Synchronous subarachnoid haemorrhage and ischaemic stroke as a result of complete internal carotid artery occlusion.

A previously healthy man in his 60s presents with a one-day history of insidious onset headache and 'walking into doors'. He reported transient right arm pain and tingling but no weakness. A CT brain showed a right middle cerebral artery (MCA) infarct as well as a synchronous right frontal lobe convexal subarachnoid haemorrhage (cSAH). An arch to vertex CT angiogram demonstrated right MCA occlusion and complete right internal carotid artery (ICA) occlusion from its origin. Reconstitution of flow was seen within the distal right ICA at the level of the distal foramen lacerum. A repeat CT of the brain after one week showed a stable appearance of the bleeding and infarct. He was commenced on antiplatelet therapy for the treatment of the ischaemic stroke as well as secondary prevention.This is a rare case of synchronous right MCA infarct as well as a right frontal cSAH secondary to ipsilateral carotid artery occlusion.

Coil Embolization of the Azygos Anterior Cerebral Artery Aneurysm: Three Case Reports.

The azygos anterior cerebral artery (ACA) is a rare anatomical anomaly. Clipping surgery has been conducted in approximately 30 reported cases because it is frequently associated with aneurysms. However, few cases in which coil embolization was performed have been reported. We report three cases of coil embolization for distal ACA aneurysms with distal azygos ACA at our institution in 7 years. All patients were over 65-year-old women with saccular aneurysms larger than 7 mm; two with subarachnoid hemorrhage and one with an unruptured aneurysm. No patient had surgical complications associated with coil embolization. Coil embolization is also useful for large aneurysms in the distal azygos ACA, and its indication for treatment could be broadened.

Risk of Cerebral Aneurysm Rupture After Liver Transplantation: Development and Validation of a Hemorrhagic Stroke Scoring Model.

BACKGROUND: Liver transplantation (LT) patients appear to be more prone to neurological events compared to individuals undergoing other types of solid-organ transplantation. The aims of the present study were to analyze the prevalence of unruptured intracranial aneurysms (UIAs) in patients undergoing liver transplantation (LT) and to examine the perioperative occurrence of subarachnoid hemorrhage (SAH). Also, it intended to systematically identify the risk factors of SAH and hemorrhagic stroke (HS) within a year after LT and to develop a scoring system which involves distinct clinical features of LT patients. METHODS: Patients who underwent LT from January 2012 to March 2022 were analyzed. All included patients underwent neurovascular imaging within 6 months before LT. We conducted an analysis of prevalence and radiological features of UIA and SAH. The clinical factors that may have an impact on HS within one year of LT were also reviewed. RESULTS: Total of 3,487 patients were enrolled in our study after applying inclusion and exclusion criteria. The prevalence of UIA was 5.4%. The incidence of SAH and HS within one year following LT was 0.5% and 1.6%, respectively. We developed a scoring system based on multivariable analysis to predict the HS within 1-year after LT. The variables were a poor admission mental status, the diagnosis of UIA, serum ammonia levels, and Model for End-stage Liver Disease (MELD) scores. Our model showed good discrimination among the development (C index, 0.727; 95% confidence interval [CI], 0.635-0.820) and validation (C index, 0.719; 95% CI, 0.598-0.801) cohorts. CONCLUSION: The incidence of UIA and SAH was very low in LT patients. A poor admission mental status, diagnosis of UIA, serum ammonia levels, and MELD scores were significantly associated with the risk of HS within one year after LT. Our scoring system showed a good discrimination to predict the HS in LT patients.

[Subarachnoid hemorrhage in a young girl]. / Een meisje met een subarachnoïdale bloeding.

BACKGROUND: Subarachnoid hemorrhage in children is rare. The most common cause is trauma, followed by an arteriovenous malformation, aneurysm or tumor. CASE DESCRIPTION: We describe the case of an 11-year-old girl who developed sudden headache with nausea and vomiting during athletics training. Her neurological exam was normal. With imaging and a lumbar puncture a subarachnoid hemorrhage was diagnosed, based on a ruptured saccular aneurysm of the right middle cerebral artery. Endovascular treatment was unsuccessful, after which the aneurysm was treated surgically. Postoperative recovery was uneventful. Additional tests for underlying conditions were negative. CONCLUSION: Also in a child with acute headache, nausea, and vomiting, the diagnosis of a subarachnoid hemorrhage should be considered, even if neurological examination is normal. Expeditious diagnosis and treatment are important in order to prevent rebleeding.

Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms.

BACKGROUND: Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms. METHODS: Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls. RESULTS: 9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2. CONCLUSIONS: Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.

Microsurgical Clip Reconstruction of a True Posterior Communicating Artery Aneurysm.

Approximately 25% of intracranial aneurysms originate at the internal carotid artery and posterior communicating artery (PCoA) junction.1 In contrast to typical PCoA aneurysms, which are usually saccular, a subset known as true PCoA aneurysms arise directly from the PCoA. These represent about 1.3% of all intracranial aneurysms and 6.8% of PCoA aneurysms.1 The first report of a true PCoA aneurysm was in 1979.2Video 1 illustrates the microsurgical clipping of a true PCoA aneurysm in a 27-year-old man with subarachnoid hemorrhage and left-sided ophthalmoplegia. Computed tomography angiography revealed a large true patient consent, Our surgical strategy included 1) an extended pterional approach, 2) early brain relaxation through basal cisterns and third ventricle opening, 3) Sylvian fissure dissection, 4) partial uncus resection, 5) tracing the PCoA to the aneurysm, 6) pilot clipping and thrombectomy, and 7) careful aneurysm dissection and definitive clipping. The patient had an uncomplicated recovery and was discharged on postoperative day 5 with resolved third nerve dysfunction. A literature review from 2022 documented only 47 cases of true PCoA aneurysms, predominantly manifesting with rupture.3 Some studies suggest that these aneurysms may have a higher rupture risk than typical internal carotid artery-PCoA junction aneurysms.4 Microsurgical clipping is a primary treatment, often in cases associated with a fetal posterior cerebral artery variant.5 Ensuring the patency of the PCoA and thalamoperforating arteries is crucial, with careful visualization of the clip's distal ends to avoid impacting nearby neurovascular structures.

Ruptured basilar artery perforator aneurysm mimicking superior cerebellar artery aneurysm.

BACKGROUND AND IMPORTANCE: The diagnosis of basilar artery perforator aneurysm is difficult due to their small size, with high rates of negative angiography. Furthermore, due to the considerable variation of basilar artery perforator (BAP), even if an aneurysm originates from a BAP, it is often difficult to clearly identify its origin on angiography. CLINICAL PRESENTATION: A 46-female patient presented with World Federation of Neurological Surgeons Scale 1 subarachnoid hemorrhage. Initial imaging study, including digital subtraction angiography (DSA), revealed no vascular lesions. Two-week after admission, DSA revealed an aneurysm arising from the left superior cerebellar artery (SCA). Endovascular coil embolization was planned first. However, aneurysm selection using microcatheter was failed. Then, surgical approach was done via pre-temporal approach. We identified SCA, but there was no aneurysm. Further dissection revealed an aneurysm arising from basilar artery perforator, which was overlapped by SCA. The parent artery of the aneurysm arose from juxtaproximal to the orifice of left SCA, and crossed SCA at the juxtadistal to the aneurismal sac. Complete clip occlusion was done preserving BAP. After the surgery, the patient developed diplopia without extraoccular movement limitations. Two-month after the surgery, she was fully recovered without any neurologic deficits. CONCLUSION: It is crucial to adequately consider the possibility of open surgery as a viable option in case that endovascular treatment of aneurysms originated from the distal segment of basilar artery proves unsuccessful.

Fecal calprotectin is a novel biomarker to predict the clinical outcomes of patients with ruptured intracranial aneurysm.

BACKGROUND: Intracranial aneurysm (IA) is a common cerebrovascular disease and the leading cause of spontaneous subarachnoid hemorrhage. Recent evidence suggests that gut microbiota is involved in the pathophysiological process of IA through the gut-brain axis. However, the role of gut inflammation in the development of IA has yet to be clarified. Our study aimed to investigate whether fecal calprotectin (FC) level, a sensitive marker of gut inflammation, is correlated with the development of IA and the prognosis of patients with ruptured IA (RIA). METHODS: 182 patients were collected from January 2022 to January 2023, including 151 patients with IA and 31 healthy individuals. 151 IA patients included 109 patients with unruptured IA (UIA) and 42 patients with RIA. The FC level was measured by enzyme-linked immunosorbent assay. Other detailed information was obtained from an electronic medical record system. RESULTS: Compared with healthy controls, the FC levels in patients with IA were increased (P < 0.0001). Patients with RIA had significantly higher FC levels than UIA patients (P < 0.0001). Moreover, the FC level in RIA patients with unfavorable outcomes was higher than in RIA patients with favorable outcomes. Logistic regression analysis showed that the elevated FC level was an independent risk factor for a 3-month poor prognosis in patients with RIA (OR=1.005, 95% CI = 1.000 -1.009, P = 0.044). CONCLUSION: Fecal calprotectin level is significantly elevated in IA patients, especially those with RIA. FC is a novel biomarker of 3-month poor outcomes in RIA patients.

Craniovertebral and spinal adhesive arachnoiditis: a late complication of ruptured vertebral and posterior inferior cerebellar arteries aneurysms.

BACKGROUND: Adhesive arachnoiditis is a rare yet serious complication that may occur following subarachnoid hemorrhage (SAH). In this circumstance, it is mainly due to ruptured vertebral artery (VA) or posterior inferior artery (PICA) aneurysms. It disrupts cerebrospinal fluid (CSF) flow leading to complications such as spinal arachnoiditis, syringomyelia, trapped 4th ventricle, or a combination of these conditions. Evidence for effective treatment strategies is currently limited. We aimed to review the epidemiology, clinical characteristics, treatment, complications, outcomes, and prognosis of cranio-vertebral junction and spinal adhesive arachnoiditis resulting from ruptured VA and PICA aneurysms. METHODS: This study involved a comprehensive literature review and complemented by our own case. We focused on adult cases of arachnoiditis, syringomyelia, and trapped 4th ventricle with SAH caused by ruptured VA or PICA aneurysms, excluding cases unrelated to these aneurysms and those with insufficient data. RESULTS: The study included 22 patients, with a mean age of 52.4 years. Symptoms commonly manifest within the first year after SAH and timely diagnosis requires a high index of suspicion. Treatment approaches included lysis of adhesions and various shunt procedures. Most patients showed improvement post-treatment, though symptom recurrence is significant. CONCLUSION: Adhesive arachnoiditis is a critical complication following SAH, most commonly from ruptured VA and PICA aneurysms. Early detection and individualized treatment based on the type of arachnoiditis and CSF flow impact are crucial for effective management. This study underscores the need for tailored treatment strategies and further research in this field.

Isolated spinal artery aneurysm: etiology, clinical characteristics, and outcomes.

OBJECTIVE: Isolated spinal aneurysms (ISAs) are rare causes of subarachnoid hemorrhage (SAH), which encompass a highly heterogeneous group of clinical entities with multifarious pathogeneses, clinical characteristics, and treatment strategies. Therefore, knowledge about the ISAs remains inadequate. In this study, the authors present a comprehensive analysis of clinical data associated with ISAs at their institutions to enhance the understanding of this disease. METHODS: Patients with ISAs confirmed by spinal angiography or surgery at the authors' institutions between 2015 and 2022 were included. Data regarding clinical presentation, lesion location, aneurysm morphology, comorbidities, treatment results, and clinical outcomes were reviewed. RESULTS: Seven patients with ISAs were included in the study. Among them, 4 patients (57.1%) experienced severe headache, and 3 patients (42.9%) reported sudden-onset back pain. Additionally, lower-extremity weakness and urinary retention were observed in 2 of these patients (28.6%). Four of the aneurysms exhibited fusiform morphology, whereas the remaining were saccular. All saccular aneurysms in this series were attributed to hemodynamic factors. Conservative treatment was administered to 3 patients, 2 of whom underwent follow-up digital subtraction angiography, which showed spontaneous occlusion of both aneurysms. Four patients ultimately underwent invasive treatments, including 2 who underwent microsurgery and 2 who received endovascular embolization. One patient died of recurrent SAH, while the remaining 6 patients had a favorable prognosis at the latest follow-up assessment. CONCLUSIONS: The morphology of aneurysms may be associated with their etiology. Saccular ISAs are usually caused by pressure due to abnormally increased blood flow, whereas fusiform lesions may be more likely to be secondary to vessel wall damage. The authors found that a saccular spinal aneurysm in young patients with a significant dilated parent artery may be a vestige of spinal cord arteriovenous shunts. ISAs can be managed by surgical, endovascular, or conservative procedures, and the clinical outcome is generally favorable. However, the heterogeneous nature of the disease necessitates personalized treatment decision-making based on specific clinical features of each patient.

Pediatric Donut-Shaped Basilar Artery Aneurysm.

Intracranial aneurysms are uncommon in the pediatric population. We present a case of an 11-year-old boy presenting with subarachnoid hemorrhage caused by a "donut-shaped" basilar tip aneurysm. It occurs when the flow geometry produces a circumferential laminar flow into the aneurysmal sac, resulting in a central thrombosis. Optimal management of this type of aneurysm is not already clear, and further studies are needed to clarify the best treatment approach, especially in the pediatric population.

The relationship between the level of vitamin D and ruptured intracranial aneurysms among patients with high sun exposure.

Non-traumatic subarachnoid hemorrhage (SAH) accounts for 3-5% of acute strokes. Intracranial aneurysm is the most common cause of non-traumatic SAH. Vitamin D influences the cardiovascular system, including the formation and rupture of cerebral aneurysms. To evaluate the serum vitamin D level in patients living in the tropical zone who suffered aneurysmal subarachnoid hemorrhage and its correlation with demographic and neurological characteristics. This is an analytical cross-sectional study to assess the serum level of vitamin D in a study population of 99 patients treated and diagnosed with aSAH in a public hospital in Recife-PE over a period of 12 months. In the study sample, composed of individuals with high sun exposure due to the lifestyle they lead in a tropical region, we observed hypovitaminosis D (85.9%), with a median of 19.9 ng/ml, although the majority of individuals are skin with high concentration of melanin (Fitzpatrick skin type IV and V). In addition, rates of sun exposure are high to all patients (Solar Index 9.03 P50). Most individuals were female (79.8%); there was no statistical difference in solar exposure/solar index between genders. As for the neurological repercussions, there was no statistical relevance in the clinical prognostic scales evaluated. As the sample was composed mainly of individuals whose economic activity is agriculture, the values of solar index found are vastly higher than those of other studies conducted in high latitude regions. In line with the literature review, some aspects were raised with the objective of justifying such findings that go from the base of the poor diet of these individuals, the increase of melanin in the skin and genetic alterations that directs us to possible mechanisms of natural photoprotection to high sun exposure. Thus, we had a vast majority (85%) of hypovitaminosis D, which in fact makes us wonder if there is any influence of calcitriol on vitamin D receptors in vascular walls and in the cardiovascular system as a whole, which influence bleeding events of this nature. As for the neurological repercussions, measured using assessment scales (Glasgow coma scale, WFNS scale, Hunt-Hess and Fisher's tomographic scale) there was no significant difference in the results. As it is only a descriptive study, the causal relationship of the facts cannot be established. However, in a population exposed to high sun exposure and affected by aneurysmal SAH, there is a significant rate of hypovitaminosis D, which supports the hypothesis that vitamin D plays a role in vascular pathologies, such as cerebral aneurysms and SAH.

Aneurysmal subarachnoid hemorrhage occurring during sleep: Clinical characteristics and risk factors.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is known to be triggered by several specific human activities. Sleep, by contrast, has not been considered a triggering activity for aSAH, and clinical characteristics of patients who sustain aSAH during sleep have rarely been reported in the literature. METHODS: This is a retrospective analysis on the data acquired through a multicenter aSAH registry. Between January 2019 and December 2021, a total of 732 aSAH patients had been registered into our database. After excluding 109 patients whose activities at aSAH onset had been unidentifiable, the remaining 623 aSAH patients were dichotomized to 59 patients who sustained aSAH during sleep (Sleep group) and 564 patients who sustained aSAH during daytime activities (Awake group). Two-group comparison of demographic variables and multivariate logistic regression analysis were performed to clarify their clinical characteristics and identify potential risk factors. RESULTS: The Sleep group exhibited significantly higher frequencies of diabetes (15.5 % vs. 6.4 %, p = 0.01) and antiplatelet use (13.8 % vs. 4.6 %, p=0.004) than the Awake group. Furthermore, multivariate logistic regression analysis showed that diabetes (OR, 3.051; 95 % CI, 1.281-7.268; p = 0.012) and antiplatelet use (OR, 3.640; 95 % CI, 1.422-9.316; p = 0.007) were correlated with aSAH occurring during sleep. There were no significant inter-group differences in the patient outcomes evaluated at discharge. CONCLUSION: The current results indicate that risk factors may exist for aSAH occurring during sleep. Further investigations on how comorbidities such as diabetes, antiplatelet use and sleep apnea affect human hemodynamic and hemostatic parameters during sleep is warranted to better understand those relationships.

Non-aneurysmal subarachnoid hemorrhage in aplastic or twig-like middle cerebral artery: A case report and literature review.

BACKGROUND: Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare vascular anomaly that can cause hemorrhagic and ischemic stroke. Ap/T-MCA can induce aneurysms due to the fragility of the vessel wall, consequently leading to subarachnoid hemorrhage. Herein, we report a case of Ap/T-MCA with subarachnoid hemorrhage without an aneurysm. CASE PRESENTATION: A 67-year-old man presented to our hospital with a sudden onset of headache. Computed tomography of the head revealed subarachnoid hemorrhage (SAH) in the left Sylvian fissure; however, no aneurysm was observed on digital subtraction angiography. Following conservative treatment, follow-up imaging showed no aneurysm or no recurrent stroke. CONCLUSION: Non-aneurysmal SAH is a possible indication of vessel wall fragility in Ap/T-MCA; however, a standardized treatment strategy for this condition remains to be established.

A foreign body that has been left for 20 years causes a pseudoaneurysm of the middle cerebral artery: a case report.

BACKGROUND: We report a patient with extensive subarachnoid hemorrhage caused by the rupture of a middle cerebral artery pseudoaneurysm from a foreign body that had been left for two decades. CASE PRESENTATION: A 74-year-old male patient from Han nationality was admitted to the emergency department of our hospital with impaired consciousness for 1 hour. Cranial computed tomography examination indicated a massive subarachnoid hemorrhage with intraventricular blood accumulation, and a high-density short strip dense shadow was seen in the M1 segment of the right middle cerebral artery, considering the possibility of a foreign body. Subsequently, a cerebral angiography was suggested; the foreign body was seen through the right middle cerebral artery, and the aneurysm was seen in the lower wall, so a pseudoaneurysm was considered. The emergent surgical intervention involved the clipping of the pseudoaneurysm and intracranial extraction of the foreign body. Unfortunately,the patient ultimately expired due to severe pulmonary infection. CONCLUSION: Intracranial pseudoaneurysm caused by foreign body has been rarely reported previously, and microsurgical treatment of an intracranial pseudoaneurysm caused by a foreign body is a good choice.

Strategy of stretched Coils: Insights from a single center experience.

OBJECTIVE: A stretched coil, characterized by excessive elongation within the parent artery during a coil embolization procedure, poses a significant risk of forming a thrombus. This study reports on cases of stretched coils spanning 16 years and discusses effective assessment methods and treatment strategies. METHOD: Retrospective analysis of the institutional database comprising 14 cases where stretched coils were observed during coil embolization procedures was conducted, starting from January 2007. RESULTS: Among the 14 cases, four involved coil embolization for subarachnoid hemorrhage due to ruptured aneurysm, while the remaining cases were unruptured aneurysms. Starting in 2017, vaso-computed tomography (vaso-CT) was employed in nine cases to evaluate the proximal end of the stretched coils. Reimplantation was performed in 3 cases. Among them, two cases were relieved by pushing the coil delivery wire or microwire, while one case underwent balloon-assisted reimplantation. The stretched coils were removed in three cases by pulling. A rescue gooseneck microsnare technique was applied in one case. The stent was fixed in five cases. In two cases, no additional procedures were performed. Thrombosis is a potential complication that occurred in three cases of stretched coils. CONCLUSION: Many studies have addressed coil stretching and introduced various rescue methods, but relying solely on angiography for diagnosis or applying an inappropriate rescue technique can lead to ischemic stroke. This study emphasized the importance of vaso-CT as a tool for accurately identifying the proximal end of a stretched coil. Additionally, we aimed to facilitate the selection of an appropriate rescue technique.

Serum Interleukin-1 Levels Are Associated with Intracranial Aneurysm Instability.

Serum interleukin-1 (IL-1) are possibly indicative of the inflammation in the intracranial aneurysm (IA) wall. This study aimed to investigate whether IL-1 could discriminate the unstable IAs (ruptured intracranial aneurysms (RIAs) and symptomatic unruptured intracranial aneurysms (UIAs)) from stable, asymptomatic UIAs. IA tissues and blood samples from 35 RIA patients and 35 UIA patients were collected between January 2017 and June 2020 as the derivation cohort. Blood samples from 211 patients with UIAs were collected between January 2021 and June 2022 as the validation cohort (including 63 symptomatic UIAs). Blood samples from 35 non-cerebral-edema meningioma patients (non-inflammatory control) and 19 patients with unknown-cause subarachnoid hemorrhage (hemorrhagic control) were also collected. IL-1ß and IL-1.ra (IL-1 receptor antagonist) were measured in serum and IA tissues, and the IL-1 ratio was calculated as log10 (IL-1.ra/IL-1ß). Based on the derivation cohort, multivariate logistic analysis showed that IL-1ß (odds ratio, 1.48, P = 0.001) and IL-1.ra (odds ratio, 0.74, P = 0.005) were associated with RIAs. The IL-1 ratio showed an excellent diagnostic accuracy for RIAs (c-statistic, 0.91). Histological analysis confirmed the significant correlation of IL-1 between serum and aneurysm tissues. IL-1 ratio could discriminate UIAs from non-inflammatory controls (c-statistic, 0.84), and RIAs from hemorrhagic controls (c-statistic, 0.95). Based on the validation cohort, the combination of IL-1 ratio and PHASES score had better diagnostic accuracy for symptomatic UIAs than PHASES score alone (c-statistic, 0.88 vs 0.80, P < 0.001). Serum IL-1 levels correlate with aneurysm tissue IL-1 levels and unstable aneurysm status, and could serve as a potential biomarker for IA instability.

Acute bilateral vision loss after endovascular treatment of an intracranial aneurysm.

Acute bilateral vision loss (ABVL) is a rare and challenging diagnostic issue that is most often caused by a neurological disorder. Since it can be the presenting symptom of potentially life-threatening diseases, priority should be given to excluding such diagnoses. Special caution is required if ABVL symptoms result after an intracranial intervention. This article reports on a diagnostic approach for a patient suffering from ABVL due to vitreous hemorrhage related to a subarachnoid hemorrhage (SAH) after endovascular intracranial aneurysm treatment. This case study highlights the importance of imaging interpretation and its consequences.

Current Smoking Status Is Not a Risk Factor for Perioperative Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage Who Underwent Craniotomy Repair.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is a rupture leading to blood accumulating in the subarachnoid region. Smoking status is often a risk factor for postoperative complications for vascular procedures. This study aims to retrospectively examine the effect of being a current tobacco smoker on postoperative outcomes in patients with nontraumatic subarachnoid hemorrhage. METHODS: Patients with aneurysmal subarachnoid hemorrhage who underwent craniotomy were identified in the American College of Surgeons-National Surgical Quality Improvement Program database. The 30-day perioperative outcomes of current smokers were compared with those of control individuals, who were patients who had not smoked tobacco in the past year. Postoperative outcomes included death, cardiac complications, stroke, operation time >4 hours, bleeding, and other events. In addition, this study examined the same surgical outcomes in patients older than 65 years. RESULTS: We found no significant difference between these 2 groups across all adverse outcomes analyzed. In patients aged >65 years, we again found no significant differences between these 2 groups across all adverse outcomes analyzed. CONCLUSIONS: This study shows that although current tobacco smoker status is commonly a risk factor for vascular diseases and postoperative complications, it is not a risk factor for the postoperative variables that we analyzed during craniotomy for aneurysmal subarachnoid hemorrhage. Additional research should be conducted to determine if different procedures to treat aneurysmal subarachnoid hemorrhage may have different outcomes among smokers.

Impact of Subarachnoid Hemorrhage in Ventriculostomy-Related Infections Prospective Comparison of Two Neurosurgical Injury Contexts.

BACKGROUND: Long thought to be immune privileged, the central nervous system is far from being devoid of local immunity. Subarachnoid hemorrhage (SAH) and traumatic brain injury represent 2 distinct central nervous system injury situations which, while both exposed to external ventricular drains, present different incidences of ventriculostomy-related infection (VRI). We sought to compare VRI incidence and initial cerebrospinal fluid (CSF) inflammatory profiles in these 2 clinical situations. METHODS: From 2015 to 2020, 227 patients treated for SAH (193) or traumatic brain injury (34) with an external ventricular drain were prospectively included. CSF samples were sent daily for microbiological examination, cell count, and biochemical analysis. VRI was defined as a positive CSF culture associated with CSF profile modifications and clinical signs. Ventriculostomy-related colonization was defined as positive catheter culture at removal. Positive events were defined as VRI and/or ventriculostomy-related colonization. RESULTS: Eleven patients suffered from VRI, with an incidence of 3.6 VRI per 1000 catheter-days. All VRIs occurred among SAH patients without a significant difference. Median duration of drainage was 12 (7-18) days, there were no significant differences for known VRI risk factors. Positive events were significantly higher in SAH patients (20.7% vs. 2.9%, P = 0.013). Inflammatory CSF markers and serum white blood cells were higher in SAH patients. CONCLUSIONS: Local inflammatory markers were markedly higher in SAH than in traumatic brain injury. However, positive events were more frequent in SAH. Furthermore, SAH may be a risk factor for VRI. Hypothesis that a primary injury to the subarachnoid space could impair central nervous system immune functions should be explored.