Subarachnoid hemorrhage or migraine?

The differential diagnosis of "the worst headache of my life" is illustrated by the following history.     

Rehabilitation therapy of cerebral hemorrhage in acute phase

Background:Acutephaseincerebralhemorrhagereferstothefirsttwoweeksandinthisperiodpatient'sconditionisunstable.Incidenceofdisabilityincerebralhemorrhageisveryhighandhowtoreducetheincidenceinmaximumandimprovepatent'slivingqualityhasbecomeanimportantclinicproblem.Objective:Toinvestigatetheeffectofrehabilitationtherapyonlivingqualityofpatientswithcerebralhemorrhageinacutephase.Subjects:147casesofcerebralhemorrhagefromMay1999toAugust2001wereinvestigatedincluding84males,63females,aged38-87(mean:57.…     

Rehabilitation therapy of cerebral hemorrhage in acute phase

To investigate the effect of rehabilitation therapy on living quality of patients with cerebral hemorrhage in acute phase.Sjbjects:147 cases of cerebral hemorrhage from May 1999 to August 2001 were investigated including 84 males,63 females, aged 38-87(mean:57.4)years old.Main prognosis index and results:According to Brunnstrom a Recovery Statges of Stroke(BRSS),function of limbs was divided into five grades.To patients with grade I to grade Ⅳ，after 1 month of treatment in acute phase,90% improved overI-Ⅱgrades,After a half year of follow-up survey,contracture of joint was observed only in 3% of patients,no disuse atrophy was found.While incases only in 3% of patients,no disuse atrophy was found.While incases not treated in acute phase,only 48% improved over I-Ⅱgrades,and articular contracture appeared in 27% of patient.Seeing from the improvement percentage of living quality,treatment started withid 2 weeks,100% improved,2 weeks-1 month,87%,1 month-3 months,76%,after 3 months ,37%.     

Rehabilitative medical intervention of hypertension induced cerebral hemorrhage

Themorbidityofhypertensioninducedcerebralhemorrhage（HICH）hasbeenincreasingduetothetotalpercentageincreaseofsenilepopulation，resultingintheeverheavierburdenforthestate，thesocietyandthefamilyaswell．ToincreasethetherapeuticefficiencyofHICHisanurgentaffairthatneedstobeaddressedbyrehabilitationclinics．Thepresentpaperwilldiscussaboutsomemeasuresthattheauthorfoundusefulinheryearsofmedicalpractice．１TreatmentwithhaemostaticagentsinHICHpatientsItiscommonpracticethathaemostaticagentsarenotus…     

Should anticoagulation be resumed after intracerebral hemorrhage?

Intracerebral hemorrhage (ICH) is the most feared and the most deadly complication of oral anticoagulant therapy, eg, with warfarin (Coumadin). After such an event, clinicians wonder whether their patients should resume anticoagulant therapy. The authors review the management of anticoagulation during and after anticoagulation-associated ICH.     

Gastrointestinal hemorrhage: is the surgeon obsolete?

The management of GI hemorrhage has undergone tremendous evolution in recent decades. Once commonly managed by surgeons, the almost continuous introduction of new technologies and pharmacotherapies has dramatically improved clinicians' ability to identify and control sources of bleeding without surgery. Although a gastroenterologist can successfully manage most cases of GI hemorrhage endoscopically, surgical consultation remains an important consideration for the emergency physician in selected cases.     

Endothelin antagonists in subarachnoid hemorrhage: what next?

In the previous issue of Critical Care, Ma and colleagues perform a meta-analysis of five randomized, clinical trials of endothelin antagonists in patients with aneurysmal subarachnoid hemorrhage. There are four trials using clazosentan and one trial with TAK-044. These studies show that endothelin plays an important role in the genesis of angiographic vasospasm. The benefit of these drugs is less on delayed cerebral ischemia and nonexistent on overall clinical outcome. Why the drugs reduce vasospasm but do not improve outcome could be because of side effects such as hypotension and pulmonary complications that are more common in patients treated with endothelin antagonists or because rescue therapy, which is used more in the placebo groups, improves outcome in these patients to the same extent as the endothelin antagonists. As the authors conclude, future studies of these drugs will need to consider these and other factors in their design.In the previous issue of Critical Care, Ma and colleagues report a meta-analysis of the randomized, clinical trials of clazosentan and TAK-044 in patients with aneurysmal subarachnoid hemorrhage (SAH) [1]. The endothelins (ETs) are a family of three (ET-1, ET-2 and ET-3) 21-amino-acid peptides that act on several receptors, principally ET_A and ET_B receptors in the vasculature. The main effect is to cause vasoconstriction. Experimental data as well as the results of this meta-analysis show that this system is important in the pathogenesis of angiographic vasospasm after SAH [2]. A variety of ET receptor antagonists have been developed. Clazosentan is a heteroarylsulfonamido pyrimidine that was specifically developed to be a relatively water-soluble, small-molecule, highly-selective ET_A receptor antagonist for prevention of angiographic vasospasm [3]. TAK-044 is a relatively nonselective antagonist of ET_A and ET_B receptors [4].Ma and colleagues identified five randomized clinical trials of ET antagonists for SAH. Their meta-analysis gives the same results as the trials, which at least for the four largest studies all had basically the same results. The pooled relative risk (RR) of angiographic vasospasm with ET antagonist treatment was 0.66 (95% confidence interval (CI) = 0.57 to 0.77), so these drugs effectively reduce vasospasm. The main consequence of vasospasm, delayed cerebral ischemia (DCI), was defined in the last three clazosentan studies as delayed ischemic neurological deficit. The current meta-analysis reports delayed ischemic neurological deficit and DCI, but DCI is defined as infarction on computed tomography ''only attributable to cerebral vasospasm and DCI'' [1], which is a partly circular definition. These varied definitions lead to confusion since the definitions vary in the studies and the terminology of Ma and colleagues does not match that recommended by Vergouwen and colleagues [5]. Interestingly, and not unexpectedly, there was a significant reduction in delayed ischemic neurological deficit (RR = 0.77, 95% CI = 0.66 to 0.90) and a trend towards reduction in DCI (RR = 0.87, 95% CI = 0.74 to 1.03). Despite these improvements, there was no effect on mortality and unfavorable outcome. Thus, considering the pathway from angiographic vasospasm to ischemia (DCI by most definitions), to infarction, and to poor outcome, the benefits of ET antagonists diminish at each step.The findings of Ma and colleagues are virtually identical to a meta-analysis conducted by Vergouwen and colleagues [6]. Vergouwen and colleagues, however, also reported data from a subset of the studies showing that there was no significant reduction in vasospasm-related cerebral infarction (RR = 0.76, 95% CI = 0.53 to 1.11) although the RR is reduced, in keeping with the analysis of Ma and colleagues. ET antagonists did not seem to have any effect on all new cerebral infarction (RR = 1.04; 95% CI = 0.91 to 1.19). This is an important finding since cerebral infarction is one of the most important prognostic factors for outcome after SAH. The odds ratios show the same pattern as mentioned above.Why is there a substantial effect on angiographic vasospasm, less effect on infarction judged to be due to vasospasm and no effect on all delayed infarcts and clinical outcome? One theory is that the delayed infarctions are not due solely to angiographic vasospasm. This theory predicts that reducing angiographic vasospasm may not be adequate to reduce infarction and improve outcome. Under this theory, the vasospasm-related and any new infarction incidences should be the same. Strictly speaking, they are the same - although, as noted above, the trends in the odds ratios seem different. One alternative theory is that side effects of the drugs, such as hypotension and pulmonary complications, counteract the beneficial effects of reducing vasospasm so that there is no overall beneficial effect on outcome. Indeed, both meta-analyses report virtually identical and significant increases in lung complications, hypotension and anemia in the patients treated with ET antagonists. To fit the data, this theory would require those side effects being sufficient to cause infarctions so that the overall infarction rate is about the same. One could argue that the data, while not conclusive, favor the second theory. Another fundamental issue is that patients in the placebo groups of these studies are administered rescue therapies for DCI in a higher percentage of cases than in the drug-treated groups. If rescue therapy is efficacious, then this also could reduce the difference between the groups in cerebral infarction and overall clinical outcome.What are some of the limitations of Ma and colleagues'' meta-analysis? The strengths of the current analysis are that it is rigorous and follows preferred reporting items for systematic review and meta-analysis (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines [7]. The results of this meta-analysis are not surprising, given that the results for all of the individual studies are the same - which is not a weakness but a comment. Another issue is the inclusion of drugs of different chemical classes and with different known pharmacologic actions in these sorts of meta-analyses. Multiple doses and methods and timing of administration of different drugs are combined into single treatment groups, which makes no sense biologically.What does the future hold for ET antagonists in SAH? Since all of the studies are only recently completed, obtaining the individual patient data from the sponsors may allow further analysis to guide further studies. This collation is obviously being done, since Actelion (Allschwill, Switzerland) sponsored all of the clazosentan studies, have the data and have invested heavily in clazosentan. According to Vergouwen and colleagues, Actelion did not provide individual patient data or data that would enable an intention-to-treat analysis [6]. The former omission is an issue. The latter missing data, however, given the small number of patients involved, are not going to change the overall findings. Actelion, however, must be complimented for supporting development of clazosentan and for conducting these studies that would not have occurred if we waited for funding from peer-reviewed granting agencies. The studies they have conducted have been fundamentally directed at improving the outcome of patients with SAH and there cannot be any question about their motivation to develop a drug that will address this.In summary, the authors'' conclusion is that future studies of ET antagonists should be ''more carefully formulated and designed''. Input into the design of these studies would be welcome, given that all of these studies were already very carefully formulated and designed. My opinion is that some method of reducing the side effects of ET antagonists, primarily hypotension and pulmonary complications, is the key to the future of these drugs.     

Subarachnoid hemorrhage: who dies,and why?

IntroductionSubarachnoid hemorrhage (SAH) is a devastating form of stroke. Causes and mechanisms of in-hospital death after SAH in the modern era of neurocritical care remain incompletely understood.MethodsWe studied 1200 consecutive SAH patients prospectively enrolled in the Columbia University SAH Outcomes Project between July 1996 and January 2009. Analysis was performed to identify predictors of in-hospital mortality.ResultsIn-hospital mortality was 18 % (216/1200): 3 % for Hunt-Hess grade 1 or 2, 9 % for grade 3, 24 % for grade 4, and 71 % for grade 5. The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55 %), aneurysm rebleeding (17 %), and medical complications (15 %). Among those who died, brain death was declared in 42 %, 50 % were do-not-resuscitate at the time of cardiac death (86 % of whom had life support actively withdrawn), and 8 % died despite full support. Admission predictors of mortality were age, loss of consciousness at ictus, admission Glasgow Coma Scale score, large aneurysm size, Acute Physiology and Chronic Health Evaluation II (APACHE II) physiologic subscore, and Modified Fisher Scale score. Hospital complications that further increased the risk of dying in multivariable analysis included rebleeding, global cerebral edema, hypernatremia, clinical signs of brain stem herniation, hypotension of less than 90 mm Hg treated with pressors, pulmonary edema, myocardial ischemia, and hepatic failure. Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality.ConclusionStrategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1036-0) contains supplementary material, which is available to authorized users.     

Is emergent anti-hypertensive treatment beneficial in intracranial hemorrhage?

A retrospective chart review of adult patients with primary intracranial hemorrhage (ICH) was conducted to determine the effects of emergent anti-hypertensives on mortality. Data included mean arterial pressure (MAP), Glascow Coma Scale score (GCS), ICH size, and anti-hypertensive treatment. Multi-variable logistic regression determined the effect of anti-hypertensives on ICH mortality. Of 66 patients studied, the overall mortality was 30.3%. Mortality was 34.5% for patients initially treated with anti-hypertensives vs. 25.8% for patients not treated. After controlling for age, MAP, GCS, and ICH size, anti-hypertensives given within the first 6 h of presentation were associated with a reduction in mortality with a p value of 0.0375 and an odds ratio of 140 (95% confidence interval [CI] 1.332 to >999). However, this effect may not occur in patients presenting with a systolic blood pressure (SBP)<200 mm Hg. In conclusion, in patients with primary intracranial hemorrhage, there was a significant decrease in mortality associated with emergent anti-hypertensive therapy. A larger prospective study is needed to confirm these findings, define the subgroups that may benefit, and better determine the effect size.     

Is ED disposition associated with intracerebral hemorrhage mortality?

Background

Early deterioration is common in intracerebral hemorrhage (ICH). Treatment at tertiary care centers has been associated with lower ICH mortality. Guidelines recommend aggressive care for 24 hours irrespective of the initial outlook. We examined the frequency of and factors associated with transfer to tertiary centers in ICH patients who initially presented at nontertiary emergency departments (EDs). We also compared observed with expected mortality in transferred and nontransferred patients using published short-term mortality predictors for ICH.

Methods

Adult patients who resided in a 5-county region and presented to nontertiary EDs with nontraumatic ICH in 2005 were identified. Intracerebral hemorrhage score and ICH Grading Scale (ICH-GS) were determined. Of 16 local hospitals, 2 were designated tertiary care centers. Logistic regression was used to assess factors associated with transfer.

Results

Of 205 ICH patients who presented to nontertiary EDs, 80 (39.0%) were transferred to a tertiary center. In multivariate regression, better baseline function (modified Rankin scale 0-2 versus 3-5; odds ratio, 0.42, 95% confidence interval, 0.21-0.85, P = .016) and black race (odds ratio, 2.28, 95% confidence interval 1.01-5.12, P = .046) were associated with transfer. A trend toward higher 30-day mortality was observed in nontransferred patients (32.5% versus 45.6%, P = .06). The ICH-GS overestimated mortality for all patients, while the ICH Score adequately predicted mortality.

Conclusions

We found no significant difference in mortality between transferred and nontransferred patients, but the trend toward higher mortality in nontransferred patients suggests that further evaluation of ED disposition decisions for ICH patients is warranted. Expected ICH mortality may be overestimated by published tools.     

Microalbuminuria is a prognostic predictor in aneurysmal subarachnoid hemorrhage

Objective To determine the prevalence and the prognostic significance of microalbuminuria in patients after aneurysmal subarachnoid hemorrhage (SAH). Design Prospective and observational clinical study. Setting Multidisciplinary intensive care unit. Patients Fifty-one consecutive patients who underwent aneurysm clipping or endovascular surgery after SAH; 8 patients who underwent surgical clipping for unruptured intracerebral aneurysm served as control. Intervention None. Measurements and Results General clinical and neurological data were recorded on admission. Urine was collected preoperatively and daily for up to 7 days postoperatively for measuring the urinary microalbumin/creatinine ratio. The Glasgow Coma Scale (GCS) score was also determined on admission and daily for up to 7 days after operation. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at 3 months after stroke. The prevalence rates of microalbuminuria were 74.5% in SAH and 37.5% in the control. Among the 51 patients, 25 had unfavorable neurological outcome (GOS 1–3). The areas under the receiver operator characteristic curves showed that the highest urinary microalbumin/creatinine ratio and the lowest GCS score during the first 8 days were the significant predictors of unfavorable neurological outcome. The threshold value, sensitivity, specificity, and likelihood ratio for the highest urinary microalbumin/creatinine ratio were 200 mg/g, 60% [95% confidence interval (CI) 41–79], 96% (95% CI 88–100), and 15.6 (95% CI 9.1–26.7), respectively. Conclusions This study confirms a high prevalence of microalbuminuria in the SAH patients, and it suggests that the highest urinary microalbumin/creatinine ratio > 200 mg/g during the first 8 days is a significant predictor of unfavorable neurological outcome.     

Experience of life nursing to dementia after senile cerebral hemorrhage

Background:The manifestation of senile dementia is irreversible and slowly progressive cognitive decrease.When rehabilitation training is performed,the principle of advancing step by step should be grasped.Objective:To explore the effect of life nursing on dementia after senile cerebral hemorrahge.Unit:Affiliated Hospital to Medical College,Beihua Universiyt.Subjects:50 patients with dementia were investigated including 38 males and 12 females aged 65-78 years old.All patients had cerebrovascular disease and cerebral infarction,lacunar infarction and atrophy were conformed by CT. Internetion:The content included:(1) Enhancement of symptomatic nursing:Kinds of need of patients should be fulfilled.After patients‘ modd got stable,patients were help to resume memory,corresponding questions were asked,inquired repeatedly and induced to help patinents resume memory early.(2)Instruction of disease acknowledge to patients:Administration condition was explained and function exercieses in recovery stage were instructed.Suggestive treatment was adopted to keep healthy mentality and make them take part in rehabilitation process and change their depending mentality.(4)Enhancement of diet nursing:Besides common basal nursing,diet nursing should be taken.Low-salt,low-fat and light diet should be administrated.Non-staple foods selected vegetables,fruits,meat with bone removed.Amount should be limited to polyphagia patients avoiding craputence.Caccagogue was used when constipation appeared.(5)Strenthening of sleep nursing:Patients were told to rest at fixed time,sleep early,wake up early.To patients unable to sleep,sedative drugs was adopted.Because of aderse effect,barbitals should be used carefully and vallium might be used.(6)Enhancement of basal nursing and prevention of complications:Besides basal nursing,patients dependent on others should be helped when walking to avoid accident tumble wound.Condition of disease should be paid attention to.To patients with long rest in bed,bed should be kept neat and clean,often turning over,rubbing pressed site of skin could prevent occurrence of bed sore.Results:After 2 years of follow-up survery,except that 5 cases died for severe pulmonary infection,other 45 cases survived and accompanyed by special person.7 patients were independent and could take part in partial social activities;20 patients were indpendent mostly and could get out bed,but need other‘s help.16 patients need other‘s help in most time;2 patients rested in bed and need other‘s help completely.Conclustion:Life nursing to patients with dementia can improve patients‘ mood and suitability to surroundings and motive coordination.