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Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18 years with aSAH for radiographic vasospasm detection. The DerSimonian–Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR −). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68–91%) and a specificity of 97% (95%CI, 93–98%), while TCD had lower sensitivity 38% (95%CI, 19–62%) and specificity of 91% (95%CI, 87–94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR − for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR − than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR − , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm. [ABSTRACT FROM AUTHOR]

S100 calcium binding protein B (S100B), a well-studied marker for neurologic injury, has been suggested as a candidate for predicting outcome after subarachnoid hemorrhage. We performed a pooled analysis summarizing the associations between S100B protein in serum and cerebrospinal fluid (CSF) with radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction, and Glasgow Outcome Scale (GOS) outcome. A literature search using PubMed, the Cochrane Library, and the EMBASE databases was performed to identify relevant studies published up to May 2015. The weighted Stouffer’s Z method was used to perform a pooled analysis of outcome measures with greater than three studies. A total of 13 studies were included in this review. Higher serum S100B level was found to be associated with cerebral infarction as diagnosed by CT (padj = 3.1 x 10−4) and worse GOS outcome (padj = 5.5 x 10−11). There was no association found between serum and CSF S100B with radiographic vasospasm or DIND. S100B is a potential prognostic marker for aSAH outcome. [ABSTRACT FROM AUTHOR]

Objective: Vasospasm and resultant clinical deterioration caused by delayed cerebral ischemia (CD-CDI) are a considerable source of morbidity after aneurysmal subarachnoid hemorrhage (SAH). Although they are a relatively common cause of spontaneous SAH, AVM rupture and ensuing vasospasm are rarely reported. Methods: We reviewed our own series of 122 patients with AVMs. Seventy-three patients sustaining 84 hemorrhages were analyzed. In addition, we performed a review of the literature of vasospasm after AVM rupture. Results: Seventy of 84 hemorrhages (83%) had an intraparenchymal component, 27 (32%) a subarachnoid component, and 51 (61%) had an intraventricular component. No patients experienced CD-DCI, and of the 84 hemorrhages reported, only one patient experienced mild angiographic vasospasm (1.1%). Alternatively, this finding represents 1 in 34 cases (2.9%) who underwent definitive angiography between the fourth and fifteenth day after the hemorrhage. Nineteen additional cases of angiographic vasospasm after AVM rupture are reported in the literature. The mean age of these patients was 33 years; there was a 1.25:1 female to male predominance in this group. One-half of these patients had an intraparenchymal hemorrhage, and only 56% of them had SAH. All patients had intraventricular hemorrhage when assessed. The median time to onset of vasospasm was nine days. Across four series, the rate of angiographic spasm after SAH from an AVM was 6.3% (9/142 cases). Conclusions: Even in cases of SAH from AVMs, angiographic vasospasm after AVM rupture is relatively rare. We thus do not recommend empiric delayed angiography to assess for vasospasm in these patients. Nevertheless, it does remain a rare possibility and should be considered in those with CD-DCI. [Copyright &y& Elsevier]

Background: Vasospasm, delayed infarcts and clinical deterioration due to delayed cerebral ischemia (CD-DCI) following digital subtraction angiography (DSA)-negative, spontaneous subarachnoid hemorrhage (SAH) are infrequently and inconsistently described in the literature. Methods: To quantify and characterize rates of each, we reviewed our own series of 77 patients with DSA-negative, spontaneous SAH. Employing a PubMed search, we reviewed the literature and calculated directly adjusted overall rates of vasospasm, delayed infarcts and CD-DCI. Results: In our own patient cohort, 26 % of patients suffered vasospasm, 4 % delayed infarcts and 4 % CD-DCI. Higher Hunt-Hess grade and diffuse SAH pattern were associated with higher rates of each. Incorporating results from 18 studies in the literature, the directly adjusted overall rate of vasospasm following DSA-negative SAH was 16.3 % (95 % CI 12.3-21.1). Adjusted overall rates of delayed infarcts and CD-DCI were 3.4 % (95 % CI 1.9-5.5) and 6.8 % (95 % CI 5.0-9.1), respectively. For the subgroup of patients with diffuse SAH, the rates of vasospasm and CD-DCI were 31.3 % (95 % CI 21.6-43.9) and 9.7 % (95 % CI 7.0-13.0), respectively, while in patients with perimesencephalic SAH, respective rates were 13.1 % (95 % CI 7.7-20.7) and 2.4 % (95 % CI 1.0-4.8). A mixed-effects meta-analysis revealed an odds ratio for CD-DCI in diffuse SAH compared to perimesencephalic SAH of 3.79 (p = 0.009). Conclusion: Although they are seen less frequently in patients with DSA-negative spontaneous SAH, vasospasm, delayed infarcts and CD-DCI do occur and may require endovascular therapy. Risk factors include a diffuse hemorrhage pattern and higher Hunt-Hess grade. [ABSTRACT FROM AUTHOR]

Objective The pathophysiology on cerebral vasospasm and delayed cerebral ischemia (DCI) remains poorly understood. Much research has been dedicated to finding genetic loci associated with vasospasm and ischemia. We present a systematic review and meta-analysis to identify genetic polymorphisms associated with delayed ischemic neurologic deficit (DIND), radiographic infarction attributed to ischemia, and radiographic vasospasm. Methods PubMed, the Cochrane Library, and Excerpta Medica dataBASE (EMBASE) databases were used to identify relevant studies published up to March 2015 containing the subject terms cerebral or intracranial vasospasm and DCI in combination with genetics, gene, polymorphism or marker. Meta-analyses were performed using a random-effects model to calculate summary odds ratio (ORs) and 95% confidence intervals for each respective gene. Results Of 269 articles initially identified, 20 studies with 1670 patients were included in our comprehensive review, including 27 polymorphisms in 11 genes. The following 6 polymorphisms in 3 genes were selected for subsequent meta-analyses: apolipoprotein E (ApoE2, E4); endothelial nitric oxide (eNOS T786C, VNTR intron 4 a/b, G894T); and haptoglobin (Hp) 1/2 phenotypes. The eNOS VNTR a allele was associated with DIND ( a vs. b allele: OR 1.92 [1.31-2.81], p adj = 0.008). The Hp 2-2 allele was associated with radiographic vasospasm (2-2 vs. 2-1 and 1-1: OR 3.86 [1.86-8.03], p adj = 0.003) but did not reach significance for DIND. Conclusions This is the first systemic review and meta-analysis to study and evaluate the associations between genetic polymorphism with DCI and radiographic vasospasm independently. In our study, eNOS VNTR and Hp polymorphisms appear to have the strongest associations with DIND and radiographic vasospasm, respectively. [ABSTRACT FROM AUTHOR]

Spontaneous subarachnoid hemorrhage is often due to rupture of an intracranial aneurysm, but some patients present with no identifiable source. Increased incidence of nonaneurysmal subarachnoid hemorrhage (naSAH) has been reported over time. We performed a retrospective analysis of naSAH from 2008−2017 to determine the rate of naSAH change over time and its association with cannabis use. Univariable and multivariable regression analyses were performed to study the trend over time, radiographic patterns of hemorrhage, and clinical outcome at the time of discharge. In addition, we compared the rate of naSAH with the rate of aneurysmal SAH (aSAH) to adjust for changes in hospital volume and prevalence/reporting of cannabis use in the population over time. A total of 86 naSAH and 328 aSAH patients were identified, with an increase in naSAH over time compared with aSAH (P = 0.0034). Increased cannabis use was associated with naSAH (odds ratio [OR] 2.1, 95% confidence interval 1.1, 4.1, P = 0.035) but not aSAH over time. Cannabis use was also associated with different subarachnoid hemorrhage patterns (P = 0.0065) in naSAH. Multivariable analysis demonstrated good neurologic outcome after naSAH to be inversely associated with cocaine use (OR 0.008 [0.002−0.4]), ventriculostomy placement (OR 0.004 [0.03−0.50]), and anticoagulant use (OR 0.016 [0.003−0.54]) but not with cannabis use. As cannabis use becomes more prevalent with legalization, it is important to further investigate this association with spontaneous SAH. [ABSTRACT FROM AUTHOR]

Recent literature suggests there are sex differences in delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Our study serves to compare sex differences in radiographic vasospasm, DCI, and clinical outcome after aSAH, and to determine whether there are age-dependent differences. A total of 328 patients with ruptured cerebral aneurysms were evaluated for radiographic vasospasm, clinical deterioration, cerebral infarction, and modified Rankin Scale–determined clinical outcome at 6 months to 1 year after rupture. Multivariate regression analyses were performed to evaluate the associations between these outcome measures and sex, adjusting for age, hypertension, aneurysm location, admission Hunt and Hess grade, and modified Fisher grade. After multivariate adjustment, women had higher rates of radiographic vasospasm (β = 0.35; 95% confidence interval [CI], 0.068–0.63; P = 0.015), clinical deterioration (odds ratio [OR], 2.8; 95% CI, 1.3–6.0; P = 0.008) and cerebral infarction (OR, 2.4; 95% CI, 1.0–5.5; P = 0.039), but no difference was observed in follow-up modified Rankin Scale (mRS) outcome score at 6 months to 1 year (P = 0.96). Older women (age >55 years) have a higher rate of clinical deterioration than men in the same age group (OR, 3.5; 95% CI, 1.0–12; P = 0.043). In contrast, younger women (age ≤55 years) had increased radiographic vasospasm (β = 0.55; 95% CI, 0.17–0.93; P = 0.005) and worse mRS outcome score (β = 0.042; 95% CI, -0.021 to 1.1; P = 0.042) compared with men. Female sex is associated with a higher risk of radiographic vasospasm, clinical deterioration, and cerebral infarction. Furthermore, this association appears to be age-dependent. This study further supports the unique role of sex, and highlights the need to better understand the possible role of female hormones in the development of complications of subarachnoid hemorrhage. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate the association between noninfectious fever onset and radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage. Methods We evaluated 44 patients for the association between noninfectious fever (greater than 101.5°F) and the development of radiographic vasospasm by digital subtraction angiography (DSA) and transcranial Doppler (TCD), DIND, DCI, and modified Rankin scale outcome score at 6 months to 2 years. Multivariate logistic regression analyses were performed to account for patient age, sex, admission Hunt and Hess grade, and Fisher grade. TCD was additionally used for temporal analysis. Results Noninfectious fever was significantly associated with radiographic vasospasm using both DSA (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2–4.5; P = 0.02) and TCD (OR, 2.4; 95% CI, 1.2–5.6; P = 0.02), but it was not associated with DIND, DCI, or outcome. The maximum cross correlation between TCD velocity and temperature occurred for temperatures taken 1 day prior to TCD velocity measurement. A quadratic mixed-effects model demonstrated that TCD velocity was significantly associated with temperature from 1 day prior to TCD velocity measurement (β = 13.5; 95% CI, 0.83–8.79, P = 0.01), posthemorrhage day (β = 20.1; 95% CI, 2.14–7.52; P < 0.001), and (posthemorrhage day)2 (β = –0.72; 95% CI, –0.26 to –0.11; P < 0.001). Conclusions Noninfectious fever was associated with the development of radiographic vasospasm but not with DIND, DCI, or clinical outcome. Furthermore, there is a temporal association between the onset of noninfectious fever and radiographic vasospasm by 1 day. Fever independent of patient's infectious profile may be an early marker for the development of radiographic vasospasm. [ABSTRACT FROM AUTHOR]

Objective Recent evidence has suggested a potential beneficial effect of aspirin on the risk of aneurysm rupture. This benefit must be weighed against its potential adverse effects as an antiplatelet agent in the setting of acute aneurysmal subarachnoid hemorrhage (SAH). Methods A total of 747 consecutive patients with cerebral aneurysms were reviewed, comparing demographics, aneurysm features, presenting clinical and radiographic grades, vasospasm, and outcome at 1 year between patients with aneurysmal SAH taking aspirin on presentation and those who were not. Results The rate of hemorrhagic presentation was significantly greater in patients not taking aspirin (40% vs. 28%; P = 0.016). Among 274 patients presenting with aneurysmal SAH, there was no significant difference in presenting clinical (Hunt and Hess) and radiographic (Fisher) grade between patients taking aspirin and those who were not. There was also no significant difference in the rate of subsequent angiographic and delayed cerebral ischemia. Multivariate analysis of outcome at 1 year found only increasing age (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.04–1.12), Hunt and Hess grade (OR 3.01, 95% CI 1.81–5.03), and associated hypertension (OR 3.30, 95% CI 1.39–7.81) to be statistically significant risk factors for poor outcome (death or dependence), whereas aspirin use was not associated with poor outcome (OR 1.19, 95% CI 0.35–4.09; P = 0.78). Conclusions In the present study, patients taking aspirin had a lower rate of hemorrhagic presentation. In addition, taking aspirin did not adversely impact presenting clinical grade or radiographic grade, vasospasm, and outcome in the setting of aneurysmal SAH. [ABSTRACT FROM AUTHOR]

Objective Vasospasm is the leading source of neurological morbidity after aneurysmal subarachnoid hemorrhage. Our objective was to evaluate the impact of treatment modality on vasospasm, delayed cerebral infarction, and clinical deterioration caused by delayed cerebral ischemia (CD-DCI). Methods We reviewed an institutional cohort, comparing rates of vasospasm, delayed cerebral infarction, and CD-DCI between patients managed with only microsurgical clipping and those treated with only endovascular coiling within 72 hours of rupture. Age, sex, smoking status, Hunt-Hess grade, and Fisher grade were adjusted for in a multivariate regression model. Results Two hundred three patients were treated with clipping and 52 with coiling. There was no significant difference in patient age, sex, smoking status, aneurysm location, and presenting clinical (Hunt-Hess) and radiographic (Fisher) grade between these two groups. Sixty-percent of patients had moderate or severe vasospasm after clipping compared with 38% after coiling (Multivariate odds ratio [OR] 2.32, 95% confidence interval [95% CI] 1.21–4.47, P = 0.01). Clipping was associated with a greater number of territories with vasospasm (mean of 3.1 vs. 2.3, P = 0.03 after multivariate analysis). Delayed radiographic cerebral infarction was more common in the clipping group (17% vs. 6%, multivariate OR 3.66, 95% CI 1.06–12.71, P = 0.04). For CD-DCI, a trend was seen as 16% of patients treated with clipping had CD-DCI compared with 6% of patients treated with coiling (multivariate OR 3.11, 95% CI 0.89–10.86, P = 0.07). Conclusion We demonstrate significantly lower rates of vasospasm and delayed infarction after endovascular coiling of ruptured aneurysms. [ABSTRACT FROM AUTHOR]