Brain Hemorrhages最新文献

Objective

Clazosentan (CLA) reduces cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, adverse events including pulmonary edema were reported. We examined whether the strict management of fluid balance reduces the adverse events and improves patient outcomes.

Methods

Patients with aSAH between 2020 and 2023 were included. They were divided into pre-CLA (before CLA approval) and post-CLA (after approval) groups. The patients in the post-CLA group were further divided into the post-CLA1 (before the change in fluid management) and post-CLA2 (after the change) groups. To achieve fluid balance of 0–500 ml/day according to the modified protocol, the infusion volume was restricted.

Results

The daily fluid balance increased from the pre-CLA to the post-CLA1 periods (p = 0.01). The protocol changes decreased the pulmonary edema (post-CLA1 vs. post-CLA2, 44 vs. 22 %, p = 0.09) and discontinuation of CLA (44 vs. 9 %, p < 0.01). The incidence of symptomatic spasm (SS) and delayed cerebral infarction (DCI) in the post-CLA2 were slightly reduced without significant differences (SS: 17 vs. 13 %, p = 0.69; DCI: 11 vs. 9 %, p = 1.00).

Conclusion

Strict management of fluid balance during CLA treatment reduced the adverse events and discontinuation of CLA administration. Fluid restriction may positively affect the management of cerebral vasospasms.

Objective

Pulmonary complications, which are occasionally severe, are common adverse events following the administration of clazosentan. This study aimed to identify factors associated with severe pulmonary adverse events due to clazosentan after aneurysmal subarachnoid hemorrhage (aSAH).

Methods

We conducted a retrospective study of 59 patients transported to our hospital and diagnosed with aSAH between April 2022 and May 2023.

Results

The analysis included 33 patients who were treated with clazosentan. Pulmonary complications occurred in 20 patients (61 %) and clazosentan administration was discontinued due to severe pulmonary complications in 7 patients (21 %). The cardiothoracic ratio on admission was significantly higher (57 % vs. 49 %, p = 0.0081) and clazosentan was initiated earlier after aSAH onset (42 vs. 66 h, p = 0.047) in patients who discontinued clazosentan compared with patients who completed administration of clazosentan. The median duration of clazosentan administration was 3.2 days in the discontinuation group. No significant associations were found between the time of clazosentan initiation and the incidence of angiographic vasospasm, delayed cerebral ischemia, or 90-day modified Rankin scale.

Conclusions

The risk of severe pulmonary complications is higher in patients with high cardiothoracic ratios on admission, and delaying clazosentan initiation may prevent pulmonary complications even in high-risk cases.

An aneurysmal subarachnoid hemorrhage (aSAH) is a devastating event associated with a high mortality and morbidity rate. Though numerous medications are used to prevent cerebral vasospasm and vasospasm-related cerebral infarction after aSAH, no effective pharmacological treatment has been established. Clazosentan, a highly selective endothelin receptor type A antagonist, was approved for use in Japan in April 2022 based on results of two pivotal randomized, placebo-controlled phase 3 studies (JapicCTI-163369, JapicCTI-163368). These studies indicated that clazosentan significantly reduced the incidence of vasospasm-related morbidity and all-cause mortality after aneurysm coiling and clipping. Clazosentan is thus expected to become a “game changer” for improving the neurological prognosis after aSAH. However, other reports indicate that even when clazosentan or nimodipine are administered for prophylaxis against delayed neurological decline, patients treated with increased colloid administration or hypertonic saline (3% sodium chloride) load exhibit poor functional outcome and higher mortality, suggesting that extra fluid and sodium derived from prophylactic colloid administration contribute to negative outcomes after aSAH. Pharmacological treatments such as clazosentan in addition to perioperative management involving delivery of less water and sodium might be crucial for achieving better outcomes than conventional therapy. Based on a literature review, we present here the future perspectives regarding clazosentan and the necessity for modifying management of the water-electrolyte balance by focusing on endothelin-1 and blood–brain barrier disruption.

Objective

This study aimed to assess the changes in patient demographics, aneurysm characteristics, and treatment modalities for subarachnoid hemorrhage (SAH) over the past two decades.

Methods

We analyzed SAH 6,446 patients between 2002 and 2022, which was divided into three periods: 2002–2011 (FP), 2012–2021 (SP), and post-clazosentan 2022 (PC). The final cohort included 2878, 2016, and 152 patients in FP, SP, and PC groups, respectively. We examined patient demographics, surgical procedures, spasm prevention therapy, and delayed ischemic neurological deficits (DIND).

Results

The mean age of the patients increased over the study period (64, 66, and 68 years in FP, SP, and PC groups, respectively). Clipping was the predominant method during FP (79 %); however, coiling surpassed clipping in 2022 (coiling vs. clipping, 47 % vs. 46.3 %). Before clazosentan introduction, fasudil was the primary spasm prevention treatment (>80 %); however, its use decreased (63.9 %) after clazosentan introduction. DIND varied across FP, SP, and PC groups (37.4 %, 24.2 %, and 16.7 % respectively). Age and generation were significantly associated with DIND and irreversibility.

Conclusion

Regarding the management of patients with SAH, shift from clipping to coiling, and the introduction of new spasm prevention treatments such as clazosentan were observed, led to a decrease in DIND.

Objective

Cerebral vasospasm is an unelucidated complication of subarachnoid hemorrhage. Various treatments exist against cerebral vasospasms however, consensus on the optimal treatment is lacking. We use clazosentan, which is used to prevent cerebral vasospasm, with multidrug combinations. In this study, we aimed to clarify the initial results of using clazosentan in multidrug combinations in the real world.

Methods

We retrospectively investigated 54 patients who were treated for subarachnoid hemorrhage and received clazosentan. We compared the results of these patients on the basis of two groups: those with good outcomes (modified Rankin scale score: 0–3) and poor outcomes (4–6) at discharge.

Results

Among the patients, poor outcome was observed in 19 patients (35.2 %). Angiographic vasospasms occurred in 10 patients (good outcome [n = 6] vs. poor outcome [n = 4]; p = 0.73), and symptomatic vasospasms occurred in 4 patients (n = 2 vs. n = 2, p = 0.61). The incidence of pleural effusion (28.6 % vs. 73.7 %, p < 0.01) and the mean daily fluid balance (303.5 mL/day vs. 785.4 mL/day, p < 0.01) were higher in the poor outcome group.

Conclusion

Pleural effusion and high positive balance may be associated with poor outcome. However, the number of cases examined was small; therefore, further large-scale studies with a bigger sample size are needed.

COVID-19, or coronavirus infection, is an acute respiratory illness caused by the corona virus that can develop into a life-threatening form of ARDS. Extracorporeal membrane oxygenation (ECMO) is a highly effective treatment for life-threatening instances. One of the many complications associated with ECMO was bleeding. COVID patients are at risk for intracerebral bleeding due to several factors, including the drug's action on ACE2 receptors, leading to hypertension, as well as hypercoagulability, dysregulated immune response, DIC, and the use of anticoagulants.

Falx interhemispheric subdural hematoma (FISH) is a rare subtype of subdural hematoma that occurs between the cerebral hemispheres along with falx cerebri. It represents less than 0.5% of all subdural hematomas and is frequently misdiagnosed due to its rarity and nonspecific clinical presentation. We present a case of 59-year-old female with a history of urticaria and hypertension who developed FISH following minor head trauma. The patient experienced presyncope, nausea, dizziness, and headache. A non-contrast computed tomography (CT) scan of the head revealed FISH, and the patient was managed conservatively without surgical intervention. This case report highlights the importance of considering FISH in the differential diagnosis of patients presenting with headache, dizziness, and presyncope, particularly in the setting of minor head trauma. We discuss the potential relationship between FISH, urticaria, and hypertension, as well as the possible causes of presyncope in this case, including orthostatic hypotension probably due to vagal nerve stimulation. Indeed, further studies are needed to explore these associations and to better understand the underlying mechanisms.

Objective

To appraise the overall outcomes of microsurgical resection of low-grade arteriovenous malformations (AVMs) in a low-middle-income country.

Methods

Data was collected prospectively from three different neurosurgical centres in Pakistan for this study and it lasted for two years. According to the Spetzler-Martin (S-M) grading system, patients diagnosed with cerebral AVMs were divided into three classes A, B, and C. AVMs of grade 1 and 2 were included in Class A. Class B contained grade 3 AVMs, while Class C contained grade 4 and 5 AVMs. All male and female patients in Class A were eligible for this study. Patients were evaluated postoperatively for seizures, haemorrhage, focal neurological deficits, and AVM cure rates. Morbidity, mortality, and functional recovery were used to evaluate the outcome. Functional recovery and cure rate were observed after 6 months of follow-up.

Results

There were a total of 22 patients. Mean age was 36.41 ± 14.32 SD years. There were 12 (54.5 %) male patients and 10 (45.5 %) female patients. 13 patients (59.1 %) presented with spontaneous intracerebral haemorrhage, while 9 patients (40.9 %) presented with seizures. 14 patients (63.6 %) had S-M grade 1 and 8 patients (36.4 %) had S-M grade 2. All patients underwent microsurgical resection. We discovered 4.5 % morbidity in our study. There was no postoperative mortality. At 6 months, an excellent functional outcome of 95.5 % (according to the Glasgow outcome scale) and 100 % cure rate was observed.

Conclusion

Microsurgery is a safe and effective treatment for low-grade AVMs in terms of morbidity, mortality, functional outcome and cure rates in our country.

Objective

This study aims to investigate the impact of the infection with the novel coronavirus Omicron variant on the outcomes of patients with severe spontaneous intracerebral hemorrhage.

Methods

We conducted a multicenter prospective non-randomized cohort study during the peak of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) Omicron strain epidemic. Clinical data were collected from nine centers in China between December 1, 2022, and February 28, 2023. Patients were categorized into good and poor outcomes groups based on modified Rankin Scale scores at discharge. Clinical characteristics were compared, and univariate and multivariate logistic regression analyses were performed. Additionally, coagulation function was compared between SARS-CoV-2 Omicron positive and negative patients.

Results

Among 86 included patients, 30 (35 %) had a favorable outcome, while 56 (65 %) had an unfavorable outcome. Of these, 32 (37 %) tested positive for SARS-CoV-2 Omicron, while 54 (63 %) tested negative. Multivariate analysis identified Glasgow Coma Scale score and hypertension as independent risk factors affecting outcomes (P < 0.05). Surprisingly, SARS-CoV-2 Omicron infection emerged as a protective factor for patient outcomes (P < 0.05). Additionally, SARS-CoV-2 Omicron-positive patients exhibited significantly elevated fibrinogen levels upon admission (P < 0.05).

Conclusion

In comparison to patients without SARS-CoV-2 Omicron infection, patients with severe spontaneous intracerebral hemorrhage who were co-infected with SARS-CoV-2 Omicron exhibited a more favorable short-term outcome.

Intracranial Hemorrhage (ICH) can lead to various clinical manifestations and complications. These include mental disorders that range from impaired cognitive function to disturbances in the sensorium, perception, thought content, and emotions. One of the most common outcomes of ICH is mood disturbances and cognitive dysfunction. Therefore, this study presents the case of a 50-year-old patient who came to the emergency room with a stroke and was diagnosed with ICH and a mental organic disorder after radiographic and laboratory examinations. The management of mental disorders must be given special attention in the care of ICH patients. This is because complications of Neurobehavioral after ICH are often recognized too late and lead to poor long-term patient outcomes. An increase in patient mortality can also occur, with decreased outcomes and quality of life, leading to sequelae.