Heart Rate Variability Predicts Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage

Background

An alternation of sympathetic and vagal nervous activity has been suggested to be one possible mechanism of neurogenic pulmonary edema (NPE) in patients with subarachnoid hemorrhage (SAH). The study aimed to explore if sympathovagal modulation assessed by frequency domains of heart rate variability (HRV) is associated with impending NPE in patients with SAH.

Methods

Two hundred forty-eight consecutive spontaneous SAH adult patients were included in this single-center cohort study. A continuous 10-min electrocardiography for HRV analysis was recorded. The patients were stratified into NPE and non-NPE based on serially clinical and radiologic findings within 24 h. Seven frequency domains of HRV were compared between these 2 groups.

Results

Compared to the non-NPE (n = 212), the NPE (n = 36) had significantly higher mean arterial pressure, higher World Federation of Neurological Surgeons (WFNS) class, higher Hunt–Hess scale, lower total power (TP), lower very low-frequency component, lower low-frequency component, lower normalized low-frequency component (LF %), higher normalized high-frequency component, and lower low-frequency component/high-frequency component ratio. Multiple logistic regression model identified WFNS class (OR 4.048; 95 % CI 1.589–10.311), LF % (OR 0.933; 95 % CI 0.910–0.958), and TP (OR 0.995; 95 % CI 0.992–0.998) as the significant variables associated with occurrence of NPE. The area under receiver operating characteristic curves of LF % and TP were found to be 0.838 (95 % CI 0.774–0.901) and 0.653 (95 % CI 0.557–0.749), respectively.

Conclusion

Loss of cardiac variability and depressed sympathovagal modulation, represented by TP and LF %, may predict the development of NPE in the early stage in patients with SAH.

     

High-Mobility Group Box 1 Protein in CSF of Patients with Subarachnoid Hemorrhage

Background  

High-mobility group box 1 protein (HMGB1) is a nuclear factor that is a potent proinflammatory mediator, and may trigger increases in other inflammatory cytokines. The inflammatory cytokines in the cerebrospinal fluid (CSF) of patients with subarachnoid hemorrhage (SAH) have been reported previously, but HMGB1 has not. In this study, we measured HMGB1 and the inflammatory cytokines in the CSF of patients with SAH.     

蛛网膜下腔出血后神经炎症反应的研究进展

动脉瘤性蛛网膜下腔出血（aneurysmal subarachnoid hemorrhage,aSAH）是一种常见的脑血 管疾病。临床手术技术的提高虽然能够治疗动脉瘤,降低因再次出血而导致患者死亡的概率。但是, 目前尚无有效的针对蛛网膜下腔出血并发症的治疗方法。神经系统的炎症反应在蛛网膜下腔出血 后的病理过程中起着重要的作用,现研究已表明炎症反应与脑血管痉挛以及脑组织损伤相关。因此, 大量的临床前研究也针对神经炎症与aSAH之间的相关性展开,并发现炎症介质在其中发挥着重要的 作用。本文就已知的aSAH后神经炎症反应及其发生机制作一综述。     

Contrast-Induced Nephropathy in Patients with Aneurysmal Subarachnoid Hemorrhage

Introduction

Patients with aneurysmal subarachnoid hemorrhage (SAH) frequently undergo multiple angiographic studies within a 48-h period. We sought to evaluate the impact of these repeated contrast loads on renal function.

Methods

We reviewed the records of a consecutive series of 104 patients with aneurysmal subarachnoid hemorrhage, most of whom underwent at least an initial CT angiogram and digital subtraction angiography. Six patients had baseline renal disease. Initial creatinine levels were compared to maximum levels over a subsequent 48-h period after their last angiographic study. We defined contrast-induced nephropathy (CIN) as an increase in creatinine of at least 0.3 from baseline.

Results

The mean change in creatinine following treatment was 0.05 ± 0.23, with three patients developing CIN (2.9 %). In 2 cases of CIN, the creatinine increase was inconsequential (0.39 and 0.44). All patients with CIN had an early return of their creatinine to baseline; none required dialysis or suffered permanent sequelae as a result of these creatinine increases. There was no statistically significant difference in the rate of CIN in patients treated with microsurgical clipping (n = 85) as compared to those who underwent coiling (n = 19).

Conclusion

Our results underscore the relative safety of the usage of multiple angiographic studies performed in patients with aneurysmal SAH, particularly in patients without baseline renal disease.     

Risk of Ventriculostomy-Associated Hemorrhage in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Anticoagulant Thromboprophylaxis

Background

Patients with subarachnoid hemorrhage (SAH) frequently need a ventriculostomy for treatment of hydrocephalus. In some ICU practices, a ventriculostomy is considered a relative contraindication for subcutaneous heparin. We studied the risk of ventriculostomy-associated hemorrhage and deep venous thrombosis (DVT) in patients with anticoagulant prophylaxis.

Methods

This is a retrospective study of 241 consecutive patients with SAH and ventriculostomies treated at Mayo Clinic, Rochester from 2001 to 2014. DVT and pulmonary emboli (PE) prevention included subcutaneous or intravenous heparin, enoxaparin, dalteparin, and warfarin. The incidence of PE and DVT were noted within 30 days of hospital admission. Hemorrhages were classified as minor or major based on size and mass effect.

Results

Fifty-three (22 %) of the 241 patients were on prophylactic doses of anticoagulation while in the intensive care unit. Three of 53 patients on prophylactic anticoagulation had minor hemorrhages and none had major hemorrhages. Four (7.5 %) of 53 patients who received prophylactic anticoagulation versus 34 (18 %) of 188 patients who did not receive prophylactic anticoagulation developed DVT (p = 0.09). One of 10 patients on therapeutic anticoagulation had a major and fatal hemorrhage.

Conclusion

In our cohort, the risk of VTE was reduced by more than half in patients receiving chemoprophylaxis. Ventriculostomy-associated hemorrhages were rare and minor. Anticoagulant thromboprophylaxis is mostly safe and required in aneurysmal SAH.

     

The Risks of Blood Transfusion in Patients with Subarachnoid Hemorrhage

Neurocritical Care -     

Metaanalysis of Tirilazad Mesylate in Patients with Aneurysmal Subarachnoid Hemorrhage

Background  Tirilazad is a non-glucocorticoid, 21-aminosteriod that inhibits lipid peroxidation. It had neuroprotective effects in experimental ischemic stroke and reduced angiographic vasospasm after experimental subarachnoid hemorrhage (SAH). Five randomized clinical trials of tirilazad were conducted in patients with SAH. We performed a meta-analysis of these trials to assess the effect of tirilazad on unfavorable outcome, symptomatic vasospasm, and cerebral infarction after SAH. Methods  Data from 3,797 patients were analyzed and modeled using random effect and Mantel-Haenszel meta-analyses and multivariable logistic regression to determine the effect of tirilazad on clinical outcome, symptomatic vasospasm, and cerebral infarction. Clinical outcome was assessed 3 months after SAH using the Glasgow outcome scale, and symptomatic vasospasm was defined by clinical criteria with laboratory and radiological exclusion of other causes of neurological deterioration. Results  The five trials were randomized, double-blind, and placebo-controlled. Tirilazad did not significantly decrease unfavorable clinical outcome on the GOS (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.89–1.20) or cerebral infarction (OR 1.04, 95% CI 0.89–1.22). There was a significant reduction in symptomatic vasospasm in patients treated with tirilazad (OR 0.80, 95% CI 0.69–0.93). There was no heterogeneity across the five trials. Conclusion  Tirilazad had no effect on clinical outcome but did decrease symptomatic vasospasm in five trials of aneurysmal SAH. The dissociation between clinical outcome and symptomatic vasospasm deserves further investigation.     

Early Systemic Procalcitonin Levels in Patients with Aneurysmal Subarachnoid Hemorrhage

Background

Early (≤24 h) systemic procalcitonin (PCT) levels are predictive for unfavorable neurological outcome in patients after out-of-hospital cardiac arrest (OHCA). Subarachnoid hemorrhage (SAH) due to aneurysm rupture might lead to a cerebral perfusion stop similar to OHCA. The current study analyzed the association of early PCT levels and outcome in patients after SAH.

Methods

Data from 109 consecutive patients, admitted within 24 h after SAH, were analyzed. PCT levels were measured within 24 h after ictus. Clinical severity was determined using the World Federation of Neurological Societies (WFNS) scale and dichotomized into severe (grade 4–5) and non-severe (1–3). Neurological outcome after 3 months was assessed by the Glasgow outcome scale and dichotomized into unfavorable (1–3) and favorable (4–5). The predictive value was assessed using receiver operating curve (ROC) analysis.

Results

Systemic PCT levels were significantly higher in patients with severe SAH compared to those with non-severe SAH: 0.06 ± 0.04 versus 0.11 ± 0.11 μg/l (median ± interquartile range; p < 0.01). Patients with unfavorable outcome had significantly higher PCT levels compared to those with favorable outcome 0.09 ± 0.13 versus 0.07 ± 0.15 ng/ml (p < 0.01). ROC analysis showed an area under the curve of 0.66 (p < 0.01) for PCT, which was significantly lower than that of WFNS with 0.83 (p < 0.01).

Conclusions

Early PCT levels in patients with SAH might reflect the severity of the overall initial stress response. However, the predictive value is poor, especially compared to the reported predictive values in patients with OHCA. Early PCT levels might be of little use in predicting neurological outcome after SAH.     

CSF Neutrophils Are Implicated in the Development of Vasospasm in Subarachnoid Hemorrhage

Background  

Cerebral vasospasm is a significant cause of morbidity in patients after aneurysmal subarachnoid hemorrhage (aSAH). There are few effective treatments. The search for new treatments has focused predominantly on dilating cerebral blood vessels. Growing evidence supports a role for inflammation in its pathogenesis but no potential target for intervention has emerged.     

脑脊液细胞学检查在蛛网膜下腔出血诊断中的价值

目的探讨脑脊液细胞学检查对临床不典型蛛网膜下腔出血(SAH)的诊断价值.方法回顾我院收治的40例不典型SAH者的临床特点和脑脊液细胞学检查结果.结果SAH 40例初诊为高血压10例,结核性脑膜炎7例,血管性头痛6例,脑出血2例,小脑肿瘤4例,散发性脑炎3例,精神病3例,癫癎3例,急性胃肠炎2例.脑脊液为血性者13例,黄变者15例,无色清亮者6例,分别可见大量红细胞、吞噬红细胞和含铁血黄素细胞.结论开展脑脊液细胞学检查,熟练掌握SAH各期细胞学变化规律,抓住脑脊液各期的特征,结合临床资料进行分析,才能提高SAH与其他疾病的鉴别,减少误诊.     

Subarachnoid Hemorrhage and Spinal Subdural Hematoma Due to Acute CSF Hypotension

Background

Intracranial subarachnoid hemorrhage (SAH) and spinal subdural hematoma (SDH) are rare complications of spine surgery, thought to be precipitated by cerebrospinal fluid (CSF) hypotension in the setting of an intraoperative durotomy or postoperative CSF leak. Considerable clinical variability has been reported, requiring a high level of clinical suspicion in patients with a new, unexplained neurologic deficit after spine surgery.

Methods

Case report.

Results

An 84-year-old man developed symptomatic spinal stenosis with bilateral lower extremity pseudoclaudication. He underwent L3-5 laminectomy at an outside institution, complicated by a small, incidental, unrepairable intraoperative durotomy. On postoperative day 2, he became confused; and head CT demonstrated intracranial SAH with blood products along the superior cerebellum and bilateral posterior Sylvian fissures. He was transferred to our neurosciences ICU for routine SAH care, with improvement in encephalopathy over several days of supportive care. On postoperative day 10, the patient developed new bilateral lower extremity weakness; MRI of the lumbar spine demonstrated worsening acute spinal SDH above the laminectomy defect, from L4-T12. He was taken to the OR for decompression, at which time a complex 1.5-cm lumbar durotomy was identified and repaired primarily.

Conclusions

We report the first case of simultaneous intracranial SAH and spinal SDH attributable to postoperative CSF hypotension in the setting of a known intraoperative durotomy. Although rare, each of these entities has the potential to precipitate a poor neurologic outcome, which may be mitigated by early recognition and treatment.

     

Nicardipine Infusion for Blood Pressure Control in Patients with Subarachnoid Hemorrhage

Introduction  

To evaluate the efficacy, tolerability, and safety of nicardipine infusion in controlling the elevated blood pressure after subarachnoid hemorrhage (SAH).     

蛛网膜下腔出血相关性肺炎发生的危险因素分析及对住院结局的影响

目的 分析蛛网膜下腔出血（subarachnoid hemorrhage,SAH）相关性肺炎发生的危险因素及其对住院 结局的影响。 方法 回顾性纳入2015年5月-2018年11月首都医科大学附属北京天坛医院收治的SAH患者,根据住 院期间是否发生肺炎分为肺炎组、非肺炎组,比较两组患者临床资料的差异。采用多因素Logistic回归 模型,分析发生肺炎的危险因素,以及发生肺炎对SAH患者院内死亡、住院天数、住院总费用的影响。 结果 共纳入457例SAH患者,平均年龄54.3±11.2岁,男性219例（47.9%）,发生肺炎76例（16.6%）。 男性（OR 2.31,95%CI 1.17～4.58,P =0.016）、吞咽障碍（OR 6.06,95%CI 1.09～33.70,P =0.039）及 Barthel指数0～20分（OR 15.58,95%CI 4.17～58.23,P＜0.001）是SAH患者发生肺炎的独立危险因素; 发生肺炎与院内死亡风险、住院天数和住院总费用增加无关。 结论 男性、吞咽障碍、Barthel指数0～20分是SAH患者发生肺炎的独立危险因素。发生肺炎与院内 死亡风险、住院天数和住院总费用增加无关。     

Continuous and Intermittent CSF Diversion after Subarachnoid Hemorrhage: a Pilot Study

Background  

We examine two accepted methods of managing cerebrospinal fluid (CSF) drainage in patients following subarachnoid hemorrhage (SAH). The first is intermittent CSF drainage when intracranial pressure (ICP) reaches a pre-defined threshold (monitor-first) and the second is continuous CSF drainage (drain-first) at set pressure thresholds. This pilot study is designed to determine if there is a cause for a randomized study of comparing the two methods.     

Risk of Thromboembolic Events with Endovascular Cooling Catheters in Patients with Subarachnoid Hemorrhage

Introduction

Endovascular cooling is currently used for hypothermia treatment and fever reduction therapy. At the same time, little is known about the risks associated to endovascular cooling in patients treated with an endovascular cooling catheter (ECC).

Methods

A retrospective chart review of 122 patients with subarachnoid hemorrhage (SAH) treated with an ECC either for therapeutic hypothermia or for fever reduction was performed. ECC-associated thromboembolic events (TEE) such as pulmonary embolism and thrombosis were recorded and compared between patients treated with an ECC and patients treated only with a central venous line (CVL). Additionally, various laboratory parameters were recorded to determine if they might be related to the frequency of TEE’s.

Results

43 Patients were treated with an ECC and 79 with a CVL. Patients in the ECC group suffered more frequently from TEE (37 %) than those with a CVL (5 %). None of the laboratory parameters was associated with an increased TEE risk. The treatment with an ECC alone was a risk factor for a TEE, independent from age as well as from Hunt and Hess grade.

Conclusion

Our data show that the treatment with ECC increases the risk of TEE in SAH patients. Therefore, especially when considered for fever reduction, non-invasive devices for surface cooling should be the first choice.     

Current Practices of Triple-H Prophylaxis and Therapy in Patients with Subarachnoid Hemorrhage

Background  

Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution (“triple-H”) therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy.     

颅内动脉瘤性蛛网膜下腔出血患者预后的多因素分析

目的探讨影响颅内动脉瘤性蛛网膜下腔出血患者预后的相关因素。方法回顾性分析本院2007年1月至12月收治的119例动脉瘤性蛛网膜下腔出血患者的临床资料,井进行Logistic多元回归分析。结果动脉瘤性蛛网膜下腔出血患者的年龄、Fisher分级和Hunt—Hess分级与预后具有显著相关性（P〈0．01）,其OR值分别是0．921、0．153和0．228,其95％可信区间分别是（0．864-0．981）、（0．063-0．374）和（0．116-0．449）。结论动脉瘤性蛛网膜下腔出血患者的年龄、Fisher分级和Hunt—Hess分级是影响患者预后的危险因素,且随着年龄的增长,Fisher分级和Hunt—Hess分级的增加,患者的预后明显愈差。