Background For the treatment of intracranial aneurysms, the low-profile visualized intraluminal support (LVIS) stent is a new generation of highly visible-braided stent that was recently introduced ...in China. Here, we report our single-center retrospective experience of safety and efficacy utilizing LVIS for stent-assisted coiling of intracranial aneurysms.
Methods We included 218 patients with intracranial aneurysms consecutively treated with LVIS SR stents at our center in this study. Postoperative and follow-up embolization scores, procedural complications, clinical and angiographic findings at mid-term follow-up, as well as recurrence rate, preoperative and follow-up mRS scores were analyzed.
Results Two hundred and eighteen patients with two hundred and twenty five intracranial aneurysms were enrolled. The locations and distribution were ICA (125, 55.6%), PcomA (47, 20.9%), VA (38, 16.8%), and BA (15, 6.7%). Two hundred and eighteen aneurysms were treated with the stent-assisted coiling and seven patients with LVIS stents alone. Angiographic follow-up was available for 115 (51.1%) aneurysms, 8 (7.0%) of which had recurrences including 7 (6.5%) unruptured aneurysms and 1(14.3%) ruptured aneurysm. The procedural complication rate was 2.75% in total, including distal hemorrhage (1, 0.45%; SAH), ischemic events (5, 2.3%).
Conclusions Our single-center retrospective experience is one of the larger studies to date assessing the LVIS device. Compared with many laser-cut stent studies, the LVIS device had a higher aneurysm complete occlusion rate at follow-up coupled with low complication rates. However, this study was our initial experience with LVIS, larger patient numbers, and longer follow-up will be needed to fully assess the long-term efficacy of LVIS in treating intracranial aneurysms.
Background
Aneurysmal subarachnoid haemorrhage (SAH) WFNS grade V is commonly known to be associated with high mortality and a very poor prognosis for survivors. Therefore, maximal invasive therapy ...is frequently delayed until any spontaneous improvement with or without an external ventricular drainage occurs. The aim of the study was to verify possible predictive factors and the probability of a favourable outcome in maximally treated patients.
Methods
One hundred and thirty-eight consecutive patients with WFNS grade V SAH were admitted between 03/2006 and 12/2010. Thirty-five patients died before aggressive therapy could proceed. One hundred and three patients received maximal treatment and were retrospectively evaluated. The outcome was assessed at discharge and in the follow-up with the Glasgow Outcome Scale. Univariate and multivariate linear regression models were performed to find predictors for an unfavourable outcome.
Results
Despite treatment, early mortality was 30 % (
n
= 31). At discharge, the rate of both vegetative and severely disabled patients was 27 % (
n
= 28). Favourable outcome at discharge was observed in 16 % (
n
= 16) of cases, whereas in the follow-up it rose to 26 % (
n
= 27). Multivariate full model regression identified intraventricular haematoma (IVH) and increasing age as independently predictive for poor outcome.
Conclusions
Despite treatment, initial mortality and severe disability remain high. Nevertheless, a favourable outcome was achieved in 26 % of aggressively treated patients, rendering the withdrawal of maximal therapy for WFNS grade V SAH patients unacceptable today. In cases of old patients with IVH, the indication for aggressive therapy should be put in place more carefully due to a very poor prognosis.
BACKGROUND AND PURPOSE—Cardiac injury persistence after aneurysmal subarachnoid hemorrhage (aSAH) is not well described. We hypothesized that post-aSAH cardiac injury, detected by elevated cardiac ...troponin I (cTnI), is related to aSAH severity and associated with electrocardiographic and structural echocardiographic abnormalities that are persistent.
METHODS—Prospective longitudinal study was conducted of patients with aSAH with Fisher grade ≥2 and/or Hunt/Hess grade ≥3. Serum cTnI was collected on Days 1 to 5; cohort dichotomized into peak cTnI ≥0.3 ng/mL (elevated) or cTnI <0.3 ng/mL. Relationships among cTnI and aSAH severity, 12-lead electrocardiography early (≤4 days) and late (≥7 days), Holter monitoring on Days 1 to 5, and transthoracic echocardiogram (left ventricular ejection fraction and regional wall motion abnormalities) early (Days 0 to 5) and late (Days 5 to 12) were evaluated.
RESULTS—Of 204 subjects, 31% had cTnI ≥0.3 ng/mL. cTnI ≥0.3 ng/mL was incrementally related to aSAH severity by admission symptoms (Hunt/Hess P=0.001) and blood load (Fisher P=0.028). More patients with cTnI ≥0.3 ng/mL had prolonged QTc on early (63% versus 30%, P<0.0001) and late electrocardiography (24% versus 7%, P=0.024). On Holter monitoring, more patients with cTnI ≥0.3 ng/mL had ventricular tachycardia/fibrillation (22% versus 9%, P=0.018) but not atrial fibrillation/flutter (P=0.241). Cardiac troponin I ≥0.3 ng/mL was associated with both early ejection fraction <50% (44% versus 5%, P<0.0001) and regional wall motion abnormalities (44% versus 4%, P<0.0001). Regional wall motion abnormalities predominated in basal and midventricular segments and persisted to some degree in 73% of patients affected, whereas ejection fraction <50% persisted in 59% of patients affected.
CONCLUSIONS—Cardiac injury is incrementally worse with increasing aSAH severity and associated with persistent QTc prolongation and ventricular arrhythmias. Regional wall motion abnormalities and depressed ejection fraction persist to some degree in the majority of those affected.
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke with a high short-term mortality rate which leads to cognitive impairments that reduce the quality of life of the majority of patients. ...The miRNA-143/145 cluster is highly expressed in vascular smooth muscle cells (VSMC) and has been shown to be necessary for differentiation and function, as well as an important determinant for phenotypic modulation/switching of VSMCs in response to vascular injury. We aimed to determine whether miRNA-143 and miRNA-145 are important regulators of phenotypical changes of VSMCs in relation to SAH, as well as establishing their physiological role in the cerebral vasculature. We applied quantitative PCR to study ischemia-induced alterations in the expression of miRNA-143 and miRNA-145, for rat cerebral vasculature, in an ex vivo organ culture model and an in vivo SAH model. To determine the physiological importance, we did myograph studies on basilar and femoral arteries from miRNA-143/145 knockout mice. miRNA-143 and miRNA-145 are not upregulated in the vasculature following our SAH model, despite the upregulation of miR-145 in the organ culture model. Regarding physiological function, miRNA-143 and miRNA-145 are very important for general contractility in cerebral vessels in response to depolarization, angiotensin II, and endothelin-1. Applying an anti-miRNA targeting approach in SAH does not seem to be a feasible approach because miRNA-143 and miRNA-145 are not upregulated following SAH. The knockout mouse data suggest that targeting miRNA-143 and miRNA-145 would lead to a general reduced contractility of the cerebral vasculature and unwanted dedifferentiation of VSMCs.
Subarachnoid Hemorrhage and Headache Ogunlaja, Oyindamola Ikepo; Cowan, Robert
Current pain and headache reports,
06/2019, Letnik:
23, Številka:
6
Journal Article
Recenzirano
Purpose for Review
Subarachnoid hemorrhage is a serious and life-threatening medical condition which commonly presents with an acute headache. Unfortunately, it remains frequently misdiagnosed at ...initial presentation with dire consequences in terms of patient morbidity and mortality. The goal of this paper is to review salient features in the clinical history, as well as recently developed clinical decision rules, which can help determine which patients warrant further investigation for subarachnoid hemorrhage when the initial presentation is that of an acute headache.
Recent Findings
A recent prospective observational study showed that occipital location, stabbing quality, presence of meningism, and onset of headache during exertion were characteristics in the clinical history that can distinguish the headache of SAH from other causes. The Ottawa headache rule is a clinical decision tool which was developed to help identify patients presenting to the ED with acute non-traumatic headache who require investigation to rule out subarachnoid hemorrhage. Using this tool, it is recommended that patients who meet any one of the following 6 criteria are investigated further: Onset greater than or equal to 40 years, presence of neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunder clap headache (pain peaking within 1 s), or limited neck flexion on exam.
Summary
An informed and thoughtful approach that takes into account the timing, presentation, risk factors, and resources, as discussed here, should help distinguish between the patient that warrants further evaluation and intervention for SAH and one who does not. The Ottawa SAH rule is a useful clinical decision tool for young inexperienced clinicians in order to avoid missed diagnoses. However, its clinical value is limited by its low specificity. Clinical decision tools with higher specificity are needed.
Perdarahan subarachnoid (SAH) yang diakibatkan oleh pecahnya aneurisma otak menyumbang sekitar 85% dari kejadian SAH non traumatik. Insidensi sekitar 8–10 per 100.000 penduduk per tahun atau sekitar ...(0,008%). Rangkaian tatalaksana kasus SAH mempengaruhi outcome dari hasil terapi, mulai dari pertolongan pertama pada prehospital, transportasi, diagnosis awal, manajemen kegawatdaruratan dini, tindakan neuroradiologi intervensi ataupun pembedahan dan perawatan intensif pasca tindakan definitif. Pada laporan kasus ini, pasien wanita usia 65 tahun, berat badan 50 kg dengan diagnosa SAH hari ke 18 karena pecahnya aneurisma arteri serebri media disertai defisit neurologis ringan. Pembedahan dilakukan tindakan kraniotomi direct clipping aneurisma. Prinsip anestesi yang dilakukan adalah pemeliharaan homeostasis dan Cerebral Perfusion Pressure (CPP)/Transmural Pressure (TMP) yang efektif, tindakan pencegahan peningkatan tekanan intrakranial (Intracranial Pressure-ICP), pembengkakan otak dan manajemen vasospasme serebral. Operasi berjalan 6 jam dan dilakukan rapid emergence. Outcome pembedahan sesuai yang diharapkan. Anestesi mempunyai peranan yang sangat penting dalam manajemen secara keseluruhan pada pasien ini untuk memberikan manajemen proteksi otak yang maksimal selama pembedahan sehingga memperoleh hasil akhir pembedahan yang sukses.
Etiology of unprovoked subarachnoid hemorrhage (SAH) is predominantly from cerebral aneurysm rupture and manifests classically as a thunderclap headache. Orgasmic cephalgia may herald SAH given that ...4-12% of SAH sufferers were found to have engaged in prior sexual activity.(1) Precipitating causes of SAH leading to aneurysmal rupture may be the rise in blood pressure caused by physical activity. A conventional angiogram (CTA) is used to reveal a source of the bleed and but occasionally this is normal, and is labelled angiogram-negative SAH or non-aneurysmal SAH. In those cases digital subtraction imaging (DSA) is needed for verification. Herein we discuss an instance of angiogram negative SAH which occurred after sexual activity in a young male with a chronic cannabis habit.
Background
Existing scoring systems for aneurysmal subarachnoid hemorrhage (SAH) patients fail to accurately predict patient outcome. Our goal was to prospectively study the Full Outline of ...UnResponsiveness (FOUR) score as applied to newly admitted aneurysmal SAH patients.
Methods
All adult patients presenting to Health Sciences Center in Winnipeg from January 2013 to July 2015 (2.5 year period) with aneurysmal SAH were prospectively enrolled in this study. All patients were followed up to 6 months. FOUR score was calculated upon admission, with repeat calculation at 7 and 14 days. The primary outcomes were: mortality, as well as dichotomized 1- and 6-month Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) values.
Results
Sixty-four patients were included, with a mean age of 54.2 years (range 26–85 years). The mean FOUR score upon admission pre- and post-external ventricular drain (EVD) was 10.3 (range 0–16) and 11.1 (range 3–16), respectively. There was a statistically significant association between pre-EVD FOUR score (total, eye, respiratory and motor sub-scores) with mortality, 1-month GOS, and 6-month GOS/mRS (
p
< 0.05 in all). The day 7 total, eye, respiratory, and motor FOUR scores were associated with mortality, 1-month GOS/mRS, and 6-month GOS/mRS (
p
< 0.05 in all). The day 14 total, eye, respiratory, and motor FOUR scores were associated with 6-month GOS (
p
< 0.05 in all). The day 7 cumulative FOUR score was associated with the development of clinical vasospasm (
p
< 0.05).
Conclusions
The FOUR score at admission and day 7 post-SAH is associated with mortality, 1-month GOS/mRS, and 6-month GOS/mRS. The FOUR score at day 14 post-SAH is associated with 6-month GOS. The brainstem sub-score was not associated with 1- or 6-month primary outcomes.
Atlantic salmon with body weight of 493 g were fed 6 graded levels of methionine in diets based on plant proteins for a period of 85 days with the aim to test whether methionine intake affected ...growth, nutrient accretion and hepatic sulphur metabolism. A negative control based on a mixture of plant proteins with low fish meal inclusion (5%) containing 1.64 g methionine 16 g−1 N was added five levels of dl-methionine resulting in dose levels from 1.64 to 2.98 g methionine 16 g−1 N. A control feed based on fish meal (26%) and plant proteins (44.9%) containing 2.30 g methionine 16 g−1 N was used as a control for growth performance. Feed intake and thus growth was generally lower in fish fed the plant protein based diets, while digestibility of amino acids was higher in fish fed the test diets as compared to those fed the fish meal based positive control diet. However, no significant differences in either feed intake or growth were present in fish fed either of the test diets containing graded levels of methionine. Neither carcass protein or lipid retention was affected by methionine intake as confirmed by the unaffected mRNA levels of growth hormone-insulin-like growth factor in hepatic and muscle tissues. Hepatic size as well as transsulfuration was significantly affected by methionine intake. Thus it is concluded that nutrient accretion was not the main effect of methionine intake (ranging from 35 to 90 mg fish−1 day−1). Rather methionine is essential to secure high synthesis of activated methyl groups for methylation reactions ensuring a healthy fish not developing increased liver size. Intakes exceeding 60 to 70 mg methionine daily in the fast growing seawater period results in increased transsulfuration analysed as increased hepatic taurine production keeping the hepatic free methionine constant at all intakes.
The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other ...haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is ~50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prog nosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10–12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.
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