Early treatment of unruptured intracranial aneurysms (IAs) is crucial to minimizing risk of rupture. Previous literature has identified disparities in access to care for neurological conditions based on socioeconomic status (SES). Our study evaluates trends in presentation and management of IAs based on SES.

This was a retrospective study of patients who presented for their initial encounter of IA management at a single institution between January 2018-January 2024. Area deprivation index (ADI) was used to categorize patients into five quintiles based on their residential address. Predictor variables of interest were race/ ethnicity, insurance status, marital status, primary care utilization and the use of interpreter services. Outcomes of interest were rupture at presentation, treatment and functional outcome at discharge.

688 patients presented with an aneurysm. 131 patients had ruptured aneurysms and 557 patients had unruptured aneurysms. In total, 439 patients underwent treatment. White race (OR: 0.11; 95 % CI: 0.01, 0.70, p = 0.02), ADI quintile 3 (OR: 0.41, 95 % CI: 0.20, 0.81, p = 0.01), PCP utilization (OR: 0.34, 95 % CI: 0.14, 0.86, p = 0.02) and requirement of interpreter services (OR: 0.16, 95 % CI: 0.06, 0.72, p = 0.03) were associated with decreased odds of presenting with a ruptured aneurysm. Male gender (OR: 0.57, 95 % CI: 0.35, 0.92, p = 0.02), ruptured aneruysms (OR: 33.23, 95 % CI: 10.13--108.96, p < 0.001) and aneurysm location were significantly associated with undergoing treatment of an intracranial aneurysm. Insurance status, ruptured aneurysms (OR: 9.76, 95 % CI: 4.04--25.19, p < 0.001) and aneurysm location was associated with higher odds of functional dependence on discharge.

Despite racial and socioeconomic disparities, our study identified that having a PCP was an independent predictor of decreased odds of presenting with a ruptured aneurysm. This indicates the importance of early detection of intracranial aneurysms in patients who receive care through PCPs.

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition that carries a high rate of morbidity.

This review highlights the pearls and pitfalls of aSAH, including presentation, diagnosis, and management in the emergency department based on current evidence.

aSAH is a type of hemorrhagic stroke, most commonly from rupture of a saccular aneurysm, which results in leakage of blood into the subarachnoid space. It presents acutely and has many mimics, making the diagnosis difficult. Patients who present with either sentinel or acute presentation of a headache that is described as sudden or severe, has associated neck stiffness, cranial nerve deficits, syncope, seizure, and/or coma should raise suspicion for the diagnosis. Non-contrast head computed tomography is the imaging modality of choice for evaluation and diagnosis of the disease in patients who present acutely. Further diagnostic testing with lumbar puncture or advanced neuroimaging may be required in patients who present >6 h after symptom onset. Patients with aSAH require critical, multidisciplinary care, with particular attention to management of airway, breathing, and circulation; expeditious referral for neurosurgical intervention; coagulopathy reversal; and prophylaxis against downstream complications.

An understanding of aSAH can assist emergency clinicians in diagnosing and managing this disease.

The increasing use of single (SAPT) and dual antiplatelet therapy (DAPT) in endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH) raises concerns about ventriculostomy-related hemorrhage (VRH). This study evaluates the impact of platelet transfusion, timing of ventriculostomy placement relative to antiplatelet therapy (APT), and APT type (DAPT vs. SAPT) on VRH risk and clinical outcomes.

A retrospective study of a prospectively collected cohort of aSAH presenting to a single academic center from 2016 to 2023 was conducted. Patients who underwent ventriculostomy placement and APT were included, while those on anticoagulation were excluded. The cohort was then split into three groups: 1) patients on APT at the time of ventriculostomy placement and who were not given platelet transfusion, 2) patients on APT at the time of ventriculostomy placement and who were given platelet transfusion, and 3) patients who were initiated on APT after ventriculostomy placement as part of their endovascular therapy. Univariate and multivariate analyses were performed examining rates of tract hemorrhage, symptomatic tract hemorrhage, and poor neurologic outcomes at three-months, defined as modified Rankin scale (mRS) > 3.

Among 404 cases identified, 129 patients were on APT during or after ventriculostomy placement. Mean age was 59.5 ± 13.9 years, 38.8 % male, and 74.4 % were White. When comparing those who were on APT and did not receive platelet transfusion (n = 24) with those who received platelet transfusion (n = 34), there were no differences in rates of VRH or symptomatic VRH on univariate (37.5 % vs. 29.4 %, p = 0.52 and 4.2 % vs. 5.9 %, p = 0.77, respectively) or multivariate analysis (OR 0.79, 95 %CI [0.24, 2.61], p = 0.7 and OR 0.28, 95 %CI [0.01, 7.99], p = 0.4. Comparing those already on APT versus those with APT initiation after ventriculostomy, there were no statistically significant differences in rates of VRH or symptomatic VRH on univariate (37.5 % vs. 25.4 %, p = 0.26 and 4.2 % vs. 1.4 %, p = 0.42, respectively) or multivariate analysis (OR 0.74, 95 %CI [0.42, 1.31], p = 0.3 and OR 0.28, 95 %CI [0.01, 7.99], p = 0.4). Furthermore, there were no differences in functional neurologic outcomes at 3-month follow-up on multivariate analysis.

Our study did not identify benefits conferred from platelet transfusion with regard to VRH or outcomes after ventriculostomy placement in aSAH on APT. We also found no differences in VRH in patients who had ventriculostomy placement before or after APT initiation. With the increasing use of endovascular therapies, ventriculostomy placement under APT is increasingly common, necessitating further research to mitigate the risk of significant VRH.

Several case series and prospective cohorts have reported the use of stent retrievers (SR) and specifically designed expanding stents (ES) to perform in situ mechanical stent angioplasty to treat cerebral vasospasm in subarachnoid vasospasm.

The aim of this study was to review and conduct a meta-analysis to evaluate the safety and efficacy of this novel technique.

A systematic review and meta-analysis was conducted according to established protocols. Searches were conducted in PubMed, Scopus, Web of Science, and EMBASE databases up to June 2024, including variations of "stent," "expanding device," "vasospasm," "subarachnoid hemorrhage." Original studies reporting treatment outcomes for vasospasm by using SR/ES in more than 5 patients were included.

Pooled data from 8 studies, comprising 156 patients and 428 targeted vessels treated with stent angioplasty for vasospasm were analyzed.

We evaluated rates of angiographic success, complications, recurrence, and neurologic improvement. Meta-analysis was performed by using a random-effects model.

The angiographic success rate was 81.8% (95% CI: 70.6-89.3). Subgroup analysis showed a success rate of 86.5% (95% CI: 62.6-96.1) with ES and 80.5% (95%CI: 62.6-93.1) with SR. Overall complication rate was 1.1% (95% CI: 0.0-3.6), due to clot formation or hemorrhage. Recurrence of vasospasm was noted in 12.8% (95% CI: 5.2-28.1) while neurologic improvement was seen in 65.9% (95% CI: 51.1-78.1) of the cases. Finally, it should be noted that all included studies used stent angioplasty in combination with intra-arterial vasodilators.

Our meta-analysis is limited by selection and reporting biases, as well as high heterogeneity. Moreover, the overall low quality of available evidence is the main limitation of our results.

Combination of stent angioplasty and intra-arterial vasodilators was found to have high rates of angiographic success and low incidences of adverse events. Randomized controlled trials are needed to confirm their efficacy and safety compared with medical and balloon angioplasty treatments.

The C-Reactive Protein/Albumin Ratio (CAR) is being studied as a potential predictor of severe outcomes in various diseases. Our study aimed to review current evidence on the prognostic value of CAR in patients with aneurysmal subarachnoid hemorrhage (aSAH). We conducted a systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar up to April 2023 and assessed the risk of bias using the NewCastle-Ottawa tool. A narrative synthesis was performed, and the GRADE system was used to evaluate the certainty of the evidence. Out of 534 articles, 4 were selected. We found that a higher CAR level is moderately associated with a lower score on the Glasgow Outcome Scale at 3 months and a higher incidence of in-hospital mortality. However, no significant association was found with the modified Rankin scale or delayed cerebral ischemia. Although the evidence is limited, CAR could be a useful tool for predicting poor prognosis in aSAH patients, but more prospective studies are needed to determine optimal cut-off points and include CAR in long-term prognostic models.

The therapeutic benefit of tranexamic acid (TXA) in patients with aneurysmal subarachnoid hemorrhage (aSAH) remains controversial. We evaluated the efficacy and safety of TXA in aSAH patients by performing a comprehensive meta-analysis of randomized controlled trials (RCTs).

We conducted a systematic review and meta-analysis of RCTs comparing TXA with either placebo or standard care in aSAH patients. A comprehensive literature search was performed across PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus from inception to July 2024. Outcomes of interest included rebleeding, mortality, functional outcomes, and delayed cerebral ischemia (DCI). Subgroup analyses were performed based on publication date and TXA administration duration.

Thirteen RCTs were included in our study. TXA significantly reduced rebleeding rates (relative risk [RR] 0.61; 95 % confidence interval [CI] 0.51-0.74, P < 0.00001) but did not affect mortality (RR 0.99; 95 % CI 0.86-1.13, P = 0.84) or good clinical outcomes (RR 0.98; 95 % CI 0.93-1.05, P = 0.63). TXA use was associated with increased occurrence of hydrocephalus (RR 1.12; 95 % CI 1.01-1.23, P = 0.03) but not DCI (RR 1.00; 95 % CI 0.84-1.20, P = 0.96). Subgroup analyses suggested greater rebleeding reduction with longer TXA administration (≥1 week) and in more recent studies (post-2000).

TXA reduces rebleeding in aSAH but does not improve survival or functional outcomes. Its routine use in aSAH is not supported by current evidence.

Exclusion criteria are designed to optimize the scientific yield and safety of clinical trials. However, periodic analysis is necessary to understand the impact on trial complexity, enrollment, generalizability, and costs. We analyzed the types of exclusion criteria used among clinical trials performed in subarachnoid hemorrhage (SAH) patients and impact upon exclusion of patients.

We identified trials involving SAH patients that provided a list of exclusion criteria and determined the number and proportion of those trials which used various exclusion criteria, proportion of excluded patients for each of the exclusion criteria and whether Consolidated Standards of Reporting Trials (CONSORT) was used. We also used target trial emulation approach and applied arbitrary trial exclusion criteria to a single center cohort of SAH patients to determine proportions of patients excluded for each of the reasons for exclusion.

A total of 109 trials involving SAH patients were identified, of which 68(62.3%) provided a list of the exclusion criteria. The median number of exclusion criteria was 6 (range 2-9). The most common exclusion criteria were pregnancy (n = 31 trials), SAH due to other causes (trauma, fusiform or mycotic aneurysm, n = 26 trials) and significant liver disease/hepatic insufficiency (n = 19 trials). CONSORT was used in 16(23.5%) trials and 18 (16.5%) trials provided the proportion of patients excluded according to each of the exclusion criteria. In a single center cohort, the highest proportion of patients were excluded because no aneurysm was identified on imaging (23%) followed by withdrawal of care (9.6%) and need for dual anti-platelet treatment (8.6%). The in-hospital mortality was higher in patients who were excluded as compared with those who were included in the hypothetical trial (22 [30.1%] of 73 and 0 [0%] of 31 patients).

Our analysis on exclusion criteria used and proportion of patients excluded in clinical trials involving SAH patients will assist in future trial enrollment, completion, and generalizability. Standardized reporting using CONSORT in clinical trials involving SAH patients is strongly recommended.

Cerebral vasospasm is a common and serious complication following non-traumatic subarachnoid hemorrhage (SAH), often leading to worsened outcomes, especially when associated with delayed cerebral ischemia (DCI). Intrathecal nicardipine has shown potential as a treatment for vasospasm, although further research is needed to establish its effectiveness and determine its role in managing this complication. A systematic search was conducted through MEDLINE, Embase, Cochrane Library, and Web of Science databases to identify studies comparing outcome measures for intrathecal nicardipine after SAH with a control group. The primary endpoints were vasospasm severity, DCI rate, and favorable outcome at 1-6 months, assessed by functional outcome scales. Secondary outcomes included mortality, infection rates, and the need for shunt placement. A total of six studies met the eligibility criteria, and a meta-analysis using a random-effects model was conducted to pool the data. In the data analyses of 2,569 patients, in comparison with standard therapy, nicardipine use has shown statistical significance in reducing the incidence of mild vasospasm (odds ratio [OR] = 0.40; 95% confidence interval [CI] [0.20, 0.80]; p = 0.010; 𝐼² = 0%), reducing mortality rate (OR = 0.58; 95% CI [0.42, 0.81]; p = 0.001; 𝐼² = 0%), and increasing infection rate, including ventriculitis and meningitis (OR = 2.54; 95% CI [1.05, 6.19]; p = 0.040; 𝐼² = 51%). The results of this present study indicate that intrathecal nicardipine may be an effective therapeutic option for reducing the severity of vasospasm and improving mortality rates in patients with non-traumatic SAH. However, it may increase the risk of infections. Further research with randomized controlled trials is needed to confirm these findings and evaluate this treatment's long-term benefits and risks.

Post-hemorrhagic cerebral vasospasm (PHCV) in aneurysmal subarachnoid hemorrhage (aSAH) often requires endovascular intervention with either intra-arterial (IA) vasodilator therapy or percutaneous transluminal balloon angioplasty (PTA). This study aimed to evaluate the angiographic efficacy of endovascular treatments with clinical outcomes.

We retrospectively reviewed patients (≥18 years) who underwent IA vasodilator therapy or PTA for PHCV following aSAH at our institution from 2007 to 2023. Patients were stratified into "good" and "poor" outcome cohorts based on a 6-month modified Rankin Scale > 2. Identifiable risk factors were assessed using univariate and multivariate analyses. We compared angiographic changes in vessel diameter, cerebral circulation time (CCT), and retreatment rates between (1) PTA plus IA vasodilator sessions vs. IA-only sessions, and (2) verapamil-only vs. verapamil plus another agent. The statistically significant variables were used to create a scoring model to predict poor outcome.

Eighty-three patients (mean age 52 years, 66 % female) with 246 treated vessels met inclusion criteria. IA vasodilators alone were used in 220 vessels, and PTA plus IA vasodilators were used in 26 vessels. 65 % of patients had a poor 6-month outcome. Male sex (p = 0.016), Black race (p = 0.030), hypertension (p = 0.015), earlier vasospasm onset (p = 0.016), and longer initial pre-treatment CCT (p = 0.033) were independently associated with poor outcomes. Vasospasm symptom of headaches alone (p = 0.044) was protective. PTA plus IA vasodilators more effectively increased the M1 diameter than IA vasodilators alone but CCT reductions were the same. Improvement in angiographic parameters was not associated with improved clinical outcome. Verapamil-only had the same angiographic and clinical outcomes compared to Verapamil plus another agent. The scoring model used 6-variables with an AUC = 0.746 to predict clinical outcomes.

In this single-center retrospective study of PHCV, despite angiographic improvements with endovascular therapy, there was no associated improvement in clinical outcomes.

Numerous grading scales were proposed for subarachnoid hemorrhage (SAH) to assess the likelihood of unfavorable neurological outcomes (UO) and the risk of delayed cerebral ischemia (DCI). We aimed to validate the Hemorrhage, Age, Treatment, Clinical Status, and Hydrocephalus (HATCH) score and the VASOGRADE, a simple grading scale for prediction of DCI after aneurysmal SAH.

This was a retrospective single-center study of patients with nontraumatic SAH (January 2016 to December 2021) admitted to the intensive care unit. We performed a receiver operating characteristic (ROC) curve analysis to assess the discriminative ability of the HATCH and the VASOGRADE to identify patients who had UO at 3 months (defined as Glasgow Outcome Scale score of 1-3), hospital mortality, and DCI and compared their performance with the World Federation of Neurosurgical Surgeons, the modified Fisher, the Sequential Organ Failure Assessment, and the Acute Physiology and Chronic Health Evaluation II scales. We performed a multivariate logistic regression analysis to assess the association between HATCH and UO at 3 months and between VASOGRADE and DCI.

We included 262 consecutive patients with nontraumatic SAH. DCI was observed in 82 patients (31.3%), whereas 78 patients (29.8%) died during hospital stay and 133 patients (51%) had UO at 3 months. HATCH was independently associated with UO (odds ratio 1.61, 95% confidence interval [CI] 1.36-1.90) and had an area under the ROC curve (AUROC) of 0.83 (95% CI 0.77-0.88), comparable to the Acute Physiology and Chronic Health Evaluation II (AUROC 0.84, 95% CI 0.79-0.89) and Sequential Organ Failure Assessment (AUROC 0.83, 95% CI 0.77-0.88).

Hemorrhage, Age, Treatment, Clinical Status, and Hydrocephalus and VASOGARDE scores had a good performance to predict UO or in-hospital mortality and DCI, respectively; however, their performance did not outperform nonspecific routinely used scores.

The diagnosis of reversible cerebral vasoconstriction syndrome (RCVS) is challenging due to its varied clinical manifestations and imaging findings. While it typically presents with a sudden, severe thunderclap headache and multifocal constriction of the cerebral arteries, the wide spectrum of radiological presentations may complicate the diagnosis.

This review presents a series of cases that show both typical and atypical presentations of RCVS. Typical cases show the characteristic "string of beads" pattern on angiography, which usually resolves within 3-6 months. However, diagnostic challenges arise when angiography appears normal in the early stages or when imaging artifacts obscure the findings. In addition, the variability in vasoconstriction patterns and the need for a differential diagnosis further complicate the accurate identification. These cases highlight the importance of considering RCVS in patients with recurrent thunderclap headaches, even when the initial imaging is inconclusive. Recognizing these challenges and the variability in presentation, along with the use of high-resolution vessel wall MRI and blood-brain barrier imaging, can improve diagnostic accuracy and improve patient outcomes.

The diagnosis of RCVS requires careful integration of clinical evaluation and advanced imaging techniques, with particular attention to radiological findings that can guide accurate diagnosis and management. Despite challenges, such as normal early stage angiography and imaging variability, maintaining a high suspicion of RCVS is essential, especially in patients with recurrent thunderclap headaches.

Introduction: The purpose of this study is to provide foundational data for nursing care in patients with external ventricular drainage (EVD) by comparatively analyzing drainage volume in relation to intracranial pressure (ICP) and drainage catheter size. Methods: In this study, we conducted a volumetric analysis using the continuity and Bernoulli equations, considering friction forces under predefined conditions. In adults in the supine position with 37 °C CSF, the ventricular drainage volume was assessed based on the height of the EVD system, ICP levels, and EVD catheter sizes. Results: The results indicated that the CSF flow rate increased with larger catheter diameters and when the EVD system was positioned lower than the reference point (foramen of Monro). Across all catheter sizes, the minimum CSF flow occurred when the EVD system was 15 cm above the reference point, while the maximum flow was observed when it was 15 cm below the reference point. This multidisciplinary study, utilizing fluid dynamics, quantitatively estimates the drainage volume in EVD systems based on ICP and catheter size, contributing to the nursing care of EVD systems. The findings underscore the importance of developing specific nursing guidelines to improve patient safety in external ventricular drainage management and incorporating them into clinical education. Conclusions: A limitation of this study is that it does not compare with patients in clinical settings for clinical empirical validity. Therefore, a stepwise validation process is necessary. So, future studies will need to compare medical record data with the results of this study to confirm the validity of the equations presented.

This study aimed to investigate the association between the triglyceride-glucose (TyG) index and the risk of acute kidney injury (AKI) in patients with aneurysmal subarachnoid hemorrhage (aSAH).

This retrospective cohort study included aSAH patients in West China Hospital. The TyG index was calculated as ln[fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The primary outcome was AKI within 7 days of admission, and secondary outcomes included hospital, 90-day, and 180-day mortality. Multivariate logistic regression and Cox proportional hazards models were used to adjust for potential confounders. The association between the TyG index and AKI was also assessed with restricted cubic spline analysis. A predictive logistic model for AKI risk was developed and its performance was assessed using the area under the receiver operating characteristic curve, calibration correction curves, and decision curve analysis. Based on the optimal model, an online Shiny R application was developed.

A total of 3271 patients with aneurysmal subarachnoid hemorrhage were included. AKI occurred in 156 patients (4.7%), with the incidence significantly increasing across TyG index quartiles (Q1: 2.7%, Q4: 8.6%; P for trend < 0.001). Each 1-unit increase in TyG index was associated with an 90% higher odds of AKI (OR 1.90, 95% CI 1.48-2.45). Mortality rates also increased with higher TyG quartiles: hospital mortality (HR 1.30, 95% CI 1.05-1.62), 90-day mortality (HR 1.20, 95% CI 1.03-1.39), and 180-day mortality (HR 1.18, 95% CI 1.02-1.37). Kaplan-Meier analysis revealed reduced survival in higher TyG quartiles (Log-rank P < 0.001). Subgroup analyses confirmed consistent associations across demographics characteristics and treatment modalities. Incorporating the TyG index into risk models improves their discriminatory power and calibration. A Shiny application based on this model is freely accessible at ( https://asahaki.shinyapps.io/asahaki/ ).

The TyG index is an independent predictor of AKI and mortality in aSAH patients. Its incorporation into clinical assessment facilitates early risk stratification and individualized management.

In the pediatric population, symptomatic nontraumatic intracranial hemorrhage (ICH) is a rarely encountered condition, yet with often very serious implications. It can result from a wide spectrum of intracranial and systemic causes. Knowledge of disease etiology is important for planning treatment and follow-up strategy. The aim of the present study was to characterize the spectrum and age dependence of the underlying causes of acute spontaneous ICH in children and adolescents from a single-center cohort.

During the period 2011-2021, we identified all pediatric patients aged from 1 month to 18 years (included) who were undergoing diagnostic neuroimaging at Copenhagen University Hospital Rigshospitalet, Denmark, and who presented with acute spontaneous ICH on diagnostic neuroimaging. Data on the underlying cause of hemorrhage were retrospectively extracted from neuroimaging records and medical files. A possible association of hemorrhage causes with patient age was investigated using the Fisher-Freeman-Halton exact test and the Fisher exact test.

Ninety-one patients with acute ICH were identified. The most common cause was arteriovenous malformation (AVM, N=29, 31.9%). Overall, patient age and cause of ICH varied statistically significantly (P < 0.001). Acute hemorrhage in patients younger than six years was less likely caused by AVM (P < 0.001) and more likely by treatment-related conditions (P = 0.01).

This is the first observational retrospective study analyzing the causes of acute ICH in the pediatric population in Denmark. The most common cause was AVM, and we found significant association between AVMs and treatment-related hemorrhages with age.

This study sought to explore the clinical and process factors that, alone or in combination, influence the accuracy of stroke diagnosis in the emergency department (ED) by applying a novel design of experiments methodology.

We used design of experiments, a branch of applied statistics, to create a screening experiment comprised of patient simulation scenarios in which purposeful changes are made to prespecified factors thought to potentially influence the outcome of interest. We used 4 base case scenarios (typical and atypical acute ischemic stroke, intracerebral hemorrhage, and complex migraine [a stroke mimic]) and 12 prespecified clinical factors thought to influence stroke diagnosis (eg, patient age, history of seizure, and interruption occurring during patient assessment that the physician must attend to [distraction]) based on literature review and expert opinion. Experimental runs were designed using a modified fractional factorial design approach. Physicians, including postgraduate trainees from 3 health systems, were invited to participate. After each run, participants were asked to provide a diagnosis and their confidence in that diagnosis; both inperson and virtual assessments were conducted. We used multivariate regression to explore factor(s) influencing physician confidence in stroke diagnosis. Confidence was signed, with positive confidence corresponding to a stroke diagnosis and negative confidence to a nonstroke diagnosis, allowing confidence levels from the regression model to be translated to misdiagnosis.

A total of 27 physicians (12 neurology and 15 emergency medicine) completed 100 experimental runs. The typical ischemic stroke base case presentation was accurately diagnosed in every run, whereas the other 3 base cases were less accurately diagnosed. Stroke overdiagnosis occurred in the complex migraine case (83% false positive) and stroke underdiagnosis in the intracerebral hemorrhage case (36% false negative). Distraction during patient evaluation and the availability of a witness from whom relevant information could be obtained exhibited significant, independent effects on diagnostic confidence. Distractions of the physician had an even stronger influence on stroke diagnostic confidence when no witness was present.

Applying the design of experiments methods to simulated scenarios, we found that distraction and presence of a witness significantly influenced diagnostic confidence and thus, stroke diagnostic accuracy. These findings should inform future studies to understand the underlying mechanisms of ED misdiagnosis and in the design of future interventions to improve stroke diagnostic formulation.

Infectious intracranial aneurysms(IIAs) are a rare complication of systemic and intracranial infections. IIAs are often diagnosed upon rupture, often leading to subarachnoid hemorrhage(SAH) similar to non-infectious aneurysms(non-IIAs). Although vasospasm is a common complication of both SAH and meningitis, the incidence, timing, and management of vasospasm in IIA patients are yet to be studied.

This is a retrospective study of patients presenting with SAH secondary to IIAs or non-IIAs between 2015 and 2023. Patients with SAH who died within 48 h were excluded. Patients' charts were reviewed for demographics, imaging findings, management, and the timing, severity, and management of vasospasm. Propensity-score-matching was used to compare patients with IIAs versus non-IIAs. Primary outcome included incidence of vasospasm. Secondary outcomes included time to vasospasm, and treatment response.

Twenty patients with ruptured IIAs were included in this study of which 30%(n = 6) developed vasospasm. Among patients with vasospasm, 83% had neurological deficits due to vasospasm. Vasospasm was managed using intrathecal nicardipine in 5 patients(83%), while 2 patients required intra-arterial vasodilators. Compared to propensity-score-matched non-IIAs, patients with IIAs had a comparable rate of vasospasm(30%vs39%,P = 0.448). However, patients with IIAs developed vasospasm significantly earlier with a mean time from rupture to vasospasm of 3.5 ± 1.05days compared to 5.27 ± 3.15days in non-IIAs(P = 0.002).

Patients with ruptured IIAs are at a similar risk of vasospasm compared to non-IIAs; however, they develop symptomatic and radiographic evidence of vasospasm earlier in the course of their disease. These findings argue for the need for routine and early screening for vasospasm in patients with ruptured IIAs.

Pathologically low brain glucose levels, referred to as neuroglucopenia, are associated with unfavorable outcomes in neurocritical care patients. We sought to investigate whether an increase in serum glucose levels would be associated with a reduction of neuroglucopenia.

In this retrospective analysis of prospectively collected data, we included 55 consecutive patients with spontaneous subarachnoid hemorrhage who underwent cerebral microdialysis (CMD) monitoring. Neuroglucopenia was defined as CMD-glucose levels < 0.7 mmol/l. We identified systemic glucose liberalization events, defined as a day with median serum glucose levels < 150 mg/dl, followed by a day with median serum glucose levels > 150 mg/dl, and compared concentrations of cerebral metabolites between these days. Unfavorable outcome was defined as modified Rankin Scale score ≥ 3 at 3 months after the bleeding.

Episodes of neuroglucopenia were more frequent in patients with unfavorable outcome (19.8% [19.3-20.3%] vs. 10.9% [10.4-11.5%], p = 0.007). Sixty-nine systemic glucose liberalization events were identified in 40 patients. Blood glucose levels increased from 141.2 (138.7-143.6) mg/dl to 159.5 (157.0-162.2) mg/dl (p < 0.001), CMD-glucose levels increased from 1.44 (1.39-1.50) mmol/l to 1.68 (1.62-1.75) mmol/l (p = 0.001), and the frequency of neuroglucopenia decreased from 24.7% (22.9-26.5%) to 20.2% (18.7-21.8%) (p = 0.002) during these events. Liberalization was not associated with changes in CMD-lactate, CMD-pyruvate, CMD-lactate-to-pyruvate ratio, CMD-glutamate, or CMD-glycerol.

In conclusion, the liberalization of serum glucose concentrations to levels between 150 and 180 mg/dl was associated with a significant reduction of neuroglucopenia.

Prognostication after subarachnoid hemorrhage (SAH) is essential to guide clinical management and improve patient care.

To investigate whether decay rates of cerebrospinal fluid (CSF) red blood cells (RBC) and total protein (TP) after SAH predict functional outcome at 3 months.

Patients with SAH treated at the Neurological Intensive Care Unit Innsbruck with a first CSF sample (CSFfirst) within 72 h after admission and at least one subsequent sample were eligible for inclusion. Decay rates of RBC and TP were measured between CSFfirst and each subsequent measurement (Weeks 1-3). Modified Rankin Scale scores at 3 months ≤ 2 were defined as good functional outcomes.

A total of 97 patients with a median age of 61 years [25th; 75th percentile: 52;71] and a median Hunt and Hess score of 4 [3;5] were included. Daily RBC decay rates decreased over time, while daily TP decay rates were highest in Week 1, showed a nadir in Week 2, and increased again in Week 3. In multivariable analysis, higher RBC (adjusted odds ratio (adjOR): 1.13, 95% confidence interval (95% CI): 1.02-1.26, p = 0.025) and TP (adjOR: 1.01, 95% CI: 1.00-1.01, p = 0.031) decay rates at Week 3 predicted a good functional outcome at Month 3. RBC and TP decreasing below 1180 cells/μL and 127.5 mg/dL, respectively, at Week 3 were associated with good functional outcome at Month 3 (adjOR: 11.04, 95% CI: 3.21-38.02, p < 0.001 and 6.03, 1.68-21.67, p = 0.006).

Decay rates of CSF RBC and TP after SAH are associated with functional outcomes.

Early-onset seizures are common in aneurysmal subarachnoid hemorrhage (aSAH), with risk factors that have been explored. However, early-onset seizures in patients with angiogram-negative nonperimesencephalic SAH (an-SAH) are less understood. We sought to compare the incidence and risk factors of early-onset seizures between these groups.

We conducted a retrospective study of a cohort of consecutive patients admitted to an academic center between July 2016 and July 2023. Patients were categorized into aSAH or an-SAH based on imaging findings. Clinical data and electroencephalogram findings were retrieved and analyzed. Multivariable logistic regression analysis was used to determine risk factors for clinical or electrographic seizures, as well as other epileptic features.

We included 473 patients (63% female) in the final analysis, of whom 79 had an-SAH and 394 had aSAH. Patients with an-SAH were older (mean age 61.9 years [standard deviation 15.9] vs. 56.7 [standard deviation 13.4]; p = 0.02). The rate of clinical or electrographic seizures was similar between the two groups (13% in aSAH vs. 11% in an-SAH; p = 0.62). Highly epileptic features (electrographic seizures, ictal-interictal continuum, and periodic epileptic discharges) occurred more frequently in the aSAH group compared with the an-SAH group, although this difference was not significant (15% vs. 8%; p = 0.09). Risk factors for seizures in aSAH were Hunt and Hess grade (odds ratio [OR] 1.25 per grade increase, 95% confidence interval [CI] 1.05-1.49; p = 0.011), modified Fisher score (OR 1.64 per point increase, 95% CI 1.25-2.15; p < 0.001), cerebral infarct (OR 3.64, 95% CI 2.13-6.23; p < 0.001), and intracerebral hemorrhage (OR 10, 95% CI 1.35-76.9; p = 0.017). However, none of these factors were associated with seizures in an-SAH.

Early-onset seizures occur at similar rates in patients with an-SAH and aSAH. However, seizure risk factors appear to differ between these groups. Larger prospective studies are needed to identify predictors of seizures in patients with an-SAH.

Stroke remains a leading cause of disability worldwide, underscoring the urgent need for novel and innovative therapeutic strategies to enhance neuroprotection, support regeneration, and improve functional recovery. Previous research has shown that phytochemicals such as curcumin, tannic acid, gallic acid, ginsenosides, resveratrol, and isorhamnetin display extensive neuroprotective properties, including antioxidant, anti-inflammatory, and anti-apoptotic effects. These natural compounds could also promote neurogenesis, angiogenesis, and the preservation of the blood-brain barrier. Despite their promising bioactivities, clinical application is often limited by poor solubility, bioavailability, and suboptimal pharmacokinetics. Hydrogels offer a promising solution by encapsulating and controlling the gradual release of these phytochemicals directly at the site of injury. Recent advancements in hydrogel formulations, constructed from biopolymers and functionalized using nanotechnological approaches, could significantly improve the solubility, stability, and targeted delivery of phytochemicals. Controlled release profiles from pH-sensitive and environment-responsive hydrogels could ensure that the compounds' therapeutic effects are optimally timed with individual and critical stages of post-stroke repair. Moreover, hydrogel scaffolds with tailored material properties and biocompatibility can create a favorable microenvironment, reducing secondary inflammation, enhancing tissue regeneration, and potentially improving functional and cognitive outcomes following stroke. This review explores the potential of integrating phytochemicals within hydrogel-based delivery systems specifically designed for post-stroke recovery. The design and synthesis of biocompatible, biodegradable hydrogels functionalized especially with phytochemicals and their applications are also discussed. Lastly, we emphasize the need for additional robust and translatable preclinical studies.

Brain tissue hypoxia and metabolic dysfunction are common in patients with subarachnoid hemorrhage (SAH) and may worsen prognosis. We aimed to assess the impact of episodes of low brain tissue partial pressure of oxygen (PbtO2) and metabolic dysfunction (elevated lactate pyruvate ratio-LPR measured by cerebral microdialysis, CMD) on neurological outcome at 6 months.

This is a multicentric retrospective cohort study of SAH patients admitted to 5 neurocritical care units who required invasive multimodal neuromonitoring. The relationship between episodes of low PbtO2 combined with elevated LPR and 6-month Glasgow Outcome Scale (GOS) was visualized in a color-coded plot. We performed a multivariate analysis of the association between the percentage of time spent with the low PbtO2 and/or high LPR and neurological outcome and mortality at 6 months.

We included 232 SAH patients with a median of 117 (IQR 77-154) h of monitoring per patient. The color-coded plot illustrated that combined episodes of low PbtO2 and elevated LPR were prevalent in patients with unfavorable neurological outcome (e.g., GOS 1-3). This association was less evident in patients with isolated low PbtO2 or isolated elevated LPR. In a multivariate model, the cumulative PbtO2/LPR burden was independently associated with unfavorable neurological outcome.

In this study, low PbtO2 and metabolic insults were more prevalent among SAH patients with unfavorable long-term neurological outcome at 6 months. The role of multimodal neuromonitoring in guiding therapies and potentially influencing the outcome of these patients warrants further studies.

Subarachnoid hemorrhage (SAH) is a critical condition with high morbidity and mortality, often complicated by cerebral vasospasm and delayed cerebral ischemia (DCI). Nicardipine, a calcium channel blocker, has shown promise in mitigating these risks. This meta-analysis evaluates the effectiveness and safety of nicardipine prolonged-release implants in reducing SAH complications.

A comprehensive literature search was conducted in PubMed, Cochrane Library, Embase, and ClinicalTrials.gov, identifying seven eligible studies involving 775 patients with SAH. Randomized controlled trials (RCTs) and observational studies were included. The primary outcome was the incidence of cerebral vasospasm, while secondary outcomes included DCI and delayed ischemic neurologic deficit (DIND). Risk ratios (RR) with 95% confidence intervals (CI) were calculated using random-effects meta-analysis.

Nicardipine implants significantly reduced the risk of cerebral vasospasm (RR = 0.38, 95% CI [0.23, 0.61], P < 0.0001) and DCI (RR = 0.33, 95% CI [0.18, 0.58], P = 0.0002). However, no significant effect was observed on DIND (RR = 0.68, 95% CI [0.33, 1.39], P = 0.29) or functional outcomes (modified Rankin scale; RR = 2.03, 95% CI [0.85, 4.87], P = 0.11).

Nicardipine prolonged-release implants are effective in reducing the incidence of cerebral vasospasm and DCI in SAH patients, with potential benefits in preventing these complications. However, they do not significantly impact functional outcomes, indicating the need for complementary rehabilitation strategies. Further large-scale studies are needed to confirm these findings.

Hydrogel-based bioelectronic systems offer significant benefits for point-of-care diagnosis, treatment of cardiac and cerebral disease, surgical procedures, and other medical applications, ushering in a new era of advancements in medical technology. Progress in hydrogel-based bioelectronics has advanced from basic instrument and sensing capabilities to sophisticated multimodal perceptions and feedback systems. Addressing challenges related to immune responses and inflammation regulation after implantation, physiological dynamic mechanism, biological toxicology as well as device size, power consumption, stability, and signal conversion is crucial for the practical implementation of hydrogel-based bioelectronics in medical implants. Therefore, further exploration of hydrogel-based bioelectronics is imperative, and a comprehensive review is necessary to steer the development of these technologies for use in implantable therapies for cardiac and brain/neural conditions. In this review, a concise overview is provided on the fundamental principles underlying ionic electronic and ionic bioelectronic mechanisms. Additionally, a comprehensive examination is conducted on various bioelectronic materials integrated within hydrogels for applications in implantable medical treatments. The analysis encompasses a detailed discussion on the representative structures and physical attributes of hydrogels. This includes an exploration of their intrinsic properties such as mechanical strength, dynamic capabilities, shape-memory features, stability, stretchability, and water retention characteristics. Moreover, the discussion extends to properties related to interactions with tissues or the environment, such as adhesiveness, responsiveness, and degradability. The intricate relationships between the structure and properties of hydrogels are thoroughly examined, along with an elucidation of how these properties influence their applications in implantable medical treatments. The review also delves into the processing techniques and characterization methods employed for hydrogels. Furthermore, recent breakthroughs in the applications of hydrogels are logically explored, covering aspects such as materials, structure, properties, functions, fabrication procedures, and hybridization with other materials. Finally, the review concludes by outlining the future prospects and challenges associated with hydrogels-based bioelectronics systems.

In aneurysmal subarachnoid hemorrhage, rebleeding prior to securing the culprit aneurysm leads to significant morbidity and mortality. Elevated blood pressure has been identified as a possible risk factor. In this systematic review, we evaluated the association between elevated blood pressure and aneurysm rebleeding during the unsecured period. We searched MEDLINE, Embase + Embase Classic, and CENTRAL, from inception to March 8th, 2024. We included studies of adults with aneurysmal subarachnoid hemorrhage reporting at least one blood pressure measurement during the unsecured period and a measure of association with rebleeding. Results were stratified by blood pressure thresholds, effect measure, and adjustment for confounding. Separate meta-analyses were performed for each of these groups. Our search identified 5,209 citations. After screening, 15 studies were included in our review. All studies were observational in design and at moderate or high risk of bias. Meta-analysis of the unadjusted results produced mixed findings across the systolic blood pressure (SBP) thresholds: SBP > 140 mm Hg, unadjusted odds ratio (uOR) 1.03 (95% confidence interval [CI] 0.55-1.93; I2 = 66%); SBP > 160 mm Hg, uOR 3.35 (95% CI 1.44-7.81; I2 = 83%); SBP > 180 mm Hg, uOR 1.52 (95% CI 0.40-5.81; I2 = 89%); and SBP > 200 mm Hg, uOR 7.99 (95% CI 3.60-17.72; I2 = 0%). Meta-analysis of adjusted results was only possible at an SBP > 160 mm Hg; adjusted hazard ratio 1.13 (95% CI 0.98-1.31; I2 = 0%). The overall quality of evidence as assessed by the Grading of Recommendations, Assessment, Development, and Evaluations tool was rated as very low. Based on very low quality evidence, our systematic review failed to determine whether there is an association between elevated blood pressure during the unsecured period and increased risk of culprit aneurysm rebleeding.

Subarachnoid hemorrhage (SAH) is a critical condition that has far-reaching implications for public health systems globally due to its severe consequences and long-term disabilities. This study aims to provide a comprehensive analysis of SAH trends from 1990 to 2021 and project future trends up to 2041, aiding in better understanding and management of its global burden.

We utilized data from the GBD (Global Burden of Disease) 2021 database, using joinpoint regression, frontier, and decomposition analyses to assess changes in SAH burden. Bayesian Age-Period-Cohort modeling was implemented to predict future trends. Our study included populations from 204 countries and territories.

From 1990 to 2021, SAH incidence decreased by -1.03% for men and -1.16% for women, while mortality rates declined by -2.56% for men and -2.69% for women. Middle sociodemographic index locations and East Asia experienced substantial declines, particularly among women. However, countries like the Philippines and Turkmenistan showed increasing trends. Population aging and growth significantly contributed to these trends, while epidemiological changes led to reductions in SAH burden. The prediction model forecasts continued decreases in SAH mortality and disability-adjusted life years over the next 20 years, although incidence rates may slightly increase.

The global burden of SAH has significantly diminished from 1990 to 2021, with considerable variations across regions, sexes, and countries. Ongoing and future research should prioritize high-risk populations and develop innovative interventions to further decrease SAH incidence and enhance outcomes.

Background: Cerebral vasospasm after craniotomy tumor (CVACT) is a rare complication that can occur following tumor craniotomy and significantly affects the outcome of patients. Unfortunately, it is not well understood, leading to delayed and ineffective management. This study aims to investigate CVACT by examining the factors contributing to its occurrence, its underlying mechanisms, diagnostic approaches, management strategies, and outcomes. The goal is to identify the characteristics and risk factors associated with CVACT, its clinical symptoms, diagnostic methods, management options, and potential outcomes. Methods: A systematic search used relevant keywords to identify cases of "cerebral vasospasm" after tumor resection in PubMed and Science Direct databases. Relevant cross-references were added by manually searching the references of all retrieved articles. Result: We included 60 inclusion patients from 14 case reports and 13 case series with 33 (55%) females and 27 (45%) males with a mean age of 44.05 ± 16.8 years. The most common tumors were pituitary adenomas, which were found in 22 (36.66%), the most common tumor location was the middle cranial fossa (75%), and the most common surgery technique used was transsphenoidal surgery (50%). Most of those who experience vasospasm have a craniotomy with the TSS technique (50%) with complications of intraoperative bleeding. The range of onset of VS symptoms postoperatively was 0-30 days (mean 6.59 d). The symptoms included asymptomatic, headache, loss of vision, hemiparesis, diplopia, etc. The vascular involvement was mainly anterior circulation (78.33%). The diagnostic tools most commonly used were angiography and transcranial doppler (TCD). The most common management of VS from the included studies was pharmacology. The survival rate was 61.66%. We found the tumor location and vascular-affected vasospasm were significantly correlated with mortality rates: p = 0.015 and p = 0.02. Conclusions: Cerebral vasospasm after craniotomy tumor removal (CVACT) frequently arises in tumors situated in the medial cranial fossa, predominantly pituitary adenomas and meningiomas. The minimally invasive surgical approach of TSS may contribute to the mechanism of CVACT incidence. The existence of preoperative vascular pathology, as encasement or narrowing, appears to be a predictor alongside the incidence of intra- or postoperative hemorrhage. The vascular structures most susceptible to vasospasm are located in the anterior circulation of the Willis circle, which appears to correlate with the vascular problems that typically undergo preoperative encasement of the internal carotid artery (ICA). The most reliable and real time diagnostic instrument employed is TCD, while imaging continues to be the gold standard. Nimodipine treatment continues to be a viable therapeutic option that can enhance patient outcomes.

Reduced health-related quality of life (HR-QoL) is common after spontaneous subarachnoid hemorrhage (SAH). Here, we aimed to describe the prevalence of HR-QoL impairment one year after SAH and to identify associated factors.

In this prospective cohort study, HR-QoL was assessed in 183 patients one year after SAH. We used the Short-Form-36 (SF-36) questionnaire, which consists of eight health domains that can be subdivided into mental and physical health components. Participants responded to scales on subjective attention deficit, mental health symptoms, and fatigue. Functional outcome was assessed with the modified Rankin Scale (mRS). Multivariable regression analysis was used to identify factors associated with reduced HR-QoL (MCS or PCS < 40).

Patients were 53 years of age (IQR, 46-61) and presented with a median Hunt&Hess score of 2 (2-3). HR-QoL was reduced in 66/183 patients (36%) with the highest abnormality in physical and emotional role. A lower Hunt&Hess score (p = 0.036), female sex (p = 0.017), self-reported depression (p = 0.001), fatigue (p < 0.001), and reduction of drive (p = 0.019) were associated with overall reduced HR-QoL and explained 68.9% of the observed variance. 26% (n = 48) scored below the normal range on the MCS, and independent associations emerged for self-reported anxiety and depression, fatigue, and reduction of drive. A reduction in the PCS was reported by 35 (19%) patients and independent associations were found for worse three-month functional outcome and fatigue.

One in three patients reported a reduction in HR-QoL one year after SAH. Mental health problems and fatigue had a significant impact on HR-QoL.

Neuroinflammation may contribute to outcomes following subarachnoid haemorrhage (SAH). Human cerebrospinal fluid (CSF) cytokine data is limited and its relationship with systemic inflammation is unknown. This study compares the inflammatory responses in CSF and plasma compartments, and their associations with outcome.

Ten cytokines were measured in CSF and plasma from 98 SAH patients and 18 control patients. Outcome was assessed with the modified Rankin scale (mRS) and Subarachnoid Haemorrhage Outcome Tool (SAHOT) at days 7, 28, 90 and 180. Regression analyses and principal component analysis (PCA) were performed.

Median levels of all CSF cytokines and plasma IL-6 were higher in SAH patients than controls (p < 0.001). Plasma IL-6 peaked earlier (3 days after SAH) than CSF cytokines (7-9 days after SAH). On day 7, CSF levels were greater than plasma levels for all cytokines (p < 0.001). There was no correlation between individual cytokines in the plasma and CSF. Only plasma IL-6 levels correlated with long-term outcome (mRS (p = 0.009) and SAHOT (p = 0.007) at day 180), accounting for WFNS and blood volume. Seven principal components of cytokines had an eigenvalue greater than 1. Only the first plasma principal component (dominated by IL-6, IL-8, IL-12, IL-13, and TNF-α) was associated with outcomes (p < 0.05). Mediation analysis suggested the effects of WFNS and blood volume on outcome were not mediated by IL-6 or this principal component.

SAH provokes an inflammatory response in CSF and plasma. The response pattern is different and distinct in each compartment. Each compartment's relationship with outcomes differ, suggesting separate roles in SAH pathophysiology. Plasma IL-6 is independently associated with outcomes.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a disease associated with high mortality, caused by the rupture of a cerebral aneurysm. Decision-support scoring systems used for managing unruptured aneurysms (UIAs) include only radiological parameters related to the size and configuration of the aneurysm, without incorporating blood-based markers. Our aim is to identify a serum marker that shows a correlation with aneurysm size in patients with ruptured aneurysms. Methods: Arterial blood samples were collected from patients who experienced aSAH within 24 h of the ictus, and serum desmosine levels were determined using ELISA. The morphological parameters of the aneurysms were assessed during 3D DSA. A favorable outcome was defined as a 3-month mRS score of 0-3. Results: This study included 135 aSAH patients and 25 controls. (i) The desmosine level in serum collected within 24 h after aneurysm rupture in patients with aSAH was significantly higher compared to the serum level in the control group (aSAH: 0.737 ng/mL [IQR: 0.401-1.214], vs. control: 0.365 ng/mL [IQR: 0.251-0.531], p < 0.001); (ii) examining the size of ruptured aneurysms, patients with aneurysms larger than 7 mm had significantly higher serum desmosine levels than those with aneurysms smaller than 7 mm; (iii) in the group with aneurysms smaller than 7 mm, serum desmosine levels correlated with the aneurysm neck width and the size ratio. Conclusions: Serum desmosine shows a strong correlation with the size of ruptured aneurysms in aSAH patients.

Although the use of vasopressors is recommended after aneurysmal subarachnoid hemorrhage (aSAH) to maintain adequate cerebral perfusion pressure, data on potential adverse effects on delayed cerebral ischemia (DCI) are lacking. The aim of this study was to evaluate the effects of early high-dose vasopressor therapy with norepinephrine alone or additional vasopressin on the subsequent occurrence of DCI, DCI-related infarction and functional outcomes.

Retrospective evaluation of aSAH patients admitted between January 2010 and December 2022. Demographic, clinical and outcome data as well as daily norepinephrine equivalent (NEE) scores were collected. Potential risk factors for DCI, DCI-related infarction and functional outcome 3 months after discharge were assessed by logistic regression analyses.

A total of 288 patients were included. 208 patients (72%) received vasopressor therapy during the first 14 postictal days with a mean NEE score of 3.8 µg/kgBW/h. The highest NEE scores were observed in the acute phase after hemorrhage and mainly in poor-grade patients. The mean NEE score during the postictal days 1-4 was significantly higher in patients who developed DCI or DCI-related infarction and who had an unfavorable functional outcome. Multivariable logistic regression analysis identified a high NEE score on postictal days 1-4 as an independent predictor of DCI and unfavorable functional outcome.

Vasopressor use is common in aSAH patients in the acute phase after hemorrhage. Our results suggest that high NEE scores during the first 4 days after ictus represent an independent prognostic factor and might aggravate the complex cerebral sequelae associated with the disease.

The effect of a liberal red-cell transfusion strategy as compared with a restrictive strategy in patients during the critical care period after an aneurysmal subarachnoid hemorrhage is unclear.

We randomly assigned critically ill adults with acute aneurysmal subarachnoid hemorrhage and anemia to a liberal strategy (mandatory transfusion at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (optional transfusion at a hemoglobin level of ≤8 g per deciliter). The primary outcome was an unfavorable neurologic outcome, defined as a score of 4 or higher on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability), at 12 months. Secondary outcomes included 12-month functional independence as assessed with the Functional Independence Measure (FIM; scores range from 18 to 126) and quality of life as assessed with the EuroQol five-dimension, five-level (EQ-5D-5L) utility index (scores range from -0.1 to 0.95) and a visual analogue scale (VAS; scores range from 0 to 100); on each assessment, higher scores indicate better health status or quality of life.

A total of 742 patients underwent randomization at 23 centers. The analysis of the primary outcome at 12 months included 725 patients (97.7%). An unfavorable neurologic outcome occurred in 122 of 364 patients (33.5%) in the liberal-strategy group and in 136 of 361 patients (37.7%) in the restrictive-strategy group (risk ratio, 0.88; 95% confidence interval [CI], 0.72 to 1.09; P = 0.22). The mean (±SD) FIM score was 82.8±54.6 in the liberal-strategy group and 79.8±54.5 in the restrictive-strategy group (mean difference, 3.01; 95% CI, -5.49 to 11.51). The mean EQ-5D-5L utility index score was 0.5±0.4 in both groups (mean difference, 0.02; 95% CI, -0.04 to 0.09). The mean VAS score was 52.1±37.5 in the liberal-strategy group and 50±37.1 in the restrictive-strategy group (mean difference, 2.08; 95% CI, -3.76 to 7.93). The incidence of adverse events was similar in the two groups.

In patients with aneurysmal subarachnoid hemorrhage and anemia, a liberal transfusion strategy did not result in a lower risk of an unfavorable neurologic outcome at 12 months than a restrictive strategy. (Funded by the Canadian Institutes of Health Research and others; SAHARA ClinicalTrials.gov number, NCT03309579.).

Stroke is a multifaceted disease with genetic and environmental components like diet and lifestyle. The central nervous and immune systems display complex interactions, with the peripheral immune response participating in brain injury and repair mechanisms following stroke. The bidirectional communication between the injured brain and peripheral blood presents an opportunity to investigate the molecular changes in the latter. There is substantial heterogeneity in stroke pathogenesis, pathophysiology, comorbidities, and response to treatment and outcome. This is captured and underscored by heterogeneity in the peripheral blood transcriptome. The current review highlights the role of the human peripheral blood transcriptome architecture for molecular phenotyping of different stroke etiologies and comorbidities, and for identifying underlying molecular correlates with clinically important variables and outcomes. Specific transcriptome features can potentially provide targets for clinical translation and for prioritizing genes and pathways for evaluation in experimental models. We also propose an approach to study the patient-specific transcriptional architecture and uncover the combinatorial heterogeneity in altered pathways in stroke patients that can also guide the search for treatment and prevention targets. Deciphering the molecular heterogeneity of stroke in a tissue that can be easily accessed and monitored, such as peripheral blood, may improve clinical trial success.

Decompressive craniectomy (DC) is a last-tier treatment for managing refractory intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (aSAH), though concerns persist about whether it primarily prolongs survival in a state of severe disability. This study investigated patient characteristics, surgical indications, complications, and outcomes following DC in aSAH.

In this Swedish, retrospective multi-center study, 123 aSAH patients treated with DC between 2008-2022 were included. Data collection included demographic details, aSAH characteristics, injury severity, DC indication, complications, and outcome at roughly six months post-DC (modified Rankin scale [mRS]) dichotomized as survival vs. mortality (0-5 vs. 6) and favorable vs. unfavorable (0-3 vs. 4-6).

The median age was 53 years and 66% were females. Two thirds presented with a WFNS grade 4-5 and 83% with a Fisher grade 4 hemorrhage. Most aneurysms were located at the middle cerebral artery (65%) and treated with clip ligation (59%). DC significantly reduced midline shift from 9 to 2 mm and obliteration rates of basal cisterns from 95 to 22% (p < 0.05). Reoperation for hematomas or extension of the DC were rare (< 5%). At follow-up, 20% were deceased, while 33% had recovered favorably. In univariate logistic regressions, younger age was associated with favorable outcome and reduced mortality. Other patient demographics, injury severity, and factors related to the DC surgery lacked association with outcome.

aSAH patients treated with DC presented with severe primary brain injuries and signs of intracranial hypertension. DC resulted in radiological improvements regarding mass effect and a low rate of postoperative complications. Although the results were based on a selected population of aSAH patients, an encouraging rate of favorable outcome was found, particularly among younger patients. However, the absence of additional outcome predictors underscores the ongoing challenges in improving patient selection for DC in aSAH.

Animal studies have suggested that valproic acid (VPA) is neuroprotective in aneurysmal subarachnoid hemorrhage (SAH). However, the effect of VPA on SAH outcomes in humans has not been investigated.

We conducted a retrospective analysis of 123 patients with nontraumatic SAH. Eighty-seven patients had an aneurysmal source and 36 patients had no culprit lesion identified. We used stepwise logistic regression to determine the association between VPA and delayed cerebral ischemia (DCI), radiographic vasospasm, and discharge modified Rankin Scale (mRS) score >3.

All 18 patients who received VPA underwent coil embolization of their aneurysm. VPA use did not have a significant association with DCI on adjusted analysis (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 0.20-5.80). The association between VPA use and vasospasm was OR = 0.64 (0.19-1.98) and discharge mRS > 3 was OR = 0.45 (0.10-1.64). Increased age (OR = 1.04, 1.01-1.07) and Hunt and Hess grade >3 (OR = 14.5, 4.31-48.6) were associated with poor discharge outcome (mRS > 3). Younger age (OR = 0.96, 0.93-0.99), modified Fisher Scale (mFS) score = 4 (OR = 4.14, 1.81-9.45), and Hunt and Hess grade >3 (OR = 2.92, 1.11-7.69) were all associated with development of radiographic vasospasm. There were no complications associated with VPA administration.

We did not observe an association between VPA and the rate of DCI. We found that VPA use was safe in SAH patients who have undergone endovascular treatment of their aneurysm.

Aim This study aims to evaluate the effect of subarachnoid hemorrhage (SAH) severity on contrast media (CM) arrival time in head computed tomography angiography (CTA) at SAH onset. Method A total of 67 patients who underwent head CTA were evaluated; 41 patients developed SAH (SAH group), and 26 patients had suspected unruptured cerebral aneurysms (non-SAH group). The patients of the SAH group were divided into mild (grades I-III), semi-severe (grade IV), and severe (grade V) groups according to Japanese guidelines. CM arrival time was measured for each case. Results The CM arrival time increased with SAH severity. The semi-severe and severe groups exhibited significantly longer CM arrival times compared to the non-SAH group (non-SAH: 11.1 ± 2.03, mild: 13.2 ± 2.97, semi-severe: 15.8 ± 3.45, severe: 16.6 ± 3.40). Conclusion The CM arrival time increases with SAH severity in head CTA at SAH onset. Therefore, it is important for operators to be aware of the possibility of slower-than-usual timing in severe cases of SAH.

The optimal duration of external ventricular drain (EVD) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is debatable. We sought to determine the association of EVD duration and output with outcomes, including cerebral infarct.

We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2023. Multivariable logistic regression was used to determine the association of EVD duration and output with outcomes, including cerebral infarct prior to discharge, poor outcome defined as 3-month modified Rankin Scale (mRS) 3-6 and ventriculoperitoneal (VP) shunt placement.

We reviewed 429 cases of aSAH and included 306 patients who received EVD with mean age 57.9 years (SD 13.9), 67 % female and 69 % white. Longer EVD duration was associated with higher odds of cerebral infarct (OR 1.04 for each day increase, 95 % CI 1.01-1.07; p = 0.003) independent of age, sex, Hunt and Hess grade and modified Fisher scale. Longer EVD duration was also associated with poor functional outcomes (OR 1.03 per each day increase, 95 % CI 1.01-1.06; p = 0.019) and VP shunt placement (OR 1.15 per each day increase, 95 % CI 1.09-1.21; p < 0.001) independent of other predictors. There was no independent association between daily EVD output and outcomes.

Although longer EVD duration was associated with more cerebral infarcts and poor outcomes in patients with aSAH, no causal interferences can be drawn. Larger multicenter prospective studies are needed to better strategize the mode, duration, and amount of CSF drainage in aSAH patients.

Aneurysmal subarachnoid hemorrhage (SAH) is frequently complicated by permanent shunt-dependent hydrocephalus, but it is difficult to predict which patients are at highest risk. This study seeks to identify novel variables associated with shunt dependency after aneurysmal SAH and to create a predictive algorithm that improves upon existing models.

Retrospective case-control design was used. Patients who presented with aneurysmal SAH and external ventricular drain (EVD) placement were included. Those who successfully weaned off their EVD were compared with those who required shunt placement. Demographic and treatment data were analyzed using univariate and multivariable logistic regression. Receiver operating characteristic was used to compare the proposed model's performance against existing ones (Barrow Neurological Institute, chronic hydrocephalus ensuing from SAH score, and shunt dependency in SAH scores).

One hundred patients were included: 50 no shunt and 50 shunt. Advanced age, elevated modified Graeb score, intraventricular hemorrhage, increased clot thickness, acute hydrocephalus, and cerebrospinal fluid protein >110 mg/dL prior to wean attempt were all found to be significantly associated with progression to shunt-dependency (P = 0.0351, 0.0022, 0.0407, 0.0274, 0.0014, and 0.0064, respectively). Multivariate regression demonstrated an area under the curve of 0.7852 (P < 0.0001), outperforming those of the other models.

Our study suggests that elevated modified Graeb score on initial computed tomography and high cerebrospinal fluid protein levels prior to EVD wean are important prognostic indicators for the development of shunt dependency after aneurysmal SAH. Integrating these findings into clinical practice may aid in earlier and more targeted decision-making.

Aneurysmal subarachnoid hemorrhage (aSAH) carries high morbidity and mortality with survivors often requiring extended care at skilled nursing facilities (SNF). Predictors of SNF discharge to home (SNFdcH) remain unclear.

Retrospective review of a single-center prospectively maintained aSAH database from June 2016-March 2024 was conducted. Patients discharged to SNF were grouped by subsequent discharge to home. Predictors of discharge to home and facility length of stay (LOS) were determined using t-tests, Fisher analyses, and cumulative link modeling.

Of 450 aSAH patients, 61 (13.5%) were discharged to SNFs. 49 (80.3%) returned home, with 61% achieving mRS <3 at discharge. Discharged patients were younger (mean 63.3 ± 11.5 vs 70.2 ± 9.3 years, P = .040) with lower median modified Fisher scores (3 [IQR 3-4] vs 4 [4-4], P = .046). Tracheostomy (OR = .14, 95% CI [.02, .75], P = .023) and gastrostomy tube (PEG) placement (OR = .13, 95% CI: .03-.51, P = .003) decreased the odds of SNFdcH. Discharged patients had shorter hospital LOS (26 ± 10 vs 39 ± 15 days, P < .001) and lower median modified Rankin scores (mRS) at hospital discharge (4 [4-5] vs 5 [4-5], P = .028) and at 90 days post-discharge (4 [3-5] vs 6 [5-6], P = .001). Multivariable regression identified age, PEG, and hospital LOS as predictors of SNFdcH. Tracheostomy and PEG predicted SNF LOS.

Most aSAH patients discharged from SNFs returned home, with 61% achieving mRS <3. Patients not discharged were medically complex with neurological deficits. These findings may guide care discussions and highlight the role of SNFs in bridging hospitalization and independence.