Independent predictors of late hydrocephalus in patients with aneurysmal subarachnoid hemorrhage--analysis by multivariate logistic regression model

OBJECT: We determined independent variables contributing to the development of late hydrocephalus after subarachnoid hemorrhage (SAH). METHODS: A total of 114 consecutive patients who underwent surgery for aneurysms within 72 h after SAH were studied. Thirty-nine patients underwent ventriculoperitoneal shunt (VPS) placement (14 patients within 30 days and 25 patients more than 30 days after onset). Univariate and multivariate analyses were performed to assess relationships among various variables and shunt placement. RESULTS: Three variables were found to be independently associated with VPS patients: (1) the rate of SAH clearance; (2) the duration of external cerebrospinal fluid drainage, and (3) presence of neurological deficits 2 weeks after surgery, which indicates brain damage mainly caused by intraoperative manipulation and cerebral vasospasm. CONCLUSION: As in previous reports, intraoperative clot removal and duration of external CSF drainage were found to be closely related to the incidence of hydrocephalus. Brain damage due to intraoperative manipulation and cerebral vasospasm is seemed to be involved in the occurrence of late hydrocephalus in this study.     

Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: The Role of Intrathecal Interleukin-6

Object

Aneurysmal subarachnoid hemorrhage (SAH) has been reported to induce an intrathecal inflammatory reaction reflected by cytokine release, particularly interleukin-6 (IL-6), which correlates with early brain damage and poor outcome. The present study examines intrathecal IL-6 production together with clinical parameters, as a predictor of posthemorrhagic shunt dependency.

Methods

Among 186 SAH patients admitted between July 2010 and December 2012, 82 received external ventricular drainage due to acute hydrocephalus. In these patients, cerebrospinal fluid (CSF) concentrations of IL-6 were measured within the first 14 days after SAH. Patients whose IL-6 values were not determined regularly and those who did not survive until discharge were excluded. The peak value of IL-6, ventricular infection during the hospital stay, microbial CSF culture, patient’s age and sex, Hunt and Hess grade, and aneurysm location were assumed as predictive for shunt dependency.

Results

Sixty-nine patients were included, 24 of whom underwent shunt surgery. Peak IL-6 values of ≥10,000 pg/ml were significantly associated with a higher incidence of shunt dependency (p = 0.009). Additional risk factors were aneurysm location on the anterior cerebral artery and its branches or in the posterior circulation (p = 0.025), and age ≥60 years (p = 0.014). In a multivariate analysis, IL-6 ≥10,000 pg/ml appeared to be the only independent predictor for shunt dependency (p = 0.029)

Conclusion

CSF IL-6 values of ≥10,000 pg/ml in the early post-SAH period may be a useful diagnostic tool for predicting shunt dependency in patients with acute posthemorrhagic hydrocephalus. The development of shunt-dependent posthemorrhagic hydrocephalus remains a multifactorial process.     

High incidence of hyponatremia in patients with ruptured anterior communicating artery aneurysms

Abstract

We studied the incidence and timing of hyponatremia (Na < 135 mEq l~¹) after subarachnoid hemorrhage (SAH) with special reference to ruptured anterior communicating artery (A-com) aneurysms. Hunt and Kosnik (HK) grading, symptomatic vasospasm in A-com aneurysm, and hydrocephalus were analyzed for connections to hyponatremia in 55 patients with ruptured A-com aneurysms, 65 with ruptured internal cerebral artery (ICA) aneurysms, and 49 with ruptured middle cerebral artery (MCA) aneurysms. Hyponatremia occurred in 28 (51%) of 55 patients with A-com aneurysms and in nine (18%) of 49 patients with MCA aneurysms. Severe hyponatremia (Na < 130 mEq^-1) occurred in 16 patients (29%) in the A-com group, four patients (6%) in the ICA group, and three patients (6%) in the MCA group. The A-com aneurysm group had a significantly higher incidence of mild hyponatremia (p < 0.01) and severe hyponatremia (p< 0.001) than other groups. Among A-com cases, hyponatremia occurred significantly more often in HK grade III and IV cases (p < 0.05), in cases with vasospasm (p < 0.001), and in cases with hydrocephalus (p < 0.01). Respective days of onset for symptomatic vasospasm and for hyponatremia were day 7.6 ±4.4 and day 10.6± 5.8 following SAH, representing a 3-day delay for hyponatremia (p<0.05). In most patients hyponatremia resolved within 28 days following SAH. Hyponatremia occurred more often with A-com aneurysms, possibly because of vasospasm around the A-com or hydrocephalus causing hypothalamic dysfunction. Since hypervolemic therapy can cause hyponatremia, particularly careful observation is required during such therapy in patients with A-com aneurysm. [Neurol Res 2000; 22: 151-155     

Intraventricular Fibrinolysis has No Effects on Shunt Dependency and Functional Outcome in Endovascular-Treated Aneurysmal SAH

Background

Intraventricular fibrinolysis (IVF) in subarachnoid hemorrhage (SAH) is an emerging strategy aiming to hasten clot lysis, treat hydrocephalus, and reduce permanent shunt rates. Because of clinical heterogeneity of investigated patient effects of IVF on permanent shunt incidence and functional outcome are widely debated. The present study is the first to investigate solely endovascular-treated SAH patients.

Methods

Overall, 88 consecutive patients with aneurysmal SAH requiring external ventricular drain placement and endovascular aneurysm closure were included. Functional outcome and shunt dependency were assessed 90 days after event. A matched controlled sub-analysis was carried out to investigate the effects of IVF treatment (n = 14; matching criteria: age, neuro-status and imaging). Multivariate modeling was performed to identify independent predictors for permanent shunt dependency.

Results

In IVF-patients neurological status was significantly poorer [Hunt&Hess: IVF = 4(3–5) vs. non-IVF = 3(1–5); p = 0.035] and the extent of ventricular hemorrhage was increased [Graeb Score: IVF = 7(6–8) vs. non-IVF = 3(1–4); p ≤ 0.001]. Consecutive matched controlled sub-analysis revealed no significant therapeutic effect of IVF with respect to shunt dependency rate and functional outcome. Multivariate analysis revealed Graeb score [OR = 1.34(1.02–1.76); p = 0.035] and sepsis [OR = 11.23(2.28–55.27); p = 0.003] as independent predictors for shunt dependency, whereas IVF did not exert significant effects (p = 0.820).

Conclusions

In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome.     

High incidence of hyponatremia in patients with ruptured anterior communicating artery aneurysms

We studied the incidence and timing of hyponatremia (Na < 135 mEq l-1) after subarachnoid hemorrhage (SAH) with special reference to ruptured anterior communicating artery (A-com) aneurysms. Hunt and Kosnik (HK) grading, symptomatic vasospasm in A-com aneurysm, and hydrocephalus were analyzed for connections to hyponatremia in 55 patients with ruptured A-com aneurysms, 65 with ruptured internal cerebral artery (ICA) aneurysms, and 49 with ruptured middle cerebral artery (MCA) aneurysms. Hyponatremia occurred in 28 (51%) of 55 patients with A-com aneurysms and in nine (18%) of 49 patients with MCA aneurysms. Severe hyponatremia (Na < 130 mEq l-1) occurred in 16 patients (29%) in the A-com group, four patients (6%) in the ICA group, and three patients (6%) in the MCA group. The A-com aneurysm group had a significantly higher incidence of mild hyponatremia (p < 0.01) and severe hyponatremia (p < 0.001) than other groups. Among A-com cases, hyponatremia occurred significantly more often in HK grade III and IV cases (p < 0.05), in cases with vasospasm (p < 0.001), and in cases with hydrocephalus (p < 0.01). Respective days of onset for symptomatic vasospasm and for hyponatremia were day 7.6 +/- 4.4 and day 10.6 +/- 5.8 following SAH, representing a 3-day delay for hyponatremia (p < 0.05). In most patients hyponatremia resolved within 28 days following SAH. Hyponatremia occurred more often with A-com aneurysms, possibly because of vasospasm around the A-com or hydrocephalus causing hypothalamic dysfunction. Since hypervolemic therapy can cause hyponatremia, particularly careful observation is required during such therapy in patients with A-com aneurysm.     

颅脑损伤去骨瓣减压术后脑积水危险因素分析及分流时机

目的 探讨颅脑损伤病人去骨瓣减压术后发生脑积水的危险因素及分流术时机。方法 回顾性分析2017年1月~2019年12月去骨瓣减压术治疗的128例颅脑损伤的临床资料。多因素logistic回归分析检验脑积水危险因素。结果 128例中,术后发生脑积水28例,发生率为21.9%。多因素Logistic回归分析结果表明,蛛网膜下腔出血、脑室出血、骨窗面积≥7 cm2是颅脑损伤去骨瓣减压术后继发脑积水的独立危险因素（P<0.05）。28例脑积水中,22例行脑室-腹腔分流术,按照分流中位时间的3.5 d分为早期分流组和晚期分流组,各11例;早期分流组术后颅内压改善效果更好（P<0.05）,颅内压恢复时间明显缩短（P<0.05）;但是两组脑脊液指标和并发症发生率均无统计学差异（P>0.05）。结论 脑积水是颅脑损伤去骨瓣减压术后常见并发症,手术治疗前应充分评估脑积水发生的因素,一旦发生脑积水应查明原因并早期进行分流手术治疗     

Predisposing Factors Related to Shunt-Dependent Chronic Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Objective

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.

Methods

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.

Results

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.

Conclusion

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.     

Prevalence, timing, risk factors, and mechanisms of anterior cerebral artery infarctions following subarachnoid hemorrhage

Anterior cerebral artery (ACA) ischemia may be underdiagnosed following subarachnoid hemorrhage (SAH). The purpose of this study is to characterize the prevalence, timing, and risk factors for ACA infarction, following primary spontaneous SAH. This was a retrospective study of consecutive SAH patients. Final admission CT scans were reviewed for the presence of ACA infarction, and prior scans serially reviewed to determine timing of infarct. Infarctions were categorized as any, early (days 0–3), late (days 4–15), or perioperative (2 days after aneurysm treatment). Demographic and clinical variables were statistically interrogated to identify predictors of infarct types. Of the 474 study patients, ACA infarctions occurred in 8 % of patients, with 42 % occurring during the early period. Multivariate logistic regression identified H/H grade 4/5 (p < 0.001), ACA/ACom aneurysm location (p < 0.001), and surgical clipping (p = 0.011) as independent predictors of any ACA infarct. In Cox hazards analysis, H/H grade 4/5 (p < 0.001), CT score 3/4 (p = 0.042), ACA/ACom aneurysm location (p < 0.001), and surgical clipping (p = 0.012) independently predicted any ACA infarct. Bivariate logistic regression identified non-Caucasian race (p = 0.032), H/H grade 3/4 (p < 0.001), CT score 3/4 (p = 0.006), IVH (p = 0.027), and ACA/ACom aneurysm (p = 0.001) as predictors of early infarct (EI). Late infarct (LI) was predicted by H/H grade 4/5 (p = 0.040), ACA/ACom aneurysm (p < 0.001), and vasospasm (p = 0.027), while postoperative infarct (PI) was predicted by surgical clipping (p = 0.044). Log-rank analyses confirmed non-Caucasian race (p = 0.024), H/H grade 3/4 (p < 0.001), CT score 3/4 (p = 0.003), IVH (p = 0.010), and ACA/ACom aneurysm (p < 0.001) as predictors of EI. LI was predicted by ACA/ACom aneurysm (p < 0.001) while surgical clipping (p = 0.046) again predicted PI. Clinical severity/grade and ACA/ACom aneurysm location are the most consistent predictors of ACA infarctions. Vasospastic and non-vasospastic processes may concurrently contribute to ACA infarcts.     

自发性脑出血术后脑积水倾向的早期诊治

目的对脑出血术后出现的脑积水倾向早期发现、早期治疗以减少脑积水的发生。方法对16例术后有脑积水倾向的脑出血患者的临床资料进行综合分析。结果本组16例术后患者早期经过持续腰大池引流，12例脑积水倾向得到纠正，4例患者发展为脑积水，行侧脑室-腹腔分流术缓解。结论脑出血术后15d内动态观察头颅CT若发现脑室脑池、蛛网膜下腔呈进行性扩大，认为有脑积水倾向存在，行持续的腰大池引流，当出现脑脊液引流量突然减少时，即可拔除引流管，此时脑积水倾向已缓解，有效阻止了脑积水的发生。     

Human tissue kallikrein ameliorates cerebral vasospasm in a rabbit model of subarachnoid hemorrhage

Objectives: Cerebral vasospasm (CVS) and early brain injury are major causes of morbidity and mortality following subarachnoid hemorrhage (SAH). We investigated the efficiency of human tissue kallikrein (HTK) to prevent CVS in a rabbit model of SAH.

Methods: Forty-eight Japanese white rabbits were randomly divided into four groups (n = 12 each): control (sham-operated), SAH, SAH + phosphate-buffered saline (PBS, vehicle), and SAH + HTK. Basilar artery (BA) diameters were measured by three-dimensional computed tomography angiography at three time points. Endothelin-1 (ET-1) and nitric oxide (NO) levels in the cerebrospinal fluid (CSF) were assayed 24 h before and 5 and 7 days after SAH. After the last measurement, the animals were killed, and endothelial cell apoptosis was assessed. Bax and Bcl-2 levels in the BA were measured by western blotting.

Results: HTK was found to significantly reduce CVS following SAH in rabbits. Inverse changes were observed in ET-1 and NO levels in the CSF collected from the SAH group. HTK increased levels of NO, which has a vasodilatory effect, but did not affect levels of ET-1, which has a vasoconstrictive effect. CTA revealed that HTK treatment significantly increased BA diameter. Moreover, HTK treatment reduced the number of apoptotic cells following SAH, presumably by increasing and decreasing Bcl-2 and Bax expression, respectively.

Conclusion: HTK ameliorated CVS and inhibited apoptosis in the BA in a rabbit model of SAH.     

The Role of Lumbar Drainage to Prevent Shunt-Dependent Hydrocephalus after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage in Good-Grade Patients

Objective

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.

Methods

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.

Results

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.

Conclusion

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.     

Predictors of 30-Day Readmission After Subarachnoid Hemorrhage

Background

Readmission within 30 days is increasingly evaluated as a measure of quality of care. There are few data on the rates of readmission after subarachnoid hemorrhage (SAH).

Objective

We sought to determine the predictors of 30-day readmission in patients with SAH.

Methods

We prospectively identified 283 patients with SAH admitted between 2006 and 2012. Readmission was determined by means of an automated query with confirmation in the electronic medical record.

Results

Overall, 21 (8 %) patients were readmitted for infection (n = 8), headache (n = 5), hydrocephalus (n = 4), cardiovascular causes (n = 2), medication-related complications (n = 1), and cerebral ischemia (n = 1). Readmission was associated with longer intensive care unit (ICU) length of stay (LOS) (15.4 [13.4–19.3] vs. 12.2 [8.2–18.5] days, P = 0.02), hospital LOS (22.2 [17.4–23.0] vs. 16.8 [12.0–24.1] days, P = 0.01), and placement of an external ventricular drain (EVD, OR 3.9, 95 % CI 1.3–12.0, P = 0.01). Readmission was not associated with admission neurologic grade, NIH Stroke scale at 14 days, modified Rankin scale at 3 months, history of cardiovascular disease, or radiographic cerebral infarction (P > 0.1).

Conclusions

Demographics, severity of neurologic injury, radiographic cerebral infarction, and outcomes were not associated with readmission after SAH. Markers of a more complicated hospital course (ICU and hospital LOS, EVD placement) were associated with 30-day readmission. Most readmissions were for infections acquired after discharge. Readmission within 30 days is difficult to predict, and, since the most common reason was infection acquired after discharge, it may be difficult to prevent without an integrated health system and coordinated care.     

Factors Associated with Acute and Chronic Hydrocephalus in Nonaneurysmal Subarachnoid Hemorrhage

Background

Hydrocephalus requiring external ventricular drain (EVD) or shunt placement commonly complicates aneurysmal subarachnoid hemorrhage (SAH), but its frequency is not as well known for nonaneurysmal SAH (NA-SAH). Those with diffuse bleeding may have greater risk of hydrocephalus compared to those with a perimesencephalic pattern. We evaluated the frequency of hydrocephalus in NA-SAH and whether imaging factors could predict the need for EVD and shunting.

Methods

We collected admission clinical and imaging variables for 105 NA-SAH patients, including bicaudate index (BI), Hijdra sum score (HSS), intraventricular hemorrhage (IVH) score, modified Fisher scale (mFS), and bleeding pattern. Hydrocephalus was categorized as acute (need for EVD) or chronic (shunt). We applied logistic regression to determine whether hydrocephalus risk was independently related to bleeding pattern or mediated through blood volume or ventriculomegaly.

Results

Acute hydrocephalus was seen in 26 (25 %) patients but was more common with diffuse (15/28, 54 %) versus perimesencephalic (10/59, 17 %, p < 0.001) bleeding. Patients developing acute hydrocephalus had worse clinical grade and higher BI, HSS, and IVH scores. Adjusting the relationship between hydrocephalus and diffuse bleeding for HSS (but not BI) nullified this association. Nine (35 %) patients requiring EVD eventually required shunting for chronic hydrocephalus, which was associated with greater blood burden but not poor clinical grade.

Conclusion

Acute hydrocephalus occurs in one-quarter of NA-SAH patients. The greater risk in diffuse bleeding appears to be mediated by greater cisternal blood volume but not by greater ventriculomegaly. Imaging characteristics may aid in anticipatory management of hydrocephalus in NA-SAH.

     

Sexual dimorphism in gene expression after aneurysmal subarachnoid hemorrhage

Background and Purpose: Inflammation and compromise in structure and function of cerebral parenchymal microvasculature begins early after subarachnoid hemorrhage (SAH). We recently found greater inflammation and greater vascular compromise in male than in female rats following SAH. In this study, we investigated whether this cross-sexual difference in pathology is reflected in expression levels of genes related to vascular inflammation and structural compromise.

Method: Age-matched male and female rats underwent sham surgery or SAH by endovascular perforation. Early physiology (intracranial pressure (ICP), blood pressure (BP), heart rate, and cerebral blood flow) was monitored. Cerebral RNA was extracted at sacrifice 3 h after surgery and assayed for expression of thrombomodulin (Thbd), endothelial nitric oxide synthase (eNos;Nos3), intracellular adhesion molecule-1 (Icam1), vascular endothelial growth factor (Vegf), interleukin-1beta (Il1β) tumor necrosis factor-alpha (Tnf-α), and arginine vasopressin (Avp).

Results: Increases in ICP and BP at SAH appeared slightly greater in males but the difference did not reach statistical difference, indicating that SAH intensity did not differ significantly between the sexes. Of the seven genes studied two; Tnf-α and Vegf, did not change after injury, while the remainder showed significant responses to SAH. Response of Nos3 and Thbd was markedly different between the sexes, with expression greater in males.

Conclusion: This study finds that sexual dimorphism is present in the response of some but not all genes to SAH. Since products of genes exhibiting sexual dimorphism have anti-inflammatory activities, our results indicate that previously found sex-based differences in vascular pathology are paralleled by sexually dimorphic changes in gene expression following SAH.     

Spontaneous Subdural Fluid Collection Following Aneurysmal Subarachnoid Hemorrhage: Subdural Hygroma or External Hydrocephalus?

Background

Subdural fluid collections (hygromas and effusions) in adults are usually seen following head trauma or overdrainage of cerebrospinal fluid (CSF) after CSF diversion procedures. We report an unusual case of subdural fluid collection that developed spontaneously 5 days after an aneurysmal subarachnoid hemorrhage (SAH). This patient neither had permanent CSF diversion procedure nor history of significant head trauma during her clinical course.

Methods

This study is a Case report of the patient suffering from an SAH.

Results

A 71-year-old woman suffered an SAH from a ruptured right-sided posterior communicating artery aneurysm. Computed tomography (CT) demonstrated diffuse SAH and signs of early hydrocephalus that did not require treatment. The aneurysm was treated with endovascular coil occlusion without any complications. Throughout her hospital course, she remained alert without neurological deficits. A large subdural fluid collection was discovered incidentally during a routine CT scan of the brain 5 days after the SAH. The patient remained asymptomatic; therefore, the collection was treated conservatively. It resolved spontaneously at five days after the initial diagnosis.

Conclusion

Subdural fluid collections following SAH can occur as a result of head trauma, external hydrocephalus, or as a treatment complication of CSF shunting and craniotomies. It is critical to differentiate simple hygromas from external hydrocephalus since their response to CSF diversion is entirely different.     

Saccular or dissecting aneurysms involving the basilar trunk: Endovascular treatment and clinical outcome

ABSTRACT

Objectives: Basilar artery trunk aneurysms (BTAs) are a rare pathology and difficult to treat. We present our experience regarding angiographic results and clinical outcomes for 16 BTAs treated by reconstructive endovascular treatment (EVT) using stent or balloon.

Methods: Between January 2003 and December 2014, 15 patients (mean age, 58.6 years; 11 males) with 16 BTAs were enrolled. Clinical manifestation, outcomes and procedural complications were evaluated retrospectively, and follow-up angiography was performed 12 and 24 months after procedure.

Results: Subarachnoid hemorrhage (SAH) developed in seven aneurysms and nine were found incidentally. In one case, SAH followed by acute infarction on pons. The location of the aneurysms was the pure basilar artery (BA) trunk in 13 and the junction of the BA and the superior cerebellar artery in 3. Reconstructive EVT was technically successful in 15 aneurysms (93.8%) and failed in one due to the difficulty of vascular access. Stent/balloon-assisted coiling was performed in 13 aneurysms and sole stent therapy in two aneurysms. One patient had periprocedural complication of acute in-stent thrombosis. All treated patients had no symptoms with the usual activities except three patients, who died from myocardial infarction, aneurysmal rebleeding, and cerebellar infarction. Angiographic follow-up was performed in nine aneurysms; three aneurysms were recanalized (33.3%) and six aneurysms had no interval change (66.7%). There was no significant event during the follow-up period (mean, 23.5 months).

Conclusion: In the treatment of BTAs, reconstructive EVT may provide a feasible and safe option to microsurgery.     

Factors influencing shunt dependency after aneurysmal subarachnoid haemorrhage

In this retrospective analysis of 138 patients treated for ruptured aneurysms the development of shunt dependent hydrocephalus was evaluated regarding possible predictive factors. In 15 patients (11%) ventriculo-atrial shunt was implanted due to hydrocephalus. One predictive factor was the localisation of aneurysms as patients with hydrocephalus had PcoA aneurysms in 40% compared to 20% in the group of patients without hydrocephalus and only 7% compared to 28% MCA aneurysms. An other predictive factor was the severity of the subarachnoid haemorrhage (SAH) as 7 patients out of the 15 were graded Fisher IV on admission. Furthermore, an important predictive factor was the presence of acute hydrocephalus as 13 out of the 15 patients (87%) with shunt dependent hydrocephalus had acute hydrocephalus requiring external ventricular drainage. An other possible factor was the intraoperative opening of the lamina terminalis as in 73% of the patients with shunt dependent hydrocephalus compared to 82% in the group of patients without hydrocephalus this procedure was performed during surgery. The results suggest that shunt dependency is more likely after severe SAH especially in the presence of an acute hydrocephalus and in patients with aneurysms located in the basal cisterns. Therefore treatment of the acute hydrocephalus and possible the opening of the lamina terminalis could have a positive effect on the development of shunt dependent hydrocephalus after SAH.     

Reducing length of stay in aneurysmal subarachnoid hemorrhage: A three year institutional experience

Hospital length of stay is a common metric of excellence in health care. With limited data evaluating hospital length of stay (LOS) and cost in subarachnoid hemorrhage (SAH), in this study we explore multiple prognostic factors and present our institutional experience in shortening LOS. 345 SAH patients were reviewed over a three year period. Patient demographics, hemorrhage grade, hospital course, hospital costs, and LOS were reviewed. Angiogram-negative SAH, Hunt and Hess (HH) Grade 5, and early mortalities were excluded. During this period a physician-led daily multidisciplinary huddle was established to identify and expedite patient discharge needs. 174 patients met inclusion criteria. Significant predictors of increased hospital LOS on univariate analysis included higher HH grade, hydrocephalus, need for ventriculostomy or ventriculoperitoneal shunt, clinical vasospasm, pneumonia, respiratory failure, deep venous thrombosis, and urinary tract infection. Need for shunt, clinical vasospasm, and pneumonia remained significant on multivariate analysis. Mean LOS times decreased to less than those cited in earlier studies, with mean hospital LOS dropping from 21.6 days to 14.1. Total hospital costs per SAH patient decreased from $328K to $269K. Readmission rate and breakdown by patient discharge site remained unchanged. Need for ventriculoperitoneal shunt, clinical vasospasm, and pneumonia were found predictive of longer LOS in SAH patients. A physician-led daily multidisciplinary huddle is a potentially valuable tool to identify patient discharge needs and lower LOS and cost in SAH patients.     

Infarct Volume Predicts Delayed Recovery in Patients with Subarachnoid Hemorrhage and Severe Neurological Deficits

Background

Recovery is common after subarachnoid hemorrhage (SAH), even in patients who are severely disabled at hospital discharge. Little is known about predictors of late recovery in such patients, even though such knowledge may influence treatment decisions. We hypothesized that cerebral infarction volume would be associated with 3 months outcomes in patients who are severely disabled at 14 days.

Methods

We prospectively identified consecutive aneurysmal SAH patients, documented the development of cerebral infarction, and ascertained the modified Rankin Scale (mRS) at 14 days and 3 months. We included patients with mRS 4 or 5 and NIH Stroke Scale (NIHSS) at least 8 on hospital day 14 (i.e., severe neurologic impairment) and calculated infarct volume in a semi-automated fashion using CT imaging. We explored outcome determinants with ordinal regression.

Results

At 14 days, 66 patients were severely disabled, 65 (98.5 %) of whom had mRS of 5; the median NIHSS was 21 [14–24]. At 3 months, 20 (32.8 %) of the 61 patients with known outcomes were independent. Larger infarction volumes were associated with death (20.4 vs. 0.85 mL, P = 0.02). In ordinal regression, increased infarct volume was associated with the worse mRS after correction for WFNS grade, age, and withdrawal of life support (OR 1.01 per mL of infarct, 95 % CI 1.01–1.03, P = 0.01).

Conclusions

After SAH, even with severe neurological injury at 14 days, good recovery is frequent and is associated with lower infarction volume. These data may help clinicians inform surrogate decision makers as they plan the future care of such severely disabled patients.     

The outcome of early surgical management of ruptured posterior circulation aneurysms

Abstract

Since 7990, early surgery within 3 days following subarachnoid hemorrhage has been performed routinely in our hospital even for ruptured posterior circulation aneurysms. Our experience with early surgical management of 25 patients with posterior circulation aneurysms, including two patients who underwent endovascular surgery, is reported. Fourteen patients had an aneurysm on the basilar, the posterior cerebral or superior cerebellar artery (BAJ, and 77 patients had an aneurysm on the vertebral or posterior inferior cerebellar artery (VA). The mortality and morbidity of the BA group were 7% and 29%, respectively, and those of the VA group were 27% and 9%, respectively. In BA, the incidence ofsymptomatic vasospasm and hydrocephalus was definitely high compared with VA, and the outcome in elderly patients was significantly unfavorable. Early surgery for posterior circulation aneurysms to prevent rebleeding might be considered in selected cases. [Neural Res 1997; 19: 385-388]