1,720,969 research outputs found
Systematic assessment of early brain injury severity at admission with aneurysmal subarachnoid hemorrhage
Full text linkAbstract Early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH) has been increasingly recognized as a risk factor for delayed cerebral ischemia (DCI). While several clinical and radiological EBI biomarkers have been identified, no tool for systematic assessment of EBI severity has been established so far. This study aimed to develop an EBI grading system based on clinical signs and neuroimaging for estimation of EBI severity at admission. This is a retrospective observational study assessing imaging parameters (intracranial blood amount, global cerebral edema (GCE)), and clinical signs (persistent loss of consciousness [LOC]) representative for EBI. The intracranial blood amount was semi-quantitatively assessed. One point was added for GCE and LOC, respectively. All points were summed up resulting in an EBI grading ranging from 1 to 5. The estimated EBI severity was correlated with progressive GCE requiring decompressive hemicraniectomy (DHC), DCI-associated infarction, and outcome according to the modified Rankin scale (mRS) at 3-month-follow up. A consecutive cohort including 324 aSAH-patients with a mean age of 55.9 years, was analyzed. The probability of developing progressive GCE was 9% for EBI grade 1, 28% for EBI grade 2, 43% for EBI grade 3, 61% for EBI grade 4, and 89% for EBI grade 5. The EBI grading correlated significantly with the need for DHC ( r = 0.25, p < 0.0001), delayed infarction ( r = 0.30, p < 0.0001), and outcome ( r = 0.31, p < 0.0001). An EBI grading based on clinical and imaging parameters allowed an early systematic estimation of EBI severity with a higher EBI grade associated not only with a progressive GCE but also with DCI and poor outcome
Early localization of tissue at risk for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: blood distribution on initial imaging vs early CT perfusion
No full textAbstract Objective Delayed cerebral ischemia (DCI) is a potentially reversible adverse event after aneurysmal subarachnoid hemorrhage (aSAH), when early detected and treated. Computer tomography perfusion (CTP) is used to identify the tissue at risk for DCI. In this study, the predictive power of early CTP was compared with that of blood distribution on initial CT for localization of tissue at risk for DCI. Methods A consecutive patient cohort with aSAH treated between 2012 and 2020 was retrospectively analyzed. Blood distribution on CT was semi-quantitatively assessed with the Hijdra-score. The vessel territory with the most surrounding blood and the one with perfusion deficits on CTP performed on day 3 after ictus were considered to be at risk for DCI, respectively. Results A total of 324 patients were included. Delayed infarction occurred in 17% (56/324) of patients. Early perfusion deficits were detected in 82% (46/56) of patients, 85% (39/46) of them developed infarction within the predicted vessel territory at risk. In 46% (25/56) a vessel territory at risk was reliably determined by the blood distribution. For the prediction of DCI, blood amount/distribution was inferior to CTP. Concerning the identification of “tissue at risk” for DCI, a combination of both methods resulted in an increase of sensitivity to 64%, positive predictive value to 58%, and negative predictive value to 92%. Conclusions Regarding the DCI-prediction, early CTP was superior to blood amount/distribution, while a consideration of subarachnoid blood distribution may help identify the vessel territories at risk for DCI in patients without early perfusion deficits
Surgical practices in decompressive hemicraniectomy for malignant middle cerebral artery infarction with hemorrhagic transformation: results from an international survey
No full textMissing a Blood Blister-Like Aneurysm in the Setting of Aneurysmal Subarachnoid Hemorrhage in a Patient Harboring Multiple Aneurysms
No full textOptimal cerebral perfusion pressure in aneurysmal subarachnoid hemorrhage and its relation to perfusion deficits on CT-perfusion
No full textPreservation of optimal cerebral perfusion is a crucial part of the acute management after aneurysmal subarachnoid hemorrhage (aSAH). A few studies indicated possible benefits of maintaining a cerebral perfusion pressure (CPP) near the calculated optimal CPP (CPPopt), representing an individually optimal condition at which cerebral autoregulation functions at its best. This retrospective observational monocenter study was conducted to investigate, whether “suboptimal” perfusion with actual CPP deviating from CPPopt correlates with perfusion deficits detected by CT-perfusion (CTP). A consecutive cohort of aSAH-patients was reviewed and patients with available parameters for CPPopt-calculation, who simultaneously received CTP, were analyzed. By plotting the pressure reactivity index (PRx) versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. Perfusion deficits on CTP were documented. In 86 out of 324 patients, the inclusion criteria were met. Perfusion deficits were detected in 47% (40/86) of patients. In 43% of patients, CPP was lower than CPPopt, which correlated with detected perfusion deficits (r = 0.23, p = 0.03). Perfusion deficits were found in 62% of patients with CPPCPPopt (OR 3, p = 0.01). These findings support the hypothesis, that a deviation of CPP from CPPopt is an indicator of suboptimal cerebral perfusion
The value of comorbidities and illness severity scores as prognostic tools for early outcome estimation in patients with aneurysmal subarachnoid hemorrhage
Full text linkAneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing brain injury but also frequently inducing a significant systemic reaction affecting multiple organ systems. In addition to hemorrhage severity, comorbidities and acute extracerebral organ dysfunction may impact the prognosis after aSAH as well. The study objective was to assess the value of illness severity scores for early outcome estimation after aSAH. A retrospective analysis of consecutive aSAH patients treated from 2012 to 2020 was performed. Comorbidities were evaluated applying the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification. Organ dysfunction was assessed by calculating the simplified acute physiology score (SAPS II) 24 h after admission. Modified Rankin scale (mRS) at 3 months was documented. The outcome discrimination power was evaluated. A total of 315 patients were analyzed. Significant comorbidities (CCI > 3) and physical performance impairment (ASA > 3) were found in 15% and 12% of all patients, respectively. The best outcome discrimination power showed SAPS II (AUC 0.76), whereas ASA (AUC 0.65) and CCI (AUC 0.64) exhibited lower discrimination power. A SAPS II cutoff of 40 could reliably discriminate patients with good (mRS ≤ 3) from those with poor outcome (p < 0.0001). Calculation of SAPS II allowed a comprehensive depiction of acute organ dysfunctions and facilitated a reliable early prognosis estimation in our study. In direct comparison to CCI and ASA, SAPS II demonstrated the highest discrimination power and deserves a consideration as a prognostic tool after aSAH
Interaction of optimal cerebral perfusion pressure with early brain injury and its impact on ischemic complications and outcome following aneurysmal subarachnoid hemorrhage
Full text linkBackground
Cerebral autoregulation is impaired early on after aneurysmal subarachnoid hemorrhage (aSAH). The study objective was to explore the pressure reactivity index (PRx) and cerebral perfusion pressure (CPP) in the earliest phase after aneurysm rupture and to address the question of whether an optimal CPP (CPPopt)–targeted management is associated with less severe early brain injury (EBI).
Methods
Patients with aSAH admitted between 2012 and 2020 were retrospectively included in this observational cohort study. The PRx was calculated as a correlation coefficient between intracranial pressure and mean arterial pressure. By plotting the PRx versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. EBI was assessed by applying the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) on day 3 after ictus. An SEBES ≥ 3 was considered severe EBI.
Results
In 90 of 324 consecutive patients with aSAH, intracranial pressure monitoring was performed ≥ 7 days, allowing for PRx calculation and CPPopt determination. Severe EBI was associated with larger mean deviation of CPP from CPPopt 72 h after ictus (r = 0.22, p = 0.03). Progressive edema requiring decompressive hemicraniectomy was associated with larger deviation of CPP from CPPopt on day 2 (r = 0.23, p = 0.02). The higher the difference of CPP from CPPopt on day 3 the higher the mortality rate (r = 0.31, p = 0.04).
Conclusions
Patients with CPP near to the calculated CPPopt in the early phase after aSAH experienced less severe EBI, less frequently received decompressive hemicraniectomy, and exhibited a lower mortality rate. A prospective evaluation of CPPopt-guided management starting in the first days after ictus is needed to confirm the clinical validity of this concept
Microsurgical management of cranial dural arteriovenous fistulas: Treating the “Sheep in Wolf's clothing”? – Three decades of experience and lessons learned
No full textInfluence of cerebrospinal fluid drainage in the first days after aneurysm rupture on the severity of early brain injury following aneurysmal subarachnoid hemorrhage
No full textAbstract Purpose Progressive cerebral edema with refractory intracranial hypertension (ICP) requiring decompressive hemicraniectomy (DHC) is a severe manifestation of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of the study was to investigate whether a more pronounced cerebrospinal fluid (CSF) drainage has an influence on cerebral perfusion pressure (CPP) and the extent of EBI after aSAH. Methods Patients with aSAH and indication for ICP-monitoring admitted to our center between 2012 and 2020 were retrospectively included. EBI was categorized based on intracranial blood burden, persistent loss of consciousness, and SEBES (Subarachnoid Hemorrhage Early Brain Edema Score) score on the third day after ictus. The draining CSF and vital signs such as ICP and CPP were documented daily. Results 90 out of 324 eligible aSAH patients (28%) were included. The mean age was 54.2 ± 11.9 years. DHC was performed in 24% (22/90) of patients. Mean CSF drainage within 72 h after ictus was 168.5 ± 78.5 ml. A higher CSF drainage within 72 h after ictus correlated with a less severe EBI and a less frequent need for DHC ( r =-0.33, p = 0.001) and with a higher mean CPP on day 3 after ictus ( r = 0.2351, p = 0.02). Conclusion A more pronounced CSF drainage in the first 3 days of aSAH was associated with higher CPP and a less severe course of EBI and required less frequently a DHC. These results support the hypothesis that an early and pronounced CSF drainage may facilitate blood clearance and positively influence the course of EBI
Microsurgical clipping as a retreatment strategy for previously ruptured aneurysms treated with the Woven EndoBridge (WEB) device: a mono-institutional case series
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