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We present a unique case of transient global amnesia following intravenous administration of a non-ionic iodinated contrast agent for abdominal CT examination. Follow up MR imaging and MR angiography studies revealed hippocampal microinfarction and transient cerebral vasospasm. To our knowledge, this is the first reported case capturing arterial vasospasm following intravenous use of iodinated contrast. Medical professionals handling contrast agents should note the potential for these rare but serious adverse effects.

Women are disproportionately affected by symptoms of angina with nonobstructive coronary arteries (ANOCA) which is associated with significant mortality and economic impact. Although distinct endotypes of ANOCA have been defined, it is underdiagnosed and is often incompletely characterized when identified. Patients are often unresponsive to traditional therapeutic options, which are typically antianginal, and the current ability to guide treatment modification by specific pathways is limited. Studies have associated specific genetic loci, transcriptomic features, and biomarkers with ANOCA. Such panomic data, in combination with known imaging and invasive diagnostic techniques, should be utilized to define more precise pathophysiologic subtypes of ANOCA in women, which will in turn help to identify targeted, effective therapies. A precision medicine-based approach to managing ANOCA incorporating these techniques in women has the potential to significantly improve their clinical care.

Background: The aim of this study was to assess the efficacy of indocyanine green (ICG) angiography during full endoscopic microvascular decompression for trigeminal neuralgia. Methods: We extracted retrospective data of patients who received ICG videoangiography during full endoscopic microvascular decompression for trigeminal neuralgia. Preoperative neurovascular contact was evaluated by three-dimensional (3D) fusion images using image analysis software Ziostation2 (ZIOSOFT, Tokyo, Japan) and Intraoperative ICG angiography was used in pre and post ICG injection to identify and assess blood flow in the offending vessel for adequate transposition planification and assess for immediate post transposition blood flow or vasospasm respectively. Patients were assessed the next morning for early signs of brainstem infarction and at one month follow up. Results: There were 44 patients. All patients had ICG videoangiography done during the procedure. The mean age was 65.5 and male female ratio 3.4:1. Some anatomical variants were identified during this procedure. Five patients (11.3%) had a trigeminocerebellar artery, three patients (6.8%) had a developed superior petrosal vein and one patient (2.2%) had dural adhesions with encasement of anterior inferior cerebellar artery. Among the 44 patients enrolled, 34 had transposition done and 10 had combined transposition either with neurolysis or Teflon interposition. The main offending vessel was Superior cerebellar artery (SCA) in 23 patients (67.6%). In 5 (14.7%) of 34 patients who underwent Transposition, vasospasm was seen and no complications were observed in all patients but 93.1% had good pain control in postoperative. Conclusion: ICG angiography in endoscopic microvascular decompression is safe and effective in depicting the offending vessel, its branches and some perforators and contributes significantly to the determination of treatment strategy.

Background: Methamphetamine is an illegal drug that poses serious public health concerns worldwide. Previous studies have demonstrated a strong association between methamphetamine abuse and non-lethal haemorrhagic stroke. Ischaemic stroke after methamphetamine intake is less common than haemorrhagic stroke. The present study investigated the clinical features and potential pathogenesis in a young methylamphetamine addict that presented with acute ischaemic stroke and reversible middle cerebral artery (MCA) occlusion. Methods: A retrospective data analysis was performed for the young methylamphetamine addict admitted to a hospital for acute ischaemic stroke followed by a literature review to explore the possible pathogenesis. Results: The patient had been receiving methamphetamine for past 2 years. His recurrent headache occurred half an hour after each consumption and was relieved within a few hours. The patient was admitted for acute ischaemic stroke. Urine toxicology screening was positive for methamphetamine. Magnetic resonance angiography revealed occlusion of the right MCA. After discontinuing medication and routine treatment, digital subtraction angiography revealed normal blood flow in the right MCA, indicating reversible MCA occlusion. Conclusion: For young patients with a stroke, a thorough investigation of the history of illicit drug use and toxicological screening of urine and serum samples should be performed. Young methamphetamine users need to be aware of the elevated risk of stroke as well as early signs and symptoms. Transient headaches in young methamphetamine users may be caused by cerebral vasospasms, suggesting the possibility of future catastrophic stroke events.

Objective: Cerebral vasospasm and the resultant delayed cerebral infarction is a significant source of mortality following aneurysmal SAH. Vasospasm is currently detected using invasive or expensive imaging at regular intervals in patients following SAH, thus posing a risk of complications following the procedure and financial burden on these patients. Currently, there is no blood-based test to detect vasospasm. Methods: PubMed, Web of Science, and Embase databases were systematically searched to retrieve studies related to cerebral vasospasm, aneurysm rupture, and biomarkers. The study search dated from 1997 to 2022. Data from eligible studies was extracted and then summarized. Results: Out of the 632 citations screened, only 217 abstracts were selected for further review. Out of those, only 59 full text articles met eligibility and another 13 were excluded. Conclusions: We summarize the current literature on the mechanism of cerebral vasospasm and delayed cerebral ischemia, specifically studies relating to inflammation, and provide a rationale and commentary on a hypothetical future bloodbased test to detect vasospasm. Efforts should be focused on clinical-translational approaches to create such a test to improve treatment timing and prediction of vasospasm to reduce the incidence of delayed cerebral infarction.

Introduction: Massive traumatic subarachnoid hemorrhage (tSAH) is a rare but potentially life-threatening condition that can mimic the clinical presentation of aneurysmal subarachnoid hemorrhage (aSAH). The accurate differentiation between these two entities is crucial, as their management and prognoses significantly differ. Case presentation: We present a case of a 64-year-old male patient who presented to our emergency department after being involved in a motor vehicle collision. His radiological findings on a computed tomography (CT) scan were suggestive of aSAH based on its location, which showed massive SAH in bilateral sylvian fissures and the basal cisterns. There was no evidence of vasospasm. The patient later developed a stroke despite the use of Nimodipine. Conclusion: While traumatic subarachnoid hemorrhage mimicking aneurysmal subarachnoid hemorrhage is a recognized phenomenon, it is relatively uncommon. We present a case of massive tSAH complicated by a stroke with no evidence of aneurysm on cerebral angiogram, shedding light on the diagnostic challenges in differentiating tSAH from aSAH and emphasizing the importance of accurate diagnosis for appropriate management, in addition, we aim to remind the readers that trauma may be a cause for massive SAH and should prompt a medical SAH management plan.

Background: “New psychoactive substances” (NPS), has been described as a “growing global epidemic”. The aim of our study was to document acute and chronic lesions that can be induced by NPS from autopsy cases for which complete toxicological analyses (including hair analysis) have been performed, in order to better define the role of NPS in the mechanisms of death. Material and methods: A retrospective study was performed at the Department of Forensic Medicine and Pathology, jointly with the Department of Pharmacology and Toxicology. All records for forensic autopsy case within a 6-year period, from January 2016 to January 2021, were reviewed for the diagnosis “death associated with NPS”. Results and discussion: Twelve young male adults complied with the inclusion criteria. Lifestyles were dominated by drug addiction and homosexual context which could be anchored in a practice of ChemSex or even of “slamming”. In regard to autopsy findings, previous pathological state was dominated by cardiovascular and hepatic lesions possibly of toxic etiology. Causes and manners of death were, on the whole, quite heterogeneous; however, an accident as a manner of death was the most frequently observed. In terms of histological findings, the most notable lesions were: (1) cardiovascular (sequelae of myocardial infarction probably secondary to a vasospasm, accelerated atherosclerosis); (2) hepatic (steatohepatitis); (3) neurological (peri mortem convulsions); (4) renal (granular cylinders that may indicate rhabdomyolysis); (5) pulmonary (chronic instertitial inflammation); all of them may have had a toxic origin. In regard to toxicological findings, our case series was mostly subject to chronic consumption of synthetic cathinones, in particular 3-MMC; their involvement in the fatal determinism was retained in 7 cases. Tissue distribution was highlighted as increased in brain, explaining at least partially psychoactive effects of these NPS. Average cardio-femoral ratio of 3.78 suggested a cardiac tropism. A lethal concentration of mexedrone, measured at 640 ng/mL, was described for the first time. Conclusion: We provide autopsy data on NPS consumption habits in Ile-de-France, namely men who have sex with men in ChemSex. Macroscopic and microscopic lesions observed were cardiovascular, hepatic, neurological, renal and pulmonary. From a toxicological point of view, we collect additional data on toxic, even lethal concentrations of NPS. Concerning 3-MMC, calculated cardio-femoral ratio is positive; moreover, it is to our knowledge the first study that demonstrates its pharmacokinetic tissue distribution.

This study aimed to investigate the relationship between prescription drugs and the slow-flow phenomenon after drug-coated balloon angioplasty. Of 30 patients, five (17%) presented with the slow-flow phenomenon. Patients with the slow-flow phenomenon were significantly less commonly prescribed calcium channel blockers than those without the slow-flow phenomenon (P = 0.03). There was no intergroup difference in the prescription of angiotensin II receptor blockers and β-blockers. The clinical outcomes, including restenosis, thrombosis, target lesion revascularization, and death, did not differ between groups during the 10-month observation period.

Acute subdural hemorrhage caused by ruptured cerebral aneurysms is rare. Herein, we report an atypical case of subdural hemorrhage caused by ruptured anterior communicating artery aneurysm in a 49-year-old woman. Computed tomography revealed subarachnoid, intracerebral, and subdural hemorrhages. After the treatment with endovascular coiling significantly decreased the patient's subdural hemorrhage. However, the subdural hemorrhage revealed and became iso-attenuation compared with the white matter on the 11th day, and hypo-attenuation on the 19th day. On the 33rd day, this subdural hemorrhage completely resolved after discontinuation of dual antiplatelet therapy. Due to rapid changes in the radiologic features of SDH, frequent computed tomography scans at least once a week may be needed especially in patients who receive antiplatelet therapy during the vasospasm phase.

Background: Eclampsia, a serious pregnancy complication, is associated with cerebral edema and infarctions but the underlying pathophysiology remains largely unexplored., Objectives: To assess the pathophysiology of eclampsia using specialized magnetic resonance imaging that measures diffusion, perfusion, and vasospasm., Study Design: This was a cross-sectional study recruiting consecutive pregnant women between April 2018 to November 2021 at Tygerberg Hospital, Cape Town, South Africa. We recruited women with eclampsia, preeclampsia, and normotensive pregnancies who underwent magnetic resonance imaging after birth. Main outcome measures were cerebral infarcts, edema, and perfusion using intravoxel incoherent motion imaging and vasospasm using magnetic resonance imaging angiography. The imaging protocol was established before inclusion., Results: Forty-nine women with eclampsia, 20 with preeclampsia and 10 normotensive women were included. Cerebral infarcts were identified in 34% of eclamptic, 5% of preeclamptic (risk difference (RD) 0.29; 95% confidence interval (CI) 0.06 to 0.52, p=0.012) and in no normotensive controls. Eclamptic women were more likely to have vasogenic cerebral edema compared to preeclamptic (80% vs 20%, RD 0.60; CI 0.34 to 0.85, p<.001) and normotensive women (RD 0.80; CI 0.47 to 1.00, p<.001). Diffusion was increased in eclampsia in the parietooccipital white matter (mean difference (MD) 0.02 x10 -3 mm 2 /s, CI 0.00 to 0.05, p=0.045) and the caudate nucleus (MD 0.02 x10 -3 mm 2 /s, CI 0.00 to 0.04, p=0.033) when compared to preeclamptic women. Diffusion was also increased in eclamptic women in the frontal (MD 0.07 x10 -3 mm 2 /s, CI 0.02 to 0.12, p=0.012) and parietooccipital white matter (MD 0.05 x10 -3 mm 2 /s, CI 0.02 to 0.07, p=0.03) and the caudate nucleus (MD 0.04 x10 -3 mm 2 /s, CI 0.00 to 0.07, p=0.028) when compared to normotensive women. Perfusion was decreased in edematous regions. Hypoperfusion was present in the caudate nucleus in eclampsia (MD -0.17 x10 -3 mm 2 /s, CI -0.27 to -0.06, p=0.003) when compared to preeclampsia. There were no signs of hyperperfusion. Vasospasm was present in 18% of eclamptic, 6% of preeclamptic and none of the controls., Conclusions: Eclampsia is associated with cerebral infarcts, vasogenic cerebral edema, vasospasm and decreased perfusion, all not usually evident on standard clinical imaging. This may explain why some have cerebral symptoms and signs despite having normal conventional imaging., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr Smilowitz is supported in part by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award K23HL150315. Dr Smilowitz serves on an advisory board and as a consultant for Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Introduction: After direct mortality from an aneurysmal subarachnoid hemorrhage (aSAH), delayed cerebral ischemia (DCI) secondary to cerebral vasospasm is a cause of severe morbidity and mortality. Distinct from perimesencephalic SAH with favorable prognosis, non-aneurysmal diffuse SAH has been observed to have a more variable outcome and requires close clinical observation as this subset of patients has a higher likelihood for developing DCI. Treatment of radiographic and clinical vasospasm is limited to only a few pharmacological agents with varying degrees of success. Several recent publications have demonstrated efficacy with using intravenous (IV) milrinone to treat cerebral vasospasm. Here, we audit the use of IV milrinone in the clinical management of vasospasm and DCI in an adult non-aneurysmal SAH population. Methods: A retrospective quality audit was conducted at a single neurosurgical center over a 1-year period (2019). Data was extracted from electronic medical records. Results: A total of 93 adult patients were admitted for management of SAH. Twenty-four patients presented with non-aneurysmal SAH. Four patients in this group required symptomatic DCI management. All 4 patients presented with a diffuse pattern of SAH. Two of these patients presented with acute hydrocephalus requiring external ventricular drain (EVD) insertion. Most non-aneurysmal SAH patients had a good clinical outcome (92%, mRS 0–2). Two patients had a poor clinical outcome (mRS 3 and 4) at clinical follow up. These two patients initially presented with a poor clinicoradiological grading score and one patient required an urgent EVD for acute hydrocephalus. Intravenous milrinone was commenced for reduced level of consciousness (LOC) in 2/4 patients, while focal neurological deficit prompted initiation of IV therapy in the remaining 2. Conclusion: Patients with diffuse non-aneurysmal SAH can develop symptomatic DCI and should be closely monitored and provided a standardized protocol for cerebral hyperdynamic therapy.

Background: We compared the long-term health of adults with prior Kawasaki disease (KD) to controls and determined whether outcomes varied by coronary artery (CA) status. Methods: We conducted a prospective cohort study of 258 KD subjects (mean 19 ± 9 years since KD) and 148 age-similar controls who completed extensive health questionnaires. KD subjects were divided into 2 groups, Cohort 1: 109 subjects followed since KD diagnosis at our institution; Cohort 2: 149 KD subjects diagnosed elsewhere. Results: KD subjects and controls were of similar age at the time of questionnaire completion (p = 0.50). Overall, 128 subjects (including 60 in Cohort 1) reported normal CAs during and after KD. Compared to controls, KD subjects with normal CAs reported several medical conditions with increased prevalence including migraine headaches, shortness of breath, and leg pain with walking, among others. When limited to Cohort 1, KD subjects were significantly more likely to report chest pain (47% vs 16%, p

Cocaine is a known vasoactive drug associated with poor clinical outcomes and high in-hospital mortality related to aneurysmal subarachnoid hemorrhage; however, the association of prior cocaine use with the incidence of vasospasm and delayed cerebral ischemia remains controversial. We report a case of a 42-year-old male with a history of active cocaine use who presented with a severe headache. Imaging demonstrated diffuse cisternal subarachnoid hemorrhage due to a ruptured basilar apex aneurysm, which was successfully treated with endovascular coil embolization. Despite expedited endovascular treatment and an initially benign clinical course, he suffered from delayed cerebral ischemia resulting in cortical blindness due to bilateral posterior cerebral artery vasospasm secondary to repeat cocaine use weeks after his initial ictus. To our knowledge, the present case is the first to describe delayed cerebral ischemia resulting in a severe neurologic deficit due to repeat cocaine use weeks subsequent to aneurysm rupture. We review the current literature on the association of cocaine use with the incidence of vasospasm and delayed cerebral ischemia as well as the effects of cocaine on the cerebrovasculature.

It is difficult to predict that vasospasm would occur in traumatic subarachnoid hemorrhage (SAH) patients. Younger age, a lower score of Glasgow coma scale (GCS≦8) on admission, and greater cisternal blood volume are considered to correlate with post-traumatic vasospasm.We present two cases of traumatic SAH with post-traumatic vasospasm; one was a 74-year-old man and the other was a 72-year-old woman. They were alert without any neurological deficits on admission, although the SAH was focally thick as if caused by an aneurysmal rupture. The thick SAH was still identified on follow-up CT performed in a few days. The patients demonstrated cognitive dysfunction at the 4th and 5th day of admission, respectively, and imaging studies revealed vasospasm at the artery in the thick SAH. After treatments, the vasospasm resolved and both patients recovered from the disorientation completely in three weeks. The authors considered that focally thick traumatic SAH with poor clearance is the most influential factor to post-traumatic vasospasm independent of age or a GCS score. A low GCS score in head trauma patients might be mainly associated with existence of brain contusion, intracerebral hemorrhage, epidural, or subdural hemorrhages, which are frequently associated with traumatic SAH. If the traumatic SAH is focally thick with poor clearance, it might be better to initiate prompt treatments for vasospasm within 3 days after trauma. The delay in treatments for vasospasm contributes to poor outcomes.

Background: Eugenol has various curative properties. It affects the dilatation of cerebral arteries through voltage-dependent Ca2+ channel inhibition. This study is the first to explore the impact of eugenol on neuroprotection and vasospasm in an experimental subarachnoid hemorrhage (SAH) model., Methods: Twenty-four adult male Sprague-Dawley rats were indiscriminately separated into 3 groups: the control group (n = 8), the SAH group (n = 8), and the eugenol group (n = 8). A double-bleeding method was used. The eugenol group received intracisternal eugenol (Sigma-Aldrich, St. Louis, MO, USA) at 30 μg/20 μl after induction of SAH. On the day 7, all groups were euthanized. Measurements were taken for basilar artery wall thickness, lumen diameter, serum endothelin-1 (ET-1), and caspase-3 levels., Results: The eugenol group exhibited significantly lower wall thickness, ET-1, oxidative stress index, and caspase-3 levels compared to the SAH group. In comparison to the control group, the eugenol group showed a higher oxidative stress index along with higher ET-1 and caspase-3 levels, but these differences were not statistically significant. Wall thickness was significantly higher in the eugenol group than in the control group., Conclusions: This study represents the first literature exploration of intrathecal eugenol's impact on vasospasm induced after experimental SAH. Administration of intrathecal eugenol demonstrates a positive effect on the treatment of experimental vasospasm as well as on the reduction of oxidative stress and apoptosis., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The association between patient age and cerebral arterial vasospasm (CVS) and delayed cerebral ischemia (DCI) risk following aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. This study aims to assess the role of age on aSAH-related complications., Methods: Single-center retrospective study comprising aSAH patients treated between January 2009 and March 2023. Age was analyzed as continuous and categorical variables (<60 yrs vs. ≥60 yrs and by decade). Outcomes of interest included radiographic CVS, DCI, cerebral infarction, in-hospital mortality, length-of-stay (LOS), ventriculoperitoneal shunt placement, and modified Rankin Scale (mRS) scores at discharge and 3-month follow-up., Results: Nine hundred and twenty-five aSAH patients were included. Most (n = 598; 64.6%) were <60 yrs old (46 ± 9.1 yrs). CVS likelihood was lower in the older cohort (aOR = 0.56 [0.38-0.82]). Patients ≥60 yrs had higher mortality rates (aOR = 2.24 [1.12-4.47]) and worse mRS scores at discharge (aOR = 2.66 [1.91-3.72]) and 3-month follow-up (aOR = 2.19 [1.44-3.32]). Advanced age did not have a significant effect on DCI or cerebral infarction risk. Higher in-hospital mortality was documented with increasing age (P < 0.001). A significant interaction between CVS and age for the outcome of DCI was documented, with a stronger positive effect on poor outcomes (i.e., higher odds of DCI) among patients aged <60 years compared to those aged ≥60., Conclusions: There is an inverse relationship between patient age and CVS incidence following aSAH. Nonetheless, patients ≥60 yrs had comparable DCI rates, higher in-hospital mortality, and worse functional outcomes than their younger counterparts. Routine screening and reliance on radiographic CVS as primary marker for aSAH-related complications should be reconsidered, particularly in older patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To assess the efficacy and safety of oral sodium chloride (Slow Sodium®) as hyponatraemia prophylaxis in patients with World Federation of Neurosurgical Societies (WFNS) Grade 1 and Grade 2 aneurysmal subarachnoid haemorrhage (aSAH). Methods: This prospective cohort study was conducted at Royal Victoria Hospital in Northern Ireland over two separate periods between 2015 and 2017, a total of 60 patients with aneurysmal subarachnoid haemorrhage were recruited. During Phase 1 (Jan 2015–Oct 2015), 32 patients were studied before hospital subarachnoid haemorrhage (SAH) protocol was modified. In Phase 2 (Jul 2016–Jan 2017), 28 patients received prophylactic oral sodium chloride (Slow Sodium®) in addition to standard SAH protocol. Primary outcomes were: incidence of hyponatraemia, length of hospital stay and Glasgow Outcome Scale (GOS) at a median of 4 months post-SAH; secondary outcome was the incidence of vasospasm. Results: Patients in Phase 2 demonstrated significantly lower incidence of hyponatraemia (p = 0.0006), shorter hospital stay (p

Objective: Vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) aggravates outcome of patients through a cascade of complications and harsh consequences. This study was conducted to evaluate the effect of cerebrospinal fluid (CSF) lumbar drainage in aSAH management and in the prevention of vasospasm at a university hospital in Vietnam. Methods: A single-center, prospective case series of aSAH treatment with CSF lumbar drainage was conducted from June 2018 to July 2019. Outcomes measured were clinical vasospasm, vasospasm-induced infarction, shunt-dependent rate, duration of treatment in hospital and Glasgow Outcome Scale (GOS) at 3 months and 1 year after discharge. Results: Among 43 patients with aSAH admitted to the clinic, thirty-two aSAH patients (71.8% female, mean age 58.8 ± 11.5 years) received lumbar drainage. The incidence of clinical vasospasm and vasospasm-induced infarction on CT scan/MRI (including asymptomatic cerebral infarction) was 21.9% and 56.3%, respectively. Four patients (12.5%) underwent another CSF shunting operation. The mean duration of hospital stay was 27.8 ± 16.9 days. Nearly 70% of aSAH patients were discharged and were able to return to normal life with no or minor neurological deficits (GOS 4–5) at 3-month and 1-year follow-ups. No serious complication of CSF lumbar drainage was observed, except for one major setback, which was meningitis during treatment (53.1%). Conclusions: CSF lumbar drainage may reduce the incidence of clinical vasospasm, shorten hospital stays, and possibly improve patient outcomes following aSAH. Our findings suggest that the selective use of CSF lumbar drainage, in addition to standard strategies, can be beneficial in preventing vasospasm and offers more choice in aSAH management.

Background: Cerebral vasospasm (CV) is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. Objective: To report our institutional experience with intrathecal (IT) nicardipine for treatment of moderate to severe CV. Methods: A retrospective study was performed for all patients treated with intrathecal nicardipine from October 2014-May 2017. The primary goal was to evaluate the safety of IT nicardipine to treat subarachnoid induced CV. Results.48 patients with aSAH were treated with IT nicardipine for moderate or severe CV. The average age of patients was 49.6 years (range 14–77 years) with mean Hunt Hess of 3.2 and mean Fisher scores of 3.1. Patients were treated with different dosing regiments ranging from 2 mg q12 to 4 mg q8hr. The average total dose was 35.1 mg (range 6 to 112 mg). The average initiation of treatment was post bleed day 6 (range day 2–15) and length of treatment was 5.9 days (range 1–15 days.) 10/48 (20.8%) patients underwent TBA with only 4/48 (8.3%) treated after initiation of IT nicardipine. Three patients (6.3%) developed meningitis/ventriculitis. Three (6.3%) patients required ventriculoperitoneal shunt. Favorable outcome (Glasgow Outcome Scale 4 or 5) was achieved in 56.3% of patients. Conclusions: The use of intrathecal nicardipine should be considered a safe option in the treatment of moderate to severe cerebral vasospasm. The use of intrathecal nicardipine has resulted in a near discontinuation of balloon angioplasty in our institution. Randomized trials to identify the optimal dosing, timing, and length of treatment is warranted.

Background: Subarachnoid hemorrhage is one of high morbidity in vascular neurology and neurosurgery and one of the clipart for this is symptomatic vasospasm that can leads to delayed cerebral ischemia. Other common complication is electrolytes and fluid homeostasis disturbance and among these, is Sodium disequilibrium, either hypo- or hypernatremia. In our institution we observed that hyponatremia is common, and it is more evident in patient with symptomatic vasospasm. For that we retrospectively looked at the association of hyponatremia and the occurrence of symptomatic vasospasm or delayed cerebral ischemia in aSAH. Methods: Retrospective chart review with daily monitoring of sodium level from day 1to day 21 from the ictus, aSAH. We include all adult patients (Age > 18 years) who were admitted to intensive care with diagnosis of aSAH and undergone aneurysm securing procedures within 48 h. Results: Among 45 patients 24 (43%) developed symptomatic vasospasm and delayed cerebral ischemia and it was most common in males (13/22: 59%). Sodium level especially hyponatremia in period between days (1–4) with median of 134 in vasospasm group (50%). Conclusions: Delayed cerebral ischemia/symptomatic vasospasm occurs more commonly in males and associated with hyponatremia (Na+

Background: The use of cocaine can lead to a variety of neurologic complications, including cerebral vasoconstriction, ischemia, aneurysm formation, and aneurysm rupture. A previous study has shown that cocaine use is associated with an increased risk of subarachnoid hemorrhage (SAH). This study conducted a systematic review and meta-analysis of observational studies to assess the association between cocaine use and the risk of poor neurological outcomes and mortality in patients with SAH., Methods: A systematic review and meta-analysis were performed following the meta-analysis of observational studies in epidemiology (MOOSE) declaration for systematic reviews and the Cochrane Manual of Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs), nonrandomized clinical trials, and prospective and retrospective cohort studies that reported data about adults who suffered Aneurysmal Subarachnoid Hemorrhage (aSAH) after having consumed cocaine recreationally were included. Variables such as mortality, vasospasm, seizures, re-bleeding, and complications were analyzed., Results: After a thorough selection process, 14 studies involving 116,141 patients, of which 2227 had a history of cocaine consumption, were included in the analysis. There was a significant increase in overall unfavorable outcomes in aSAH patients with a history of cocaine use (OR 5.51 CI 95% [4.26-7.13] P = <0.0001; I2 = 78%), with higher mortality and poor neurologic outcomes. There were no significant differences in the risk of hydrocephalus, seizures, or re-bleeding. Cocaine use was found to increase the risk of vasospasm and overall complications., Conclusions: This study insinuates that cocaine use is associated with worse clinical outcomes in aSAH patients. Despite the cocaine users did not exhibit a higher risk of certain complications such as hydrocephalus and seizures, they had an increased risk of vasospasm and overall complications. These findings highlight the importance of addressing the issue of cocaine consumption as a primary preventive measure to decrease the incidence of aSAH and improve patient outcomes., (Copyright © 2023. Published by Elsevier Inc.)

Competing Interests: Funding Support and Author Disclosures Dr Vishnevsky has served on the Speakers Bureau for Shockwave Medical. Dr Fischman has reported that he has no relationships relevant to the contents of this paper to disclose.

Introduction: Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH., Methods: Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality., Results: A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99)., Conclusions: For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Subarachnoid hemorrhage (SAH) is a cerebrovascular disorder with significant mortality and morbidity. Neural injury in SAH is mediated through a variety of pathophysiological processes. Currently available treatments are either nonspecific in targeting the basic pathophysiological mechanisms that result in neural damage in SAH, or merely focus on vasospasm. Ferroptosis is a type of programmed iron dependent cell death, which has received attention due to its possible role in neural injury in SAH. Herein, we review how intracellular iron overload mediates the production of reactive free radicals and lipid peroxidation through a variety of biochemical pathways in SAH. This in turn results in induction of ferroptosis, as well as exacerbation of vasospasm. We also discuss several therapeutic agents that have been shown to inhibit ferroptosis through targeting different steps of the process. Such agents have proven effective in ameliorating vasospasm, neural damage, and neurobehavioral outcomes in animal models of SAH. Human studies to test the safety and efficacy of intrathecal or parenteral administration of the inhibitors of ferroptosis in improving outcomes of SAH patients are warranted. There are currently a few ongoing clinical trials pursuing this therapeutic concept, the results of which will be critical to determine the value of ferroptosis as a novel therapeutic target in SAH., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Stellate ganglion block (SGB) may have protective effects in patients at risk of vasospasm following subarachnoid hemorrhage (SAH) due to reduced sympathetic activity. However, the safety and clinical outcomes of SGB in this scenario are not definitively known. The objective was to evaluate the safety, clinical outcomes, and cerebral blood flow velocity in patients submitted to SGB or cervical sympathectomy with SAH., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review and meta-analysis of studies investigating SGB or cervical sympathectomy use in SAH were conducted. PubMed, Cochrane Library, and Embase were evaluated. Patients with mRS from 0 to 2, GOS from 4 to 5, or symptom resolution were considered favorable clinical outcomes. Related mortality was defined as death by vasospasm or delayed cerebral ischemia., Results: The analysis included 8 studies comprising 182 patients. Only 2 studies employed SGB prophylactically. The results revealed favorable outcomes in 52% of patients (95% CI: 37%-65%). The overall incidence of complications was 2% (95% CI: 0% -26%). The mortality rate was 13% (95% CI: 7%-21%), with a vasospasm-related mortality rate of 11% (95% CI: 2%-20%). A decrease of cerebral blood flow velocity was reported in 4 studies., Conclusions: The notable reduction in cerebral blood flow velocity following SGB, alongside positive outcomes and a low occurrence of mortality and complications, highlights its significance as a therapeutic intervention for vasospasm following SAH. While the number of studies evaluating SGB as a preventive measure is limited, the promising results emphasize the importance of future research., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Migrainous infarction is defined as a migraine attack occurring as migraine with aura, typical of the patient's previous attacks, except that one or more aura symptoms persist for >60min, and neuroimaging demonstrates ischemic infarct in the relevant area. To better understand migrainous infarction, one must disentangle the complex interactions between migraine and stroke. In this chapter, we first discuss the migraine-stroke association in sections including "Increased Risks of Stroke and Subclinical Infarcts in Patients With Migraine," "Migrainous Headache Cooccurring or Triggered by Ischemic Stroke," "Stroke Progression in Patients With Migraine," and "Clinic Conditions Associated With Higher Risks of Both Migraine and Stroke." As an extreme example of migraine-stroke association, the annual incidence of migrainous infarction was reported to be 0.80/100,000/year, with the incidence in females nearly twofold that of male patients. Patients diagnosed with migrainous infarction are typically younger (average age 29-39 in case series), have fewer traditional vascular risk factors, and have more favorable prognosis compared to strokes from traditional risk factors. Thorough evaluation is recommended to rule out other etiologies of stroke. Patients diagnosed with migrainous infarction should receive antiplatelet therapy and migraine preventive therapy to avoid future events. Vasoactive medications, including triptans and ergots, should be avoided., Competing Interests: Conflict of interest statement The authors have reported no conflicts of interest., (Copyright © 2024 Elsevier B.V. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA., Materials and Methods: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression., Results: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports., Conclusions: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries., Competing Interests: Declaration of Competing Interest The authors have no competing interests to disclose., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) causes serious neurological complications, despite surgical clipping of the aneurysm. Intrathecal urokinase (UK) infusion has been shown to effectively prevent symptomatic vasospasm in patients who have undergone endovascular obliteration of the ruptured aneurysms., Objective: To investigate whether intrathecal UK infusion can prevent symptomatic vasospasm in patients undergoing surgical or endovascular treatment., Methods: A total of 90 patients with severe aneurysmal SAH were enrolled and assigned to a surgical neck clipping (n = 56) or an endovascular coil embolization (n = 34) groups. After treatment, UK infusion from the lumbar drain was repeated in 32 patients in the surgical neck clipping group (group B) and all in the endovascular coil embolization group (group C) until complete resolution of the SAH was observed on computed tomography. The remaining 24 of the surgical neck clipping group, without UK infusion, were assigned to group A., Results: Symptomatic vasospasm occurred in 7 (29.2%) patients in group A, 2 (6.3%) in group B, and none in group C (group A vs. group B [P = 0.02]; group B vs. group C [P = 0.14]). Excellent clinical outcomes (modified Rankin score, 0 or 1) were observed in 37.5%, 59.4%, and 76.5% of patients in group A, B, and C, respectively (group A vs. group B [P = 0.11])., Conclusion: Clearance of SAH via intrathecal UK infusion significantly reduced symptomatic vasospasm in patients in both UK groups, resulting in better clinical outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Cerebral vasospasm is one of the most fatal complications after spontaneous aneurysmal subarachnoid hemorrhage. Although various treatments have been tried for the treatment of cerebral vasospasm so far, the effect is insignificant or temporary except for oral nimodipine. Phosphodiesterase isozyme type 5 inhibitor, which is used to treat erection dysfunction, recently has been known to have a cerebrovascular vasodilation. It is thought that this will be effective in cerebral vasospasm, and the effect will be compared and analyzed with oral nimodipine through an animal model of cerebral vasospasm., Material and Methods: A total of 40 rabbits were used to make subarachnoid hemorrhage model and were divided into three groups - a control group, nimodipine group, and tadalafil group. The cerebral vessels were angiographically measured before and on the third day of subarachnoid hemorrhage. Then vertebrobasilar arteries were harvested and evaluated. Under the microscope, lumen area and media area were measured for each group and were compared., Results: Angiographically, tadalafil group showed significant vasodilation compared with the control group (p < 0.01). Histologically, tadalafil showed a similar effect on lumen and on media area to that of nimodipine group compared with the control group., Conclusions: Cerebral vasospasm could leave neurologic deficit or sequelae even after proper treatment. Therefore, prevention is important. Tadalafil showed preventive effect against cerebral vasospasm and vasodilative effect similar to that of nimodipine. Therefore, tadalafil could be considered an alternative preventive treatment of cerebral vasospasm., Competing Interests: Declaration of Competing Interest None of the authors has any relevant financial or non-financial interests to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: The most common complaint from patients after subarachnoid hemorrhage (SAH) is headache. The headache appears to be persistent and often severe. Although this problem is pervasive in the care of SAH patients, very little data have been published to describe the nature and severity of the headache nor is there evidence-based guidance on the appropriate treatment of headache due to SAH. Methods: This was a retrospective medical record review of adults with aneurysmal SAH. Basic demographics, along with pain scores and analgesic medication administration, were collected. Patients with early vasospasm (within 7 days of ictus) were compared with patients with no vasospasm. Results: The patient population was characteristic of the typical SAH population. Approximately 31.5% of patients exhibited early vasospasm. These patients had higher pain scores (median 8/10) than did patients without vasospasm (median 6/10) and required more analgesics such as acetaminophen/butalbital/caffeine. Treatment success with any analgesic used in this population was minimal. The pain scores associated with headache increased over the first 7 days in both groups. Conclusions: Headache after SAH is persistent and treatment refractory. There may be an association with development of vasospasm and worsening of headache. Novel treatment strategies to attenuate headache in this population are needed.

We report a case of vasospasm complicating delayed pituitary necrosis after craniopharyngioma resection in an 18-year old female. This is the first reported case that utilizes aggressive blood pressure management, fluid optimization, and rheologic doses of mannitol to successfully treat severe symptomatic vasospasm.

Background: Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction., Methods: A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging., Results: We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively., Conclusions: We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Effects of early mobilization are not well documented in patients with aneurysmal subarachnoid hemorrhage (aSAH). Only a few studies have investigated it through progressive mobilization protocols and suggested that it is safe and feasible. This study aimed to determine the impact of early out-of-bed mobilization (EOM) on 3-month functional outcome and cerebral vasospasm (CVS) occurrence in patients with aSAH., Methods: A retrospective review of consecutive patients admitted to the intensive care unit with a diagnosis of aSAH was performed. EOM was defined as out-of-bed (OOB) mobilization performed before or on day 4 after aSAH onset. The primary outcome was 3-month functional independence (i.e., a modified Rankin Scale below 3) and the occurrence of CVS., Results: A total of 179 patients with aSAH met the inclusion criteria. Thirty-one patients constituted the EOM group, and 148 patients were in the delayed out-of-bed mobilization group. Functional independence was more frequent in the EOM group than in the delayed out-of-bed mobilization group (n = 26 [84%] vs. n = 83 [56%], P = 0.004). In a multivariable analysis, EOM was an independent predictor of functional independence (adjusted odds ratio = 3.11; 95% confidence interval, 1.11-10.36; P < 0.05). The delay between bleeding and first OOB mobilization was also identified as an independent risk factor for the occurrence of CVS (adjusted odds ratio = 1.12; 95% confidence interval = 1.06-1.18, P < 0.001)., Conclusions: EOM was independently associated with favorable functional outcome after aSAH. The delay between bleeding and OOB mobilization was an independent risk factor for reduced functional independence and CVS occurrence. Prospective randomized trials are necessary to confirm these results and improve clinical practice., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: As soon as possible treatment initiation for aneurysmal subarachnoid hemorrhage (aSAH) is recommended. However, some patients require treatment in "subacute" phase of aSAH, defined in this study as "more than one day after the onset". To establish an optimal treatment strategy for these patients, we retrospectively analyzed the clinical experience of treating ruptured aneurysm with either clipping or coiling in subacute phase., Methods: Patients treated for aSAH between 2015 and 2021were analyzed. Patients were divided into the hyperacute phase (within 24 h) and subacute phase (later than 24 h) groups. The subacute group was analyzed to determine whether the selected procedure and its timing affected postoperative course and clinical outcomes. In addition, we conducted a multivariate logistic regression analysis to determine the independent factors that affect clinical outcomes., Results: Of 215 patients, 31 were treated in the subacute phase. While cerebral vasospasm at initial imaging was more frequently observed in subacute group, there was no difference in incidence of postoperative vasospasms. Patients in subacute group seemed to have better clinical outcomes due to the milder severity at the time of treatment initiation. Risk of angiographic vasospasm seemed to be higher in patients treated with clipping than coiling, while no difference was seen in clinical outcomes. Multivariate logistic regression analysis showed that the timing and selected treatment did not significantly affect the clinical outcome or the occurrence of delayed vasospasm., Conclusions: Treatment of aSAH in the subacute phase may also result in favorable clinical outcomes, similar to patients treated in the hyperacute phase with mild presentation. However, further investigations are required to establish the optimal treatment strategies for such patients., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)