Endothelin-receptor antagonists for aneurysmal subarachnoid hemorrhage: an updated meta-analysis of randomized controlled trials

Introduction

The previous meta-analysis on the use of endothelin-receptor antagonists (ETRAs) to treat aneurysmal subarachnoid hemorrhage (SAH) has become outdated due to recently published phase 3 clinical trials. An up-to-date meta-analysis is needed to provide the best available evidence for the efficacy of ETRAs for aneurysmal SAH.

Methods

We performed a systematic review and meta-analysis of published randomized controlled trials that investigate efficacy of ETRAs in patients with aneurysmal SAH. Mortality, unfavorable outcome, delayed ischemic neurological deficit (DIND), delayed cerebral infarction (DCI), angiographic vasospasm and adverse events were analyzed. Meta-analysis was performed in terms of the risk ratio (RR) and 95% confidence interval (CI).

Results

Five eligible studies were reviewed and analyzed, involving 2,595 patients. The pooled RRs of mortality and unfavorable outcome after SAH were 1.03 (95% CI = 0.77 to 1.36) and 1.07 (95% CI = 0.93 to 1.22), respectively. The pooled RRs were 0.87 (95% CI = 0.74 to 1.03) for DCI, 0.77 (95% CI = 0.66 to 0.90) for DIND, and 0.66 (95% CI = 0.57 to 0.77) for angiographic vasospasm. There were significant increases in lung complications (RR = 1.80, 95% CI = 1.55 to 2.09), hypotension (RR = 2.42, 95% CI = 1.78 to 3.29) and anemia (RR = 1.47, 95% CI = 1.19 to 1.83) in patients administered ETRAs.

Conclusion

There is no evidence that ETRAs could benefit clinical outcome in patients with SAH. Owing to the increased adverse events, further clinical trials of ETRAs in SAH patients should be more carefully formulated and designed. The present results also suggest that DCI may be a better outcome measure than vasospasm and DIND in SAH clinical trials and observational studies.     

Aneurysmal vasculopathy in human-acquired immunodeficiency virus-infected adults: Imaging case series and review of the literature

Background

Intracranial vasculopathy in adult patients with human-acquired immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a rare but increasingly recognized disease entity.

Objective

We aimed to contribute to and summarize the adult literature describing patients with HIV/AIDS who have intracranial vasculopathy.

Methods

A retrospective review of adult patients with HIV/AIDS undergoing diagnostic cerebral angiography at our institution from 2007–2013 was performed. A literature review of relevant existing studies was performed.

Results

Five adult patients with HIV-related aneurysmal and occlusive vasculopathy were diagnosed and/or treated at our institution. A comprehensive review of the literature yielded data from 17 series describing 28 adult patients with HIV/AIDS and intracranial vasculopathy. Our review suggests that low CD4 count, motor weakness, and meningismus may be associated with the sequelae of intracranial vasculopathy/vasculitis in patients with HIV/AIDS.

Conclusion

Patients with HIV/AIDS who have aneurysmal and stenotic vascular disease may benefit from earlier surveillance with the onset of neurological symptoms. The roles of medical, open surgical, and endovascular therapy in this unique entity will be further defined as the pathological basis of the disease is better understood.     

A novel technique to quantify the instantaneous mitral regurgitant rate

Background

The systolic variation of mitral regurgitation (MR) is a pitfall in its quantification. Current recommendations advocate using quantitative echocardiographic techniques that account for this systolic variation. While prior studies have qualitatively described patterns of systolic variation no study has quantified this variation.

Methods

This study includes 41 patients who underwent cardiovascular magnetic resonance (CMR) evaluation for the assessment of MR. Systole was divided into 3 equal parts: early, mid, and late. The MR jets were categorized as holosystolc, early, or late based on the portions of systole the jet was visible. The aortic flow and left ventricular stroke volume (LVSV) acquired by CMR were plotted against time. The instantaneous regurgitant rate was calculated for each third of systole as the difference between the LVSV and the aortic flow.

Results

The regurgitant rate varied widely with a 1.9-fold, 3.4-fold, and 1.6-fold difference between the lowest and highest rate in patients with early, late, and holosystolic jets respectively. There was overlap of peak regurgitant rates among patients with mild, moderate and severe MR. The greatest variation of regurgitant rate was seen among patients with mild MR.

Conclusion

CMR can quantify the systolic temporal variation of MR. There is significant variation of the mitral regurgitant rate even among patients with holosystolic MR jets. These findings highlight the need to use quantitative measures of MR severity that take into consideration the temporal variation of MR.     

Subarachnoid Hemorrhage in Type 1 Diabetes: A prospective cohort study of 4,083 patients with diabetes

OBJECTIVE

To estimate for the first time the incidence of subarachnoid hemorrhage (SAH) in type 1 diabetes.

RESEARCH DESIGN AND METHODS

Using the nationwide Finnish Diabetic Nephropathy (FinnDiane) Study cohort of 4,083 patients with type 1 diabetes (mean age of 37.4 ± 11.8 years at enrollment), we analyzed the incidence of first-ever SAH events.

RESULTS

During the follow-up time of 36,680 person-years (median 9.4 years), 15 patients with type 1 diabetes experienced an aneurysmal or nonaneurysmal SAH, and thus the crude incidence of SAH was 40.9 (95% CI 22.9–67.4) per 100,000 person-years. One patient had a verified aneurysmal SAH, and four patients died suddenly of an SAH, which was most likely caused by an aneurysm. SAHs in 10 out of 15 patients were classified as nonaneurysmal SAH, and thus the crude incidence of nonaneurysmal SAH was 27.3 (13.1–50.1) per 100,000 person-years. None of the nonaneurysmal SAHs were fatal. In univariate analysis, current smokers had a hazard ratio of 4.82 (95% CI 1.31–17.81) for nonaneurysmal SAH.

CONCLUSIONS

The incidence of nonaneurysmal SAH is high among patients with type 1 diabetes. Our findings suggest that nonaneurysmal SAH is a distinct new microvascular complication in type 1 diabetes.Subarachnoid hemorrhage (SAH) is a life-threatening cerebrovascular event, which is usually caused by a rupture of a cerebrovascular aneurysm. These aneurysms are mostly found in relatively large-caliber (≥1 mm) vessels and can often be considered as macrovascular lesions. The overall incidence of SAH has been reported to be 10.3 per 100,000 person-years (1), even though the variation in incidence between countries is substantial (1). Notably, the population-based incidence of SAH is 35 per 100,000 person-years in the adult (≥25 years of age) Finnish population (2). The incidence of nonaneurysmal SAH is globally unknown, but it is commonly believed that 5–15% of all SAHs are of nonaneurysmal origin. Prospective, long-term, population-based SAH risk factor studies suggest that smoking (2–4), high blood pressure (2–4), age (2,3), and female sex (2,4) are the most important risk factors for SAH, whereas diabetes (both types 1 and 2) does not appear to be associated with an increased risk of SAH (2,3).An increased risk of cardiovascular disease is well recognized in people with diabetes. There are, however, very few studies on the risk of cerebrovascular disease in type 1 diabetes since most studies have focused on type 2 diabetes alone or together with type 1 diabetes. Cerebrovascular mortality in the 20–39-year age-group of people with type 1 diabetes is increased five- to sevenfold in comparison with the general population but accounts only for 15% of all cardiovascular deaths (5). Of the cerebrovascular deaths in patients with type 1 diabetes, 23% are due to hemorrhagic strokes (5). However, the incidence of SAH in type 1 diabetes is unknown.By knowing the incidence of SAH in type 1 diabetes, the overall risk of stroke in patients with type 1 diabetes could be estimated more accurately. Moreover, comprehensive prospective patient cohorts that are susceptible to cerebrovascular events may provide new knowledge of the risk factors for SAH. In this prospective cohort study of 4,083 patients with type 1 diabetes, we aimed to determine the incidence and characteristics of SAH.     

Impairment of cardiac metabolism and sympathetic innervation after aneurysmal subarachnoid hemorrhage: a nuclear medicine imaging study

Introduction

Although aneurysmal subarachnoid hemorrhage (SAH) is often complicated by myocardial injury, whether this neurogenic cardiomyopathy is associated with the modification of cardiac metabolism is unknown. This study sought to explore, by positron emission tomography/computed tomography, the presence of altered cardiac glucose metabolism after SAH.

Methods

During a 16-month period, 30 SAH acute phase patients underwent myocardial ¹⁸ F- fluorodesoxyglucose positron emission tomography (¹⁸F-FDGPET), ^99mTc-tetrofosmin and ¹²³I-meta-iodobenzylguanidine (¹²³I-mIBG) scintigraphy, respectively, assessing glucose metabolism, cardiac perfusion, and sympathetic innervation. Patients with initial abnormalities were followed monthly for two months for ¹⁸F-FDG, and six months later for ¹²³I-mIBG.

Results

In this SAH population, acute cardiac metabolic disturbance was observed in 83% of patients (n = 25), and sympathetic innervation disturbance affected 90% (n = 27). Myocardial perfusion was normal for all patients. The topography and extent of metabolic defects and innervation abnormalities largely overlapped. Follow-up showed rapid improvement of glucose metabolism in one or two months. Normalization of sympathetic innervation was slower; only 27% of patients (n = 8) exhibited normal ¹²³I-mIBG scintigraphy after six months. Presence of initial altered cardiac metabolism was not associated with more unfavorable cardiac or neurological outcomes.

Conclusions

These findings support the hypothesis of neurogenic myocardial stunning after SAH. In hemodynamically stable acute phase SAH patients, cardiomyopathy is characterized by diffuse and heterogeneous ¹⁸F-FDG and ¹²³I-mIBG uptake defect.

Trial registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01218191","term_id":"NCT01218191"}}NCT01218191. Registered 6 October 2010.     

Mapping iron in human heart tissue with synchrotron x-ray fluorescence microscopy and cardiovascular magnetic resonance

Background

MRI assessment of cardiac iron is particularly important for assessing transfusion-dependent anaemia patients. However, comparing the iron distribution from histology or bulk samples to MRI is not ideal. Non-destructive, high-resolution imaging of post-mortem samples offers the ability to examine iron distributions across large samples at resolutions closer to those used in MRI. The aim of this ex vivo case study was to compare synchrotron X-ray fluorescence microscopy (XFM) elemental iron maps with magnetic resonance transverse relaxation rate maps of cardiac tissue samples from an iron-loaded patient.

Methods

Two 5 mm thick slices of formalin fixed cardiac tissue from a Diamond Blackfan anaemia patient were imaged in a 1.5 T MR scanner. R₂ and R_2* transverse relaxation rate maps were generated for both slices using RF pulse recalled spin echo and gradient echo acquisition sequences. The tissue samples were then imaged at the Australian Synchrotron on the X-ray Fluorescence Microscopy beamline using a focussed incident X-ray beam of 18.74 keV and the Maia 384 detector. The event data were analyzed to produce elemental iron maps (uncalibrated) at 25 to 60 microns image resolution.

Results

The R₂ and R_2* maps and profiles for both samples showed very similar macro-scale spatial patterns compared to the XFM iron distribution. Iron appeared to preferentially load into the lateral epicardium wall and there was a strong gradient of decreasing iron, R₂ and R_2* from the epicardium to the endocardium in the lateral wall of the left ventricle and to a lesser extent in the septum. On co-registered images XFM iron was more strongly correlated to R_2* (r = 0.86) than R₂ (r = 0.79). There was a strong linear relationship between R_2* and R₂ (r = 0.87).

Conclusions

The close qualitative and quantitative agreement between the synchrotron XFM iron maps and MR relaxometry maps indicates that iron is a significant determinant of R₂ and R_2* in these ex vivo samples. The R₂ and R_2* maps of human heart tissue give information on the spatial distribution of tissue iron deposits.

Electronic supplementary material

The online version of this article (doi:10.1186/s12968-014-0080-2) contains supplementary material, which is available to authorized users.     

Systemic glucose variability predicts cerebral metabolic distress and mortality after subarachnoid hemorrhage: a retrospective observational study

Introduction

Cerebral glucose metabolism and energy production are affected by serum glucose levels. Systemic glucose variability has been shown to be associated with poor outcome in critically ill patients. The objective of this study was to assess whether glucose variability is associated with cerebral metabolic distress and outcome after subarachnoid hemorrhage.

Methods

A total of 28 consecutive comatose patients with subarachnoid hemorrhage, who underwent cerebral microdialysis and intracranial pressure monitoring, were studied. Metabolic distress was defined as lactate/pyruvate ratio (LPR) >40. The relationship between daily glucose variability, the development of cerebral metabolic distress and hospital outcome was analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes.

Results

Daily serum glucose variability was expressed as the standard deviation (SD) of all serum glucose measurements. General linear models were used to relate this predictor variable to cerebral metabolic distress and mortality at hospital discharge. A total of 3,139 neuromonitoring hours and 181 days were analyzed. After adjustment for Glasgow Coma Scale (GCS) scores and brain glucose, SD was independently associated with higher risk of cerebral metabolic distress (adjusted odds ratio = 1.5 (1.1 to 2.1), P = 0.02). Increased variability was also independently associated with in hospital mortality after adjusting for age, Hunt Hess, daily GCS and symptomatic vasospasm (P = 0.03).

Conclusions

Increased systemic glucose variability is associated with cerebral metabolic distress and increased hospital mortality. Therapeutic approaches that reduce glucose variability may impact on brain metabolism and outcome after subarachnoid hemorrhage.     

Clinical and angiographic outcomes of stent-assisted coiling of intracranial aneurysms

Background

Despite the increasing use of stent-assisted coiling (SAC), data on its long-term clinical and angiographic results are limited.

Objective

The objective of this article is to assess the long-term clinical and angiographic outcomes in SAC in our single-center practice.

Methods

We conducted a retrospective analysis of intracranial aneurysms treated with detachable coils during the period 2003–2012. Patients were divided into SAC and non-SAC groups and were analyzed for aneurysm occlusion, major recurrence and clinical outcome. Logistic regression analyses identified factors associated with clinical/angiographic outcomes (p value <0.05 was statistically significant).

Results

A total of 516 procedures met inclusion criteria: Sixty-three (12.2%) patients underwent SAC, of whom 56 (89%) had an elective procedure whereas 286 (63.1%) aneurysms from the non-SAC group were ruptured. In the unruptured subcohort, baseline class I was achieved in 24 (38%, p = 0.91), and predischarge modified Rankin scale score (mRS) 0–2 was obtained in 96.4% of cases in the SAC group versus 90.4% in the non-stent group. The major recurrence was 9.5% versus 11.3% in the SAC and non-SAC group, respectively (p = 0.003). At last clinical assessment, 98.2% of the patients from the unruptured SAC group had mRS 0–2 (mean follow-up, 58 months) versus 93.6% (mean follow-up, 56 months) in the unruptured non-SAC group (p = 0.64). Periprocedural vasospasm was associated with long-term poor outcome in the unruptured SAC subcohort (p = 0.0008).

Conclusions

SAC and non-SCA techniques show comparable safety and clinical outcome. The SAC technique significantly decreases retreatment rates. Periprocedural vasospasm resulting from vessel manipulation is associated with poor outcome in SAC of unruptured aneurysms.     

CTA联合全脑血流灌注成像在蛛网膜下腔出血后的临床应用

目的：探讨CTA联合全脑灌注成像在蛛网膜下腔出血（SAH）后的临床应用价值。方法：SAH病人29例,通过双源CT全脑血流灌注（PBV）检查,重建CTA图像和PBV图像,在检出动脉瘤等同时,以灌注参数评估SAH后脑血管痉挛及其所致的脑缺血改变情况。结果：29例病人中检出27例的28个动脉瘤。额、颞、顶、枕叶及小脑PBV值SAH组分别为11.17±3.13;10.92±2.91;11.08±2.53;9.88±3.01;19.83±5.12,对照组分别为17.10±3.60;15.98±5.03;15.84±3.53;16.14±1.86;23.54±4.64,额、顶、枕叶差异显著（P<0.05）;存活组与死亡组各脑叶PBV值均未见显著性差异;优势出血侧和非优势出血侧低灌注出现情况无显著性差异。结论：CTA联合全脑PBV灌注成像能够在诊断SAH出血原因的同时显示脑血管痉挛引起的脑组织缺血改变。     

C-type natriuretic peptide concentrations in the plasma and cerebrospinal fluid of patients with subarachnoid hemorrhage

Background

Cerebral vasospasm is a poor resulting outcome of a ruptured cerebral aneurysm; to clarify the mechanism of vasospasm it is important to improve this outcome. C-type natriuretic peptide (CNP) is present in the brain as a cerebral vasodilator; it is also an endothelium-derived relaxing factor produced via cGMP. We speculated that CNP might be an inhibitor of cerebral vasospasm after subarachnoid hemorrhage (SAH).

Methods

To clarify the role of CNP in cerebral vasospasm after SAH, we conducted 1 week monitoring of CNP concentrations in the plasma and cerebrospinal fluid (CSF) of 26 patients who had undergone clipping within 24 hours of the occurrence of SAH, and divided them into group A (positive for angiographic spasm) and group B (negative for angiographic spasm). We also examined CNP concentrations in the CSF of patients who were receiving spinal anesthesia for small orthopedic operations, as reference patients.

Results

The CNP concentration in the CSF on day 1 was higher than in the reference patients and decreased in both test groups, but we did not observe any significant difference between the groups. CNP concentrations in the plasma did not change in either group.

Conclusions

CNP concentrations in the CSF were high in the acute phase after SAH, whereas plasma CNP concentrations remained constant. However, our findings did not support our hypothesis because we did not find any relationship between vasospasm and changes in CNP concentrations in the CSF.     

Safety of Abciximab injection during endovascular treatment of ruptured aneurysms

Background and purpose

We aimed to determine the safety of intra-arterial Abciximab injection in the management of thromboembolic complications during endovascular treatment of ruptured cerebral aneurysms.

Methods

In a monocentric consecutive series of endovascular treatment of 783 ruptured aneurysms, 42 (5.3%) patients received Abciximab after the aneurysm was secured. Bleeding complications were registered and dichotomized as follows: new intracranial hemorrhage and peripheral bleeding. For each patient, World Federation of Neurosurgery (WFNS) subarachnoid hemorrhage (SAH) grade, shunting, and clinical outcomes in the post-operative period and at 3–6 months were recorded.

Results

SAH WFNS grades were as follows: grade I n = 14, grade II n = 10, grade III n = 11, grade IV n = 4, grade V n = 3. Ten patients had intracranial hematoma additionally to the SAH prior to embolization. Four patients (9.5%) presented more blood on the post-embolization CT but only one suffered a new clinically relevant intracranial hemorrhage. Two patients (4.8%) experienced significant peripheral bleeding but none were associated with long-term disabilities. Fourteen patients had a shunt installed less than 24 h prior to Abciximab injection and one less than 48 h later. At 3–6-month follow-up, 31 patients (74%) achieved a modified Rankin Scale score (mRS) of 2 or less, six patients (14%) had a mRS of 3–5, three were dead (7%), and two were lost at follow-up.

Conclusion

When the aneurysm is secured, intra-arterial Abciximab injection is a low complication rate treatment modality for thromboembolic events during embolization of cerebral ruptured aneurysm.     

High-resolution,three-dimensional,and contrast-enhanced ultrasonographic findings in diseases of the eye

Objectives

To review the contrast-enhanced ultrasound (CEUS) and 3D ultrasound findings (3D-US) in various pathologies involving the eye and orbit and to compare them with high-resolution US (HRUS) findings.

Background

CEUS is a valid diagnostic tool for study several districts. There are numerous pathological conditions of the eye in which CEUS can be very helpful or detrimental.

Image Findings

We review a wide range of ocular lesions, traumatic (retinal and choroidal detachments) and malignant (choroidal melanoma, tumors inside and outside the muscle cone) evaluated alternatively with CEUS and 3D and compare these findings with those obtained with HRUS. Dysthyroid orbitopathy is not included in this review.

Conclusion

CEUS plays a central role in the differentiation of detached retina (vascular) and vitreous membranes (avascular). It is also helpful in the assessment of tumor of the eye, in planning treatment for choroidal melanoma, and in assessing orbital masses for neovascularization. HRUS is highly effective in the detection of traumatic and non-traumatic lesions of the eye, but it is less effective for the assessment of orbital lesions. The 3D module has increased the diagnostic value of CEUS. CEUS is cost-effective and can be used when CT and MR cannot be performed.     

Lipopolysaccharide infusion enhances dynamic cerebral autoregulation without affecting cerebral oxygen vasoreactivity in healthy volunteers

Introduction

Sepsis may be associated with disturbances in cerebral oxygen transport and cerebral haemodynamic function, thus rendering the brain particularly susceptible to hypoxia. The purpose of this study was to assess the impact of isocapnic hypoxia and hyperoxia on dynamic cerebral autoregulation in a human-experimental model of the systemic inflammatory response during the early stages of sepsis.

Methods

A total of ten healthy volunteers were exposed to acute isocapnic inspiratory hyperoxia (F_IO₂ = 40%) and hypoxia (F_IO₂ = 12%) before and after a 4-hour lipopolysaccharide (LPS) infusion (2 ng kg^-1). Middle cerebral artery blood follow velocity was assessed using transcranial Doppler ultrasound, and dynamic autoregulation was evaluated by transfer function analysis.

Results

Transfer function analysis revealed an increase in the phase difference between mean arterial blood pressure and middle cerebral artery blood flow velocity in the low frequency range (0.07–0.20 Hz) after LPS (P<0.01). In contrast, there were no effects of either isocapnic hyperoxia or hypoxia on dynamic autoregulation, and the cerebral oxygen vasoreactivity to both hyperoxia and hypoxia was unaffected by LPS.

Conclusions

The observed increase in phase suggests that dynamic cerebral autoregulation is enhanced after LPS infusion and resistant to any effects of acute hypoxia; this may protect the brain from ischaemia and/or blood–brain barrier damage during the early stages of sepsis.     

Continuous vs. intermittent hemodialysis: with which spin will my patient win?

Citation

Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 2006;368(9533):379–85 [1].

Background

Whether continuous renal replacement therapy is better than intermittent haemodialysis for the treatment of acute renal failure in critically ill patients is controversial.

Methods

Objective

To compare the effect of intermittent haemodialysis and continuous venovenous haemodiafiltration on survival rates in critically ill patients with acute renal failure as part of multiple-organ dysfunction syndrome.

Design

Prospective, randomized, controlled trial

Setting

21 medical or multidisciplinary intensive-care units from university or community hospitals in France between Oct 1, 1999 and March 3, 2003.

Subjects

360 critically ill patients with acute renal failure as part of multiple-organ dysfunction syndrome.

Intervention

Patients were randomized to intermittent haemodialysis (n = 184) or continuous venovenous haemodiafiltration (n = 175). Guidelines were provided to achieve optimum haemodynamic tolerance and effectiveness of solute removal in both groups. The two groups were treated with the same polymer membrane and bicarbonate-based buffer.

Measurements and main results

The primary endpoint was 60-day survival based on an intention-to-treat analysis. Rate of survival at 60-days did not differ between the groups (32% in the intermittent haemodialysis group versus 33% in the continuous renal replacement therapy group [95 % CI -8.8 to 11.1,]), or at any other time.

Conclusion

These data suggest that, provided strict guidelines to improve tolerance and metabolic control are used, almost all patients with acute renal failure as part of multiple-organ dysfunction syndrome can be treated with intermittent haemodialysis.     

Subarachnoid hemorrhage induces an early and reversible cardiac injury associated with catecholamine release: one-week follow-up study

Introduction

The occurrence of cardiac dysfunction is common after subarachnoid hemorrhage (SAH) and was hypothesized to be related to the release of endogenous catecholamines. The aim of this prospective study was to evaluate the relationship between endogenous catecholamine and cardiac dysfunction at the onset and during the first week after SAH.

Methods

Forty consecutive patients admitted for acute SAH without known heart disease were included. Catecholamine plasma concentrations and transthoracic echocardiography (TTE) were documented on admission, on day 1 (D1), and day 7 (D7).

Results

At baseline, 24 patients had a World Federation of Neurosurgical Societies score (WFNS) of one or two; the remaining 16 had a WFNS between three and five. Twenty patients showed signs of cardiac dysfunction on admission, including six with left ventricle (LV) systolodiastolic dysfunction and 14 with pure LV diastolic dysfunction. On admission, norepinephrine, epinephrine, dopamine, B-type Natriuretic Peptide (BNP) and Troponin Ic (cTnI) plasmatic levels were higher in patients with the higher WFNS score and in patients with altered cardiac function (all P <0.05). Among patients with cardiac injury, heart function was restored within one week in 13 patients, while seven showed persistent LV diastolic dysfunction (P = 0.002). Plasma BNP, cTnI, and catecholamine levels exerted a decrease towards normal values between D1 and D7.

Conclusion

Our findings show that cardiac dysfunction seen early after SAH was associated with both a rapid and sustained endogenous catecholamine release and WFNS score. SAH-induced cardiac dysfunction was regressive over the first week and paralleled the normalization of catecholamine concentration.     

Migraine and risk of hemorrhagic stroke: a study based on data from general practice

Background

We investigated the association between hemorrhagic stroke and migraine using data from The Health Improvement Network database.

Findings

We ascertained 1,797 incident cases of intracerebral hemorrhage (ICH) and 1,340 of subarachnoid hemorrhage (SAH). Density-based sampling was used to select 10,000 controls free from hemorrhagic stroke. Using unconditional logistic regression models, we calculated the risk of hemorrhagic stroke associated with migraine, adjusting for age, sex, calendar year, alcohol, body mass index, hypertension, previous cerebrovascular disease, oral contraceptive use, and health services utilization.The risk (odds ratio [OR]) of ICH among migraineurs was 1.2 (95% confidence interval [CI] 0.9–1.5), and of SAH was (1.2, 95% CI 0.9–1.5). The association with ICH was stronger for migraine diagnosed ≥20 years prior to ICH (OR 1.6, 95% CI 1.0–2.4), but not with SAH (OR 1.1, 95% CI 0.6–2.1). In analyses stratified by migraine type and gender, the OR of ICH in women with migraine with aura was 1.7 (95% CI 0.9–3.4) and the corresponding OR of SAH in women was 1.2 (95% CI 0.6–2.3).

Conclusion

No clear increased risk of ICH or SAH was observed in migraineurs.     

TransForm occlusion balloon catheter for the treatment of intracranial aneurysms,initial experience

Introduction

The technique of balloon remodeling allows the endovascular treatment of wide-neck intracranial aneurysms. For many years the only available devices were the Hyperform and the Hyperglide balloon catheters. Recently, other companies have developed newer devices, single or dual-lumen. We present our initial experience with the TransForm occlusion balloon catheter for the treatment of intracranial aneurysms.

Methods

We retrospectively analysed from our prospectively gathered aneurysm database all aneurysms that were treated with balloon remodelling using TransForm occlusion balloon catheters from January 2013 to February 2014. We assessed patient demographics, morphological features of the aneurysms, procedure feasibility, technical and clinical complications.

Results

Thirty-three patients harbouring 36 intracranial saccular aneurysms were treated during 33 procedures. Clinical finding were: 15 incidental discovery, 13 subarachnoid haemorrhage (SAH), five aneurysms with mass effect, one ruptured aneurysm with SAH and mass effect, one recanalisation and one intraparenchymal haematoma. Thirty-five aneurysms were in the anterior and one in the posterior circulation. Mean dome and neck size were, respectively, 5.8 mm and 3.6 mm. Twenty-three aneurysms were treated with TransForm C and 13 with TransForm SC. We had two procedural thromboembolic complications, without permanent clinical events. No early rebleeding occurred.

Conclusions

In our small series, the TransForm occlusion balloon catheter seems to be safe and effective for the treatment of intracranial aneurysms, in ruptured and unruptured cases.     

Tuberous sclerosis in a term newborn with opisthotonus – The value of ultrasound

Purpose

We describe the clinical findings and the results of cerebral imaging studies [ultrasound (US), magnetic resonance imaging (MRI)] in a full-term newborn with tuberous sclerosis (TS) complex. This condition is inherited as an autosomal dominant trait and characterized by hamartomas involving multiple organs. Diagnosis is based on physical examination together with imaging support.

Methods

Since the TS complex can result in numerous CNS abnormalities, cerebral US should be used to further characterize this malformation.

Conclusion

Sonography is a useful modality for evaluation of the full-term neonatal brain.     

Ethyl pyruvate attenuates delayed experimental cerebral vasospasm following subarachnoid haemorrhage in rats: possible role of JNK pathway

The pathophysiology of delayed cerebral vasospasm (CVS) after subarachnoid haemorrhage (SAH) is multifaceted and involves endothelial apoptosis and inflammation. Ethyl pyruvate (EP) could attenuate early brain injury following SAH via anti-inflammation and inhibition of the c-Jun N-terminal kinase (JNK) signalling pathway. However, the role of EP in the delayed CVS has yet to be determined. In this study, we examined the effect of EP on endothelial apoptosis and inflammation and explore possible signalling pathways. We found that EP could significantly attenuate the delayed CVS. Possible mechanisms include a decrease in the endothelial cell apoptosis of the basilar artery and alleviation of endothelial inflammation. The JNK signalling pathway may play an important role in the neuroprotective effects of EP on delayed CVS. The results suggest that EP may be a possible therapy for delayed CVS, and the JNK signalling pathway should be targeted for therapeutic purposes in the future.

The pathophysiology of delayed cerebral vasospasm (CVS) after subarachnoid haemorrhage (SAH) is multifaceted and involves endothelial apoptosis and inflammation.