Neeraj S. Naval

Controversies in the management of aneurysmal subarachnoid hemorrhage

Background:The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management. Objective:To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation. Data Source:Search of MEDLINE and Cochrane databases and manual review of article bibliographies. Data Synthesis and Conclusions:Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.

Intensive care of aneurysmal subarachnoid hemorrhage: an international survey

BackgroundPatients with aneurysmal subarachnoid hemorrhage (SAH) are routinely admitted to the intensive care unit for the management of neurological and systemic complications.ObjectiveTo determine the clinical practices of intensive care physicians treating SAH, and to evaluate the relationship between these practices and published evidence.DesignSurvey.ParticipantsPhysicians identified through the Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine (ESICM), and the Neurocritical Care Society (NCS).InterventionsThe research team classified published clinical research on key interventions in SAH diagnosis and therapy, and then generated a 45-item online questionnaire which was distributed to SCCM, NCS, and ESICM members.ResultsThere were 626 completed surveys, 51% from the USA or Canada, 35% from Europe, and 14% from other regions. Respondents included anesthesiologists (38%), internists (29%), neurologists (14%), and neurosurgeons (8%). Agreement with selected evidence-based recommendations was variable (39–92%) and did not depend on the quality of the supporting data. Significant practice differences were noted between respondents from North America and Europe, and between those working in high and low-volume centers (respectively >40 and ≤40 SAH cases per year).ConclusionsThis study demonstrates that the practices of intensive care physicians treating SAH are heterogeneous and often at variance with available evidence.

Improved aneurysmal subarachnoid hemorrhage outcomes: A comparison of 2 decades at an academic center

OBJECTIVE Management of aneurysmal subarachnoid hemorrhage (aSAH) has evolved over the past 2 decades, including refinement of neurosurgical techniques, availability of endovascular options, and evolution of neurocritical care; their impact on SAH outcomes is unclear. DESIGN/METHODS Prospectively collected data of patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed. We compared survival to discharge and functional outcomes at initial clinic appointment postdischarge (30-120 days) in patients admitted between 1991 and 2000 (phase 1 [P1]) and 2000 and 2009 (phase 2 [P2]), respectively, using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5). RESULTS A total of 1134 consecutive patients with aSAH were included in the analysis (P1 46.4%, P2 53.6%). There were higher rates of poor grade Hunt and Hess (P1 23%, P2 28%; P < .05), admission Glasgow Coma Scale score lower than 8 (P1 14%, P2 21%; P < .005), known medical comorbidites (P1 54%, P2 64%; P = .005), associated intraventricular hemorrhage (P1 47%, P2 55%; P < .05), and older population (P1 51.5%, P2 53.5%; P < .05) in P2. Good outcomes were more common in P2 (71.5%) compared with P1 (65.2%), with 2-fold adjusted odds of good outcomes after correction for various confounding factors (P < .001). CONCLUSIONS Our institutional experience over 2 decades confirms that patients with aSAH have shown significant outcome improvements over time.

Impact of Acute Cocaine Use on Aneurysmal Subarachnoid Hemorrhage

Background and Purpose— Acute cocaine use has been temporally associated with aneurysmal subarachnoid hemorrhage (aSAH). This study analyzes the impact of cocaine use on patient presentation, complications, and outcomes. Methods— Data of patients admitted with aSAH between 1991 and 2009 were reviewed to determine impact of acute cocaine use (C). These patients were compared with aSAH patients without recent cocaine exposure (NC) in relation to their presentation, complications such as aneurysmal rerupture and delayed cerebral ischemia, and outcomes including hospital mortality and functional outcome. Results— Data of 1134 aSAH patients were reviewed; 142 patients (12.5%) had associated cocaine use. Cocaine users were more likely to be younger (mean age: C, 49±11; NC, 53±14; P<0.001). There were no differences in rates of poor-grade Hunt and Hess (4–5); (C, 21%; NC, 26%; P>0.05), associated intraventricular hemorrhage (C, 56%; NC, 51%; P>0.05), or hydrocephalus on admission Head CT (C, 49%; NC, 52%; P>0.05). Aneurysm rerupture incidence was higher among cocaine users (C, 7.7%; NC, 2.7%; P<0.05). The association of cocaine use with higher risk of delayed cerebral ischemia (C, 22%; NC, 16%; P<0.05) was not significant after correcting for other factors. Cocaine users were less likely to survive hospitalization compared with nonusers (mortality: C, 26%; NC, 17%; P<0.05); the adjusted odds of hospital mortality were 2.9 times higher among cocaine users (P<0.001). There were no differences in functional outcomes between the 2 groups. Conclusions— Acute cocaine use was associated with a higher risk of aneurysm rerupture and hospital mortality after aSAH.

Impact of pattern of admission on outcomes after aneurysmal subarachnoid hemorrhage

OBJECTIVE Patients with aneurysmal subarachnoid hemorrhage (aSAH) require management in centers with neurosurgical expertise necessitating emergent interhospital transfer (IHT). Our objective was to compare outcomes in aSAH IHTs to our institution with aSAH admissions from our institutional emergency department (ED). METHODS Data for consecutive patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed from a prospectively obtained database. We compared in-hospital mortality and functional outcomes at first clinical appointment post-aSAH (30-120 days) using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5) in ED admissions with IHTs. RESULTS A total of 1134 consecutive patients with aSAH were included in analysis (ED 40.1%, IHT 59.9%). Direct ED admissions had a higher incidence of poor Hunt and Hess grade (4/5) and major medical comorbidities, with no significant differences between the 2 groups in age, intraventricular hemorrhage, and hydrocephalus. In-hospital mortality for ED admissions (14.9%) was significantly lower than that for IHTs (20.5%), with 1.8 times greater adjusted odds of survival after multivariate analysis (P = .001). Emergency department admissions had nearly 2-fold greater odds of good outcomes (odds ratio, 1.89; P < .001) after multivariate analysis. CONCLUSIONS Our institutional ED SAH admissions had significantly better outcomes than did IHTs, suggesting that delays in optimizing care before transfer could deleteriously impact outcomes.

Management of Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

Impact of case volume on aneurysmal subarachnoid hemorrhage outcomes

PURPOSE To compare aneurysmal subarachnoid hemorrhage (aSAH) outcomes between high- and low-volume referral centers with dedicated neurosciences critical care units (NCCUs) and shared neurosurgical, endovascular, and neurocritical care practitioners. MATERIALS AND METHODS Prospectively collected data of aSAH patients admitted to 2 institutional NCCUs were reviewed. NCCU A is a 22-bed unit staffed 24/7 with overnight in-house NCCU fellow and resident coverage. NCCU B is a 14-bed unit with home call by NCCU attending/fellow and in-house residents. RESULTS A total of 161 aSAH patients (27%) were admitted to NCCU B compared with 447 at NCCU A (73%). Among factors that independently impacted hospital mortality, there were no differences in baseline characteristics: mean age (A: 53.5 ± 14.1 years, B: 53.1 ± 13.6 years), poor grade Hunt and Hess (A: 28.2%, B: 26.7%), presence of multiple medical comorbidities (A: 28%, B: 31.1%), and associated cocaine use (A: 11.6%, B: 14.3%). There was no significant difference in hospital mortality (A: 17.9%, B: 18%), poor functional outcome (A: 30%, B: 25.4%), aneurysm rerupture (A: 2.8%, B: 2.4%), or delayed cerebral ischemia (A: 14.1%, B: 16.1%). CONCLUSIONS The noninferior outcomes at the lower SAH volume center suggests that provider expertise, not patient volume, is critical to providing high-quality specialized care.

ICH aspiration and thrombolysis.

Intracerebral hemorrhage (ICH) is associated with the highest mortality among all forms of stroke. Evolution in the medical management of ICH has not improved patient outcomes while the results of conventional surgery have generally been disappointing. Minimally invasive surgery (MIS) using stereotactic clot aspiration followed by clot lysis is gaining credibility as an alternative management strategy. We review the published data on this methodology in the treatment of ICH.

In-hospital outcomes of aneurysmal subarachnoid hemorrhage associated with cocaine use in the USA

Cocaine use is associated with higher mortality in small retrospective studies of brain-injured patients. We aimed to explore in-hospital outcomes in a large population based study of aneurysmal subarachnoid hemorrhage (aSAH) with cocaine use. aSAH patients were identified from the 2007-2010 USA Nationwide Inpatient Sample using International Classification of Disease, Ninth Revision codes. Demographics, comorbidities and surgical procedures were compared between cocaine users and non-users. The primary outcomes were in-hospital mortality and home discharge/self-care. Secondary outcomes were vasospasm treated with angioplasty, hydrocephalus, gastrostomy and tracheostomy. There were 103,876 patients with aSAH. The cocaine group were younger (45.8 ± 9.8 versus 58.4 ± 15.8, p<0.001), predominantly male (53.3% versus 38.5%, p<0.001) and had a higher proportion of black patients (36.9% versus 11.5%, p<0.001). The incidence of seizures was higher among cocaine users (16.2% versus 11.1%, p<0.001). Endovascular coiling of intracranial aneurysms (24% versus 18.5%, p<0.001) was more frequent in cocaine users. The univariate analysis showed higher rates of in-hospital mortality and vasospasm treated with angioplasty, but lower home discharge in the cocaine group. In the multivariate analysis, the cocaine cohort had higher in-hospital mortality (odds ratio [OR] 1.43, 95% confidence interval [CI] 1.27-1.61, p<0.001) and lower home discharge rates (OR 0.79, 95% CI 0.69-0.87, p<0.001) after adjusting for confounders. Rates of vasospasm treated with angioplasty however were similar between the two groups. Cocaine use was found to be independently associated with poor outcomes, particularly higher mortality and lower home discharge rates. Cocaine use however, was not associated with vasospasm that required treatment with angioplasty. Prospective confirmation is warranted.

Organ failure: Central nervous system

Central nervous system (CNS) failure represents a spectrum of disease ranging from mild neurological impairment that may have motor, sensory, visual, speech, cognitive manifestations, or a combination thereof, to comatose states and brain death. This article summarizes the common causes of CNS failure and analyzes the role of clinical, radiological, laboratory, and other ancillary testing in establishing the underlying diagnosis and assessing severity of CNS failure in each condition; we also comment on various treatment options for each of the causes of CNS failure.