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BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) and angiographic vasospasm following subarachnoid hemorrhage (SAH) have been associated for more than 50years. We aimed to examine whether the knowledge gained by theoretical research on vasospasm has actually translated into better patient outcomes in practice. METHODS This is a narrative review of the concept of vasospasm as a cause of DCI after SAH. We discuss recent studies that have assessed the accuracy and reliability of the diagnostic tests (transcranial Doppler ultrasound [TCD], CT angiography, and catheter angiography), which are used to identify SAH patients at-risk of DCI. RESULTS Both the diagnostic accuracy of TCD and the reliability of CT angiography to identify patients in severe vasospasm are poor. For the gold standard catheter angiography, the repeatability of the diagnosis of vasospasm, made by multiple raters, is only fair. Interventions on angiographic vasospasm have never been proven to improve patient outcomes. A pragmatic trial integrating the meaning of the diagnosis of vasospasm into a study protocol that assesses the value of endovascular interventions in the prevention of DCI after SAH seems to be in order. Such a trial could provide a pragmatic definition of clinically meaningful vasospasm. CONCLUSION We must move beyond research conceived as an enterprise aiming to acquire theoretical knowledge to one where research is integrated into clinical practice to improve clinical outcomes in real time.

Objective To describe transcranial Doppler (TCD) findings in a population with clinical probable RCVS . Exploratory objectives included the study of clinical characteristics of probable RCVS patients with and without spasm detected by TCD. Methods Cross-sectional cohort study of patients with thunderclap headache (TCH) without subarachnoid hemorrhage (SAH) of our neurology and headache center between 2010 and 2019, selecting patients with clinical diagnosis of probable RCVS (negative angiography study) by ICHD-3 criteria and with at least two TCD studies. Results From 114 TCH patients, 36/114 had probable RCVS by ICHD-3 criteria and had at least two TCD studies available. The mean age at RCVS onset was 42.9 years (21–72 years); 29/36 (80.6%) were female, 7/28 (25%) had cardiovascular risk factors and 20/36 (55.6%) had history of migraine. Most common triggers were stressful emotion, drugs, valsalva maneuvers and sexual activity. Five/36 (13.9%) had complications and 3/36 (8.3%) had late recurrence. Initial TCD was performed on average of 16 (6–26) days after headache onset. Twenty-nine had vasospasm on TCD, presenting mean flow velocity of MCA (VMCA) of 135.7 ± 17.0 cm/s and mean maximum VMCA of 138.3 ± 17.2. Vasospasm was mild in 21/29 patients (72.4%) and moderate in 8/29 (27.6%). Complete VMCA normalization occurred on average 41 (30–70) days after headache onset and 24 (11–47) days after initial TCD. The group of patients with vasospasm detected by TCD had more female patients (26/29, 89.7% vs. 3/7, 42.8%, P = 0.016), and more TCH attacks (mean of 3.6 vs. 2.14, P = 0.049). Conclusion TCD may be a useful tool in the identification of vasospasm in patients with probable RCVS, supporting the diagnosis of RCVS in patients presenting with recurrent TCH without SAH.

Resumen Objetivo El objetivo es informar de nuestro estudio multicentrico de seguridad y eficacia acerca de la angioplastia con stent recuperable en el vasoespasmo secundario a la hemorragia subaracnoidea por aneurisma (HSAa). Metodos Realizamos un analisis retrospectivo de una base de datos prospectiva de pacientes consecutivos sometidos a tratamiento endovascular mediante angioplastia con stent recuperable para el vasoespasmo relacionado con la HSAa en cuatro departamentos de neurorradiologia intervencionista, entre enero de 2018 y julio de 2019. Incluimos a pacientes consecutivos mayores de 18 anos con vasoespasmo mayor del 50% de la arteria carotida interna (ACI), la arteria cerebral anterior (ACA) y/o las arterias cerebrales medias (ACM) secundario a HSAa, tratado endovascularmente mediante angioplastia con stent recuperable. Las complicaciones del procedimiento y las complicaciones clinicas se registraron como variables de seguridad. Las variables de eficacia radiologica del procedimiento se definieron como la mejora en el porcentaje de estenosis despues del tratamiento endovascular y la mejora o normalizacion del tiempo de circulacion cerebral (TCC). Resultados Incluimos 16 procedimientos de angioplastia con stent recuperable en 13 pacientes, con 33 segmentos arteriales tratados (10 ACI, 15 ACM y 8 ACA). No encontramos complicaciones de procedimiento en ningun paciente, ni complicaciones clinicas en pacientes no intubados. Todos los pacientes con TCC retrasado al principio del procedimiento, excepto uno, mostraron una mejora en el TCC. La mejora en el porcentaje de estenosis en la ACI fue de 18 ± 11,65 (media ± DE), 30,67 ± 18,45 en la ACM y 28,38 ± 15,49 en la ACA. No encontramos ninguna asociacion estadisticamente significativa entre las variables de tratamiento endovascular y la mejora en el porcentaje de estenosis. Conclusion La angioplastia con stent recuperable como tratamiento del vasoespasmo secundario a la HSAa es un procedimiento seguro y eficaz que mejora el TCC y la estenosis del vaso despues del tratamiento.

Purpose The purpose of this study was to assess the accuracy of computed tomography angiography (CTA) for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage in proximal and middle segments of intracranial arteries. Materials and methods Twenty consecutive patients (7 men, 13 women; mean age, 47 ± 7 [SD] years; age range: 27–78 years) with aneurysmal subarachnoid hemorrhage who underwent CTA and digital subtracted angiography (DSA) with a 6-hour window at baseline and during vasospasm period were included. Twelve artery segments were analyzed in each patient. Vasospasm was blindly quantified on CTA and digital subtracted angiography (DSA) by two independent readers with discordance > 10% resolved by open data consensus. Inter-reader and inter-test correlations with DSA as reference, and causes of discordant readings were analyzed. The best sensitivity and specificity of CTA for determination of vasospasm ≥ 50% on DSA was determined using receiver operating curve analysis. Results Two-hundred-and-ten arterial segments were analyzed after exclusion of 30 segments with missing data or metallic artifacts. An inter-reader discordance >10% was observed in 82 segments (82/210; 39% [95% CI: 32–46]). Inter-test discordances >10% were observed respectively in 115 segments (115/210; 55% [95% CI: 49–62]) with the junior reader and in 73 segments (73/210; 35% [95% CI: 29–42]) with the senior reader. They were related to reader error in 55 (55/210; 26% [95% CI: 20–32]) with the junior reader and 13 (13/210; 6% [95% CI: 3–9]) with the senior reader, as well systematic biases in 8 (8/210; 4% [95% CI: 1–6]), and intrinsic limitation in 52 (52/210; 25% [95% CI: 19–31]). Best sensitivity and specificity of CTA were observed for a threshold value of 30% (sensitivity = 88% [95% CI: 78–97%]; specificity = 84% [95% CI: 77–90%]; area under curve = 0.92 [95% CI: 0.86–0.97]). On a patient basis, sensitivity was 100% (specificity = 60% [95% CI: 38–81%]; area under curve = 0.97 [95% CI: 89–100%] for this same threshold. Conclusion Our study shows a moderate accuracy of CTA for the quantification of cerebral vasospasm, mostly related to challenging interpretation and intrinsic limitations. CTA may rule-out angiographic vasospasm ≥ 50% when no segment has vasospasm over than 30%.

To report the clinical outcomes of vasospasm embolization technique in treating lower gastrointestinal bleeding (LGIB).Fifty LGIB patients (32 men and 18 women; mean age, 70.4 years) with positive contrast extravasation on multidetector computed tomography were treated with pharmaco-induced vasospasm embolization by semiselective catheterization technique. Distal rectal bleeding was excluded. The bleedings in three patients were considered to be tumor related. Eighteen underwent regular hemodialysis, and 22 showed unstable hemodynamic at intervention.Forty-two bleeders were found in superior mesenteric territory and eight in the inferior mesenteric territory. Successful, immediate hemostasis was achieved in 49 (98%) patients. Early recurrent bleeding (30 days) was found in 13 (26.5%) patients with 6 local rebleeding (12.2%), 5 new-foci bleeding (10.2%), and 2 uncertain foci bleeding (4.1%). Repeated vasospasm embolization therapy was given to five patients, with successful hemostasis in four. All the three tumor-related bleeding patients undergoing vasospasm embolization had ceased bleeding and discharged. Patient-based primary and overall clinical successes were achieved in 73.5% and 83.7%, and lesion-based primary and overall clinical successes were 83.0% and 86.7%, respectively. The 30-day mortality rate was 21.3%, and the 1- and 2-year survival rates were 51.5% and 43.8%. No major procedure-related complications (eg, bowel ischemia) were encountered.This study confirmed our prior preliminary conclusion that pharmaco-induced vasospasm embolization is easy, safe, and effective for LGIB. This treatment may be considered the first-line alternative approach for LGIB, especially for patients of advanced age with complex medical problems and/or when vasa rectal embolization isn't feasible.

BACKGROUND: Nimodipine improves outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the impact of alternative dosing strategies on outcome remains unclear. METHODS: We performed a retrospective cohort study of consecutive patients admitted with aSAH to an academic referral center from 2016 to 2019. Patients with a confirmed aneurysm cause who received nimodipine were included; patients who died or had withdrawal of life-sustaining treatment within 24 hours of admission were excluded. Univariable and multivariable modified Poisson regression models were used to identify predictors of using modified nimodipine dosing (30 mg every 2 hours) versus standard dosing (60 mg every 4 hours). Inverse probability weighted and modified Poisson regression models were used to estimate adjusted risk ratios (RRs) for outcome measures, with poor outcome defined as modified Rankin Scale score 4–6 at 3 months. RESULTS: We identified 175 patients with aSAH who met eligibility criteria (mean [SD] age = 57 [13.2] years, 62% female, 73% White); 49% (n = 86) received modified nimodipine dosing. A modified dose was used more frequently in women (RR 2.08, 95% confidence interval [CI] 1.11–3.89, P = 0.02), patients with vasospasm (RR 3.47, 95% CI 1.84–6.51, P < 0.001), and patients who required vasopressors (RR 1.73, 95% CI 1.3–2.32, P < 0.001). Modified dosing was not associated with poor functional outcome (inverse probability weighted RR 1.1, 95% CI 0.8–1.4, P = 0.65). CONCLUSIONS: Modified dosing of nimodipine is well tolerated and may not be associated with worse functional outcome. Prospective studies are needed to better assess the relationship between nimodipine dosing and outcomes in patients with aSAH.

Актуальність. Питання лікування післяопераційного болю залишаються предметом активного обговорення і великої кількості медичних публікацій. Мета дослідження: оцінити ефективність застосування декскетопрофену трометамолу при лікуванні післяопераційного больового синдрому у хворих, які перенесли оперативне втручання на органах черевної порожнини. Матеріали і методи. Обстежено 40 хворих, яких було прооперовано з приводу патології органів черевної порожнини. Залежно від характеру післяопераційного знеболювання (застосування диклофенаку натрію або декскетопрофену трометамолу) хворі були розподілені на 2 групи. Результати. При лікуванні післяопераційного больового синдрому диклофенаком натрію упродовж перших двох діб після операції зберігався помірний больовий синдром, що потребувало додаткового знеболювання наркотичними анальгетиками у 80–90 % хворих (дворазово — в 1-шу добу, одноразово — в 2-гу добу). Післяопераційний біль супроводжувався симпатикотонією, гіперглікемією, вазоспазмом і тахікардією. Формувався відносно гіпердинамічний тип кровообігу. Активація симпатичної ланки вегетативної нервової системи сприяла збільшенню системного транспорту і споживання кисню. Застосування декскетопрофену трометамолу при лікуванні післяопераційного больового синдрому було ефективним і дозволяло якісно обмежити розвиток післяопераційної гіпералгезії. Висновки. Традиційне використання диклофенаку натрію для лікування болю після планового оперативного втручання в абдомінальній хірургії зберігає помірний больовий синдром, що у 80–90 % хворих вимагає неодноразового додаткового введення наркотичних анальгетиків протягом перших двох діб. При застосуванні декскетопрофену трометамолу больовий синдром зменшується до легкого вже з 1-ї доби після операції, що у 40–60 % пацієнтів вимагає тільки одноразового додаткового знеболювання, сприяє нормалізації судинного тонусу і серцевого ритму, транспорту і споживання кисню при відносній парасимпатикотонії.

Purpose To evaluate the diagnostic accuracy of computed tomography angiography (CTA) acquired with shuttle technique (CTAs) and helical CTA (CTAh) for vasospasm, using digital subtraction angiography (DSA) obtained within 24 h as reference standard. Methods Thirty-six patients with suspected vasospasm in the setting of aneurysmal subarachnoid hemorrhage (ASAH, 30/36) or acute inflammatory/infectious conditions (6/36) who underwent CTAs (17/36) or CTAh (19/36) followed by DSA within 24 h were identified retrospectively. Presence of vasospasm in the proximal cerebral arterial segments was assessed qualitatively and semi-quantitatively on CTA and subsequent DSA. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Inter-rater variability was assessed using Cohen's kappa. Results On CTAs, 35% of patients had low and 65% had high vasospasm burden. On CTAh, 37% had low and 63% had high vasospasm burden. ROC analysis demonstrated an AUC of 0.87 for CTAs (95%CI 0.67–1.00, p = 0.015) and 0.88 for CTAh (0.72–1.00, p = 0.028). Cohen's kappa was 0.843 (95%CI 0.548–1.000). Thresholding with Youden's J index, CTAs had a sensitivity of 85.71% (95%CI 48.69 to 99.27) and specificity of 66.67% (35.42 to 87.94). CTAh had sensitivity of 100% (56.55 to 100.00) and specificity of 78.57% (52.41 to 92.43). Conclusion CTAs and CTAh yielded similar sensitivity, specificity, and AUC values on ROC analysis for the detection of vasospasm using DSA as reference standard. Our findings suggest that CTAs is a promising alternative to CTAh especially in patients requiring serial imaging, given its potential advantages of decreased radiation exposure, contrast dose, and cost-effectiveness.

Background Occipital artery–posterior inferior cerebellar artery (OA–PICA) bypass is a challenging procedure and not frequently performed due to difficulties in occipital artery (OA) harvest. To facilitate the harvest, the intersection between the sternocleidomastoid and splenius capitis (known as the “OA triangle”) is used as the anatomical landmark to identify the OA segment that carry the highest risk of damage. This clinical study aimed to demonstrate the efficacy and safety of OA harvest using this landmark. Methods Eighteen patients who underwent the OA harvest using the OA triangle as a landmark for treatment of vertebral artery and PICA aneurysms were retrospectively evaluated for the safety and patency of OA after the harvest and OA–PICA bypass. Results Eighteen patients experienced ruptured and unruptured vertebral artery and PICA aneurysms. Thirteen patients (72.2%) underwent OA–PICA bypass and 5 patients (27.8%) did not undergo bypass. The OA was completely harvested without damage in all patients. After the harvest, the OA was patent in 17 patients (94.4%) and was occluded in one patient due to vasospasm, who then underwent recanalization resulting in good patency of the OA–PICA bypass thereafter. The patency rate of the OA–PICA bypass was 100%. Conclusions The OA triangle, which is the anatomical landmark of the proximal end of the transitional segment of OA, facilitated the OA harvest using the distal-to-proximal harvest technique with safety and good patency. To the best of our knowledge, this is the first study of OA harvest in the clinical cases.

Objective: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular event; patients are routinely admitted to the intensive care unit (ICU) for initial management. Because complications may be delayed, unplanned ICU readmissions can occur. Therefore, in this study we evaluate the rate of and factors associated with readmission after aSAH and identify if readmission is associated with poor clinical outcomes.Methods: We retrospectively reviewed the medical records of all patients receiving surgical or endovascular treatment for aSAH and admitted to the ICU between January 2008 and December 2019. We categorized patients by readmission and analyzed their clinical parameters.Results: Of the 345 patients who transferred to ward-level care after an initial ICU stay (Group 2), 27 (7.3%) were readmitted to the ICU (Group 1). History of hypertension (HTN), initial Glasgow Coma Scale (GCS) score, modified Fisher grade, and vasospasm therapy during first ICU stay were significantly different between the groups. The most common reason for readmission was delayed cerebral ischemia (DCI; 70.3%; OR 5.545; 95% CI 1.25−24.52; p=0.024). Comorbid HTN (OR 5.311; 95% CI 1.75−16.12; p=0.03) and vasospasm therapy during first ICU stay (OR 7.234; 95% CI 2.41−21.7; p＜0.01) also were associated with readmission. Readmitted patients had longer hospital stay and lower GCS scores at discharge (p＜0.01).Conclusions: DCI was the most common cause of ICU readmission in patients with aSAH. Readmission may indicate clinical deterioration, and patients who are at a high risk for DCI should be monitored to prevent readmission.

The correlation of neuroinflammation with the development of cerebral vasospasm following subarachnoid hemorrhage has been well documented in the literature; both clinical and preclinical. The exact mechanisms by which this process occurs, however, are poorly elucidated. Recent evidence indicates that interleukin-6 is not only an important prognostic biomarker for subarachnoid hemorrhage and subsequent vasospasm development but also an integral component in the progression of injury following initial insult. In this review, we briefly highlight other pathways under investigation and focus heavily on what has been discovered regarding the role of interleukin 6 and cerebral vasospasm following subarachnoid hemorrhage. A proposed mechanistic pathway is highlighted in written and graphical format. A discussion regarding the human correlative findings and initial pre-clinical mechanistic studies is addressed. Finally, in the future investigation section, innovative developments and a clear description of areas warranting further scientific inquiry are emphasized. This review will catalyze continued discovery in this area of emerging significance and aid in the quest for effective vasospasm treatment where limited clinical therapeutics currently exist.

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 Spontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH. Methods We retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis. Results Of the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode. Conclusion SAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients.

Background Patients with aneurysmal subarachnoid hemorrhage (aSAH) may develop refractory arterial cerebral vasospasm requiring multiple endovascular interventions. The aim of our study is to evaluate variables associated with need for repeat endovascular treatments in refractory vasospasm and to identify differences in outcomes following one versus multiple treatments. Methods We retrospectively reviewed patients treated for aSAH between 2017 and 2020 at two tertiary care centers. We included patients who underwent treatment (intraarterial infusion of vasodilatory agents or mechanical angioplasty) for radiographically diagnosed vasospasm in our analysis. Patients were divided into those who underwent single treatment versus those who underwent multiple endovascular treatments for vasospasm. Results Of the total 418 patients with aSAH, 151 (45.9%) underwent endovascular intervention for vasospasm. Of 151 patients, 95 (62.9%) underwent a single treatment and 56 (37.1%) underwent two or more treatments. Patients were more likely to undergo multiple endovascular treatments if they had a Hunt-Hess score > 2 (odds ratio [OR] 5.10 [95% confidence interval (CI) 1.82-15.84]; p = 0.003), a neutrophil-to-lymphocyte ratio > 8.0 (OR 3.19 [95% CI 1.40-7.62]; p = 0.028), and more than two fevers within the first 5 days of admission (OR 7.03 [95% CI 2.68-20.94]; p Conclusions A Hunt-Hess score > 2, a neutrophil-to-lymphocyte ratio > 8.0, and early fevers may be predictive of need for multiple endovascular interventions in refractory cerebral vasospasm after aSAH. These patients have poorer functional outcomes at discharge and higher rates of in-hospital complications.

Introduction: Continuous neurologic assessment in the pediatric intensive care unit is challenging. Current electroencephalography (EEG) guidelines support monitoring status epilepticus, vasospasm detection, and cardiac arrest prognostication, but the scope of brain dysfunction in critically ill patients is larger. We explore quantitative EEG in pediatric intensive care unit patients with neurologic emergencies to identify quantitative EEG changes preceding clinical detection. Methods: From 2017 to 2020, we identified pediatric intensive care unit patients at a single quaternary children's hospital with EEG recording near or during acute neurologic deterioration. Quantitative EEG analysis was performed using Persyst P14 (Persyst Development Corporation). Included features were fast Fourier transform, asymmetry, and rhythmicity spectrograms, “from-baseline” patient-specific versions of the above features, and quantitative suppression ratio. Timing of quantitative EEG changes was determined by expert review and prespecified quantitative EEG alert thresholds. Clinical detection of neurologic deterioration was defined pre hoc and determined through electronic medical record documentation of examination change or intervention. Results: Ten patients were identified, age 23 months to 27 years, and 50% were female. Of 10 patients, 6 died, 1 had new morbidity, and 3 had good recovery; the most common cause of death was cerebral edema and herniation. The fastest changes were on “from-baseline” fast Fourier transform spectrograms, whereas persistent changes on asymmetry spectrograms and suppression ratio were most associated with morbidity and mortality. Median time from first quantitative EEG change to clinical detection was 332 minutes (interquartile range: 201-456 minutes). Conclusion: Quantitative EEG is potentially useful in earlier detection of neurologic deterioration in critically ill pediatric intensive care unit patients. Further work is required to quantify the predictive value, measure improvement in outcome, and automate the process.

The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). Eighty patients aged 8.6 years (3.3–14.8 years, 25–75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4–12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5–10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1–4]) vs. children without vasospasm (score of 4 [2–4]) (p = 0.09). These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.

Background Microsurgical clipping and endovascular coiling are viable treatment options for posterior communicating artery (PComA) aneurysms, but there are still major limitations to evidence-based decisions regarding standard-of-care treatment. In this study, we aimed at assessing potential selection biases that may influence our ability to extract conclusions about the comparative effectiveness or efficacy of the aneurysm treatment. Objective To study the patient/aneurysm characteristics as possible biases in the option for endovascular or neurosurgical treatment of PComA aneurysms. Methods A single-center, retrospective cohort study was performed, including all patients with treated PComA aneurysms with neurosurgical clipping or endovascular coiling between January 2010 and January 2021. Clinical and morphological data were collected from electronic records, and statistical analysis was performed. Results A total of 64 patients was eligible for inclusion; 24 (37.5%) patients were proposed for neurosurgical treatment, while 40 (62.5%) for endovascular treatment; 10 patients (25%) crossed over to the clipping group whereas none crossed over to the coiling side. Actual treatment analysis showed significantly higher diameters of mother vessel (t-test, p = 0.034) and aneurysm neck (Mann–Whitney, p = 0.029) in the clipping group and higher aspect and dome-to-neck ratios in the endovascular group (Mann–Whitney, p = 0.008). A significantly higher vasospasm frequency was found in the clipping group but only in the intention-to-treat analysis (Chi-square, p = 0.032). Conclusion Significant morphological differences between effective endovascular and surgical groups and differences in intention-to-treat analysis may limit the validity of a direct comparison between treatment options and suggest the presence of a possible selection bias.

Angiographic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI)-related cerebral infarction (radiological DCI) and worsened neurological outcome. Transcranial Doppler (TCD) measurements of cerebral blood flow velocity are commonly used after aSAH to screen for vasospasm; however, their association with cerebral infarction is not well characterized. We sought to determine whether time-varying TCD-measured vasospasm severity is associated with cerebral infarction and investigate the performance characteristics of different time/severity cutoffs for predicting cerebral infarction. We conducted a retrospective single-center cohort study of consecutive adult patients with aSAH with at least one TCD study between 2011 and 2020. The primary outcome was radiological DCI, defined as a cerebral infarction developing at least 2 days after any surgical or endovascular intervention without an alternative cause. Cox proportional hazards models were used to examine associations between time-varying vasospasm severity and radiological DCI. Optimal TCD-based time/severity thresholds for predicting radiological DCI were then determined. Of 262 patients with aSAH who underwent TCD studies, 27 (10%) developed radiological DCI. Patients with radiological DCI had higher modified Fisher scale scores and trended toward earlier onset of vasospasm. Adjusted for age, Hunt and Hess scores, and modified Fisher scale scores, the worst-vessel vasospasm severity was associated with radiological DCI (adjusted hazard ratio 1.7 [95% confidence interval 1.1–2.4]). Vasospasm severity within a specific vessel was associated with risk of delayed infarction in the territory supplied by that vessel. Optimal discrimination of patients with radiological DCI was achieved with thresholds of mild vasospasm on days 4–5 or moderate vasospasm on days 6–9, with negative predictive values greater than 90% and positive predictive values near 20%. TCD-measured vasospasm severity is associated with radiological DCI after aSAH. An early, mild TCD-based vasospasm severity threshold had a high negative predictive value, supporting its role as a screening tool to identify at-risk patients.

Spontaneous subarachnoid haemorrhage is characterized by extravasation of blood into the subarachnoid space without a preceding trauma. The leading cause is a ruptured intracranial aneurysm. Serious neurologic complications can occur, such as rebleeding, cerebral vasospasm and delayed cerebral ischemia. Subarachnoid haemorrhage is a serious condition with a high mortality rate and those who survive often suffer long-term consequences. Prevention of rebleeding by aneurysm repair is essential and guidelines recommend this procedure should be done as soon as possible or within 72 hours. Management requires intensive care with emphasis on accurate blood pressure control, maintaining normal fluid and electrolyte balance and monitoring the level of consciousness. All patients should be treated with the calcium channel blocker nimodipine to reduce the risk of vasospasm and delayed cerebral ischemia which are among the most serious complications of subarachnoid haemorrhage.

Cerebrovascular disease is a broad topic. This document focuses on the imaging recommendations for the varied clinical scenarios involving intracranial aneurysms, vascular malformations, and vasculitis, which all carry high risk of morbidity and mortality. Additional imaging recommendations regarding complications of these conditions, including subarachnoid hemorrhage and vasospasm, are also covered. While each variant presentation has unique imaging recommendations, the major focus of this document is neurovascular imaging techniques. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Introduction Cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) are among the most hazardous complications of aneurysmal subarachnoid hemorrhage (aSAH). Genetic factors are thought to play a significant role in the development of both complications. Aim To perform a comprehensive meta-analysis of studies that study the association between different genetic polymorphisms and development of DCI and/or CV. Methods We searched MEDLINE and Science Direct databases on May 29, 2021, using iterations of the keywords "subarachnoid hemorrhage", "vasospasm", "delayed cerebral ischemia", and "gene". After duplicates were removed, the two reviewers screened the titles of the articles and abstracts independently. A random-effect model was used to calculate the relative risk with 95% CI; a fixed-effect model was additionally explored. Results We pooled data from 16 articles that reported an association between eNOS, apolipoprotein E4 (ApoE4), haptoglobin (Hp), or ryanodine-1 (RYR-1) and CV, DCI, or both. Presence of Hp 2-2 was associated both with CV (RR 2.10, 95% CI 1.33-3.31, p = 0.0014) and DCI (RR 1.57, 95%CI 1.06-2.34, p = 0.026). ApoE4 allele had a borderline association with CV (RR 1.48, 95%CI 0.99-2.21, p = 0.054). Conclusion Our meta-analysis supports the association between the presence of the Hp2-2 allele and the occurrence of CV and DCI after aSAH. Further studies investigating this association are needed to reinforce this finding.

O envenenamento por aranhas marrons (Loxosceles) ou loxoscelismo, pode produzir extensa dermonecrose e hemorragia no local da picada e, eventualmente, reações sistêmicas que podem se tornar letais. A evolução é caracterizada pela intensificação da dor, isquemia, vaso-espasmo, eritema, edema e parestesia. A picada da aranha marrom pode provocar um quadro cutâneo necrótico e mais raramente o quadro sistêmico, e fase cutâneo-visceral está associada à hemólise intravascular e em casos raros, levando a morte do paciente. No presente relato de caso, a paciente de 77 anos deu entrada no Hospital Regional do Cariri após surgimento de ferida dolorosa associada à vermelhidão na região da mama. Relatou uma picada de aranha no local há aproximadamente 20 dias. Durante o internamento evoluiu com acometimento sistêmico devido à extensa lesão necrótica de partes moles. Foram realizados dois desbridamentos e excisão extensa na área da mama e região torácica. Apesar de todos os tratamentos e procedimentos realizados, a paciente apresentou agravamento no quadro e não resistiu, falecendo 22 dias após admissão no hospital. Palavras-chave: loxoscelismo, acidente aracnídeo, aracnidismo, dermatopatias.

Aim – to assess the benefits of modern methods for endovascular occlusion of ruptured cerebral aneurysms in the acute period of subarachnoid hemorrhage (SAН). Materials and methods. Medical records of patients undergoing treatment in the acute period of aneurysmal SAН between 2010–2021 were analyzed. 2 groups were formed: I – the use of standard surgical catheters, minimal use of adjunctive techniques for aneurysm embolization (2010–2016), II – routine use of triaxial access systems, intraarterial infusion of nimodipine, active use of adjunctive techniques for aneurysm embolization, intraoperative antiplatelet therapy immediately after aneurysm occlusion – 500 mg of solution Acelysin administrated intravenously (2017–2021). The severity of SAН according to the Hunt–Hess, Fisher scales, the treatment outcome according to the modified Rankin Scale (mSR), the location and size of aneurysms and intraoperative complications were analyzed. Results. There were 156 observations in group I, 91 – in group II. The median age was 48.26 years in group I, 51.44 years – in group II. On the basis of gender status, there was a majority of women in both groups. Aneurysms of the anterior cerebral-anterior communicating artery complex predominated in both groups; the internal carotid artery was the second most frequent localization. The severity of SAН according to the generally accepted scales (Hunt–Hess, Fisher) did not differ significantly. Coil embolization was used in 100 % of cases, balloon-assisted coiling was used in 6.48 % in group I and in 14.80 % – in group II, stent-assisted coiling – in 2.56 % and 9.30 %, respectively, distal access catheter with the triaxial system was not used in group I and it was performed in 57.4 % of cases in group II. Pharmacoangioplasty using nimodipine solution was used in 16.6 % in group I and in 22.2 % in group II. Intravenous drip infusion of 0.5 g Acelysin was performed immediately after aneurysm occlusion in 22.2 % of cases in group II. Intraoperative aneurysm rupture was observed in 5.1 % in group I and in 1.1 % in group II. Distal coil migration or into the maternal artery occurred in 6.41 % in group I and in 2.20 % in group II. Thromboembolic complications were noted in 7.69 % and in 2.20 %, respectively. The mean value of dysfunction degree on mSR amounted to 2.27 in group I and 1.45 – in group II. A good treatment outcome (mRS score 1–2) was defined in 71.2 % of observations in group I and in 87.9 % – in group II. The death rate was 12.82 % and 7.62 %, respectively. Conclusions. Routine use of triaxial access systems and intraarterial pharmacoplasty with nimodipine allow adequate prevention of mechanically induced vasospasm during catheterization of the aneurysm cavity. The triaxial access system stability provides better control of the microguidewire and microcatheters reducing the risk of aneurysmal wall perforation during catheterization. The use of adjunctive techniques for embolization of ruptured cerebral aneurysms in the acute period of SAH and prophylactic infusion of Acelysin solution after aneurysm occlusion significantly reduces the incidence of thromboembolic complications. The earliest possible occlusion of a ruptured cerebral aneurysm is not only the prevention of re-rupture, but also expands the possibilities of intensive care for preventing secondary complications of SAH.

BACKGROUND/AIM This study investigated the effect of vascular endothelial growth factor (VEGF) inhibitor bevacuzimab (BVZ) on the rabbit basilar artery using an experimental subarachnoid hemorrhage (SAH) model. MATERIALS AND METHODS Eighteen adult male New-Zealand white rabbits were randomly divided into three groups: a control group (n=6), SAH group (n=6), and SAH+BVZ group (n=6). Experimental SAH was created by injecting autologous arterial blood into the cisterna magna. In the treatment group, the subjects were administered a daily dose of 10 mg/kg, intravenous BVZ 2 days after the SAH. Basilar artery diameters were measured with magnetic resonance angiography (MRA) 72 hours after the SAH in all groups. After 72 hours the animals? whole brains, including the upper cervical region, were obtained from all the animals after perfusion and fixation of the animal. The wall thickness, luminal area, and the apoptosis at the basilar arteries were evaluated in all groups. RESULTS BVZ significantly prevented SAH induced vasospasm confirmed in-vivo with MRA imaging with additional suppression of apoptosis on basilar artery wall. CONCLUSION VEGF inhibition with BVZ has shown to have a vasospasm and apoptosis attenuating effect on basilar artery in a SAH model.

STUDY OBJECTIVE: Vasopressin may be administered to treat vasospasm follow aneurysmal subarachnoid hemorrhage (aSAH). Few data support this practice, and it has recently been associated with clinically significant hyponatremia. The objectives of this study were to describe five cases of suspected vasopressin-induced hyponatremia after aSAH and to review the literature on this adverse effect. DESIGN: Single-center, observational case series of intensive care unit (ICU) patients SETTINGS: Ten-bed neurological intensive care unit at Maine Medical Center in Portland, Maine PATIENTS: Convenience sample of patients with aSAH treated with a vasopressin for symptomatic, radiologically-confirmed vasospasm MEASUREMENTS AND MAIN RESULTS: A total of five patients were included in the case series with a median age of 57 (51, 65) years and all were female. The median Glasgow coma scale score was 15 (11, 15) on admission and the Hunt and Hess scale score was 3, (3, 4). All patients were treated with endovascular coiling of their aneurysm. Vasopressin was administered to treat symptomatic, radiographically-confirmed vasospasm on median post-bleed day (PBD) 10 (10, 15) at a fixed-dose of 0.03 units/min. Serum sodium at baseline was 140 (140, 144) mEq/L and decreased to 129 (126, 129) mEq/L within 26 (17, 83) hours of vasopressin initiation for a median change of −16 (−10, −16) mEq/L. Serum sodium returned to baseline within 18 (14, 22) hours of stopping the infusion. CONCLUSIONS: Vasopressin administration to treat vasospasm after aSAH may be associated with clinically significant hyponatremia within 24 hours of starting the infusion. Hyponatremia appears to resolve within 24 hours of stopping the vasopressin infusion. Additional study in a larger sample size is needed to determine if a causal relationship exists.

The optimal treatment for blood blister-like aneurysm (BBA) has not yet been determined, and BBA has a high recurrence rate after stent-assisted embolization. The purpose of the present study was to evaluate the safety and feasibility of patients with BBA rupture in the acute phase or patients with BBA who have recurrence after stent-assisted coil embolization. Eight patients (8 women, mean age 50.3 ± 3.7 years) who presented with ruptured BBA or recurrence BBA that had been treated by stent-assisted embolization (5 patients after primary treatment of stent-assisted embolization) were retrospectively reviewed. Clinical follow-up was performed at 1 year after endovascular treatment. All patients were successfully treated with the WCS, and immediate postoperative angiography showed that the aneurysms were completely isolated. The ophthalmic artery was covered by WCS in one patient; however, this patient did not show any clinical visual field or vision symptoms. Procedure-related complications such as aneurysm rupture, vasospasm, acute thrombosis, or thromboembolism did not occur in any case. All patients were followed up for 1 year after endovascular treatment, and they were in good condition without recurrence. One patient developed delayed bleeding at the right temporal lobe. All patients had good clinical prognosis (modified Rankin Scale score ≤ 2). WCS implantation may be a safe and feasible strategy for patients with BBA rupture in the acute phase and patients with BBA who have recurrence after stent-assisted coil embolization and is a promising option worth exploring.

La anafilaxia es una causa poco frecuente de síndrome coronario agudo por vasoespasmo con o sin la presencia de enfermedad coronaria subyacente. Presentamos el caso de un síndrome de Kounis en un paciente masculino sin factores de riesgo conocidos para enfermedad coronaria quien presentó un síndrome coronario agudo con elevación de ST que requirió manejo con adrenalina, soporte vital básico e ingreso a Unidad de Cuidados Intensivos; con arteriografía coronaria sin evidencia de enfermedad subyacente.

A good working view is critical for safe and successful endovascular treatment of cerebral aneurysms. In a few cases, endovascular treatment of cerebral aneurysms may be challenging due to difficulty in obtaining a proper working view. In this report of 6 cases, we described the advantage of using a distal intracranial catheter (DIC) to achieve better visualization of cerebral aneurysms hidden by a parent artery or its branches. Between September 2017 and January 2021, we treated 390 aneurysms with endovascular techniques. In 6 cases in which it was difficult to obtain a proper working view, the DIC was placed distally close to the aneurysm in order to remove the parent artery projection from the working view and obtain better visualization of the aneurysm. Clinical and procedural outcomes and complications were evaluated. The position of the DIC was above the internal carotid artery siphon in the 6 cases. All aneurysms were successfully embolized. Raymond–Roy class 1 occlusion was achieved in all 4 unruptured aneurysms, while the result was class 2 in the 2 ruptured aneurysms. Placement of the DIC was atraumatic without dissections or significant catheter-induced vasospasm in all patients. Transient dysphasia was seen in 2 cases and transient aphasia in 1. Using this technique, we have found it possible to better visualize the aneurysm sac or neck and thereby treat cases we otherwise would have considered untreatable.

Background Vasospasm is a major problem following microsurgical reconstruction which can result in the partial or complete loss of the flap tissue. The aim of this study was to investigate the efficiency of hydrodilatation for the prevention of vasospasm. Methods Thirty male Wistar rats were used for this experimental study. Femoral arteries of were exposed, photographed, and transected. In group 1, group 2, and group 3 papaverine solution, hydrodilatation, and minimal mechanical dilatation (control group) was performed, respectively. The anastomosis was completed and the arteries were photographed again 10 minutes after completion of the anastomosis. Following 7-day period samples for transmission electron microscopy (TEM) and light microscopy were obtained. Results The mean vessel diameters prior to transection were 0.43, 0.45, and 0.52 mm in the papaverine, hydrodilatation, and control groups, respectively. The mean vessel diameter 10 minutes following the completion of anastomosis was 0.76, 0.75, and 0.51 mm in the papaverine, hydrodilatation, and control groups, respectively. Median score for papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 2, 3, 2, and 3 positive, respectively. Median score for the papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 3, 3, 3, and 3 positive, respectively. All the histological scores were negative in the control group. The difference between the control group and the experiment groups 1 and 2 was significant regarding all four histological parameters (p Conclusion Hydrodilatation and papaverine application were both effective in preventing vasospasm following microsurgical intervention but papaverine caused slightly less damage to the endothelial lining and less edema in the tunica adventitia when compared with the hydrodilatation. Hydrodilatation group showed a vasodilatory effect that was statistically similar to that of papaverine, which has a proven efficacy.

Scleroderma renal crisis is a life-threatening condition. It usually starts with a sudden onset of severe hypertension, followed by renal failure, hypertensive encephalopathy, congestive heart failure, and/or microangiopathic hemolytic anemia. Renal ischemia, hyperplasia of the juxtaglomerular apparatus, activation of the renin-angiotensin-aldosterone system (RAAS), and an increase in blood pressure are caused by decreased blood flow caused by structural changes in the blood vessels as well as renal vasospasm ("Raynaud's phenomenon"). This overview discusses the evaluation, diagnosis, and treatment of scleroderma renal crisis, emphasizing the importance of early detection of disease, strong correlation of corticosteroids intake and the disease incidence, and best approach of such cases.

The aim of this study was to evaluate whether the Serum Netrin-1 and Urinary KIM-1 (Kidney Injury Molecule-1) levels are associated with the detection of preeclampsia. A total of 90 patients, including 36 normal pregnant women, 29 patients with nonsevere preeclampsia and 25 patients with severe preeclampsia, were included in this study. Maternal serum Netrin-1 and Urinary KIM-1 levels were measured by using an enzyme-linked immunosorbent assay (ELISA). The results showed that the Levels of Netrin-1 and KIM-1 were statistically higher in women with preeclampsia as compared with normal pregnant women. Furthermore, the Netrin-1 level in women with severe preeclampsia was significantly higher than nonsevere preeclamptic women. inconclusion the current study showed that Maternal serum level of Netrin-1 and Urinary level of KIM-1 can be used as early biomarkers for the detection of preeclampsia.IMPACT STATEMENTWhat is already known on this subject? Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs after 20 weeks' gestation. Netrin-1 was found to promote angiogenesis. Alteration of placental angiogenesis in early pregnancy is a well-known reason for placental dysfunction such as preeclampsia. Kidney injury with proteinuria is a characteristic feature of preeclampsia. Urine KIM-1 is the most potential biomarker for renal injury in preeclampsia. Due to these facts, we aimed to investigate the role of maternal serum Netrin-1 and Urine KIM-1 levels in preeclampsia presence and severity.What the results of this study add? A significant relationship between Netrin-1 and KIM-1 levels with preeclampsia.What the implications are of these findings for clinical practice and/or further research? Based on these findings, we concluded that increased levels of Netrin-1 and KIM-1 are associated with severe preeclampsia.

Neurogenic stunned myocardium is a form of stress cardiomyopathy. The disorder is sometimes referred to as atypical Takotsubo cardiomyopathy. The pathophysiology of neurogenic stunned myocardium is hypothesized to involve significant overdrive of the sympathetic nervous system after a brain injury. Treatment options for a patient with a brain injury who has progressed to cardiogenic shock remain controversial, with no consistent guidelines. A patient with subarachnoid hemorrhage who progresses to cardiogenic shock with concurrent cerebral vasospasm presents a special treatment challenge. Neurogenic stunned myocardium is reversible; however, it must be recognized immediately to avoid or manage potential complications, such as cardiogenic shock and pulmonary edema. A multifaceted treatment approach is needed for the patient with cardiogenic shock and concurrent vasospasm.

OBJECTIVES This study investigated the effect of very low concentrations of ethanol on artery and vein anastomosis. Also, it was aimed to determine the appropriate ethanol concentration to be used in vasospasm. METHODS Rats were divided into five groups of eight rats, each group, as follows: Group i: saline; Group ii: 2.5% ethanol; Group iii: 5% ethanol; Group IV: 7.5% ethanol; and Group V: 10% ethanol. During the femoral artery and vein anastomosis, 1ml of the agent was used for irrigation in each group. Vessel diameters were measured before the anastomosis, at the fifth and 15th minutes, and the third week after the anastomosis. Histopathological samples were taken in the third week. RESULTS In Groups ii and iii, the mean vessel diameters were found to increase 15th minute. Also observed was an increase in mean vessel diameter that continued in the third week. Although acute vasodilation was detected in Groups IV and V, arterial and venous thrombosis was observed in the third week. Intima and media thickness decreased in Group ii, while it increased in Group iii. Perivascular inflammation and fibrosis increased as the ethanol concentration increased. CONCLUSION 2.5% ethanol causes acute and prolonged vasodilation and does not cause endothelial cell damage, perivascular inflammation, and fibrosis. 2.5% ethanol will be a powerful alternative use in many situations that occur with vasospasm.

Intravenous (IV) milrinone, in combination with induced hypertension, has been proposed as a treatment option for cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, data on its safety and efficacy are scarce. This was a controlled observational study conducted in an academic hospital with prospectively and retrospectively collected data. Consecutive patients with cerebral vasospasm following aSAH and treated with both IV milrinone (0.5 µg/kg/min−1, as part of a strict protocol) and induced hypertension were compared with a historical control group receiving hypertension alone. Multivariable analyses aimed at minimizing potential biases. We assessed (1) 6-month functional disability (defined as a score between 2 and 6 on the modified Rankin Scale) and vasospasm-related brain infarction, (2) the rate of first-line or rescue endovascular angioplasty for vasospasm, and (3) immediate tolerance to IV milrinone. Ninety-four patients were included (41 and 53 in the IV milrinone and the control group, respectively). IV milrinone infusion was independently associated with a lower likelihood of 6-month functional disability (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.10–0.77]) and vasospasm-related brain infarction (aOR = 0.19, 95% CI 0.04–0.94). Endovascular angioplasty was less frequent in the IV milrinone group (6 [15%] vs. 28 [53%] patients, p = 0.0001, aOR = 0.12, 95% CI 0.04–0.38). IV milrinone (median duration of infusion, 5 [2–8] days) was prematurely discontinued owing to poor tolerance in 12 patients, mostly (n = 10) for “non/hardly-attained induced hypertension” (mean arterial blood pressure

Background The additional information that transcranial Doppler can provide as part of a multimodal imaging protocol in many clinical settings has not been evaluated. Main body Transcranial Doppler is a bedside procedure used to assess cerebral blood flow velocity via cerebral circulation and pulsatility index (PI). Many diseases can lead to cerebral vessels vasospasm as in subarachnoid hemorrhage and trauma. Cerebral vessels vasospasm represented by abnormal elevation of cerebral blood flow velocity. Intracranial pressure can be monitored by pulsatility index which reflects blood flow resistance in cerebral vessels. Transcranial Doppler ultrasonography is also the unique modality for detection of micro emboli in high-risk patients. Also, it can be used for evaluation of circulatory arrest with subsequent confirmation of brain death Conclusion Transcranial Doppler ultrasonography is the only diagnostic modality that provides a reliable assessment of cerebral blood flow patterns in real time. The physiological information obtained from TCD is complementary to the anatomical details obtained from other neuroimaging modalities. TCD is relatively cheap, can be performed bedside, and allows monitoring in acute emergency settings.

Retropharyngeal cellulitis/abscesses are deep neck infections that may become life-threatening if airway compromise occurs. This condition is more common in children than in adults, and associated intracranial vessel narrowing has been reported. We report an adult patient with extensive retropharyngeal cellulitis and intracranial vasospasm. The patient was a 62-year-old woman who presented with fever, sore throat, and neck pain. She also had uncontrolled type 2 diabetes mellitus. Leukocytosis, prolonged erythrocyte sedimentation rate, elevated C-reactive protein, and hyperglycemia were present on admission. Computed tomography and contrast-enhanced magnetic resonance imaging revealed severe swelling in the nasopharyngeal, retropharyngeal, prevertebral, and bilateral carotid spaces. Gadolinium enhancement extended to the middle cranial fossa and visceral space. Multiple stenoses in several intracranial vessels was also identified. Intravenous antibiotic therapy was initiated, the patient's symptoms resolved, and repeat imaging confirmed improvement. Intracranial vasospasm should be considered in patients with retropharyngeal cellulitis.

Summary Vasospasm and tissue desiccation due to dryness are two different problems in microsurgical procedures that requires special attention and measures to minimize their occurrence. However, they can both have a potentially detrimental effect on the flow of the procedure from the technical aspect as well affecting flap outcomes and results. The authors present a simple innovative and cost-effective method to preserve moisture and prevent vasospasm by applying lidocaine gel externally on the harvested flap pedicle and recipient vessels during surgery. In this article, we discuss pearls and tips of using this approach in routine microsurgical operations.

Background Cerebral vasospasm is a common complication of subarachnoid hemorrhage. Nimodipine is the most frequently used drug for cerebral vasospasm management and is the only approved medication that has been demonstrated to reduce ischemic complications, infarct size and improve neurological outcome after aneurismal subarachnoid hemorrhage. The main purpose of this systematic review was to conduct a comprehensive analysis of the main cerebral and extracerebral side effects of continuous intra-arterial infusion of nimodipine in management of delayed cerebral ischemia in subarachnoid hemorrhage patients. Materials and methods A protocol with the inclusion and exclusion criteria for matched cases and the method of analysis were established and agreed by all authors. We defined the scope of this review to include articles (prospective and retrospective) reporting the side effects of continuous intra-arterial infusion of nimodipine in human subjects. PRISMA guidelines were used to conduct this systematic review. Results A total of 8 articles reporting 136 patients were included in the review and analyzed. The side effects associated with continuous intra-arterial infusion of nimodipine were arterial hypotention, heparin-induced thrombocytopenia, atrial fibrillation or flutter, infections, acute kidney injury, hepatic and gastro-intestinal side effects. Conclusion The most frequent side effects reported in the articles included in this systematic review associated with the continuous intra-arterial infusion of nimodipine were arterial hypotension and heparin-induced thrombocytopenia. Intracerebral hemorrhage, the elevation of ICP, heart rhythm disorders, infectious complications, and thrombosis of the catheter might be also associated with CIAN. Future prospective studies are warranted to establish the risks and incidence of procedure-related side effects.

This is a case of a 32-year-old primigravid who developed sudden severe headache on the 7th day postpartum associated with focal neurologic deficits and altered sensorium. She had a GCS score of 6, anisocoric pupils and an NIHSS score of 31. Cranial MRI with MRA showed multifocal hyperacute to acute infarcts on the left occipital lobe, left thalamus, and midbrain which was more prominent on the right. Due to clinical deterioration, a repeat Cranial MRI with MRA was done and showed progression of infarcts involving both thalami and right pons with interval appearance of contour irregularities in the proximal anterior cerebral, posterior cerebral, basilar and internal carotid arteries. Serial transcranial Doppler showed significant distal right middle cerebral artery vasospasm. She was managed as a case of reversible cerebral vasoconstriction syndrome, associated with postpartum cerebral angiopathy. Intravenous pulse methylprednisolone was started subsequently IVIG was initiated. Intravenous immunoglobulin was given for 5 days. The patient gradually improved, underwent rehabilitation therapy, and was discharged stable after 6 weeks.

Kounis syndrome is an anaphylactic reaction leading to acute coronary syndrome. The acute treatment of anaphylaxis is epinephrine; however, epinephrine may cause coronary vasoconstriction, reduce coronary blood flow, increase myocardial oxygen demand, and worsen myocardial ischemia. On the other hand, coronary vasodilation, a treatment for acute coronary syndrome, can aggravate hypotension in patients with anaphylaxis. Herein, the authors report a case of type II Kounis syndrome, with vasospasm in a patient with coronary disease, requiring the administration of epinephrine and a coronary vasodilator for resuscitation. The authors administered intravenous epinephrine continuously from lower dosages and performed delicate titration. The coronary vasodilator nicorandil, which has little effect on hemodynamics, also was administered. These treatments improved hemodynamics without complications. Circulatory management that considers both anaphylaxis and coronary lesions is crucial to improve prognosis in this syndrome.

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) remains an important problem with a complex pathophysiology. We used data from a single-center randomized trial to assess the effect of a phosphodiesterase inhibitor, cilostazol, in patients with aneurysmal SAH to explore the relationships of DCI with vasospasm, spreading depolarization (SD) and microcirculatory disturbance. A post hoc analysis of a single-center, prospective, randomized trial of the effect of cilostazol on DCI and SD after aneurysmal SAH was performed. From all randomized cohorts, patients who underwent both SD monitoring and digital subtraction angiography (DSA) on day 9 ± 2 from onset were included. Cerebral circulation time (CCT), which was divided into proximal CCT and peripheral CCT (as a measure of microcirculatory disturbance), was obtained from DSA. Logistic regression was conducted to determine factors associated with DCI. Complete data were available for 28 of 50 patients. Of the 28 patients, 8 (28.5%) had DCI during the study period. Multivariate analysis indicated a strong association between the number of SDs on the day DSA was performed (i.e., a delayed time point after SAH onset) and DCI (odds ratio 2.064, 95% confidence interval 1.045–4.075, P = 0.037, area under the curve 0.836), whereas the degree of angiographic vasospasm and peripheral CCT were not significant factors for DCI. There is a strong association between SD and DCI. Our results suggest that SD is an important therapeutic target and a potentially useful biomarker for DCI.

By July 2021, the United States had over 34.4 million confirmed COVID-19 cases. Various cardiovascular manifestations of COVID-19 have been reported including ST-elevation myocardial infarction (STEMI), and there is concern that SARS-CoV-2 may be associated with a higher thrombus burden. We performed a retrospective chart review of 535 adult patients with COVID-19 admitted at Yale-New Haven Health Greenwich Hospital from February 1, 2020, to May 13, 2020. All admitted patients had undergone testing for serum troponin I and various inflammatory markers, and we identified three patients who were diagnosed with acute STEMI. Data was collected via manual chart review and included patient demographics, comorbidities, laboratory tests, electrocardiogram (ECG) results, echocardiography results, diagnoses during hospitalization, inpatient therapies, and outcomes including length of hospital stay, revascularization results, and mortality. Three of our patients had obstructive coronary artery disease confirmed via angiography. One subject was noted to display vasospasm in addition to coronary atherosclerotic obstruction and refractory thrombus formation. Among our patients with COVID-19 and STEMI, presentations were variable in terms of timing of onset of ECG changes, age, gender, race, comorbidities, symptomology, and outcomes.

Introduction: Cerebral vasospasm (CV) is common following subarachnoid hemorrhage (SAH). However, its impact on neurological outcome, especially in head trauma, has not been yet elucidated. Controversy exists about the true relationship between TBI, SAH and Traumatic Vasospasm. Hence, this study aims to determine the association of vasospasm in TBI with SAH. Methods: This is Observational cross-sectional study with 124 head injury patients. 31 patients were excluded. Transcranial Doppler ultrasonography (TCD) was conducted on daily bases in all patients with traumatic brain injury (TBI). Vasospasm in the MCA and ACA was defined by a mean Flow velocity (FV) exceeding 120 cm/s and three times the mean FV of the ipsilateral ICA. Results: Among 93 included patients, 72 (77%) were male and 21 (23%) were female. Mean age was (35+10) years. Mean GCS score was (11+4.1). 61 (66%) patients suffered with severe head injury. Vasospasm was detected in 45 % (42) of the total patients. Vasospasm was severe among 4.3% (4 patients), and moderate among 65.6% (61 patients). Association was found between severity of trauma and the severity of vasospasm in MCA (r= 0.41 and 0.38, p value< 0.005) and in ACA (r =0.25, p value < 0.005). The presence of SAH is highly correlated with an amplified incidence of vasospasm. The patients who developed vasospasm, 55% (23) had SAH whereas 45% (19) didn’t have SAH, the corresponding p value is 0.04 which is significant. Conclusion: The high incidence of vasospasm is associated with SAH in severe TBI patients. Further studies are recommended to determine predictors of vasospasm in TBI patients with SAH.

Neurocritical care 35(1), 172-183 (2021). doi:10.1007/s12028-020-01169-x, Published by Springer, New York, NY

Background Acute brain injuries are associated with high mortality rates and poor long-term functional outcomes. Measurement of cerebrospinal fluid (CSF) biomarkers in patients with acute brain injuries may help elucidate some of the pathophysiological pathways involved in the prognosis of these patients. Methods We performed a systematic search and descriptive review using the MEDLINE database and the PubMed interface from inception up to June 29, 2021, to retrieve observational studies in which the relationship between CSF concentrations of protein biomarkers and neurological outcomes was reported in patients with acute brain injury [traumatic brain injury, subarachnoid hemorrhage, acute ischemic stroke, status epilepticus or post-cardiac arrest]. We classified the studies according to whether or not biomarker concentrations were associated with neurological outcomes. The methodological quality of the studies was evaluated using the Newcastle–Ottawa quality assessment scale. Results Of the 39 studies that met our criteria, 30 reported that the biomarker concentration was associated with neurological outcome and 9 reported no association. In TBI, increased extracellular concentrations of biomarkers related to neuronal cytoskeletal disruption, apoptosis and inflammation were associated with the severity of acute brain injury, early mortality and worse long-term functional outcome. Reduced concentrations of protein biomarkers related to impaired redox function were associated with increased risk of neurological deficit. In non-traumatic acute brain injury, concentrations of CSF protein biomarkers related to dysregulated inflammation and apoptosis were associated with a greater risk of vasospasm and a larger volume of brain ischemia. There was a high risk of bias across the studies. Conclusion In patients with acute brain injury, altered CSF concentrations of protein biomarkers related to cytoskeletal damage, inflammation, apoptosis and oxidative stress may be predictive of worse neurological outcomes.

To the best of our knowledge, this is the largest clinical retrospective study in AN‐SAH patients, and is the first time to establish accurate predictive models paired with bleeding pattern. Background Angiogram‐negative subarachnoid hemorrhage (AN‐SAH) has a definite incidence of delayed cerebral ischemia (DCI) and poor clinical outcomes. The purpose is to screen independent factors and establish a nomogram to guide the clinical therapy and assess post‐discharge prognosis. Methods We identified 273 consecutive patients referred to our institute from 2013 to 2018 for AN‐SAH. A nomogram to predict poor outcomes was formulated based on the multivariable models of independent risk factors. The accuracy and discrimination of nomograms were determined in training and internal validation cohorts. Results The overall poor outcome rates of AN‐SAH were 14.3% and 8.7% at 3 months and 12 months, respectively. In addition, perimesencephalic AN‐SAH (PAN‐SAH) presented with a more unfavorable prognosis compared with non‐perimesencephalic AN‐SAH (NPAN‐SAH). The clinical prognosis was associated with the World Federation of Neurosurgical Societies scale (WFNS) (odds ratio, 3.82 [95% CI, 1.15‐12.67] for 3‐month outcome; and odds ratio, 31.69 [95% CI, 3.65‐275.43] for 12‐month outcome), Subarachnoid hemorrhage Early Brain Edema Score (SEBES) (odds ratio, 10.39 [95% CI, 1.98‐54.64] for 3‐month outcome; odds ratio, 10.01 [95% CI, 1.87‐53.73] for 12‐month outcome), and symptomatic vasospasm (odds ratio, 3.16 [95% CI, 1.03‐9.70] for 3‐month outcome; odds ratio, 5.15 [95% CI, 1.34‐19.85] for 12‐month outcome). The nomogram was constructed based on the above features, which represented great predictive value in clinical outcomes. Conclusions Symptomatic vasospasm, high WFNS, cerebral edema, and NPAN‐SAH after hemorrhage were associated with poor outcome of AN‐SAH. The nomogram with WFNS (3‐5), SEBES (3‐4), vasospasm, and NPAN‐SAH represented a practical approach to provide individualized risk assessment for AN‐SAH patients., To the best of our knowledge, this is the largest clinical retrospective study in AN‐SAH, and is the first time to establish accurate predictive models paired with bleeding pattern.

Background Red blood cell-induced cerebral inflammation and toxicity has been shown to be attenuated by induction of the heme-catalyzing enzyme, hemoxygenase-1 (HO-1), in animal models of subarachnoid hemorrhage (SAH). Although inflammatory mechanisms leading to secondary neuronal injury in SAH are becoming increasingly well understood, markers of cerebral inflammation have so far not been implemented in clinical prediction models of SAH. Methods In this biomarker observational study, HO-1 messenger ribonucleic acid (mRNA) expression levels were determined in cerebrospinal fluid (CSF) and blood of 66 patients with aneurysmal SAH on days 1, 7, and 14 after the SAH event. HO-1 mRNA expression was determined via real time polymerase chain reaction (PCR), and relative expression changes were quantified in comparison with expression levels in nonhemorrhagic control CSF. Subarachnoid blood burden, as well as presence of vasospasm and delayed cerebral ischemia (DCI), were recorded. Short and long-term clinical outcomes were assessed using the Modified Rankin Scale at discharge and 1 year after the SAH event. Results CSF HO-1 expression levels showed a significant increase over the 14-day observation period (p F = 22.53) and correlated with intracranial hematoma burden (ρ = 0.349, p = 0.025). In multivariate analyses, CSF HO-1 expression levels did not reach significance as independent predictors of outcome. Vasospasm on computed tomographic angiography was associated with lower CSF HO-1 expression levels on day 7 after SAH (n = 53, p = 0.010), whereas patients with DCI showed higher CSF HO-1 expression levels on day 14 after SAH (n = 21, p = 0.009). Conclusions HO-1 expression in CSF in patients with SAH follows a distinct temporal induction pattern and is dependent on intracranial hematoma burden. CSF HO-1 expression was unable to predict functional outcome. Associations of early low HO-1 expression with vasospasm and late elevated HO-1 expression with DCI may point to detrimental effects of late HO-1 induction, warranting the need for further investigation in a larger study population.

Intensive therapies of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) have still controversial and unproven benefit. We aimed to compare the overall efficacy of two different center-driven strategies for the treatment of DCI respectively with and without vasospasm angioplasty. Two hundred consecutive patients with aSAH were enrolled in each of two northern European centers. In an interventional center, vasospasm angioplasty was indicated as first line rather than rescue treatment of DCI using distal percutaneous balloon angioplasty technique combined with intravenous milrinone. In non-interventional center, induced hypertension was the only intensive therapy of DCI. Radiological DCI (new cerebral infarcts not visible on immediate post-treatment imaging), death at 1 month, and favorable outcome at 6 months (modified Rankin scale score ≤ 2) were retrospectively analyzed by independent observers and compared between two centers before and after propensity score (PS) matching for baseline characteristics. Baseline characteristics only differed between centers for age and rate of smokers and patients with chronic high blood pressure. In the interventional center, vasospasm angioplasty was performed in 38% of patients with median time from bleeding of 8 days (Q1 = 6.5;Q3 = 10). There was no significant difference of incidence of radiological DCI (9% vs.14%, P = 0.11), death (8% vs. 9%, P = 0.4), and favorable outcome 74% vs. 72% (P = 0.4) between interventional and non-interventional centers before and after PS matching. Our results suggest either that there is no benefit, or might be minimal, of one between two different center-driven strategies for intensive treatment of DCI. Despite potential lack of power or unknown confounders in our study, these results question the use of such intensive therapies in daily practice without further optimization and validation.