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A significant number of patients admitted for aneurysmal subarachnoid hemorrhage (aSAH) are active smokers and are at risk of developing nicotine withdrawal symptoms (e.g., cravings, irritability, insomnia, headaches, etc.). This study aimed to evaluate the use of nicotine replacement therapy (NRT) regarding headache severity and analgesics consumption.A retrospective study was conducted using prospectively collected data from 2014 to 2019 in the neurointensive care unit of the Hospices Civils in Lyon, France. We performed a propensity score matching analysis. The covariables used were age, sex, initial World Federation of Neurosurgical Societies score, Hijdra sum score, and factors associated with pain following aSAH (history of chronic pain, anxiety, or depression). Smokers received NRT through a transdermal device. The primary end point was headache control. Secondary end points were mean numerical pain rating scale score and analgesics consumption.One hundred and fifty-five patients were included among 523 patients hospitalized for aSAH. Fifty-one patients underwent nicotine substitution and were matched to 51 unsubstituted patients. The headache control rate was not different between the two groups (43.1% vs. 31.4%, p = 0.736). The mean numeric pain rating scale score in the substituted group was 2.2 (1.1-3.5) and 2.4 (1.6-3.1) in the unsubstituted group (p = 0.533). The analgesics consumption (acetaminophen, tramadol, and morphine) was the same in the two groups.The use of NRT in the acute phase of aSAH does not seem to have an impact on the intensity of headaches or analgesics consumption.

Delayed cerebral ischemia (DCI) is a poorly predictable complication occurring after aneurysmal subarachnoid hemorrhage (SAH) that can have dramatic functional consequences. Identifying the patients with the highest risk of DCI may help to institute more suitable monitoring and therapy. Early brain injuries and aneurysm-securing procedure complications could be regarded as confounding factors leading to severity misjudgment. After an early resuscitation phase, a subacute assessment may be more relevant to integrate the intrinsic SAH severity. A retrospective analysis was performed upon patients prospectively included in the registry of SAH patients between July 2015 to April 2020. The amount of cisternal and intraventricular blood were assessed semi-quantitatively on acute and subacute CT scans performed after early resuscitation. A clot clearance rate was calculated from their comparison. The primary endpoint was the occurrence of a DCI. A total of 349 patients were included in the study; 80 (22.9%) experienced DCI. In those patients, higher Fisher grades were observed on acute (p = 0.026) and subacute (p = 0.003) CT scans. On the subacute CT scan, patients who experienced DCI had a higher amount of blood, either at the cisternal (median Hijdra sum score: 11 vs 5, p 0.001) or intraventricular (median Graeb score: 4 vs 2, p 0.001) level. There was a negative linear relationship between the cisternal clot clearance rate and the risk of DCI. The assessment of the amount of subarachnoid blood and clot clearance following resuscitation after aneurysmal SAH can be useful for the prediction of neurological outcome.

Resume L’ischemie cerebrale retardee (ICR) reste une complication frequente et dramatique de l’hemorragie meningee anevrismale, dont l’incidence, elevee avant le onzieme jour post-saignement, impose une surveillance continue. Le diagnostic clinique d’une anomalie de perfusion avec un deficit neurologique peut etre rendu difficile chez les patients qui ont des troubles de la conscience. La surveillance clinique seule est a risque de diagnostic trop tardif pour une prevention efficace de la lesion cerebrale definitive. Une approche multimodale pour un diagnostic precoce du risque d’ICR peut associer le Doppler transcrânien, de l’electrophysiologie, de l’oxymetrie ou du metabolisme cerebral, ou encore un biomarqueur plasmatique, qui devra etre confirme par une imagerie de perfusion. Cette difficulte diagnostique reflete la complexite des mecanismes a l’origine de l’ICR que les etudes experimentales ont bien mis en evidence. En accord avec cette complexite, differentes strategies de prevention therapeutique ont cible la spasticite vasculaire, l’inflammation, l’agregation plaquettaire, le metabolisme cerebral, ou l’elimination du sang dans les espaces sous-arachnoidiens. Les resultats inconstants des etudes cliniques ont confirme la complexite de la lesion d’ICR. La nimodipine reste le seul traitement preventif recommande avec un impact sur le devenir neurologique. Plus recemment, l’antagoniste du recepteur a l’endotheline semblait efficace sur la vasomotricite des arteres cerebrales sans amelioration du devenir neurologique. Les prochaines etudes cliniques devraient preciser l’interet des inhibiteurs des phosphodiesterases ou du drainage du liquide cephalorachidien. La encore, une approche multimodale des therapeutiques devrait permettre la prevention optimale de cette complication redoutable.

Levetiracetam is an anti-epileptic drug commonly used in intensive care when seizure is suspected as a possible cause of coma. We propose to question the cofounding effect of Levetiracetam during the prognostication process in a case of anoxic coma. We report the story of a young woman presenting a comatose state following a hypoxic cardiac arrest. After a first EEG presenting an intermediate EEG pattern, a seizure suspicion led to prescribe Levetiracetam. The EEG showed then the appearance of burst suppression, which was compatible with a very severe pattern of post-anoxic coma. This aggravation was in fact related to an overdose of Levetiracetam (the only medication introduced recently) and was reversible after Levetiracetam cessation. The increased plasmatic dosages of Levetiracetam confirming this overdose could have been favoured by a moderate reduction of renal clearance, previously underestimated because of a low body-weight. This EEG dynamic was unexpected under Levetiracetam and could sign a functional instability after anoxia. Burst suppression is classically observed with high doses of anaesthetics, but is not expected after a minor anti-epileptic drug. This report proposes that Levetiracetam tolerance might not be straightforward after brain lesions and engages us to avoid confounding factors during the awakening prognostication, which is mainly based on the severity of the EEG. Hence, prognosis should not be decided on an isolated parameter, especially if the dynamic is atypical after a new prescription, even for well-known drugs. For any suspicion, the drug's dosage and replacement should be managed before any premature care's withdrawal.