New daily persistent headache after SARS-CoV-2 infection in Latin America: a cross-sectional study.

BACKGROUND: Persistent headache is a frequent symptom after coronavirus disease 2019 (COVID-19) and there is currently limited knowledge about its clinical spectrum and predisposing factors. A subset of patients may be experiencing new daily persistent headache (NDPH) after COVID-19, which is among the most treatment-refractory primary headache syndromes. METHODS: We conducted a cross-sectional study in Latin America to characterize individuals with persistent headache after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to identify factors associated with NDPH. Participants over 18 years old who tested positive for SARS-CoV-2 infection and reported persistent headache among their symptoms completed an online survey that included demographics, past medical history, persistent headache clinical characteristics, and COVID-19 vaccination status. Based on participants' responses, NDPH diagnostic criteria were used to group participants into NDPH and non-NDPH groups. Participant data was summarized by descriptive statistics. Student's t and Mann-Whitney U tests were used according to the distribution of quantitative variables. For categorical variables, Pearson's chi-square and Fisher's exact tests were used according to the size of expected frequencies. Binomial logistic regression using the backward stepwise selection method was performed to identify factors associated with NDPH. RESULTS: Four hundred and twenty-one participants from 11 Latin American countries met the inclusion criteria. One in four participants met the NDPH diagnostic criteria. The mean age was 40 years, with most participants being female (82%). Over 90% of the participants reported having had mild/moderate COVID-19. Most participants had a history of headache before developing COVID-19 (58%), mainly migraine type (32%). The most predominant clinical characteristics in the NDPH group were occipital location, severe/unbearable intensity, burning character, and radiating pain (p < 0.05). A higher proportion of anxiety symptoms, sleep problems, myalgia, mental fog, paresthesia, nausea, sweating of the face or forehead, and ageusia or hypogeusia as concomitant symptoms were reported in participants with NDPH (p < 0.05). Palpebral edema as a concomitant symptom during the acute phase of COVID-19, occipital location, and burning character of the headache were risk factors associated with NDPH. CONCLUSION: This is the first study in Latin America that explored the clinical spectrum of NDPH after SARS-CoV-2 infection and its associated factors. Clinical evaluation of COVID-19 patients presenting with persistent headache should take into consideration NDPH.

Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. METHODS: We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. RESULTS: Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90). CONCLUSION: Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.

Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes.

BACKGROUND: We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. METHODS: Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. RESULTS: 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (ß per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). CONCLUSION: After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation.

OBJECTIVE: Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation. METHODS: Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression. RESULTS: A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours. CONCLUSIONS: In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

Effect of cerebrospinal fluid drainage on clinical outcomes following aneurysmal subarachnoid hemorrhage.

OBJECTIVES: We study the relationship between external ventricular drainage (EVD) of cerebrospinal fluid output and functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: A retrospective chart review of patients presenting to a single center with aSAH was performed. The primary outcome was good functional outcomes assessed by a composite of the modified Rankin scale (mRS 0-2) at last follow-up. Secondary outcomes were clinical and radiographic vasospasm. For data analysis, multivariable generalized estimating equations adjusting for potential confounders were used. RESULTS: A total of 119 patients were included; 91 (75.6%) presented with a modified Fisher grade 4 and 76 (63.9%) had hydrocephalus. The median EVD duration was 13 days. On average, most EVDs were set at 15 cmH2O (50, 42%). Follow-up was available in 109 patients; median time was 10.7 months; 69 (63.3%) had good outcomes. Multivariable analysis showed that EVDs set at 10 cmH2O had increased odds of good outcomes for every ml increase in the EVD output (OR = 1.02; 95% CI 1.01-1.03; p = 0.001). Post estimation analyses show that EVDs at 10 cmH2O with output close to 200 ml predicted a 50% probability of good outcomes. CONCLUSIONS: Increased EVD outputs were associated with favorable outcomes at the last follow-up.

Sodium Variability and Probability of Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVES: Vasospasm is a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) that generally occurs 4-14 days post-hemorrhage. Based on American Heart Association guidelines, the current understanding is that hyponatremic episodes may lead to vasospasm. Therefore, we sought to determine the association between repeated serum sodium levels of aSAH patients and its relationship to radiographic vasospasm. MATERIALS AND METHODS: A single-center retrospective analysis from 2007-2016 was conducted of aSAH patients. Daily serum sodium levels were recorded up to day 14 post-admission. Hyponatremia was defined as a serum sodium value of < 135 mEq/L. We evaluated the relationship to radiologic vasospasm, neurologic deterioration, functional status at discharge, and mortality. A repeated measures analysis using a mixed-effect regression model was performed to assess the interindividual relationship between serum sodium trends and outcomes. RESULTS: A total of 271 aSAH patients were included. There were no significant differences in interindividual serum sodium values over time and occurrence of radiographic vasospasm, neurologic deterioration, functional, or mortality outcomes (p = .59, p = .42, p = .94, p = .99, respectively) using the mixed-effect regression model. However, overall mean serum sodium levels were significantly higher in patients who had neurologic deterioration, poor functional outcome (mRS 3-6), and mortality. CONCLUSIONS: Serum sodium level variations are not associated with subsequent development of cerebral vasospasm in aSAH patients. These findings indicate that serum sodium may not have an impact on vasospasm, and avoiding hypernatremia may provide a neurologic, functional and survival benefit.

The use of staples for external ventricular drain catheter fixation: A single-institution experience.

BACKGROUND: Sutures are conventionally used for external ventricular drain (EVD) catheter fixation, but staples are an appealing alternative as they are quicker and easier to learn. We report our institutional experience with EVD fixation techniques and the patterns of catheter fixation. METHODS: We conducted a retrospective review of all aneurysmal subarachnoid hemorrhage (aSAH) patients treated in a single US center between 2007 and 2017. RESULTS: Out of 307 patients, 217 patients (62.2% female, mean age 59.5 years) met inclusion criteria harboring 268 EVDs. Two main configurations were used for EVD catheter fixation; spiral-shaped EVDs in 139 (51.9%) cases and arciform (C-shaped) EVDs in 129 (48.1%) of the cases. 220 (82.1%) were secured with staples and 48 (17.9%) with sutures. The most common complication was obstruction (n = 43, 16.2%), followed by infections (n = 18, 6.8%). Catheter dislodgements occurred in 16 (5.9%) catheters and 61 (22.8%) required repositioning/replacement. EVD dislodgement rates did not differ between the staples and sutures group, or between the spiral and C-shaped EVDs (p = 0.5 and 0.93, respectively). No cases of catheter perforation by the staples were encountered in our cohort. CONCLUSION: Staples and sutures are equally valid and acceptable methods for EVD fixation with similar dislodgement rates. Scarce data exist in the literature regarding dislodgements, and further studies are needed to address its incidence and the best preventive strategies.

Evaluation of the utility of early routine computed tomography angiography in subarachnoid hemorrhage patient outcomes.

OBJECTIVES: The role of an early CTA approach in neurologically stable patients with nontraumatic SAH has not been assessed. This study explored the use of CTA in clinically stable SAH patients to pre-emptively identify cerebral vasospasm, to evaluate whether this approach is associated with improved clinical outcomes. METHODS: We conducted a retrospective chart review of SAH patients presenting between July 2007 and December 2016 in a single academic center. Patients were divided into two groups: (1) Early CTA (stable patients who underwent a CTA between days 5-8 post-SAH), and (2) Standard Protocol. The co-primary outcomes were a composite of the mRS at discharge and last clinical follow-up (good = 0-2; poor = 3-6). A multivariable binary logistic regression was conducted to compare both groups against outcomes, controlling for potential confounders. RESULTS: A total of 415 patients were included, 103 (24.8%) with early CTA, and 312 (75.2%) undergoing the standard protocol; the mean age was 57 years and 248 (59.8%) patients were female. Patients in the early CTA group had a higher modified Fisher grade (3-4) (87.4% vs 63.1%; p < 0.02). The multivariable analysis showed that early CTA was independently associated with lower poor outcomes at discharge (OR = 0.21, 95% CI 0.07-0.61, p = 0.004). Plus, vasospasm detection was associated with an increased risk of poor outcomes (OR = 4.77, 95% CI 1.41 - 16.10, p = 0.01). Early CTA was not associated with outcomes at clinical follow-up. CONCLUSION: The early CTA surveillance approach was associated with better functional outcomes at discharge when compared to the current imaging standard practice.

Trends of Ruptured and Unruptured Aneurysms Treatment in the United States in Post-ISAT Era: A National Inpatient Sample Analysis.

Background The ISAT (International Subarachnoid Aneurysm Trial) has generated a paradigm shift towards endovascular treatment for intracranial aneurysms but remains unclear if this has led to a true reduction in the risk for aneurysmal subarachnoid hemorrhage (aSAH). We sought to study the association between the treatment burden of unruptured and ruptured aneurysms in the post-ISAT era. Methods and Results Admissions data from the National Inpatient Sample (2004-2014) were extracted, including patients with a primary diagnosis of aSAH or unruptured intracranial aneurysms treated by clipping or coiling. Within each year, this combined group was randomly matched to non-aneurysmal control group, based on age, sex, and Elixhauser comorbidity index. Multinomial regression was performed to calculate the relative risk ratio of undergoing treatment for either ruptured or unruptured aneurysms in comparison with the reference control group, adjusted for time. After adjusting for National Inpatient Sample sampling effects, 243 754 patients with aneurysm were identified, 174 580 (71.6%) were women; mean age, 55.4±13.2 years. A total of 121 882 (50.01%) patients were treated for unruptured aneurysms, 79 627 (65.3%) endovascularly and 42 256 (34.7%) surgically. A total of 121 872 (49.99%) patients underwent procedures for aSAH, 68 921 (56.6%) endovascular, and 52 951 (43.5%) surgically. Multinomial regression revealed a significant year-to-year decrease in aSAH procedures compared with the control group of non-aneurysmal hospitalizations (relative risk ratio, 0.963 per year; P<0.001), while there was no statistical significance for unruptured aneurysms procedures (relative risk ratio, 1.012 per year; P=0.35). Conclusions With each passing year, there is a significant decrease in relative risk ratio of undergoing treatment for aSAH, concomitant with a stable annual risk of undergoing treatment for unruptured intracranial aneurysms.

Minimally invasive surgiscopic evacuation of intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is a devastating form of stroke associated with a 40% mortality rate at 30 days and a 75% functional dependence rate at 6 months. The role of surgery to treat ICH remains controversial. Preclinical studies suggest minimally invasive clot evacuation following ICH may benefit patients by mitigating primary and secondary brain injury.1 2 In this video, we report the operative technique used in minimally invasive surgicsopic evacuation following ICH (video 1). We demonstrate our presurgical approach using preoperative volumetric imaging loaded onto a stereotactic guidance system. Evacuation of intraparenchymal and intraventricular components of a hemorrhage are shown under direct surgiscopic vision using the Aurora System (Integra LifeSciences, Princeton, NJ, USA). Hemostasis is achieved when actively bleeding vessels are directly cauterized and irrigation of the clot cavity yields no fresh blood. Pre- and postevacuation radiographic differences illustrate the mitigation of clot burden in an elderly patient. neurintsurg;13/4/400/V1F1V1Video 1.

Flow Diversion Endovascular Treatment Improves Headaches in Patients with Unruptured Intracranial Aneurysms.

OBJECTIVE: Headache is the presenting symptom of unruptured intracranial aneurysm (UIA) in more than one-third of cases. Some patients may expect their headache to remit after aneurysm treatment. This study aims to identify factors influencing headache outcomes following endovascular treatment of UIA. METHODS: This prospective observational study was conducted in patients with UIAs treated with flow diversion. Subjects reported their headache intensity with a visual analog scale (VAS) and completed 3 surveys before treatment: Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6), and Patient Health Questionnaire-2 (PHQ-2). Follow-up was at 1 month, 3 months, and 6 months after treatment. Analysis was performed using generalized mixed-effects models. RESULTS: We identified 38 patients, 29 of whom reported headaches at baseline (76.3%). Mean patient age was 55.3 ± 12.4 years, and 79% of the cohort was female. Mean aneurysm diameter was 6.8 ± 5.3 mm, and treatment modality was Pipeline embolization in all cases. At the last follow-up, 5 aneurysms (15.1%) were incompletely occluded. The mean VAS scores for patients with headache at baseline were 4.36 ± 0.59 at baseline, 4.08 ± 0.60 at 1 month, 3.04 ± 0.62 at 3 months, and 2.76 ± 0.57 at 6 months. Controlling for occlusion status, medication, and depression, significant improvement was seen at the 3- and 6-month follow-ups. Similar patterns were observed with MIDAS and HIT-6. CONCLUSIONS: In the present study, endovascular UIA treatment led to significantly decreased headache intensity in patients with headache at baseline, after a short delay. Our data shed light on postintervention headache patterns and can help inform patient discussions and treatment expectations.

Role of aspirin and statin therapy in patients with cerebral cavernous malformations.

Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.

Pipeline Embolization Device Versus Stent-Assisted Coiling for Intracranial Aneurysm Treatment: A Retrospective Propensity Score-Matched Study.

BACKGROUND: Pipeline embolization device (PED; Medtronic) and stent-assisted coiling (SAC) are established modalities for treatment of intracranial aneurysms. OBJECTIVE: To comparatively assess the efficacy of these techniques. METHODS: We conducted a retrospective analysis of patients with aneurysms treated at our institution with either PED from 2013 to 2017 or SAC from 2009 to 2015. All large (>10 mm), ruptured, fusiform, anterior communicating artery, posterior circulation aneurysms, and patients with no available follow-up imaging were eliminated before running the propensity score matching (PSM). Patients were matched using nearest neighbor controlling for: age, gender, smoking, exact location, maximal diameter, and presence of multiple aneurysms. Total hospital costs for equipment and implants were calculated from procedure product and hospital billing records, and compared between the propensity-matched pairs. RESULTS: Out of 165 patients harboring 202 aneurysms; 170 (84.2%) were treated with the PED, and 32 (15.8%) were treated using SAC. PSM resulted in 23 matched pairs; with significantly longer follow up in the SAC group (mean 29.8 vs 14.1 mo; P = .0002). Complete occlusion rates were not different (82.6 vs 87%; P = .68), with no difference between the groups for modified Rankin Scale on last clinical follow-up, procedural complications or retreatment rates. Average total costs calculated from the hospital records, including equipment and implants, were not different between propensity-score matched pairs (P = .48). CONCLUSION: PED placement and SAC offer equally efficacious occlusion rates, functional outcomes, procedural complication rates, and cost profiles for small unruptured anterior circulation saccular aneurysms which do not involve the anterior communicating artery.

Effect of Blood Pressure Variability During the Acute Period of Subarachnoid Hemorrhage on Functional Outcomes.

BACKGROUND: The association of blood pressure variation with poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH) is unknown. OBJECTIVE: To evaluate the association of systolic blood pressure (SBP) variation and clinical outcomes in aSAH. METHODS: We conducted a retrospective chart review of all aSAH patients treated at an academic institution between 2007 and 2016. Patient demographics, aSAH characteristics, and blood pressure observations for the first 24 h of admission in 4-h intervals were obtained. SBP variability metrics assessed were mean, standard deviation, maximum, minimum, peak, trough, coefficient of variation, and successive variation. The primary outcome was a composite of the modified Rankin scale as good (0-2) or poor (3-6) at last follow-up. Comparisons between outcome groups were performed. Logistic regression models for each significant SBP metric controlling for potential confounders were constructed. RESULTS: The study population was 202 patients. The mean age was 57 yr; 66% were female. The median follow-up time was 18 mo; 57 (29%) patients had a poor outcome. Patients with poor outcomes had higher standard deviation (17.1 vs 14.7 mmHg, P = .01), peak (23.5 vs 20.0 mmHg, P = .02), trough (22.6 vs 19.2 mmHg, P < .01), coefficient of variation (13.9 vs 11.8 mmHg, P < .01), and lower minimum SBP (101.4 vs 108.4, P < .01). The logistic regression showed that every 1-mmHg increase in the minimum SBP increased the odds of good outcomes (odds ratio = 1.03; 95% CI = 1.001-1.064; P = .04). Models including other SBP metrics were not significant. CONCLUSION: Hypotension was found to be independently associated with poor outcomes in patients with aSAH.

A Cohort Comparison Analysis of Fixed Pressure Ventriculoperitoneal Shunt Valves With Programmable Valves for Hydrocephalus Following Nontraumatic Subarachnoid Hemorrhage.

BACKGROUND: Hydrocephalus after nontraumatic subarachnoid hemorrhage (SAH) is a common sequela that may require the placement of ventriculoperitoneal shunts (VPS). Adjustable-pressure valves (APVs) are being widely used in this situation though more expensive than differential-pressure valves (DPVs). OBJECTIVE: To compare outcomes between APV and DPV in SAH-induced hydrocephalus. METHODS: We performed a retrospective chart review of patients with nontraumatic SAH who underwent VPS placement for the treatment of hydrocephalus after SAH, between July 2007 and December 2016. Patients were classified according to the type of valve (APV vs DPV). We evaluated factors that could predict the type of valve used, outcomes in VPS revision/replacement rate, and complications. RESULTS: A total of 66 patients underwent VPS placement who were equally distributed into the 2 groups of valves. VPS failure with the need for revision/replacement occurred in 13 (19.7%) cases. Ten (30.3%) patients with DPV had a VPS failure, while 3 (9.1%) patients with an APV had a similar failure with the need for revision/replacement (P = .03). VPS placement before discharge during the initial hospitalization (P = .02) was statistically significant associated with the use of a DPV, while the reason of external ventricular drain (EVD) failure (P = .03) was associated with the use of an APV. CONCLUSION: APVs had a lower rate of surgical revisions compared to DPVs. Early placement of VPS was associated with the use of a DPV. The need for EVD replacement due to EVD infection or malfunction was associated with higher rates of APV use.

Symptomatic Hemorrhage From Cerebral Cavernous Malformations: Evidence from a Cohort Study.

OBJECTIVE: Patients with a cerebral cavernous malformation (CCM) can have intracranial hemorrhages ranging from insignificant and chronic microbleeds to life-threatening hemorrhage. Management decisions and patient counseling are based on a heterogeneous body of evidence. We sought to improve the literature by providing our results based on the standardized definitions and aimed to delineate differences in the symptomatic burden for CCMs, based on their anatomic location and presence of developmental venous anomalies. This evidence will aid in clinical decision making and patient counseling. METHODS: A retrospective cohort analysis between 1990 and 2018 was performed, including patients with a diagnosis of a CCM. The primary outcome was acute symptomatic hemorrhages. RESULTS: We identified 438 patients harboring 632 CCMs. Mean age at diagnosis was 50 years (standard deviation ±17 years). Median follow-up was 26 months (interquartile range, 7-72 hours). Multiple lesions were encountered in 64 patients (15%). An initial symptomatic presentation was observed in 64% of the patients. There were 438 supratentorial lesions (69%) and 194 infratentorial lesions (31%). A symptomatic hemorrhage was observed in 25% of the supratentorial lesions and 29% of the infratentorial lesions (P < 0.001). A linear mixed-effects regression model showed a significant difference in developing a symptomatic hemorrhage at diagnosis or follow-up between CCMs with an infratentorial location and those with a supratentorial location (odds ratio, 1.81; 95% confidence interval, 1.17-2.81; P = 0.008). CONCLUSIONS: Infratentorial cavernous malformations are more likely to present with symptomatic hemorrhages at diagnosis or during follow-up when accounting for size differences between lesions.

Effect of Premorbid Antiplatelet Medication Use on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-matched Study.

Introduction Delayed cerebral ischemia (DCI) is a serious complication of aneurysmal subarachnoid hemorrhage (aSAH) and a major predictor of poor functional outcomes in patients surviving the initial insult. Several theories have postulated that platelet activation, microthrombi formation, and subsequent vasospasm are mechanisms involved. We, therefore, assessed the effect of premorbid antiplatelet medication (APM) use on discharge functional outcomes and cerebral infarction due to DCI in patients presenting with aSAH. Methods Retrospective analysis of patients admitted to a single US center with aSAH from 2007 to 2016 was performed. Patients who were receiving APM prior to admission were then matched to those who did not receive them using nearest-neighbor propensity-score-matching (PSM) controlling for the following variables: age, hypertension, smoking status, Hunt-&-Hess classification, and management type. Results Out of the 267 patients identified, 38 (14.2%) were on APMs when admitted. On univariate analysis, patients on APM were older (p < 0.001) and more likely to be hypertensive (p = 0.005). Modified Rankin Scale (mRS) at discharge was significantly worse for patients on APMs compared to those who were not (mRS 3-6 in 55.3% vs 32.7%; p = 0.007). No significant difference in cerebral infarction due to DCI was found (p = 0.82). PSM resulted in 20 patients in the APMs group and 20 patients in the comparison group. After matching, no significant difference was found in discharge mRS (p = 0.56) and cerebral infarction due to DCI (p = 0.7). Conclusion This study identified no significant effect of admission APMs on discharge functional outcomes and cerebral infarction due to DCI in aSAH patients after matching.