CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study

Computed tomography was performed on 1,378 patients admitted within 3 days of subarachnoid hemorrhage (SAH) at 71 centers in a cooperative study. CT on the day of SAH (day 0) was abnormal in 95.8%. Intracranial blood was detected in 95.3% of patients on day 0, 90.5% on the first day after SAH (day 1), and 73.8% on day 3. CT was normal in only 1 of 284 patients in stupor or coma but was normal in 14.6% of 638 alert patients. In the first few days after SAH, CT is highly accurate, often obviating the need of CSF examinations. The interval from SAH until CT and the seriousness of the patient's condition are two factors that influence the results of CT.     

Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study

Hydrocephalus is an important complication of subarachnoid hemorrhage (SAH). We analyzed several factors possibly related to hydrocephalus following SAH in 3521 patients from the International Study on the Timing of Aneurysm Surgery. Hydrocephalus was diagnosed on admission computed tomographic (CT) scans in 15% of patients and was thought to be clinically symptomatic in 13.2% of patients. There was a 5.9% overlap between these groups. Using contingency table analysis, we found the following were significantly related to clinical hydrocephalus: increasing age; preexisting hypertension; admission blood pressure measurements; postoperative hypertension; admission CT findings of intraventricular hemorrhage, a diffuse collection of subarachnoid blood, and a thick focal collection of subarachnoid blood; posterior circulation site of aneurysm; focal ischemic deficits; use of antifibrinolytic drugs preoperatively; hyponatremia; admission level of consciousness; and a low score on the Glasgow outcome scale. Using discriminate factor analysis to predict clinical hydrocephalus, the most important variables in order were the following: CT hydrocephalus, intraventricular hemorrhage, admission level of consciousness, presubarachnoid hypertension, increasing age, subarachnoid blood noted on CT scan, posterior circulation aneurysm site, and hypertension postoperatively (canonical correlation = .399). We conclude that the development of hydrocephalus after SAH is multifactorial. Factors that compromise cerebrospinal fluid circulation acutely (eg, intraventricular hemorrhage, hemorrhage from a posterior circulation site of aneurysm, and diffuse spread of subarachnoid blood) contribute to the development of acute hydrocephalus. These same factors, plus the use of antifibrinolytic drugs preoperatively, are also important in the pathogenesis of clinical hydrocephalus, perhaps by promoting subarachnoid fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Incidence and prognosis of internal medicine complications in spontaneous intracranial hematomas

The records of 133 consecutive patients with spontaneous intracranial hemorrhage were reviewed to assess the frequency of systemic complications and their influence on outcome and neurological complications. The mean age of 63 patients with spontaneous intracerebral hemorrhage (ICH) was 11 years higher compared to 70 patients with spontaneous subarachnoid hemorrhage (SAH). Concomitant disease was more frequent in ICH than in SAH, and general atherosclerosis, chronic obstructive pulmonary disease and cardiac failure were associated with an increased mortality. 94% of all ICH and 79% of all SAH patients developed at least one systemic complication. A correlation was found between initial and late hyperglycemia, and high mortality rate and poor survival quality. In both groups an association of cardiac arrhythmias with intracranial pressure and an unfavourable outcome were observed. SAH patients with QT-prolongation had an increase in mortality and developed ischemic deficits more frequently. Pulmonary complications and disturbances of blood pressure regulation were associated with an unfavourable outcome, and in SAH patients with occurrence of neurologic complications.     

Predicting cerebral ischemia after aneurysmal subarachnoid hemorrhage: influences of clinical condition, CT results, and antifibrinolytic therapy. A report of the Cooperative Aneurysm Study

Cerebral ischemia from vasospasm is a major cause of death and disability following aneurysmal subarachnoid hemorrhage (SAH). This study examines and compares the relative utility of the initial neurologic examination and early CT in predicting cerebral ischemia after SAH. The influence of antifibrinolytic drugs (AFD) in the development of cerebral ischemia was also studied. AFD increased the risk of cerebral ischemia regardless of the admitting neurologic condition or the findings of CT. Among patients given AFD, impaired orientation or alertness was associated with a higher risk of ischemia. Other neurologic signs were not predictive of ischemia. Clinical features were not predictive of ischemia among patients not given AFD. Focal, thick collections of blood on CT were highly predictive of ischemia, whether or not patients received AFD. Admitting CT is the best prognostic indicator for the development of cerebral ischemia after SAH. It should be used to supplement the clinical examination in selecting patients best suited for therapy to prevent vasospasm.     

Initial hyperglycemia as an indicator of severity of the ictus in poor-grade patients with spontaneous subarachnoid hemorrhage

An association between hyperglycemia and outcome in spontaneous subarachnoid hemorrhage (SAH) has been sporadically reported. Our hypothesis was that hyperglycemia is a sign of central metabolic disturbance linked with specific appearances on computerized tomography (CT) scans reflecting different degrees of corresponding brain injury. The admission plasma glucose level, initial CT findings, and outcome after 6 months were analysed in a cohort of 99 patients with SAH in Hunt & Hess Grade IV or V. The CT scans were quantitatively assessed for subarachnoid blood, intracerebral hematoma, intraventricular hemorrhage, hydrocephalus, midline shift and compression of the perimesencephalic cisterns. These findings were combined to determine a three-point CT severity score. All patients showed elevated (>5.8 mmol/l) plasma glucose levels on admission. Mortality among 33 patients with glucose concentration below 9.0 mmol/l was 33.3%, 71.1% for the 45 patients with glucose level between 9.0 and 13.0 mmol/l, and 95.2% for the 21 patients with concentration above 13.0 mmol/l (P<0.0001). Glucose level was higher in Grade V than in Grade IV patients (mean+/-SD) (11.8+/-3.2 vs 9.8+/-2.9 mmol/l; P=0.0012). Patients with mild CT findings (n=10) had the lowest glucose level (8.9+/-1.8 mmol/l; P=0.0082), whereas patients with severe findings (n=56) had the highest glucose (11.4+/-3.5 mmol/l; P=0.011). Despite association with clinical grade and extent of CT findings, logistic multiple regression revealed the admission plasma glucose level to be an independent prognosticator of outcome. The prognostic potential of the initial plasma glucose level may be beneficial in management protocols of poor-grade SAH patients.     

Early prediction of clinical outcomes in patients with aneurysmal subarachnoid hemorrhage using computed tomography texture analysis

Radiological evaluation of subarachnoid hemorrhage (SAH) is often subject to interobserver variability. The aim of this study was to retrospectively detect computed tomography (CT) texture parameters in the early postictal state to predict cerebral vasospasm, delayed cerebral ischemia (DCI), and functional outcome in aneurysmal SAH using quantitative CT texture analysis (CTTA) via a commercially available software program and routine CT images. 40 patients with aneurysmal SAH surgically treated at the Keio University Hospital during a four-year period were analyzed. CT texture analyses were performed using a commercially available software program (Synapse Vincent). The following texture parameters of blood clots in the subarachnoid space and cerebral edema were assessed: mean CT value, entropy, skewness, and kurtosis. The mean CT value of blood clots in the subarachnoid space was significantly associated with cerebral vasospasm, DCI, and functional outcome. The mean CT value ≥ 49.64 Hounsfield units (HU) predicted cerebral vasospasm with a sensitivity and specificity of 85.7% and 61.5%, respectively (area under the curve [AUC] = 0.758). The mean CT value ≥ 49.95 HU predicted DCI with a sensitivity and specificity of 100% and 60.6%, respectively (AUC = 0.810). The mean CT value ≥ 53.00 HU predicted poor functional outcome with a sensitivity and specificity of 56.3% and 91.7%, respectively (AUC = 0.747). CTTA using a commercially available software program demonstrated that the mean CT value of clots in the subarachnoid space in the early postictal state could predict vasospasm, DCI, and clinical outcome with a high sensitivity and specificity.     

The relationship between rebleeding after spontaneous SAH and APOE polymorphisms in a Chinese population

Rebleeding leads to lots of patients' disability and mortality after spontaneous subarachnoid hemorrhage (SAH), but the risk factors of rebleeding have not been fully understood. More evidence showed apolipoprotein E (apoE protein, APOE gene) influenced the outcome of spontaneous SAH. In this study, we aimed to investigate the relationship of APOE polymorphisms with rebleeding after spontaneous SAH. A total of 185 patients with spontaneous SAH were involved in the current study. Genomic DNA was extracted from venous blood samples to identify the APOE genotype by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Rebleeding was defined as acute clinical deterioration that was accompanied by computed tomography (CT) evidence of rebleeding in the subarachnoid space. A total of 21 patients occurred rebleeding in 185 patients with spontaneous SAH in the hospital. Data were analyzed by χ(2)-test and logistic regression analyses. The statistical analysis indicated no significant association between APOE genotype and rebleeding in a Chinese population.     

Subarachnoid hemorrhage of unknown etiology

Abstract

During a 10-year-period, 80 of 510 (16%) patients with primary subarachnoid hemorrhage (SAH) had negative angiographic studies. On admission, 70 of 80 patients (88%) were in grades I-II according to Hunt and Hess, 9 (11%) in grade III, and 1 (1%) in grade IV. The most frequent CT feature was preponderance of subarachnoid blood in the peripontine cistern as observed in 35 of 51 cases (69%) in whom blood was visible on CT. During hospitalization, 3 patients (4%) rebledand 3 others (4%) had an infarction. However, in all of these complicated cases maximum hemorrhage was outside the peripontine cistern. Outcome after hospitalization as assessed by the Glasgow-Outcome-Scale (GOS) was favorable (GOS 1 and 2) in all patients who had maximum blood in the peripontine cistern, but only in 62% showing preponderance of blood outside the peripontine cistern, and 4 of them (25%) had died (GOS 5). These differences are statistically significant (p < 0.001). Long-term outcome of 56 patients as graded according to the Activities of Daily Living (ADL) system was favorable in 88% of cases with peripontine hemorrhage who returned to normal activities (ADL 1). At the same time> another patient with diffuse hemorrhage had died. Thus; overall mortality was 8.9% at a mean observation time of 5.5 years. In conclusion, SAH of unknown etiology generally has a good prognosis, although a nonneglegible percentage of patients have persistent minor side-effects. In our experience, maximum blood in the peripontine cistern particularly indicates a favorable outcome/ since all patients with this CT pattern survived in a good condition. [Neurol Res 1996; 18: 220–226]     

Early cerebral blood flow and vascular reactivity to acetazolamide in predicting the outcome after ruptured cerebral aneurysm

The sequential cerebral blood flow (CBF) and CBF response to acetazolamide (AZ; 1 g i.v.) within 4 days after initial subarachnoid hemorrhage (SAH) were monitored in 50 patients by stable xenon-enhanced computed tomography (xenon CT). The mean global CBF of the subjects declined with the neurological grading (Hunt & Kosnik), and it was impossible to predict the occurrence of vasospasm from the value of the plain CBF at the acute phase of SAH. However, the CBF response to AZ at the acute phase of SAH among patients resulting in a poor outcome was significantly diminished compared to that among patients resulting in a good outcome. The usefulness of the CBF response to AZ in the acute phase of SAH is discussed.     

非动脉瘤性自发性蛛网膜下腔出血分析

目的总结非动脉瘤性自发性蛛网膜下腔出血的临床特点。方法自发性SAH患者首次CTA和DSA均未发现动脉瘤和其他血管病变者,3～4周复查CTA或DSA,结果仍为阴性者诊断为非动脉瘤性SAH。分为中脑周围非动脉瘤性蛛网膜下腔出血(PMN)组和非中脑周围非动脉瘤性蛛网膜下腔出血(nPMN)组。结果 51例患者首次CTA和DSA未发现动脉瘤和其他血管病变,其中4例复查CTA或DSA发现动脉瘤,另有6例患者未复查即死亡。诊断为非动脉瘤性蛛网膜下腔出血共41例,其中PMN组29例,nPMN组12例。平均随访2.3年,两组均无死亡,全部的PMN病例和83.3%的nPMN病例预后良好。结论非中脑周围非动脉瘤性蛛网膜下腔出血(nPMN)临床过程和预后介于动脉瘤性SAH和PMNSAH之间,需要通过重复造影检查排除动脉瘤的可能。     

Familial subarachnoid hemorrhage. Outcome study

BACKGROUND AND PURPOSE: The aim of our study was to compare outcome and its determinants in familial subarachnoid hemorrhage and in sporadic subarachnoid hemorrhage in a large and well-documented patient population. METHODS: Patients with aneurysmal subarachnoid hemorrhage (SAH) treated at the Department of Neurosurgery, Kuopio University Hospital, from 1977 to 1995 were included. Patients with polycystic kidney disease were excluded. The Glasgow Outcome Scale (GOS) score at 12 months was studied. RESULTS: There were 120 patients (97 first-, 15 second-, and 8 third-degree family connections) in 96 different families with familial SAH and 1237 patients with sporadic SAH. Age, gender, and admission grade on the Hunt and Hess scale did not differ between these 2 groups. In both groups >80% of patients were in relatively good condition at admission. The outcome was good (GOS score of 1 to 2) in 87 patients (73%) with familial SAH and in 874 patients (71%) with sporadic SAH. Analysis of 20 variables, including presence of coexisting diseases, aneurysm site and size, amount of blood shown on CT scan, intraventricular bleeding, preoperative intracerebral hematoma and hydrocephalus, as well as postoperative bleeding and vasospasm, revealed no significant differences between study groups. The degree of family connection (first-, second-, and third-degree) did not have any statistically important effect on outcome in the familial group in the Finnish study population. In multivariate analysis the knowledge of familial SAH was not an independent prognostic factor. CONCLUSIONS: Admission status, postoperative course, and outcome were similar in the familial and sporadic SAH groups in this Finnish population, in contrast to previous results. Familial SAH may not be a significant risk factor for poor outcome.     

Non-traumatic subarachnoid hemorrhage with normal angiogram. Long-term follow-up and CT predictors of complications.

We investigated 91 patients with non-traumatic subarachnoid hemorrhage (SAH) in whom no aneurysm was found on initial angiography. In 31 of these patients CT did not show subarachnoid blood. A typical feature was a localized blood clot in the prepontine or interpeduncular cistern. Follow-up was obtained 6 months to 11.8 years after SAH by personal re-examination (n = 49) or questionnaire sent to patients or their doctors. 79 patients were free of neurological signs, 3 had a mild and one a severe neurological deficit. Five patients had died from SAH. Those patients who died or had complications often had blood in the frontal basal interhemispheric fissure. None of the 3 therapeutic regimens applied proved to be superior. We conclude that prognosis is good, but an unidentified aneurysm must be considered and repeat angiogram is warranted if blood is found in the anterior part of the basal cisterns. When the hemorrhage is in the prepontine cistern, repeat angiogram is not necessary.     

Long-term prognosis of subarachnoid hemorrhages of unknown etiology

Summary Forty-nine patients who suffered a spontaneous subarachnoid hemorrhage (SAH), and in whom panangiography did not show the cause of the bleeding, were evaluated after a long follow-up (median 8 years). No relationship was found between outcome and antifibrinolytic treatment or blood pressure level. Angiography was repeated in cases with spasm or after rebleeding: one aneurysm was found (7%). The authors suggest that angiography should be repeated in these circumstances. The early mortality was 2%. Late functional capacity was normal in 94% of the patients. No particular restrictions should therefore be recommended.     

Pseudo-subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) appears on CT as hyperdensity in the subarachnoid space. In rare circumstances a similar appearance may occur in the absence of subarachnoid blood, a finding that has been termed “pseudo-subarachnoid hemorrhage.” We describe three patients who presented with abrupt alterations in mental status in whom CT falsely suggested SAH, and we review the literature regarding this imaging finding. In contrast to prior reports, all three of our patients had a favorable outcome.     

术中终板造瘘治疗动脉瘤性蛛网膜下腔出血后脑积水

目的对动脉瘤性蛛网膜下腔出血(SAH)患者进行出血后脑积水测查,同时评价动脉瘤夹闭术中行终板造瘘在脑积水治疗中的作用.方法应用出血后2周的CT或MRI评价SAH后脑积水的发生,18例脑积水患者中7例行动脉瘤夹闭术中终板造瘘,术后随访观察疗效.结果脑积水的总体发生率为13.6% (18/132),7例终板造瘘患者6例术后脑积水得到明显缓解,随访未见相应并发症出现,1例无效.结论动脉瘤夹闭术中行终板造瘘技术相对简单,不会加重患者的经济负担和神经系统损害,对大部分SAH后脑积水疗效肯定.     

Timing of Computed Tomography and Prediction of Vasospasm after Aneurysmal Subarachnoid Hemorrhage

Background  The initial noncontrast computed tomography (CT) study of the head after an aneurysmal subarachnoid hemorrhage (SAH) is used to predict the risk of developing vasospasm. Changes in the extent of subarachnoid blood seen on CT images occur as a function of time after SAH, but there is no consensus on the time interval during which this study needs to be completed. Methods  Clinical and radiological information on adult SAH patients were reviewed. Patients were grouped based on the time elapsed from ictus to the initial head CT study. The amount of subarachnoid blood on CT was graded using the Hijdra sum score (HSS) and the modified Fisher scale (MFS). The relationship between the initial CT grading score and the risk of angiographic vasospasm was assessed for each group. Results  A total of 224 consecutive patients were identified (145 females, 65%). Initial CT was performed within 24 h of the event in 163 (Group 1, 73%) and after 24 h in 61 patients (Group 2, 27%). A total of 54 patients (24%) developed angiographic vasospasm. A statistically significant association between the extent of subarachnoid blood and subsequent development of vasospasm was observed only if the initial CT imaging study was performed within 24 h of aneurysmal rupture (P = 0.0001 and 0.02 for HSS and MFS, respectively). Conclusions  We propose that only CT scans obtained within 24 h of a subarachnoid bleeding event should be used to estimate the risk of vasospasm.     

动脉瘤性蛛网膜下腔出血血管内栓塞后D-dimer浓度变化与预后的关系

目的探讨动脉瘤性蛛网膜下腔出血(SAH)血管内栓塞后D-dimer浓度的变化以及D-dimer浓度升高能否做为预后不良的独立预测因素。方法对204例发病48 h内入住我院和郑州大学第二附属医院神经内科的SAH病人,在手术当天早晨和动脉瘤填塞后14 d检测血浆D-dimer浓度,3个月时根据格拉斯哥预后评分和CT随访脑梗塞的发生做为预后不良的预测因素。结果动脉瘤栓塞后预后不良的病人较预后良好者D-dimer浓度明显升高,手术当天2组各自平均为(1 368±298)μg/L和(756±144)μg/L,14 d时分别为(1 129±166)μg/L和(356±73)μg/L,P<0.001。重复检测发现,预后良好者D-dimer浓度降低较快,排除其他影响因素后,D-dimer与预后不良有明显关系。结论 SAH后血浆D-dimer升高是预后不良的独立预测因素,可能与凝血酶代谢产物过量积聚引起的损害有关。     

Onset seizures independently predict poor outcome after subarachnoid hemorrhage

OBJECTIVE: To determine whether onset seizures after subarachnoid hemorrhage (SAH) carry independent prognostic information and to investigate the risk factors for late seizures after SAH. BACKGROUND: Modern management of SAH, including early operation, has substantially reduced mortality. No study has adequately assessed the importance of onset seizures in a contemporary SAH cohort. METHODS: The authors analyzed the records and initial CT scans of 412 consecutive patients with aneurysmal or nonaneurysmal SAH admitted to the Royal Melbourne Hospital from 1990 to 1996. Each patient with an onset seizure (n = 32, 7.8% of cohort) was age and sex matched to two nonseizure patients of the same cohort. Each patient with a late seizure (n = 17, 5.1% of cohort) was matched to five control subjects of the same cohort. RESULTS: With use of logistic regression analysis, onset seizures correlated with the sum score of blood on initial CT scan (OR = 1.1, p = 0.05), but there was no significant correlation with duration of loss of consciousness at onset, Glasgow Coma Score (GCS), presence of aneurysm, or past history of hypertension or epilepsy. Disability 6 weeks after SAH according to the Glasgow Outcome Scale was independently predicted by initial GCS of <6 (OR = 13.7, p < 0.01) and onset seizure (OR = 7.8, p = 0.04). Late seizures within the first 6 weeks were independently related to rebleeding (OR = 94, p < 0.01) and onset seizures (OR = 27, p < 0.01) but not to other onset variables, development of hydrocephalus, or vasospasm. CONCLUSION: In this single-institution cohort of patients with SAH, onset seizures were an independent risk factor for late seizures and a predictor of poor outcome.     

Amount of blood during the subacute phase and clot clearance rate as prognostic factors for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) is a poorly predictable complication occurring after aneurysmal subarachnoid hemorrhage (SAH) that can have dramatic functional consequences. Identifying the patients with the highest risk of DCI may help to institute more suitable monitoring and therapy. Early brain injuries and aneurysm-securing procedure complications could be regarded as confounding factors leading to severity misjudgment. After an early resuscitation phase, a subacute assessment may be more relevant to integrate the intrinsic SAH severity.A retrospective analysis was performed upon patients prospectively included in the registry of SAH patients between July 2015 to April 2020. The amount of cisternal and intraventricular blood were assessed semi-quantitatively on acute and subacute CT scans performed after early resuscitation. A clot clearance rate was calculated from their comparison. The primary endpoint was the occurrence of a DCI.A total of 349 patients were included in the study; 80 (22.9%) experienced DCI. In those patients, higher Fisher grades were observed on acute (p = 0.026) and subacute (p = 0.003) CT scans. On the subacute CT scan, patients who experienced DCI had a higher amount of blood, either at the cisternal (median Hijdra sum score: 11 vs 5, p < 0.001) or intraventricular (median Graeb score: 4 vs 2, p < 0.001) level. There was a negative linear relationship between the cisternal clot clearance rate and the risk of DCI.The assessment of the amount of subarachnoid blood and clot clearance following resuscitation after aneurysmal SAH can be useful for the prediction of neurological outcome.     

Randomized pilot trial of postoperative aspirin in subarachnoid hemorrhage

OBJECTIVE: To assess the safety and feasibility of a clinical trial on the effectiveness of acetylsalicylic acid (ASA) in subarachnoid hemorrhage (SAH). BACKGROUND: Several studies have indicated that increased platelet activity might be involved in the pathogenesis of delayed cerebral ischemia (DCI) after SAH. METHOD: Fifty patients who had early surgery (< or =4 days) for a ruptured aneurysm were enrolled in this randomized, double-blind, placebo-controlled trial. Trial medication, consisting of suppositories with 100 mg ASA versus placebo, was started immediately after surgical clipping of the aneurysm and continued for 21 days. End points were functional outcome and quality of life at 4 months, clinical deterioration after operation, development of DCI, hypodense lesion on postoperative CT, and hemorrhagic complications. RESULTS: One-third of all patients with aneurysmal SAH were eligible for the trial. Fifteen of 26 patients receiving placebo deteriorated clinically versus 10 of 24 patients receiving ASA; 4 patients in each group deteriorated from DCI. Postoperative hypodensities on CT were observed in 27 patients, distributed equally in both groups. Functional outcome and quality-of-life scores were slightly in favor of patients who had received ASA, but not to a significant degree (p = 0.22). Two patients in the ASA group had an asymptomatic hemorrhagic complication, and one patient in the placebo group had a fatal and another a symptomatic hemorrhagic complication. CONCLUSION: This pilot study shows that a clinical trial of acetylsalicylic acid (ASA) in subarachnoid hemorrhage (SAH) is feasible and probably safe. The effectiveness of ASA on functional outcome and delayed cerebral ischemia has to be studied in a larger trial.