Results of surgery for aneurysmal subarachnoid haemorrhage in northern Norway: a retrospective study with special focus on timing of surgery in a rural area

OBJECTIVES: This study reports data on time consumption before aneurysm surgery and the results of treatment in northern Norway. MATERIAL AND METHODS: A total of 279 cases were identified and included in our analysis of time span from bleeding to arrival at our department. Fifty-one patients were treated conservatively, either because of bad clinical condition or because angiography revealed no aneurysm. The remaining 228 patients were operated and included in our analysis of outcome after early aneurysm surgery. RESULTS: Among all 279 patients with aneurysmal subarachnoid haemorrhage (SAH), median time from ictus to arrival at the university hospital was 1 (0-30) day. Forty-one per cent arrived at the day of bleeding and 86% within the first 3 days after bleeding. Among the 228 patients who underwent surgical aneurysm repair, median time from bleeding to operation was 2 (0-33) days. Early aneurysm surgery (< 72 h) was performed in 146 patients (64%). Fifty patients (22%) underwent intermediate surgery (days 4-10) and 32 patients (14%) were operated later (day 11 or later). A significant association was found between Hunt and Hess (HH) grade and Glasgow Outcome Scale (GOS) score (P < 0.001). CONCLUSIONS: Most patients suffering aneurysmal SAH in northern Norway undergo early aneurysm surgery and the outcome is comparable with that obtained in other Scandinavian centres. Initial Hunt and Hess grade is a major determinant for outcome in aneurysmal subarachnoid haemorrhage.     

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.     

A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage

OBJECTIVE: To review systematically the frequency and prognostic significance of vitreous haemorrhage in patients with subarachnoid haemorrhage (Terson's syndrome). METHODS: Papers relating to vitreous haemorrhage in patients with subarachnoid haemorrhage were retrieved. The only studies considered were those with at least 10 consecutive cases of subarachnoid haemorrhage with or without vitreous haemorrhage. The frequency of vitreous haemorrhage in such cases was calculated in prospective and retrospective studies. Mortality was compared in patients with and without Terson's syndrome. RESULTS: 154 papers were reviewed. Three prospective studies and six retrospective studies satisfied the inclusion criteria. Of 181 patients with subarachnoid haemorrhage assessed prospectively (mean age, 51.7 years), 24 (13%) had vitreous haemorrhage; among 1086 retrospective records, 37 (3%) had documented vitreous haemorrhage (p<0.001). Patients with Terson's syndrome had higher Hunt and Hess grades than those without (mean grade, 3.6 v 2.6). Patients with Terson's syndrome were also more likely to die (13 of 30 (43%) v 31 of 342 (9%); odds ratio 4.8; p<0.001). CONCLUSIONS: Prospective studies show a higher frequency of Terson's syndrome than retrospective studies, suggesting that vitreous haemorrhage is not well documented. Vitreous haemorrhage is an adverse prognostic finding in patients with subarachnoid haemorrhage.     

Acute Ischemic Injury on Diffusion-Weighted Magnetic Resonance Imaging after Poor Grade Subarachnoid Hemorrhage

Background

Poor clinical condition is the most important predictor of neurological outcome and mortality after subarachnoid hemorrhage (SAH). Rupture of an intracranial aneurysm was shown to be associated with acute ischemic brain injury in poor grade patients in autopsy studies and small magnetic resonance imaging series.

Methods

We performed diffusion-weighted magnetic resonance imaging (DWI) within 96 h of onset in 21 SAH patients with Hunt–Hess grade 4 or 5 enrolled in the Columbia University SAH Outcomes Project between July 2004 and February 2007. We analyzed demographic, radiological, clinical data, and 3 months outcome.

Results

Of the 21 patients 13 were Hunt–Hess grade 5, and eight were grade 4. Eighteen patients (86%) displayed bilateral and symmetric abnormalities on DWI, but not on computed tomography (CT). Involved regions included both anterior cerebral artery territories (16 patients), and less often the thalamus and basal ganglia (4 patients), middle (6 patients) or posterior cerebral artery territories (2 patients), or cerebellum (2 patients). At 1-year, 15 patients were dead (life support had been withdrawn in 6), 2 were moderately to severely disabled (modified Rankin Scale [mRS] = 4–5), and 4 had moderate-to-no disability (mRS = 1–3).

Conclusions

Admission DWI demonstrates multifocal areas of acute ischemic injury in poor grade SAH patients. These ischemic lesions may be related to transient intracranial circulatory arrest, acute vasoconstriction, microcirculatory disturbances, or decreased cerebral perfusion from neurogenic cardiac dysfunction. Ischemic brain injury in poor grade SAH may be a feasible target for acute resuscitation strategies.     

Migraine and delayed ischaemic neurological deficit after subarachnoid haemorrhage in women: a case–control study

The aim of the present case–control study was to investigate the role of migraine as a potential risk factor for a delayed ischaemic neurological deficit (DIND) after subarachnoid haemorrhage (SAH). A telephone interview was performed in patients or their relatives to determine the prevalence of migraine. Thirty-six women aged <60 years had SAH with Hunt & Hess grade I–III and DIND (group A). This group was compared with an age-matched group of 36 female SAH patients, Hunt & Hess grade I–III without DIND (group B). The two populations were also characterized regarding hypertension, smoking, diabetes mellitus and alcohol use. A significant difference was only found for the prevalence of migraine with 47% in group A and 25% in group B ( P  < 0.05; odds ratio: 2.68, confidence interval: 0.99–7.29). Migraineurs revealed similar prevalences of risk factors independently of the presence of DINDs. This retrospective study suggests that women with migraine have a higher risk to develop a DIND than women without migraine.     

Distal calcarine fusiform aneurysm: a case report and review of literature

A 50 year old female who was operated for atrial septal defect 8 years back, presented with clinical features suggestive of subarachnoid haemorrhage (grade I, Hunt and Hess). CT scan of brain revealed haemorrhage in all the supratentorial basal cisterns, sylvian cistern and small haematoma in the left occipital lobe. Conventional CT and MR angiography revealed aneurysm in relation to distal part of the calcarine branch of the left posterior cerebral artery (PCA). Left occipital craniotomy in prone position followed by deep dissection in the occipital lobe showed fusiform aneurysm of the distal part of the calcarine branch. PCA aneurysms constitute only 0.2 to 1% of all intracranial aneurysms and among them distal PCA aneurysms are most rare, constituting only 1.3%. They too are mostly seen at the bifurcation of the PCA. The present case however, is unique in the sense that it has developed as a fusiform aneurysm in the distal part of the calcarine branch. To the best of our knowledge this is rare among the rarest.     

Early surgery for posterior circulation aneurysms following subarachnoid haemorrhage

A retrospective analysis of 32 patients with posterior circulation aneurysms operated on within three days of subarachnoid haemorrhage is presented. The cases were treated at two Australian neurosurgery units over a five year period (1988-1992), both units having a policy of treating patients of all grades and all ages with early surgery. No patients suffered rebleeding. Five patients developed clinical vasopasm. Twenty-four patients (75%) had a good outcome (Glasgow Outcome Score 1-2), three had a poor outcome (GOS 3), and five died (16%). Of the five deaths, three presented as Hunt and Hess grade V. The results are considered in detail and the literature regarding the timing of surgery for posterior circulation aneurysms is reviewed.     

Roller coaster-associated subarachnoid hemorrhage--report of 2 cases

The most common neurological injuries associated with roller coaster rides are subdural hematoma and cervical artery dissection. We report two cases of roller-coaster associated subarachnoid hemorrhage (SAH). A 40-year-old healthy man developed a strong, holocephalic headache during a roller coaster ride. SAH Hunt & Hess grade II and Fisher grade 3 was diagnosed. An underlying aneurysm of the anterior communicating artery was successfully treated with coil embolization. A 41-year-old female (smoker, otherwise healthy) experienced a sudden, strong headache and diplopia during a roller coaster ride. A perimesencephalic SAH (Hunt & Hess grade II, Fisher grade 3) was disclosed by a CT scan. No aneurysm was detected on angiography. Both patients were discharged without neurological disability. In conclusion, SAH is a rare but relevant differential diagnosis in cases of acute headache during roller coaster rides. Both aneurysmal and non-aneurysmal perimesencephalic SAH can occur. A combination of mechanical factors and excessive blood pressure rises in vulnerable persons is discussed.     

Risk factors and outcome in 100 patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE: Clinical and surgical outcome of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysm were assessed in comparison to pre-operative data and risk factors such as previous medical history, clinical presenting condition, CT findings and site of bleeding. METHODS: We evaluated 100 consecutive patients with aneurysmal SAH. Gender, color, history of hypertension, smoking habit, site and size of aneurysm, admittance and before surgery Hunt Hess scale, need for cerebro-spinal fluid shunt, presence of complications during the surgical procedure, Glasgow Outcome Scale, presence of vasospasm and of rebleeding were assessed and these data matched to outcome. For statistical analysis, we applied the chi-squared test or Fisher's test using the pondered kappa coefficient. Kruskal-Wallis test was used for comparison of continue variables. Tendency of proportion was analyzed through Cochran-Armitage test. Significance level adopted was 5%. RESULTS: Patients studied were mainly white, female, without previous history of hypertension and non-smokers. Upon hospital admittance, grade 2 of Hunt-Hess scale was most frequently observed (34%), while grade 3 of Fisher scale was the most prevalent. Single aneurysms were most frequent at anterior circulation, between 12 and 24 mm. The most frequent Glasgow Outcome Scale observed was 5 (60%). Hunt Hess upon the moment of surgery and presence of complications during surgical procedure showed positive correlation with clinical outcome (p=0.00002 and p=0.001, respectively). Other variables were not significantly correlated to prognosis. Tendency of proportion was observed between Hunt-Hess scale and Fisher scale. CONCLUSION: Among variables such as epidemiological data, previous medical history and presenting conditions of patients with ruptured aneurysms, the Hunt-Hess scale upon the moment of surgery and the presence of surgical adversities are statistically related to degree of disability.     

蛛网膜下腔出血患者并发下肢深静脉血栓的危险因素及预防策略

目的 探讨蛛网膜下腔出血(SAH)患者并发下肢深静脉血栓(LDVT)的危险因素和预防策略.方法 对98例蛛网膜下腔出血患者进行双下肢血管超声检查,根据是否发生LDVT分为LDVT组和对照组,对患者长期卧床、血浆纤维蛋白原、股静脉穿刺、静脉曲张、高血压、性别、吸烟、饮酒、糖尿病、肥胖、Hunt和Hess分级等相关因素与LDVT的相关性进行分析.结果 98例蛛网膜下腔出血患者中LDVT组1 8例(18.37％),对照组80例(81.63％).高龄、长期卧床、股静脉穿刺、高血压、高血浆纤维蛋白原、Hunt和Hess分级高为LDVT较显著的危险因素(P＜0.05);而静脉曲张、饮酒、吸烟、糖尿病、肥胖、性别等因素与LDVT无显著相关性.结论 蛛网膜下腔出血合并LDVT患者多见于年龄偏大、合并高血压等、Hunt和Hess分级较高,血浆纤维蛋白原水平较高、股静脉穿刺者.     

Cerebral aneurysms: assessment of 377 cases (1956-1982)

A review of 177 patients with cerebral aneurysms is made, out of whom 106 with ruptured aneurysms were examined, whose operational timing and prognostic chances were well documented (group B, 1979-1982) and in part updated to 1984. Furthermore, relevant data of a previous series of 200 cases of cerebral aneurysm, treated between 1956-1978 were used (group A). The patients were graded according to Hunt and Hess, assessing the risks involved. The percentages of recurrent bleeding were in group A 36.5% and 28% in group B. The incidence of vasospasm (as seen in angiography) was in group B 39.6% (42/106 patients). The highest rate of vasospasm in the spasm group division B was found to occur in the second and third week after subarachnoid haemorrhage and amounted to 64.7% and 62.5%. A pre-operatively present vasospasm had no negative effects on the mortality rate, but influenced the outcome for the survivors effectively. The total mortality in group A was 22.5% and in group B 11.7%. Timing of the operation among patients in Hunt and Hess-grades I and II needs to discussion. The surgical position of patients in grade V is also certain. What remains to be discussed and needs attention is grade III and patients in grade IVa. Here the time of operative intervention must be planned individually depending on the course of the neurological status.     

Correlation between cerebral blood flow, somatosensory evoked potentials, CT scan grade and neurological grade in patients with subarachnoid hemorrhage.

Cerebral blood flow (CBF) and central conduction time (CCT) were recorded from 58 subarachnoid hemorrhage patients and from 49 age-matched controls. CBF was calculated following Xenon inhalation and CCT was determined from somatosensory evoked potentials (SSEP's) following median nerve stimulation. Each patient had a CT scan on the day of admission which was graded from I-IV. CBF, CCT and neurological grade (Hunt and Hess classification) were concomitantly recorded 1, 4, 7 and 14 days after subarachnoid hemorrhage. Mean CBF was highest in patients with neurological grades I and II (48.6 +/- 12.3 and 48.1 +/- 10.3 ml/100gm/min respectively) and lowest in patients with neurological grade IV (37.3 +/- 9.6 ml/100gm/min). Patients in neurological grade I or II had mean CBF and CCT measurements that were significantly different from those obtained from patients in neurological grade IV (P less than 0.05). Neurological grade and CT scan grade correlated with CBF (P less than 0.0001) better than CCT (P = 0.015). Unexpectedly low CBF's from patients in neurological grades II and III (less than 37 and less than 31 ml/100gm/min respectively) failed to significantly prolong CCT suggesting CCT is unable to detect marginal ischemia. A significant correlation between CBF and CCT occurred only when CBF was less than 30 ml/100gm/min (R = 0.75, P = 0.05). It appears that prolonged CCT is associated with a drop in CBF only when CBF drops below a certain threshold.     

Evaluation of a revised Glasgow Coma Score scale in predicting long-term outcome of poor grade aneurysmal subarachnoid hemorrhage patients

Although many scales attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH), none have achieved universal acceptance, and most scales in common use are not statistically derived. We propose a statistically validated scale for poor grade aSAH patients that combines the Hunt and Hess grades and the Glasgow Coma Scale (GCS) scores; we refer to this as the Poor Grade GCS (PGS).The GCS scores of 160 poor grade aSAH patients (Hunt and Hess Grades 4 and 5) were recorded throughout their hospital stay. Outcomes were assessed by the modified Rankin scale (mRS). Analysis of variance and the Chi-square test were used to guide an analysis of GCS breakpoints according to outcomes. Multivariable logistic regression analysis was used to assess the ability of the Hunt and Hess, GCS, World Federation of Neurological Surgeons Grading Scale, and the PGS to predict long-term outcome.Outcome analysis revealed significant breakpoints in admission GCS scores: PGS-A (GCS 10–12); PGS-B (GCS 8–9); PGS-C (GCS 5–7); PGS-D (GCS 3–4) (p < 0.001). In surgical patients, 95.2% of PGS-A, 58.1% of PGS-B, 35.4% of PGS-C, and 28.6% of PGS-D had a favorable one-year outcome. When controlling for age, sex, and operation status, PGS was the only scale predictive of long-term outcome. The odds ratios (OR) for unfavorable outcome according to PGS admission scores (with PGS-A as the reference) were: PGS-B, OR = 14.2 (95% CI 1.5–140.5); PGS-C, OR = 38.5 (95% CI 4.2–340.0); and PGS-D, OR = 63.4 (95% CI 5.6–707.1). In addition to PGS admission scores, an age of 70 or greater was a significant predictor of poor outcome with an OR of 7.5 (95% CI 1.8–30.7). No patients with a PGS-C or PGS-D over the age of 70 had a favorable long-term outcome.Therefore, elements of the Hunt and Hess and GCS can be combined into the PGS to predict long-term outcome in poor grade aSAH patients. However, patients with PGS-C and PGS-D over the age of 70 should be assessed carefully prior to definitive treatment.     

Neurological and psychosocial outcome after subarachnoid haemorrhage, and the hunt and hess scale as a predictor of clinical outcome

In a retrospective study, the outcome of 87 patients with ruptured intracranial aneurysm was assessed. Follow-up included neurological examination, grading of the Glasgow Outcome Scale (GOS) of each patient, and answering a psycho-social questionnaire. This questionnaire was answered by the patients themselves or by a relative when the patient was not able to answer. The follow-up was performed more than 12 months after the occurrence of subarachnoid hemorrhage (SAH) in each patient. The psycho-social questionnaire pertained to the degree of independence in everyday activities, household management, stress endurance, memory and concentration, social and leisure activities, social contacts, occupational status, and marital relationships. By summarizing the results of these domains, the quality of life was then determined using the method described by McKenna et al. Neurological deficits in the form of an incomplete paresis of the third cranial nerve and subjective reduction of memory and concentration were identified in 3.5 % and 34.5-39 % of the patients, respectively. Of the 87 study participants, 58.2 % were fully independent, 22.4 % were able to live at home with the support of their relatives, and 5 patients were fully dependent. The occupational status of 21 patients who were fully employed before SAH was unaffected, whereas 3 patients were placed in positions with less responsibility, and 21 patients were either unable to continue working, unemployed, or retired. The quality of life was not reduced in 57.2 %, while a mild reduction in the quality of life was reported by 23.8 % and a severe reduction by 19.0 % of the participants. The ability of the initial Hunt and Hess grade, the initial Fisher grade, the extent of neurological deficits, and the occupational status after SAH to predict the patient's outcome was also evaluated. For statistical analysis, the Kendall-Tau-b-test for non-parametric correlations was applied. Significant correlations were found between the initial Hunt and Hess grade and the initial Fisher grade, between neurological deficits and GOS, between quality of life and occupational outcome, as well as between the GOS and quality of life assessment, but not between initial Hunt and Hess grade and GOS or quality of life, between neurological deficits and quality of life, between initial Hunt and Hess grade and occupational outcome, between initial Fisher grade and occupational outcome, and also not between initial Fisher grade and GOS or quality of life. Our results suggest that neither the initial Hunt & Hess grade nor the initial Fisher grade are suitable parameters for predicting the outcome of patients with ruptured intracranial aneurysms. The fact that GOS and quality of life correlated significantly confirms the use of GOS as a simple method for evaluating patient outcome, although it is not a grading system for evaluating functional disorders such as memory or subtle cognitive impairments.     

Endothelin-1 levels in plasma and cerebrospinal fluidfollowing subarachnoid haemorrhage

A serial measurement of endothelin-1(ET-1) levels in plasma, cisternal and ventricular cerebrospinal fluid(CSF) was performed in 16 patients with subarachnoid haemorrhage (SAH). The patients were classified as grade III or IV according to the clinical grade of Hunt and Hess, and computerised tomography(CT) was classified as Fisher's CT group 3. Cisternal and ventricular CSF and plasma were obtained from the patients on the day of operation days 0-3, days 5-8 and days 14-18 after SAH. ET-I concentration in each sample was quantified by sandwich-enzyme immunoassay. ET-I levels in plasma and CSF were the highest between days 0-3 and then decreased. The ET-I levels in the cisternal CSF were significantly higher during days 0-3(p<0. 01) and days 5-8(p<0. 01) than those in the ventricular CSF It is suggested that ET-I could play an important role in the early stages of the cerebral vasospasm.     

Clinical outcome of spontaneous non-aneurysmal subarachnoid hemorrhage in 108 patients

Background: The cause of spontaneous subarachnoid hemorrhage (SAH) is unknown in 15% of cases; idiopathic SAH has a better prognosis than aneurysmal SAH. When bleeding is confined to the perimesencephalic cisterns, SAH has an especially benign course. Methods: We retrospectively studied 108 patients admitted for spontaneous non‐aneurysmal SAH between 1991 and 2004. We divided patients into two groups according to the bleeding pattern at cranial CT: perimesencephalic pattern (n = 60) and aneurysmal pattern (n = 48). We included only patients in whom no source of bleeding was detected at angiography; patients with aneurysmal pattern underwent at least two angiographic examinations. Mean follow‐up was 5.5 years; follow‐up consisted of telephone interview in 84.7% of patients. Results: All but one patient with perimesencephalic pattern were classified as grade I or II on the Hunt and Hess scale; the exception was the only patient in this group with a complication (hydrocephalus), who was classified as grade IV. Three‐quarters of the patients with aneurysmal pattern were classified as grade I or II on the Hunt and Hess scale; 5 patients presented with hydrocephalus that required drainage and 2 with vasospasms without repercussions. No rebleeding or long‐term complications were observed in either group. Conclusions: Non‐aneurysmal SAH with a perimesencephalic pattern of bleeding has a benign course and excellent short‐term and long‐term prognosis. Patients with non‐aneurysmal SAH with an aneurysmal pattern of bleeding have more complications, and the initial clinical situation has a significant impact on their prognosis.     

Prolonged Elevated Heart Rate is a Risk Factor for Adverse Cardiac Events and Poor Outcome after Subarachnoid Hemorrhage

Introduction

Sympathetic nervous system hyperactivity is common after subarachnoid hemorrhage (SAH). We sought to determine whether uncontrolled prolonged heart rate elevation is a risk factor for adverse cardiopulmonary events and poor outcome after SAH.

Methods

We prospectively studied 447 SAH patients between March 2006 and April 2012. Prior studies define prolonged elevated heart rate (PEHR) as heart rate >95 beats/min for >12 h. Major adverse cardiopulmonary events were documented according to the predefined criteria. Global outcome at 3 months was assessed with the modified Rankin Scale (mRS).

Results

175 (39 %) patients experienced PEHR. Nonwhite race/ethnicity, admission Hunt–Hess grade ≥4, elevated APACHE-2 physiological subscore, and modified Fisher score were significant admission predictors of PEHR, whereas documented pre-hospital beta-blocker use was protective. After controlling for admission Hunt–Hess grade, Cox regression using time-lagged covariates revealed that PEHR onset in the previous 48 h was associated with an increased hazard for delayed cerebral ischemia, myocardial injury, and pulmonary edema. PEHR was associated with 3-month poor outcome (mRS 4–6) after controlling for known predictors.

Conclusions

PEHR is associated with major adverse cardiopulmonary events and poor outcome after SAH. Further study is warranted to determine if early sympatholytic therapy targeted at sustained heart rate control can improve outcome after SAH.     

Cerebral inflammatory response and predictors of admission clinical grade after aneurysmal subarachnoid hemorrhage

Poor admission clinical grade is the most important determinant of outcome after aneurysmal subarachnoid hemorrhage (aSAH); however, little attention has been focused on independent predictors of poor admission clinical grade. We hypothesized that the cerebral inflammatory response initiated at the time of aneurysm rupture contributes to ultra-early brain injury and poor admission clinical grade. We sought to identify factors known to contribute to cerebral inflammation as well as markers of cerebral dysfunction that were associated with poor admission clinical grade. Between 1997 and 2008, 850 consecutive SAH patients were enrolled in our prospective database. Demographic data, physiological parameters, and location and volume of blood were recorded. After univariate analysis, significant variables were entered into a logistic regression model to identify significant associations with poor admission clinical grade (Hunt–Hess grade 4–5). Independent predictors of poor admission grade included a SAH sum score >15/30 (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.5–3.6), an intraventricular hemorrhage sum score >1/12 (OR 3.1, 95% CI 2.1–4.8), aneurysm size >10 mm (OR 1.7, 95% CI 1.1–2.6), body temperature ?38.3 °C (OR 2.5, 95% CI 1.1–5.4), and hyperglycemia >200 mg/dL (OR 2.7, 95% CI 1.6–4.5). In a large, consecutive series of prospectively enrolled patients with SAH, the inflammatory response at the time of aneurysm rupture, as reflected by the volume and location of the hemoglobin burden, hyperthermia, and perturbed glucose metabolism, independently predicts poor admission Hunt–Hess grade. Strategies for mitigating the inflammatory response to aneurysmal rupture in the hyper-acute setting may improve the admission clinical grade, which may in turn improve outcomes.     

Lower initial red blood cell count in cerebrospinal fluid predicts good functional outcome in patients with spontaneous subarachnoid haemorrhage

Background and purpose

Red blood cell (RBC) degradation after subarachnoid haemorrhage (SAH) negatively affects functional outcome. Although the detection of RBCs in the cerebrospinal fluid (CSF) is a widely available part of neurological routine diagnostics, the prognostic value as a biomarker remains unclear. This study was undertaken to investigate whether CSF RBC count correlates with established radiological markers of SAH volume and whether the CSF RBC count can predict functional outcome in SAH patients.

Methods

A total of 121 consecutive spontaneous SAH patients were retrospectively analyzed. CSF was collected from external ventricular drain as part of routine diagnostic procedures. We used multivariable binary logistic regression to investigate associations between CSF RBC counts and functional outcome 3 months after SAH or hospital survival. Good functional outcome was defined as modified Rankin Scale ≤ 2.

Results

Patients' age was 60 ± 14 years, and the median admission Hunt & Hess grade (H&H) was 4. CSF samples were collected 2 days after intensive care unit admission. High CSF RBC counts positively correlated with radiological measurements for SAH volume, for example, modified Fisher score (p = 0.002) and Hijdra ventricle score (p = 0.016). Multivariable regression analysis adjusted for age, H&H grade, modified Fisher and Hijdra scores showed that low CSF RBC counts predicted hospital survival (per 100,000 CSF RBCs: adjusted odds ratio [adjOR] = 0.74, 95% confidence interval [CI] = 0.61–0.89, p = 0.001) and good functional outcome after 3 months (per 100,000 CSF RBC: adjOR = 0.76, 95% CI = 0.60–0.96, p = 0.020).

Conclusions

CSF RBC counts correlate with radiographic scores quantifying SAH volume and may serve as an early independent biomarker for hospital survival and good functional 3-month outcome in patients requiring ventriculostomy after SAH.     

Predictors for cognitive impairment one year after surgery for aneurysmal subarachnoid hemorrhage

OBJECTIVE: To assess predictors for cognitive impairment one year after spontaneous subarachnoid hemorrhage (SAH). Evaluated predictors were the total amount of cisternal blood seen on computed tomography (CT) in the acute phase as measured by the Fisher grade, neurological grade at admission classified according to the Hunt and Hess scale, aneurysm site and patient's age, gender and education level. METHOD: 44 patients were operated by surgical clipping within 72 hours after CT verified aneurysmal SAH. After twelve months the remaining 42 patients were assessed by neuropsychological test, Beck Depression Inventory (BDI), the Glasgow Outcome Scale (GOS) and CT. Multiple regression analysis was conducted where predictor variables were independent factors and a global impairment index calculated for each patient was the dependent factor. RESULTS: The Fisher grade was the only independent predictor for neuropsychological impairment. Most patients had good neurological outcome as measured by the GOS and at the same time suffered from some degree of cognitive impairment at follow-up. Individual analysis of cognitive test scores showed mild to moderate dysfunction across multiple cognitive domains. Most frequent impairments were found in domains of memory, executive function and speed of information processing. Age below 50 years was associated with relatively better outcome. CONCLUSION: The severity of cognitive impairment one year post SAH is predicted by the volume of blood in the subarachnoid space as measured by the Fisher score.