RESUMEN
Delayed cerebral ischemia (DCI) is one of the most important outcome determinants for aneurysmal subarachnoid hemorrhage (aSAH). VASOGRADE, which combines World Federation of Neurological Surgeons grade and modified Fisher grade, is a useful scale for predicting DCI after aSAH. However, no studies have investigated whether VASOGRADE influences the treatment options. We retrospectively analyzed 781 aSAH patients who were prospectively enrolled in 9 primary stroke centers from 2013 to 2021. The total cohort consisted of 76 patients (9.7%) with VASOGRADE-Green, 390 patients (49.9%) with VASOGRADE-Yellow, and 315 patients (40.3%) with VASOGRADE-Red. Worse VASOGRADE had higher incidences of DCI, which occurred in 190 patients (24.3%). As only 5 patients (6.6%) with VASOGRADE-Green developed DCI, we searched for DCI-associated factors in patients with VASOGRADEs-Yellow and -Red. Multivariate analyses revealed independent treatment factors suppressing DCI as follows: no postoperative hemorrhagic complication, combined administration of fasudil hydrochloride and cilostazol, combination of clipping and cisternal drainage, and coiling for VASOGRADE-Yellow; and clipping, and administration of fasudil hydrochloride with or without cilostazol for VASOGRADE-Red. The findings suggest that treatment strategies should be determined based on VASOGRADE to prevent DCI after aSAH.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/cirugía , Masculino , Femenino , Persona de Mediana Edad , Isquemia Encefálica/etiología , Anciano , Estudios Retrospectivos , Adulto , Cilostazol/uso terapéutico , Estudios de Cohortes , Resultado del Tratamiento , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/complicaciones , 1-(5-Isoquinolinesulfonil)-2-Metilpiperazina/análogos & derivadosRESUMEN
Aneurysmal subarachnoid hemorrhage(SAH) causes brain injury and systemic complications, including cardiopulmonary dysfunction, which mutually affect each other. Post-SAH brain injury includes early brain injury(EBI) and delayed cerebral ischemia(DCI). EBI is a non-iatrogenic pathology occurring within 72 h of clinical SAH, primarily induced by increased intracranial pressure, subsequent transient global cerebral ischemia, and extravasated blood components. DCI typically develops between days 4 and 14 after clinical SAH because of erythrolysis(free hemoglobin) and EBI-mediated reactions. EBI and DCI share many pathologies, including large-artery spasm, microvascular spasm, microthrombosis, blood-brain barrier disruption, neuroinflammation, disturbance of venous outflow, and neuroelectric disturbances such as spreading depolarization and epileptic discharge. However, EBI and DCI differ not only in the timing of onset but also in their distribution, with EBI mainly occurring throughout the brain, while DCI occurs locally. Many substances, such as glutamic acid, cytokines, and matricellular proteins, mediate EBI and DCI pathologies. Further elucidation of EBI and DCI pathologies is essential for developing novel treatment strategies.
Asunto(s)
Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/complicaciones , Lesiones Encefálicas/patología , Lesiones Encefálicas/etiología , Animales , Isquemia Encefálica/etiologíaRESUMEN
BACKGROUND: The prognosis, recurrence rates, and secondary prevention strategies varied significantly among different subtypes of acute ischemic stroke (AIS). Machine learning (ML) techniques can uncover intricate, non-linear relationships within medical data, enabling the identification of factors associated with etiological classification. However, there is currently a lack of research utilizing ML algorithms for predicting AIS etiology. OBJECTIVE: We aimed to use interpretable ML algorithms to develop AIS etiology prediction models, identify critical factors in etiology classification, and enhance existing clinical categorization. METHODS: This study involved patients with the Third China National Stroke Registry (CNSR-III). Nine models, which included Natural Gradient Boosting (NGBoost), Categorical Boosting (CatBoost), Extreme Gradient Boosting (XGBoost), Random Forest (RF), Light Gradient Boosting Machine (LGBM), Gradient Boosting Decision Tree (GBDT), Adaptive Boosting (AdaBoost), Support Vector Machine (SVM), and logistic regression (LR), were employed to predict large artery atherosclerosis (LAA), small vessel occlusion (SVO), and cardioembolism (CE) using an 80:20 randomly split training and test set. We designed an SFS-XGB with 10-fold cross-validation for feature selection. The primary evaluation metrics for the models included the area under the receiver operating characteristic curve (AUC) for discrimination and the Brier score (or calibration plots) for calibration. RESULTS: A total of 5,213 patients were included, comprising 2,471 (47.4%) with LAA, 2,153 (41.3%) with SVO, and 589 (11.3%) with CE. In both LAA and SVO models, the AUC values of the ML models were significantly higher than that of the LR model (P < 0.001). The optimal model for predicting SVO (AUC [RF model] = 0.932) outperformed the optimal LAA model (AUC [NGB model] = 0.917) and the optimal CE model (AUC [LGBM model] = 0.846). Each model displayed relatively satisfactory calibration. Further analysis showed that the optimal CE model could identify potential CE patients in the undetermined etiology (SUE) group, accounting for 1,900 out of 4,156 (45.7%). CONCLUSIONS: The ML algorithm effectively classified patients with LAA, SVO, and CE, demonstrating superior classification performance compared to the LR model. The optimal ML model can identify potential CE patients among SUE patients. These newly identified predictive factors may complement the existing etiological classification system, enabling clinicians to promptly categorize stroke patients' etiology and initiate optimal strategies for secondary prevention.
Asunto(s)
Algoritmos , Accidente Cerebrovascular Isquémico , Aprendizaje Automático , Humanos , Accidente Cerebrovascular Isquémico/clasificación , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/diagnóstico , Estudios Prospectivos , Femenino , Masculino , Persona de Mediana Edad , Anciano , China/epidemiología , Pronóstico , Máquina de Vectores de Soporte , Isquemia Encefálica/clasificación , Isquemia Encefálica/etiología , Sistema de Registros/estadística & datos numéricos , Modelos LogísticosRESUMEN
OBJECTIVES: Vasospasm is a complication of aneurysmal subarachnoid hemorrhage (aSAH) that can change the trajectory of recovery and is associated with morbidity and mortality. Earlier detection of vasospasm could improve patient outcomes. Our objective is to evaluate the accuracy of smartphone-based quantitative pupillometry in the detection of radiographic vasospasm and delayed cerebral ischemia (DCI) after aSAH. MATERIALS AND METHODS: We prospectively collected pupillary light reflex (PLR) parameters from patients with aSAH admitted to a neurocritical care unit at a single hospital twice daily using quantitative smartphone pupillometry recordings. PLR parameters included: Maximum pupil diameter, minimum pupil diameter, percent change in pupil diameter, latency in beginning of pupil constriction to light, mean constriction velocity, maximum constriction velocity, and mean dilation velocity. Two-tailed t-tests for independent samples were performed to determine changes in average concurrent PLR parameter values between the following comparisons: (1) patients with and without radiographic vasospasm (defined by angiography with the need for endovascular intervention) and (2) patients with and without DCI. RESULTS: 49 subjects with aSAH underwent 323 total PLR recordings. For PLR recordings taken with (n=35) and without (n=241) radiographic vasospasm, significant differences were observed in MIN (35.0 ± 7.5 pixels with vasospasm versus 31.6 ± 6.2 pixels without; p=0.002). For PLR recordings taken with (n=43) and without (n=241) DCI, significant differences were observed in MAX (48.9 ± 14.3 pixels with DCI versus 42.5 ± 9.2 pixels without; p<0.001). CONCLUSIONS: Quantitative smartphone pupillometry has the potential to be used to detect radiographic vasospasm and DCI after aSAH.
Asunto(s)
Valor Predictivo de las Pruebas , Reflejo Pupilar , Teléfono Inteligente , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/fisiopatología , Hemorragia Subaracnoidea/diagnóstico , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/fisiopatología , Masculino , Persona de Mediana Edad , Femenino , Estudios Prospectivos , Anciano , Adulto , Reproducibilidad de los Resultados , Pupila/fisiología , Factores de Tiempo , Técnicas de Diagnóstico Oftalmológico/instrumentación , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatología , Isquemia Encefálica/etiología , Isquemia Encefálica/complicacionesRESUMEN
INTRODUCTION: Facial gunshot wounds have devastating functional and aesthetic consequences for the patient. If associated with penetrating craniocerebral injuries, the prognosis is rather compromised even with appropriate medical and surgical treatment. Chop-off injuries with penetrating wounds constitute a challenging situation for the facial reconstructive surgeon in facial trauma. OBSERVATION: This case involved a 49-year-old man who sustained an accidental facial shot from a pellet gun. Radiological and clinical investigations revealed complex ballistic trauma to the maxillofacial region, with projectiles reaching the base of the skull. One of the projectiles migrated via the carotid canal towards a cerebral artery, leading to obstruction of the artery with cerebral infarction. An autopsy was performed which evaluated that the shooting distance was compatible with a long distance, causing the dispersion of lead grains with the absence of a wad inside the trauma site. CONCLUSION: In some cases of facial gunshot wounds, despite a complex and extensive lesion assessment, death may occur due to a neurological complication rather than sustaining hemodynamic shock, depending on the trajectory of the projectiles.
Asunto(s)
Autopsia , Estenosis Carotídea , Traumatismos Faciales , Heridas por Arma de Fuego , Humanos , Masculino , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/diagnóstico , Persona de Mediana Edad , Resultado Fatal , Estenosis Carotídea/etiología , Estenosis Carotídea/diagnóstico , Traumatismos Faciales/complicaciones , Isquemia Encefálica/etiología , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/patologíaRESUMEN
Background and Objectives: Silent cerebral ischemia (SCI) is defined as a condition that can be detected by biochemical markers or cranial imaging methods but does not produce clinical symptom. This study aims both to compare the frequency of SCI in PCIs performed with right transradial access and left transradial access and to evaluate the influencing factors. Materials and Methods: A prospective, single-center study included 197 patients undergoing PCI via transradial access between November 2020 and July 2022. The patients were categorized into right radial and left radial groups. Neuron-specific enolase (NSE) values were measured and recorded before and 18 h after the procedure. A post-procedure NSE level higher than 20 ng/dL was defined as SCI. Results: SCI occurred in 60 of the 197 patients. NSE elevation was observed in 37.4% (n = 37) of the right radial group and in 23.5% (n = 23) of the left radial group (p = 0.032). Patients with SCI had higher rates of smoking (p = 0.043), presence of subclavian tortuosity (p = 0.027), and HbA1c (p = 0.031). In the multivariate logistic regression analysis, the level of EF (ejection fraction) (OR: 0.958 95% CI 0.920-0.998, p = 0.039), right radial preference (OR: 2.104 95% CI 1.102-3.995 p = 0.023), and smoking (OR: 2.088 95% CI 1.105-3.944, p = 0.023) were observed as independent variables of NSE elevation. Conclusions: Our findings suggest that PCI via right radial access poses a greater risk of SCI compared to left radial access. Anatomical considerations and technical challenges associated with right radial procedures and factors such as smoking and low ejection fraction contribute to this elevated risk.
Asunto(s)
Isquemia Encefálica , Intervención Coronaria Percutánea , Arteria Radial , Humanos , Femenino , Masculino , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/efectos adversos , Persona de Mediana Edad , Arteria Radial/cirugía , Anciano , Estudios Prospectivos , Isquemia Encefálica/etiología , Fosfopiruvato Hidratasa/sangre , Fosfopiruvato Hidratasa/análisis , Factores de Riesgo , Modelos LogísticosAsunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagen , Isquemia Encefálica/etiología , Isquemia Encefálica/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/diagnóstico por imagenRESUMEN
BACKGROUND: Atrial fibrillation (AF) is a risk factor for cerebral ischemia. Identifying the presence of AF, especially in paroxysmal cases, may take time and lacks clear support in the literature regarding the optimal investigative approach; in resource-limited settings, identifying a higher-risk group for AF can assist in planning further investigation. OBJECTIVE: To develop a scoring tool to predict the risk of incident AF in the poststroke follow-up. METHODS: A retrospective longitudinal study with data collected from electronic medical records of patients hospitalized and followed up for cerebral ischemia from 2014 to 2021 at a tertiary stroke center. Demographic, clinical, laboratory, electrocardiogram, and echocardiogram data, as well as neuroimaging data, were collected. Stepwise logistic regression was employed to identify associated variables. A score with integer numbers was created based on beta coefficients. Calibration and validation were performed to evaluate accuracy. RESULTS: We included 872 patients in the final analysis. The score was created with left atrial diameter ≥ 42 mm (2 points), age ≥ 70 years (1 point), presence of septal aneurysm (2 points), and score ≥ 6 points at admission on the National Institutes of Health Stroke Scale (NIHSS; 1 point). The score ranges from 0 to 6. Patients with a score ≥ 2 points had a fivefold increased risk of having AF detected in the follow-up. The area under the curve (AUC) was of 0.77 (0.72-0.85). CONCLUSION: We were able structure an accurate risk score tool for incident AF, which could be validated in multicenter samples in future studies.
ANTECEDENTES: Fibrilação atrial (FA) é um fator de risco para isquemia cerebral. Identificar a presença de FA, especialmente em casos paroxísticos, pode demandar tempo, e não há fundamentos claros na literatura quanto ao melhor método de proceder à investigação; em locais de parcos recursos, identificar um grupo de mais alto risco de FA pode auxiliar no planejamento da investigação complementar. OBJETIVO: Desenvolver uma ferramenta de escore para prever o risco de FA no acompanhamento após acidente vascular cerebral (AVC). MéTODOS: Estudo longitudinal retrospectivo, com dados coletados dos prontuários eletrônicos de pacientes hospitalizados e acompanhados ambulatorialmente por isquemia cerebral, de 2014 a 2021, em um centro de AVC terciário. Foram coleados dados demográficos, clínicos, laboratoriais, de eletrocardiograma e ecocardiograma, além de dados de neuroimagem. Mediante uma regressão logística por stepwise, foram identificadas variáveis associadas. Um escore com números inteiros foi criado com base nos coeficientes beta. Calibração e validação foram realizadas para avaliar a precisão. RESULTADOS: Foram incluídos 872 pacientes na análise final. O escore foi criado com diâmetro de átrio esquerdo ≥ 42 mm (2 pontos), idade ≥ 70 anos (1 ponto), presença de aneurisma septal (2 pontos) e pontuação à admissão ≥ 6 na escala de AVC dos National Institutes of Health (National Institutes of Health Stroke Scale, NIHSS, em inglês; 1 ponto). O escore tem pontuação que varia de 0 a 6. Pacientes com escore ≥ 2 pontos tiveram cinco vezes mais risco de terem FA detectada no acompanhamento. A área sob a curva (area under curve, AUC, em inglês) foi de 0.77 (0.720.85). CONCLUSãO: Pudemos estruturar uma ferramenta precisa de escore de risco de FA, a qual poderá ser validada em amostras multicêntricas em estudos futuros.
Asunto(s)
Fibrilación Atrial , Humanos , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/etiología , Masculino , Femenino , Anciano , Estudios Retrospectivos , Factores de Riesgo , Persona de Mediana Edad , Estudios Longitudinales , Medición de Riesgo/métodos , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/complicaciones , Anciano de 80 o más Años , Valor Predictivo de las Pruebas , Modelos Logísticos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/etiología , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/etiologíaAsunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Tomografía Computarizada por Rayos X , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagen , Isquemia Encefálica/etiología , Isquemia Encefálica/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Persona de Mediana Edad , Masculino , Femenino , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/diagnóstico por imagen , Adulto , AncianoRESUMEN
BACKGROUND: Pediatric spontaneous intracranial dissecting aneurysms are rare, but systematic studies comparing hemorrhagic and ischemic presentations are lacking. This study addresses gaps in understanding their epidemiology, clinical presentation, management, and outcome. METHODS: A retrospective analysis of 23 pediatric patients with nontraumatic intracranial dissecting aneurysms treated between July 2018 and December 2023 was conducted. Patients were divided into 2 groups based on presentation: hemorrhagic (n = 16) and ischemic (n = 7). Clinical data were analyzed, including demographics, radiologic findings, treatment modalities, and outcomes. RESULTS: Clinical presentations varied, with limb weakness being more prevalent in hemorrhagic cases (P = 0.014), while headache and seizures were more common in ischemic cases. Angiographic analysis revealed distinct patterns, with hemorrhagic cases showing more distal involvement on vessel segments with stenosis and dilatation (pearl string sign). At the same time, the ischemic group exhibited the double-lumen sign. Various treatments, including microsurgery and endovascular techniques, were utilized, with perioperative complications observed, including one mortality in a hemorrhagic case. Multiple regression analysis identified significant risk factors for perioperative complications, namely, the configuration of the dissecting aneurysm (P = 0.016) and the type of presentation (P = 0.0006). Long-term Glasgow Outcome Scores were comparable, but patients with hemorrhagic manifestations experienced prolonged hospital and ICU stays (P = 0.001). CONCLUSIONS: Pediatric intracranial dissecting aneurysms, particularly hemorrhagic cases, are associated with severe neurologic deficits and higher perioperative complications. Despite similar long-term outcomes, hemorrhagic cases require prolonged hospitalization, increasing treatment costs. Optimizing management strategies for pediatric intracranial dissecting aneurysms, especially those with hemorrhagic features, is essential to improve outcomes and reduce healthcare expenditures.
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Disección Aórtica , Isquemia Encefálica , Procedimientos Endovasculares , Aneurisma Intracraneal , Humanos , Masculino , Femenino , Procedimientos Endovasculares/métodos , Niño , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/epidemiología , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/terapia , Estudios Retrospectivos , Adolescente , Disección Aórtica/cirugía , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/epidemiología , Isquemia Encefálica/etiología , Isquemia Encefálica/epidemiología , Isquemia Encefálica/cirugía , Países en Desarrollo , Preescolar , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: The prior trials investigating triple-H therapy for preventing delayed cerebral ischemia (DCI) enrolled patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent early aneurysm therapy within 3 days. However, surgical clipping might be performed during 4-7 days that high incidence cerebral vasospasm is likely. We examined effects of hypervolemia-augmented blood pressure (HV-ABP) protocol on DCI prevention when clipping was delayed. METHODS: The study enrolled aSAH patients hospitalized during 2013-2019 who underwent clipping 4-7 days after rupture in a university hospital in Thailand. DCI and secondary outcomes were compared among patients who achieved the HV-ABP protocol (3-5 L/day fluid intake and 140-180 mmHg systolic blood pressure maintained for 72 hours postoperatively) and those who did not. The intervention-outcome associations were estimated using logistic regression for the whole group and a patient subgroup with similar propensity scores (PS) for protocol achievement. RESULTS: One hundred seventy-seven aSAH patients were clipped 4-7 days after rupture; 97 patients (54.8%) achieved the HV-ABP protocol, while 80 patients (45.2%) did not. One hundred twenty-two patients with one-to-one PS matching reduced the originally unequal patient characteristics. The observed DCI was lower in patients with protocol-achieved (8.3%) than in their nonachieved counterparts (22.5%). This resulted in an association with the HV-ABP intervention with adjusted odds ratios of 0.201 (95% confidence interval, 0.066-0.613) in the whole sample and 0.228 (0.065-0.794) in the PS-matched subsample. No statistically significant differences in the secondary outcomes were found. CONCLUSIONS: Achieving the targets recommended in the HV-ABP protocol was associated with reducing the DCI incidence in patients with aSAH who underwent delayed clipping.
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Presión Sanguínea , Isquemia Encefálica , Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/cirugía , Hemorragia Subaracnoidea/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Isquemia Encefálica/prevención & control , Isquemia Encefálica/etiología , Anciano , Presión Sanguínea/fisiología , Procedimientos Neuroquirúrgicos/métodos , Adulto , Aneurisma Roto/cirugía , Aneurisma Roto/prevención & control , Vasoespasmo Intracraneal/prevención & control , Vasoespasmo Intracraneal/etiología , Fluidoterapia/métodos , Instrumentos QuirúrgicosAsunto(s)
Demencia , Enfermedad de Parkinson , Humanos , Enfermedad de Parkinson/fisiopatología , Demencia/fisiopatología , Demencia/etiología , Envejecimiento , Encéfalo/fisiopatología , Encéfalo/irrigación sanguínea , Gravitación , Isquemia Encefálica/fisiopatología , Isquemia Encefálica/etiología , Factores de Edad , Circulación CerebrovascularRESUMEN
BACKGROUND: The occurrence of delayed cerebral ischemia and vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) results in high morbidity and mortality, but the diagnosis remains challenging. This study aimed to identify neuroimaging perfusion parameters indicative of delayed cerebral ischemia in patients with suspected vasospasm. METHODS: This is a case-control study. Cases were adult aSAH patients who underwent magnetic resonance perfusion or computed tomography perfusion (CTP) imaging ≤ 24 h before digital subtraction angiography performed for vasospasm diagnosis and treatment. Controls were patients without aSAH who underwent CTP. Quantitative perfusion parameters at different thresholds, including Tmax 4-6-8-10 s delay, cerebral blood flow and cerebral blood volume were measured and compared between cases and controls. The Vasospasm Index Score was calculated as the ratio of brain volume with time-to-max (Tmax) delay > 6 s over volume with Tmax > 4 s. RESULTS: 54 patients with aSAH and 119 controls without aSAH were included. Perfusion parameters with the strongest prediction of vasospasm on cerebral angiography were the combination of the Vasospasm Index Score (Tmax6/Tmax4) + CBV ≤ 48 % (area under the curve value of 0.85 [95 % CI 0.78-0.91]) with a sensitivity of 63 % and specificity of 95 %. CONCLUSION: The Vasospasm Index Score in combination with CBV ≤ 48 % on cerebral perfusion imaging reliably identified vasospasm as the cause of DCI on perfusion imaging.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/complicaciones , Femenino , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Masculino , Persona de Mediana Edad , Estudios de Casos y Controles , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/complicaciones , Isquemia Encefálica/etiología , Anciano , Imagen de Perfusión/métodos , Angiografía de Substracción Digital/métodos , Adulto , Sensibilidad y Especificidad , Angiografía Cerebral/métodos , Tomografía Computarizada por Rayos X/métodos , Circulación Cerebrovascular , Reproducibilidad de los ResultadosRESUMEN
Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high in-hospital mortality rates. Delayed cerebral ischemia (DCI), a secondary complication associated with aSAH, can also contribute to morbidity and mortality. Although draining the hematoma from the subarachnoid space has been considered effective in preventing DCI, the placement of a drainage system could increase the risk of bacterial meningitis and ventriculitis. This study aimed to examine the association between meningitis following aSAH and the occurrence of DCI, focusing on the role of cerebral vasospasm. Patients who underwent endovascular coiling or surgical clipping for aSAH from April 2001 to March 2022 were included in this study, while those who did not undergo postoperative drainage were excluded. The patient's clinical characteristics, treatment modalities, and outcomes were then analyzed, after which logistic regression was used to assess the odds ratios (OR) for DCI. A total of 810 patients with aSAH were included in this study. Meningitis following aSAH was identified as an independent factor associated with DCI (odds ratio 5.0 [95% confidence intervals (CI) 2.3-11]). Other significant factors were female sex (odds ratio 1.5 [95% CI 0.89-2.5]) and surgical clipping (odds ratio 2.1 [95% CI 1.3-3.4]). This study demonstrated a significant association between meningitis following aSAH and the development of DCI, suggesting that the inflammatory environment associated with meningitis may contribute to cerebral vasospasm. Early recognition and treatment of meningitis in patients with aSAH could reduce the risk of DCI and improve patient outcomes.
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Meningitis Bacterianas , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Vasoespasmo Intracraneal/etiología , Hemorragia Subaracnoidea/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Meningitis Bacterianas/etiología , Meningitis Bacterianas/complicaciones , Anciano , Estudios Retrospectivos , Adulto , Procedimientos Endovasculares/efectos adversos , Isquemia Encefálica/etiología , Factores de Riesgo , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/terapiaRESUMEN
PURPOSE OF REVIEW: The anesthetic management of patients with Moyamoya disease (MMD) is challenging and continues to evolve. The goal of this review is to provide updated recommendations on the anesthetic management of adult MMD patients based on the relevant existing literature. RECENT FINDINGS: Key findings include the importance of aggressive hydration preoperatively to sustain cerebral perfusion. Hypertension induced intraoperatively may prevent cerebral hypoperfusion. Vigilance against cerebral hyperperfusion after revascularization is necessary, with specific blood pressure targets recommended. Fluid management should aim for normovolemia to mild hypervolemia. Maintaining body temperature helps prevent cerebral vasospasm induced by hypothermia. Maintaining adequate oxygen supply during surgery is crucial. In cases of ischemic stroke, managing hematocrit and oxygen carrying capacity is essential to prevent further ischemia. Extubation decisions should consider baseline neurological function, while postoperative normocapnia helps prevent cerebral hyperperfusion and hypertension. In intensive care, cautious blood pressure management is crucial to prevent secondary complications. SUMMARY: Strategies in the preoperative, intraoperative, and postoperative anesthetic management of MMD patients should aim to maintain adequate cerebral perfusion to prevent cerebral ischemia.
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Anestesia , Enfermedad de Moyamoya , Humanos , Enfermedad de Moyamoya/cirugía , Anestesia/métodos , Anestesia/efectos adversos , Adulto , Circulación Cerebrovascular , Isquemia Encefálica/prevención & control , Isquemia Encefálica/etiologíaRESUMEN
BACKGROUND: Transcranial Doppler (TCD) is a technique to assess blood flow velocity in the cerebral arteries. TCD is frequently used to monitor aneurysmal subarachnoid hemorrhage (aSAH) patients. This study compares TCD-criteria for vasospasm and its association with Delayed Cerebral Ischemia (DCI). An overall score based on flow velocities of various intracranial arteries was developed and evaluated. METHODS: A retrospective diagnostic accuracy study was conducted between 1998 and 2017 with 621 patients included. Mean flow velocity (MFV) of the cerebral artery was measured between 2-5 days and between 6-9 days after ictus. Cutoff values from the literature, new cutoff values, and a new composite score (Combined Severity Score) were used to predict DCI. Sensitivity, specificity, and area under the curve (AUC) were determined, and logistic regression analysis was performed. RESULTS: The Combined Severity Score showed an AUC 0.64 (95%CI 0.56-.71) at days 2-5, with sensitivity 0.53 and specificity 0.74. The Combined Severity Score had an adjusted Odds Ratio of 3.41 (95CI 1.86-6.32) for DCI. MCA-measurements yielded the highest AUC to detect DCI at day 2-5: AUC 0.65 (95%CI 0.58-0.73). Optimal cutoff MFV of 83 cm/s for MCA resulted in sensitivity 0.73 and specificity 0.50 at days 2-5. CONCLUSION: TCD-monitoring of aSAH patients may be a valuable strategy for DCI risk stratification. Lower cutoff values can be used in the early phase after the ictus (day 2-5) than are commonly used now. The Combined Severity Score incorporating all major cerebral arteries may provide a meaningful contribution to interpreting TCD measurements.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Ultrasonografía Doppler Transcraneal , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/complicaciones , Ultrasonografía Doppler Transcraneal/métodos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/etiología , Anciano , Adulto , Velocidad del Flujo Sanguíneo/fisiología , Valor Predictivo de las Pruebas , Circulación Cerebrovascular/fisiología , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Sensibilidad y EspecificidadRESUMEN
Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel-related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20-13.70; P = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18-10.26; P = 0.023]. Postprocedural target vessel-related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.