasm; nitric oxide; genotype; outcome
Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many SAH patients are seriously ill and require a prolonged ICU stay. Cardiopulmonary complications are common. The management of SAH patients focuses on the anticipation, prevention and management of these secondary complications.
Source data were obtained from a PubMed search of the medical literature.
Data Synthesis and Conclusion
The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means.
Over the first 1-2 weeks after hemorrhage, patients are at risk for delayed ischemic deficits due to vasospasm, autoregulatory failure and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty and intra-arterial vasodilators. Subarachnoid hemorrhage is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
aneurysm; subarachnoid hemorrhage; vasospasm; hypertension; treatment; endovascular
The incidence of hydrocephalus requiring shunts in children with myelomeningocele (MMC) is reported to be very high. Shunt-related complications are a significant cause of morbidity and mortality in this population. In order to minimize shunt placements, we used very rigid clinical selection criteria and followed them in all patients who had myelomeningocele and enlarged ventricles. The follow-up outcome of this retrospective study is reported.
From 2000 to 2007, 23 patients with myelomeningocele and variable degree of hydrocephalus were treated at our institute with primary surgical closure of their myelomeningoceles without a CSF diversion procedure. Patients with severe hydrocephalus who required immediate shunt insertion, and those with no significant associated hydrocephalus were not included in this study. Data regarding the surgical results and complications, postoperative management, and the outcome at follow-up were obtained from their hospital records.
Initially increased size of the ventricular system was found to have decreased or stabilized in 17 (81%) patients postoperatively. However, ventriculomegaly continued to progress further in 4 (19%) out of 21 patients. Of 11 patients who presented with enlarged head, eight (73%) patients showed reduction or stabilization in their head circumference. Three (27%) children continued to have progressive head enlargement in the postoperative period and required shunt placement. Signs of raised intracranial pressure observed in six patients on admission, improved in two (33%) and persisted or worsened in four (67%) patients who eventually improved after the insertion of a shunt. Eight (35%) patients experienced wound-related complications following closure of the MMC, including CSF leak in four, wound infection in three, wound breakdown in three, and pseudomeningocele in two patients. Shunt placement was required in the postoperative period in 13 (56.5%) patients to treat raised intracranial pressure in 11 and CSF leak from the wound in two patients.
Our experience suggests that the placement of shunts can be reduced by adopting a policy with strict clinical and radiographic criteria. Shunt insertion should be reserved for only those patients who have severe hydrocephalus with clinical features of elevated intracranial pressure. Mild to moderate ventricular dilatation, persistent ventriculomagaly, and some increase in ventricular size after myelomeningocele repair can be treated successfully without a shunt.
Hydrocephalus; myelomeningocele; shunt placement
The serum S100 protein has been known to reflect the severity of neuronal damage. The purpose of this study was to assess the prognostic value of the serum S100 protein by Elecsys S100 immunoassay in patients with subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) and to establish reference value for this new method.
Serum S100 protein value was measured at admission, day 3 and 7 after bleeding in 42 consecutive patients (SAH : 20, ICH : 22) and 74 healthy controls, prospectively. Admission Glasgow coma scale (GCS) score, Hunt & Hess grade and Fisher grade for SAH, presence of intraventricular hemorrhage, ICH volume, and outcome at discharge were evaluated. Degrees of serum S100 elevation and their effect on outcomes were compared between two groups.
Median S100 levels in SAH and ICH groups were elevated at admission (0.092 versus 0.283 µg/L) and at day 3 (0.110 versus 0.099 µg/L) compared to healthy controls (0.05 µg/L; p<0001). At day 7, however, these levels were normalized in both groups. Time course of S100 level in SAH patient was relatively steady at least during the first 3 days, whereas in ICH patient it showed abrupt S100 surge on admission and then decreased rapidly during the next 7 days, suggesting severe brain damage at the time of bleeding. In ICH patient, S100 level on admission correlated well with GCS score (r=-0.859; p=0.0001) and ICH volume (r=0.663; p=0.001). A baseline S100 level more than 0.199 µg/L predicted poor outcome with 92% sensitivity and 90% specificity. Logistic regression analyses showed Ln (S100) on admission as the only independent predictor of poor outcome (odd ratio 36.1; 95% CI, 1.98 to 656.3).
Brain damage in ICH patient seems to develop immediately after bleeding, whereas in SAH patients it seems to be sustained for few days. Degree of brain damage is more severe in ICH compared to SAH group based on the S100 level. S100 level is considered an independent predictor of poor outcome in patient with spontaneous ICH, but not in SAH. Further study with large population is required to confirm this result.
S100 protein; Prognosis; Subarachnoid hemorrhage; Elecsys S100 immunoassay; Intracerebral hemorrhage
Hyponatremia is the most common electrolyte abnormality seen in patients with aneurysmal SAH. Clinically significant hyponatremia (Serum Sodium <131 mEq/L) which needs treatment, has been redefined recently and there is a paucity of outcome studies based on this. This study aims to identify the mean Serum Sodium (S.Na+) level and its duration among inpatients with SAH and to identify the relationship between hyponatremia and the outcome status of patients undergoing surgery for SAH.
Materials and Methods:
This outcome study is undertaken in the department of neurosurgery, The Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala. Medical records of all patients with SAH from 1st January to 31st July 2010 were reviewed. Preoperative status was assessed using World Federation of Neurosurgical Societies (WFNS) grading system. Discharge status was calculated using the Glasgow outcome score scale.
Fifty nine patients were included in the study and 53 (89.8%) of them have undergone surgical treatment. Hyponatremia was observed in 22 of 59 patients (37%). The mean Sodium level of hyponatremic patients was 126.97 mEq/L for a median duration of two days. Glasgow outcome score was good in 89.8% of patients. We lost two patients, one of whom had hyponatremia and vasospasm.
Hyponatremia is significantly associated with poor outcome in patients with SAH. Anticipate hyponatremia in patients with aneurysmal subarachnoid hemorrhage, timely detect and appropriately treat it to improve outcome. It is more common in patients who are more than 50 years old and whose aneurysm is in the anterior communicating artery. Our comprehensive monitoring ensured early detection and efficient surgical and nursing management reduced morbidity and mortality.
Aneurysmal subarachnoid hemorrhage; hyponatremia; neurosurgical; outcome
The purpose of this study is to investigate the incidence of aneurysmal subarachnoid hemorrhage (SAH) in Youngdong district for 10 years.
From Jan. 1997 to Dec. 2006, 732 patients (327 males, 405 females, mean age: 54.8±13.1 years) with spontaneous SAH were admitted to our hospital. We reviewed the medical records and radiological findings regarding to the ictus of SAH, location and size of the ruptured aneurysms, Hunt-Hess grade and Fisher grade on admission, personal details such as address, age, and sex, and previous history of medical diseases.
In these 732 patients, 672 cases were confirmed as aneurysmal SAH. Among them, 611 patients (262 males, 349 females, mean age: 54.9±13.2 years) came from Youngdong district. The average crude annual incidence of aneurysmal SAH for men, women, and both sexes combined in Youngdong district was 7.8±1.7, 10.5±2.7, and 9.1±2.1 per 100,000 population, respectively. Because of the problems related to the observation period and geographical confinement, it was suspected that the representative incidence of aneurysmal SAH in Youngdong district should be made during the later eight years in six coastal regions. Therefore, the average age-adjusted annual incidence for men, women, and both sexes combined was 8.8±1.4, 11.2±1.3 and 10.0±1.0, respectively in the coastal regions of Youngdong district from 1999 to 2006.
In overall, our results on the incidence of aneurysmal SAH was not very different from previous observations from other studies.
Aneurysmal SAH; Epidemiology; Incidence
Cerebral vasospasm is a serious complication of ruptured aneurysm. In order to avoid short- and long-term effects of cerebral vasospasm, and as there is no single or optimal treatment modality employed, we have instituted a protocol for the prevention and treatment of vasospasm in patients suffering aneurysmal sub-arachnoid hemorrhage (SAH). We then reviewed the effectiveness of this protocol in reducing the mortality and morbidity rate in our institution. In this study we present a retrospective analysis of 52 cases. Between March 2004 and December 2008 52 patients were admitted to our service with aneurysmal SAH. All patients commenced nimodipine, magnesium sulphate (MgSO4) and triple H therapy. Patients with significant reduction in conscious level were intubated, ventilated and sedated. Intracranial pressure (ICP) monitoring was used for intubated patients. Sodium thiopental coma was induced for patients with refractory high ICP; angiography was performed for diagnosis and treatment. Balloon angioplasty was performed if considered necessary. Using this protocol, only 13 patients (25%) developed clinical vasospasm. Ten of them were given barbiturates to induce coma. Three patients underwent transluminal balloon angioplasty. Four out of 52 patients (7.7%) died from severe vasospasm, 3 patients (5.8%) became severely disabled, and 39 patients (75%) were discharged in a condition considered as either normal or near to their pre-hemorrhage status. Our results confirm that the aforementioned protocol for treatment of cerebral vasospasm is effective and can be used safely.
cerebral vasospam; ruptured aneurysm.
We investigated differences in the treatment strategies for ruptured aneurysms among 26 hospitals affiliated with Nagoya University and any changes in those strategies based on responses to a questionnaire. We also surveyed the data concerning patients with a ruptured aneurysm collected from our affiliated hospitals between 2001 and 2002. In half of the institutes, angiography is performed immediately after an urgent medical examination, there are only five hospitals (20%) which have a basic policy of terminating the angiography within three to six hours after onset. In half of the institutes, the timing of the treatment also depends on the location of the aneurysm. In particular, the treatment for vertebro-basilar aneurysms tends to be done the next day or later. Low-grade subarachnoid hemorrhage (SAH) patients with mild symptoms tended not to be given any sedative drugs (46%), while patients with SAH in some institutes were sedated without informed consent regardless of the severity. The main treatment method for most anterior circulation aneurysms was clipping. Concerning aneurysms located in the posterior circulation and the origin of the ophthalmic artery, clipping and coiling were equally selected. Almost all the hospitals (92%) responded that their treatment strategy had not changed even after the report of the International Subarachnoid Aneurysm Trial (ISAT). There is a great deal of difference in treatment strategies and indications among institutions. In particular, institutions without neuroendovascular interventionists (NETists) frequently persist in the conventional policy, making it urgently necessary to bring NETists up-to-date on the latest advance in endovascular treatment.
ruptured aneurysm, endovascular treatment, subarachnoid hemorrhage
Massive intraventricular haemorrhage (IVH) complicating aneurysmal subarachnoid haemorrhage (SAH) is associated with a poor prognosis. Small observational studies suggest favourable results from fibrinolysis of the intraventricular blood. We performed an observational study on IVH in a large series of patients with SAH to assess the proportion of patients that may benefit from fibrinolytic treatment. From our prospective database we retrieved patients with aneurysmal SAH admitted between January 2000 and January 2005. We calculated the proportion of patients with massive IVH and the proportion of patients that are eligible for fibrinolysis on basis of clinical and CT-scan characteristics and assessed neurological outcome in a treatment strategy without fibrinolysis. Poor neurological condition was defined as World Federation of Neurological Surgeons scale 4 and 5, poor outcome as death or dependence 3 months after SAH. Of the 573 patients admitted with aneurysmal SAH, 59 (10%; 95% confidence interval CI 8–13%) had massive IVH, of which 55 were in poor clinical condition. For these 55 patients, the case-fatality rate was 78% (95% CI 66–88%) and the proportion with poor outcome 91% (95% CI 81–97%). Of the 55 patients, 31 (56%, and 5% of all patients SAH within the study period) fulfilled our eligibility criteria and were considered suitable for intraventricular fibrinolysis. At 3 months, 30 of these 31 eligible patients (97%; 95% CI 85–100%) had a poor outcome. Massive IVH occurs in 10% of patients with aneurysmal SAH. Half of these patients may benefit from intraventricular fibrinolysis. Without fibrinolysis outcome is almost invariably poor in these patients.
Aneurysm; Subarachnoid; Intraventricular; Haemorrhage; Fibrinolysis