Search

Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are common complications following SAH that contribute significantly to the poor outcomes observed in these patients. Intrathecal (IT) nicardipine delivered via an existing external ventricular drain is an off-label intervention that has been shown to be correlated with reduced DCI and improved patient outcomes. The current study aims to characterize the population pharmacokinetic (popPK) properties of intermittent IT nicardipine. Following informed consent, serial cerebrospinal fluid (CSF) samples were obtained from 16 SAH patients (50.4 ± 9.3 years old; 13 females) treated with IT nicardipine every 6 h (q6h, n = 8) or every 8 h (q8h, n = 8) for an average of 72 ± 21 doses. High-performance liquid chromatography was used to quantify CSF concentration from each sample. Our popPK analysis showed that the CSF pharmacokinetics of IT nicardipine in the cohort was adequately described by a two-compartment model with a lag time. Model parameter estimates were reliable (relative standard error <50%). Intracranial pressure influenced both the total clearance and the central volume of nicardipine (i.e., negative correlation, P <-.001). Calculated PK parameters were similar between q6h and q8h dosing regimens. Despite a small cohort of SAH patients, we successfully developed a popPK model to describe the nicardipine disposition kinetics in the CSF following IT administration. These findings may help inform future clinical trials designed to examine the optimal dosing of IT nicardipine., (© 2024 The Author(s). The Journal of Clinical Pharmacology published by Wiley Periodicals LLC on behalf of American College of Clinical Pharmacology.)

Background: The early phase of the COVID-19 pandemic led to significant healthcare avoidance, perhaps explaining some of the excess reported deaths that exceeded known infections. The impact of the early COVID-19 era on aneurysmal subarachnoid hemorrhage (aSAH) care remains unclear., Objective: To determine the impact of the early phase of the COVID-19 pandemic on latency to presentation, neurological complications, and clinical outcomes after aSAH., Methods: We performed a retrospective cohort study from March 2, 2012, to June 30, 2021, of all patients with aSAH admitted to our center. The early COVID-19 era was defined as March 2, 2020, through June 30, 2020. The pre-COVID-19 era was defined as the same interval in 2012 to 2019., Results: Among 499 patients with aSAH, 37 presented in the early COVID-19 era. Compared with the pre-COVID-19 era patients, patients presenting during this early phase of the pandemic were more likely to delay presentation after ictus (median, interquartile range; 1 [0-4] vs 0 [0-1] days, respectively, P < .001). Radiographic-delayed cerebral ischemia (29.7% vs 10.2%, P < .001) was more common in the early COVID-19 era. In adjusted analyses, presentation in the early COVID-19 era was independently associated with increased inhospital death or hospice disposition (adjusted odds ratio 3.29 [1.02-10.65], P = .046). Both latency and adverse outcomes returned to baseline in 2021., Conclusion: aSAH in the early COVID-19 era was associated with delayed presentation, neurological complications, and worse outcomes at our center. These data highlight how healthcare avoidance may have increased morbidity and mortality in non-COVID-19-related neurosurgical disease., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype., Methods: We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared., Results: Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6 months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016)., Conclusions: We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

The video highlights a challenging case of bilateral vertebral artery dissection presenting with subarachnoid hemorrhage. The patient was found to have a critical flow-limiting stenosis in his dominant right vertebral artery and a ruptured pseudoaneurysm in his left vertebral artery. A single-stage endovascular treatment with stent reconstruction of the right vertebral artery and coil embolization sacrifice of the left side was performed. The case highlights the rationale for treatment and potential alternative strategies.The video can be found here: https://youtu.be/e0U&#95;JE2jISw.

Background Although aspiration and stent retriever thrombectomy perform similarly in proximal occlusions, no comparative series are available in distal occlusions. We aimed to compare the 3 mm Trevo Retriever against the 3MAX thromboaspiration catheter in distal arterial occlusions. Methods A single-center retrospective review of a prospectively maintained databank for patients treated with the 3 mm Trevo stent retriever or 3MAX thromboaspiration as the upfront approach for distal occlusions (middle cerebral artery mid/distal M2/M3, anterior cerebral artery A1/A2/A3 or posterior cerebral artery P1/P2) from January 2014 to July 2018 was performed. The primary outcome was the rate of distal occlusion first-pass reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3). Results Of 1100 patients treated within the study period, 137 patients/144 different arteries were treated with the 3 mm Trevo (n=92) or 3MAX device (n=52). The groups had comparable demographics and baseline characteristics. There was a higher rate of first-pass mTICI 2b-3 reperfusion (62% vs 44%; p=0.03), a trend towards a higher rate of final mTICI 2b-3 reperfusion (84% vs 69%; p=0.05), and lower use of adjuvant therapy (15% vs 31%; p=0.03) with the 3 mm Trevo compared with the 3MAX. The median number of passes (p=0.46), frequency of arterial spasm (p=1.00), rates of parenchymal hematomas (p=0.22)/subarachnoid hemorrhage (p=0.37) in the territory of the approached vessel were similar across the two groups. The 90-day rate of good outcomes (45% vs 46% in the 3 mm Trevo and 3MAX groups, respectively; p=0.84) was comparable. Multivariable regression identified baseline NIH Stroke Scale (NIHSS) score (OR 0.9; 95% CI 0.8 to 0.97; p<0.01) and use of 3 mm Trevo (OR 2.2; 95% CI 1.1 to 4.6; p=0.02) independently associated with first-pass mTICI 2b-3 reperfusion. Conclusions In the setting of distal arterial occlusions, the 3 mm Trevo may lead to higher rates of first-pass reperfusion than direct 3MAX thromboaspiration. Lower NIHSS was found to be associated with improved reperfusion rates as observed in more proximal lesions. Further studies are warranted. [ABSTRACT FROM AUTHOR]

Background The pipeline embolization device (PED) is approved for the treatment of large aneurysms of the proximal internal carotid artery (ICA). Its off-label application in treating aneurysms located specifically at the ica terminus (ICA-T) has not been studied. Methods We conducted a retrospective chart review of patients from 2011 to 7 treated with PeDs. Out of 365 patients, 10 patients with ICA-T aneurysms were included. Patient demographics, procedural information, follow-up imaging, and clinical assessments were recorded. Results Mean age was 46.9 years (± 8.8), and 6 (60%) patients were women. The mean maximum diameter of the aneurysms treated was 14.7 mm (± 10.7) and the mean neck diameter was 9.3 mm (± 6.6). Reasons for presentation included six incidental findings, one acute subarachnoid hemorrhage (sah), and three patients with prior SAH. Kamran--Byrne Occlusion scale scores for the treated aneurysms were as follows: three class IV (complete obliteration), four class III (<50% filling in both height and width for fusiform aneurysms or residual neck for saccular aneurysms), one class ii fusiform aneurysm, 1 class 0 saccular aneurysm (residual aneurysm body), and one not classified due to pipeline thrombosis. Two clinically asymptomatic complications were noted: one patient who had a small distal cortical sah post PeD and one patient whose stent was found to be thrombosed on follow-up angiogram. All patients were seen in follow-up, and no patients were found to have worsening of their pre-procedure modified rankin scale score. Conclusion The PED has potential for treating ICA-T aneurysms not amenable to conventional treatment strategies. Further studies are warranted to confirm the long term outcomes. [ABSTRACT FROM AUTHOR]

Background The off-label use of flow diverters in the treatment of distal aneurysms continues to be debated. Objective To report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED). Methods The neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. Results Twenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling. Conclusions The treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness. [ABSTRACT FROM AUTHOR]

This document is a reply to a comment on a previous manuscript regarding the pharmacokinetics of nicardipine in patients with subarachnoid hemorrhage. The authors address some details that were omitted from the original manuscript, such as sample storage and patient outcomes. They explain that the purpose of their study was to determine the pharmacokinetics of nicardipine and that reporting patient outcomes in a small cohort may lead to misinterpretation. They also discuss the relevance of another study and mention the dosing regimen used in a clinical trial. The authors conclude by stating that larger and more rigorously designed studies are needed to develop an optimal dosing strategy for intrathecal nicardipine. [Extracted from the article]

Background Since its introduction in the early 1990s, endovascular treatment of cerebral aneurysms has had a steady upward trend and is the primary mode of treatment for most intracranial aneurysms. Concurrently, the need for retreatment of aneurysms after previous endovascular treatment has continued to increase, some of which can only be treated with microsurgical techniques. The factors that dictate outcomes in this group of patients are incompletely understood. Objective To study factors contributing to patient outcomes after microsurgical treatment of aneurysms with previous endovascular treatment. Methods The records of the senior author (D.L.B.) since 2002 were retrospectively reviewed for aneurysms treated after previous endovascular treatment. Demographics, treatment details, and imaging were reviewed for all patients. A systematic review of the literature on microsurgical treatment of aneurysms previously treated by endovascular therapy was also conducted. Results A total of 91 patients were identified from the retrospective review. Mean age at the time of initial treatment was 49 ± 12.68 years. Most patients initially presented with subarachnoid hemorrhage before initial endovascular treatment, with only 11 patients (12%) presenting with incidentally discovered lesions. Modified Rankin Scale score at discharge after initial treatment was good (0–3) in 81.4% of cases. Functional outcomes at the last known follow-up showed a modified Rankin Scale score of 0–3 in 77 patients (84.6%). Only aneurysm neck size was found to be a significant predictor of surgical complications (Wald χ2 = 10.79; P = 0.0010) with an odds ratio of 2.32 (95% confidence interval, 1.40–3.83) for a 2-mm increase in neck size. Systematic review identified 37 studies who were used to pool data on 370 patients. Although type of surgery was identified as a predictor of poor outcomes, this was significantly confounded by Hunt and Hess grade in the systematic review. Conclusions Favorable outcomes can be obtained even for highly complex cerebral aneurysms that have failed endovascular treatment at high-volume cerebrovascular centers. Initial presentation grade and aneurysm size are important predictors of final patient outcomes. [ABSTRACT FROM AUTHOR]