Appreciation of CT-negative, lumbar puncture-positive subarachnoid haemorrhage: risk factors for presence of aneurysms and diagnostic yield of imaging.

OBJECTIVE: Patients without a subarachnoid haemorrhage (SAH) on brain CT scan (CT-negative), but a lumbar puncture (LP)-proven SAH, are a challenging patient category. The optimal diagnostic approach is still a matter of debate. Also, there is little knowledge on the probability of finding an underlying vascular lesion. DESIGN: In this observational study, a consecutive cohort of 94 patients with CT-negative, LP-positive SAH was prospectively collected between 1998 and 2013. The yield of diagnostic modalities as well as patient outcome was studied. In addition, risk factors for the presence of a vascular lesion were analysed. RESULTS: In 40 patients (43%), an intracranial vascular abnormality was detected: 37 aneurysms and three arterial dissections. Female gender was significantly associated with detection of a vascular lesion. Time between ictus and diagnosis of SAH was not associated with the presence of vascular pathology. Overall, 99% of patients had a modified Rankin Score of 0-2 after a median follow-up of 72 months. The yield of additional digital subtraction angiography in patients with a negative CT angiography was zero. CONCLUSIONS: In this study, the chance of finding a vascular lesion in a patient with CT-negative, LP-positive SAH was 43%, underlining the need for an adequate diagnostic workup. In general, the patient outcome was favourable. Female gender was found to be predictive for detecting a vascular lesion. In contrast with previous reports, the interval between ictus and LP was not associated with the presence of an aneurysm.

Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients.

BACKGROUND: Only a small percentage of World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients have a favorable outcome. The influence of clinical parameters on outcome was assessed. METHODS: Retrospective evaluation of consecutive patients admitted from 2000-2007 with grade V subarachnoid hemorrhage at two institutions by evaluating, over time, the motor value of the Glasgow Coma Scale, effects of external ventricular drainage and rebleeding on outcome. Six-month outcome was assessed with the extended Glasgow Outcome Scale; favorable outcome was defined as good recovery or moderately disabled. FINDINGS: Of 126 patients, 28 had absent brainstem reflexes, without improvement after external ventricular drainage. Rebleeding occurred in 26 patients, resulting in treatment withdrawal in 14. Only one patient had a favorable outcome after rebleeding. Of the 84 remaining patients, 61 improved at day 2 after subarachnoid hemorrhage to Glasgow Coma Scale motor value ≥4; 24 of these (39%) had a favorable outcome. All 23 patients with a Glasgow Coma Scale motor value ≤3 had an unfavorable outcome or died. Patients younger than 65 yrs of age had a better outcome (p < .03). Hydrocephalus was present in 71 of 84 patients. Favorable outcome was similar for patients with a positive external ventricular drainage response (8 of 28) as compared to no response to external ventricular drainage (12 of 43). INTERPRETATION: The high rebleeding rate and subsequent poor outcome in World Federation of Neurologic Surgeons grade V patients warrants early treatment to secure the ruptured aneurysm. Favorable outcome was seen in 39% of patients with a Glasgow Coma Scale motor value ≥4 at day 2. In this study, patients with Glasgow Coma Scale motor value ≤3 at day 2 all had a very poor prognosis.

Atmospheric Pressure Variation is a Delayed Trigger for Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: There is an ongoing search for conditions that induce spontaneous subarachnoid hemorrhage (SAH). The seasonal pattern of SAH is shown in a large meta-analysis of the literature, but its explanation remains undecided. There is a clear need for sound meteorologic data to further elucidate the seasonal influence on SAH. Because of the stable and densely monitored atmospheric situation in the north of the Netherlands, we reviewed our unique cohort on the seasonal incidence of SAH and the association between SAH and local atmospheric changes. METHODS: Our observational cohort study included 1535 patients with spontaneous SAH admitted to our neurovascular center in the north of the Netherlands between 2000 and 2015. Meteorologic data could be linked to the day of the ictus. To compare SAH incidences over the year and to test the association with meteorologic conditions, incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs) were used, calculated by Poisson regression analyses. RESULTS: Atmospheric pressure variations were significantly associated with aneurysmal SAH. In particular, the pressure change on the second and third day before the ictus was independently correlated to a higher incidence of aneurysmal SAH (IRR, 1.11; 95% CI, 1.00-1.23). The IRR for aneurysmal SAH in July was calculated 0.67 (95% CI, 0.49-0.92) after adjustment for temperature and atmospheric pressure changes. CONCLUSIONS: Atmospheric pressure variations are a delayed trigger for aneurysmal SAH. Also, a significantly decreased incidence of aneurysmal SAH was noted in July.

Prediction of outcome after subarachnoid hemorrhage: timing of clinical assessment.

OBJECTIVE Currently, early prediction of outcome after spontaneous subarachnoid hemorrhage (SAH) lacks accuracy despite multiple studies addressing this issue. The clinical condition of the patient on admission as assessed using the World Federation of Neurosurgical Societies (WFNS) grading scale is currently considered the gold standard. However, the timing of the clinical assessment is subject to debate, as is the contribution of additional predictors. The aim of this study was to identify either the conventional WFNS grade on admission or the WFNS grade after neurological resuscitation (rWFNS) as the most accurate predictor of outcome after SAH. METHODS This prospective observational cohort study included 1620 consecutive patients with SAH admitted between January 1998 and December 2014 at our university neurovascular center. The primary outcome measure was a poor modified Rankin Scale score at the 2-month follow-up. Clinical predictors were identified using multivariate logistic regression analyses. Area under the receiver operating characteristic curve (AUC) analysis was used to test discriminative performance of the final model. An AUC of > 0.8 was regarded as indicative of a model with good prognostic value. RESULTS Poor outcome (modified Rankin Scale Score 4-6) was observed in 25% of the patients. The rWFNS grade was a significantly stronger predictor of outcome than the admission WFNS grade. The rWFNS grade was significantly associated with poor outcome (p < 0.001) as well as increasing age (p < 0.001), higher modified Fisher grade (p < 0.001), larger aneurysm size (p < 0.001), and the presence of an intracerebral hematoma (OR 1.8, 95% CI 1.2-2.8; p = 0.002). The final model had an AUC of 0.87 (95% CI 0.85-0.89), which indicates excellent prognostic value regarding the discrimination between poor and good outcome after SAH. CONCLUSIONS In clinical practice and future research, neurological assessment and grading of patients should be performed using the rWFNS to obtain the best representation of their clinical condition.

Minimally important change values of a measurement instrument depend more on baseline values than on the type of intervention.

OBJECTIVES: Multi-item questionnaires are frequently used to measure outcomes in randomized controlled trials (RCTs) in patients with sciatica. Knowing the minimaly important change (MIC) values for these instruments will facilitate interpretation of change scores. MIC values have been shown to be dependent on baseline values. The question is whether they also depend on the type of intervention. To estimate the MIC of the Roland Morris Disability Questionnaire (modified 23 item version) (RMDQ) and of intensity of leg pain measured by a Visual Analogue Scale (VAS) in patients with sciatica and to assess to what extent MIC values depend on type of intervention and on baseline values. STUDY DESIGN AND SETTING: This is a secondary analysis of RCT data of the effects of early surgery vs. prolonged conservative treatment in patients with sciatica. Baseline and 8-week data were used to assess MIC of the RMDQ-23 and VAS leg pain. We used the receiver operator characteristic (ROC) method to assess the MIC. Global Perceived Recovery (rated 8 weeks after baseline) was used as anchor. Subgroups were created based on type of treatment and baseline severity. RESULTS: The MIC value of the RMDQ-23 for the total group of sciatica patients was 7.5. The values were 8.1 and 6.9 for surgery and conservative treatment, respectively. For high and low baseline values, the MICs were 9.0 and 4.9, respectively, irrespective of treatment received. The MIC values of the VAS leg pain were 34.4 for the total group. For surgery and conservative treatment, the MIC values were 38.5 and 30.4, respectively, whereas for groups with high and low baseline values, MIC values of 53.5 and 17.2 were found. CONCLUSION: The MIC values of the RMDQ-23 and VAS leg pain were found to be highly dependent on their baseline values, although the type of intervention appeared to influence the MIC value only slightly.

Repeat digital subtraction angiography after a negative baseline assessment in nonperimesencephalic subarachnoid hemorrhage: a pooled data meta-analysis.

OBJECT: A repeat digital subtraction angiography (DSA) study of the cranial vasculature is routinely performed in patients with diffuse nonperimesencephalic subarachnoid hemorrhage (SAH) after negative baseline CT angiography (CTA) and DSA studies. However, DSA carries a low but substantial risk of neurological complications. Therefore, the authors evaluated the added value of repeat DSA in patients with initial angiographically negative diffuse nonperimesencephalic SAH. METHODS: A systematic review of the contemporary literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies from January 2000 onward were reviewed since imaging modalities have much improved over the last decade. A pooled analysis was conducted to identify the detection rate of repeat DSA. In addition, the diagnostic yield of repeat DSAs in a prospectively maintained single-center series of 1051 consecutive patients with SAH was added to the analysis. RESULTS: An initial search of the literature yielded 179 studies, 8 of which met the selection criteria. Another 45 patients from the authors' institution were included in the study, providing 368 patients eligible for the pooled analysis. In 37 patients (10.0%, 95% CI 7.4%-13.6%) an aneurysm was detected on repeat DSA. The timing of the repeat DSA varied from 1 to 6 weeks after the initial DSA. The use of 3D techniques was poorly described among these studies, and no direct comparisons between CTA and DSA were made. CONCLUSIONS: Repeat DSA is still warranted in patients with a diffuse nonperimesencephalic SAH and negative initial assessment. However, the exact timing of the repeat DSA is subject to debate.