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.

Clinical Characteristics of Driving-related Stroke Occurring as a Recurrent Stroke.

BACKGROUND: Although the number of seemingly healthy subjects who suffer a minor stroke increases, there are no data on how frequently they sustain another stroke while driving. METHODS: A single-center, retrospective study was conducted to clarify the clinical characteristics of driving-related stroke occurring as a recurrent stroke by analyzing data prospectively acquired between January 2009 and June 2019 on 3452 acute stroke patients. RESULTS: One hundred-thirty five patients (85 ischemic stroke [IS] and 50 hemorrhagic stroke [HS]) had suffered a driving-related stroke. Of them, 22 (16%) had suffered a prior stroke (recurrent stroke group), while 113 had never suffered a stroke before (first-time stroke group). While the use of anti-thrombotics was significantly more common in the RS group, other variables including the frequency of road traffic accidents, did not differ significantly. The first stroke-recurrent stroke interval ranged from 0.2 to 18 years. The stroke type at the time of recurrence was IS in the majority of patients with prior IS. When compared to 432 patients with recurrent IS unrelated to driving, patients with recurrent IS related to driving (n = 16) had significantly higher frequency of lacunar strokes (56% vs 27%, P = .02) and lower frequency of cardioembolic strokes (6% vs 29%, P = .04). CONCLUSION: The current finding that 16% of patients who presented with driving-related stroke had previously suffered a stroke indicates that drivers with a prior stroke may be at increased risk for recurrent stroke while driving, and prolonged follow-up be necessary for minor stroke patients who resume driving.

Airbag deployment and cervical spine injury in restrained drivers following motor vehicle collisions.

PURPOSE: Seatbelts and airbags are the most important devices protecting drivers from cervical spine injury (CSI) following motor vehicle collisions (MVCs). However, there have been few reports on the radiographic characteristics of CSI sustained by restrained, airbag-deployed drivers. METHODS: A single-center, retrospective observational study was conducted using prospectively acquired data. Between January 2011 and December 2017, 564 restrained drivers, whose vehicle had been severely damaged in MVCs, underwent whole-body computed tomography for evaluation of bodily injuries. The drivers were dichotomized into airbag (+) group (n = 218) and airbag (-) group (n = 139), after excluding 207 drivers in whom airbag deployment status was unknown. RESULTS: Eight and nine drivers sustained CSIs in the airbag (+) and airbag (-) group, respectively. The frequency of CSI did not differ significantly between the two groups (3.7% vs. 6.5%, p = 0.31). All eight CSIs in the airbag (+) group were classified as hyperextension injuries, and four of them sustained concomitant spinal cord injuries caused by dislocation. Within the airbag (+) group, the drivers with CSIs were significantly older than those without CSIs (65.2 ± 18.5 vs. 44.8 ± 18.7 years, p = 0.002). CONCLUSION: Although it is without doubt that the combination of seatbelt and airbag reduces the frequency and severity of CSIs following MVCs, the CSIs sustained in restrained, airbag (+) drivers may not always be mild, and elderly drivers may be at an elevated risk of CSI. In addition, the possibility of a causal role of airbags in CSI requires consideration in this population.

Thromboembolisms in atrial fibrillation and heart failure patients with a preserved ejection fraction (HFpEF) compared to those with a reduced ejection fraction (HFrEF).

Heart failure (HF) is classified into three clinical subtypes: HF with a preserved ejection fraction (HFpEF: EF ≥ 50%), HF with a mid-range ejection fraction (HFmrEF: 40 ≤ EF < 49%), and HF with a reduced ejection fraction (HFrEF: EF < 40%). These types often coexist with atrial fibrillation (AF). We investigated the rate of strokes/systemic embolisms (SSEs) in AF patients with HFpEF (AF-HFpEF) compared to that in those with HFrEF (AF-HFrEF: HFmrEF and HFrEF), and examined the independent predictors. We prospectively enrolled 1350 patients admitted to our hospital for worsening HF. We identified 301 patients with either AF-HFpEF (n = 129, 43%) or AF-HFrEF (n = 172, 57%). Compared to the patients with AF-HFrEF, those with AF-HFpEF were older and more likely to be female. Oral anticoagulant use was 63 vs. 66%, respectively. During a mean follow-up period of 26 months, 21 (7%) and 66 (22%) patients had SSEs and all-cause death, respectively. The crude annual rates of SSEs (3.9 vs. 2.7%, P = 0.47) were similar between the groups. In a multivariate Cox regression analysis, an age ≥ 75 years (hazard ratio 2.14, 95% confidence interval 1.32-3.58, P < 0.01) and the plasma B-type natriuretic peptide (BNP) level ≥ 341 pg/ml (hazard ratio 1.60, 95% confidence interval 1.07-2.39, P < 0.05) were associated with SSEs. The EF was not an independent predictor of SSEs (hazard ratio 1.01, 95% confidence interval 0.98-1.04, P = 0.51). There were no significant differences in the rates of SSEs between AF-HFpEF and AF-HFrEF. Patients with HF and concomitant AF should be treated with anticoagulants irrespective of EF.

Frequency and characteristics of traumatic brain injury in restrained drivers involved in road traffic accidents.

BACKGROUND: While seatbelt is an important device protecting drivers from traumatic brain injury (TBI), it has rarely been reported how often and in what circumstances restrained drivers sustain TBI after road traffic accident (RTA). Whole-body computed tomography (WBCT) for blunt trauma patients may provide a unique opportunity to investigate the frequency and characteristics of TBI sustained by restrained drivers. METHODS: A single-center, retrospective observational study was conducted using prospectively acquired data. Between January 2013 and December 2017, 409 restrained drivers (284 men/125 women, mean age of 45.0 ± 19.1 years) whose vehicle had been severely damaged in RTAs underwent WBCT for evaluation of injuries. Multivariate regression analysis was performed to identify variables predictive of TBI. Influence of collision patterns (frontal, lateral or rollover) on the frequency and severity of TBI was evaluated. Relationship between collision patterns and CT findings was also reviewed. RESULTS: Thirty-one restrained drivers (7.6%) sustained TBI after RTA. The distribution of Glasgow Coma Scale (GCS) scores among the 31 drivers was 15 in 9, 13-14 in 9, 9-12 in 4, and ≤ 8 in 9, indicating that the majority of TBIs were classifiable as mild. The frequency of TBI in alert and oriented drivers, i.e., those with a GCS score of 15, was 2.9%. Multivariate regression analysis showed that both altered mental status (OR, 4.933; 95% CI, 1.135-21.431) and loss of consciousness (OR, 6.492; 95% CI, 1.669-25.249) were associated with TBI. The frequency of TBI tended to be higher in drivers with rollover collision than those with frontal collision (6 vs. 13%, p = 0.07). Interhemispheric acute subdural hematoma and subcortical petechial hemorrhage seemed to be characteristic CT findings in drivers with frontal and lateral collision, respectively. CONCLUSIONS: The key finding of this study, i.e., that (1) TBI was observed in 7.6% of restrained drivers with severe vehicular damage, may provide useful information to neurosurgeons who take care of RTA victims. The majority of the TBIs were mild without need for neurosurgical intervention. While association may exist between type of collision and type of brain injury, further studies with prospective design are warranted.

Electrocadiographic Scoring Helps Predict Left Ventricular Wall Motion Abnormality Commonly Observed after Subarachnoid Hemorrhage.

BACKGROUND: Cardiac wall motion abnormality (WMA) is a common complication in patients with subarachnoid hemorrhage (SAH) and is one determinant of their prognosis. The aim of this study was to examine whether the electrocardiography (ECG) findings at admission could predict WMA commonly observed after SAH. MATERIALS AND METHODS: We studied 161 SAH patients with SAH who were hospitalized in our institution between April 2007 and November 2010. We performed bedside 2-dimensional transthoracic echocardiography and 12-lead surface ECG within 24hours of SAH onset. Each of the following ECG changes was scored as having 1 point: ST elevation, ST depression and T wave inversion. We summed up the points in every patient and compared with WMA evaluated by echocardiography. RESULTS: The study subjects were classified into 2 groups based on the presence of WMA. Multivariate analysis revealed that ST elevation, ST depression and T wave inversion were strong independent predictors of WMA. Receiver operating characteristic curve determined that the threshold value to predict WMA was 4 points (sensitivity 86.5%, specificity 83.1%, AUC 0.94, P < .0001). CONCLUSIONS: In conclusion, a novel ECG score may well predict WMA after SAH which may associate with an increased risk of mortality.

Prediction of genetic subgroups in adult supra tentorial gliomas by pre- and intraoperative parameters.

Recent progress in neuro-oncology has validated the significance of genetic diagnosis in gliomas. We previously investigated IDH1/2 and TP53 mutations via Sanger sequencing for adult supratentorial gliomas and reported that PCR-based sequence analysis classified gliomas into three genetic subgroups that have a strong association with patient prognosis: IDH mutant gliomas without TP53 mutations, IDH and TP53 mutant gliomas, and IDH wild-type gliomas. Furthermore, this analysis had a strong association with patient prognosis. To predict genetic subgroups prior to initial surgery, we retrospectively investigated preoperative radiological data using CT and MRI, including MR spectroscopy (MRS), and evaluated positive 5-aminolevulinic acid (5-ALA) fluorescence as an intraoperative factor. We subsequently compared these factors to differentiate each genetic subgroup. Multiple factors such as age at diagnosis, tumor location, gadolinium enhancement, 5-ALA fluorescence, and several tumor metabolites according to MRS, such as myo-inositol (myo-inositol/total choline) or lipid20, were statistically significant factors for differentiating IDH mutant and wild-type, suggesting that these two subtypes have totally distinct characteristics. In contrast, only calcification, laterality, and lipid13 (lipid13/total Choline) were statistically significant parameters for differentiating TP53 wild-type and mutant in IDH mutant gliomas. In this study, we detected several pre- and intraoperative factors that enabled us to predict genetic subgroups for adult supratentorial gliomas and clarified that lipid13 quantified by MRS is the key tumor metabolite that differentiates TP53 wild-type and mutant in IDH mutant gliomas. These results suggested that each genetic subtype in gliomas selects the distinct lipid synthesis pathways in the process of tumorigenesis.

Clinical Characteristics of Stroke Occurring while Bathing.

BACKGROUND: Stroke can occur during any human activity. Although cardiac arrests or drowning accidents while bathing have been studied extensively, there are few studies focusing on stroke occurring while bathing. The objectives of this study were to evaluate the clinical characteristics of stroke occurring while bathing and the association between stroke and drowning accidents. METHODS: Clinical data prospectively acquired between January 2011 and December 2015 on 1939 patients with stroke (1224 cerebral infarctions [CIs], 505 intracerebral hemorrhages [ICHs], and 210 subarachnoid hemorrhages [SAHs]) were reviewed to identify patients who sustained a stroke while bathing. The ratio of bathing-related strokes to strokes occurring during other activities was evaluated. Moreover, the demographics of these 2 groups were compared in each stroke type. RESULTS: Among the 1939 patients, 78 (CI, 32; ICH, 28; and SAH, 18) sustained a stroke while bathing. The ratio of bathing to other activities in the SAH group was the highest (8.6%), followed by the ICH group (5.5%), whereas that in the CI group was the lowest (2.6%). Regardless of stroke type, only a minority of patients were found to have collapsed inside the bathtub. CONCLUSIONS: The higher ratio of bathing in hemorrhagic strokes may indicate that there is a small risk of hemorrhagic stroke while bathing in vulnerable subjects. This retrospective study did not establish a causal relationship between bathing and stroke nor identify risk factors, which means that future prospective studies are warranted. The finding that the great majority of bathing-related stroke patients were found to have collapsed outside the bathtub suggests that the involvement of stroke in drowning accidents in the bathtub may be small.

Acute coronary syndromes occurring while driving: frequency and patient characteristics.

BACKGROUND: Acute coronary syndrome (ACS) may occur during any human activity, including driving. The objectives of this study were to report the frequency of ACS occurring while driving, clarify patient characteristics, and analyze the behavioral patterns of drivers who sustained ACS. METHODS: A single-center, retrospective observational study was conducted using prospectively acquired data. Among 1605 ACS patients admitted between January 2011 and December 2016, 65 (60 men/5 women) patients who sustained ACS while driving were identified. Clinical variables were compared between these 65 patients and 1540 patients who sustained ACS while performing other activities. Furthermore, multivariable regression analysis was performed to identify variables associated with ACS. RESULTS: The frequency of ACS occurring while driving was 4.0% (65/1605). Compared with patients who sustained ACS while performing other activities, those who sustained ACS while driving were significantly younger (66.2 ± 13.0 vs. 57.5 ± 12.2 years, p < 0.001) and more likely to smoke (34.2 vs. 60.0%, p < 0.001). Multivariable regression analysis showed that age (OR 0.961; 95% CI 0.940-0.982) and current smoking (OR 1.978; 95% CI 1.145-3.417) were associated with ACS. While 55 drivers (85%) who remained conscious after ACS could seek medical attention without causing accidents, the other 10 (15%) who sustained cardiac arrest caused accidents. CONCLUSIONS: The association between current smoking and ACS occurring while driving suggests that smoking cessation is advised for smokers who drive from the standpoint of driving safety. We expect that prospective studies be conducted to verify our findings and identify individuals at risk for ACS while driving.

Intrathecal administration of colistin for meningitis due to New Delhi metallo-ß-lactamase 1(NDM-1)-producing Klebsiella pneumoniae.

Infection by bacteria carrying New Delhi metallo-ß-lactamase 1 (NDM-1) is becoming a global health problem. We report a case of meningitis caused by NDM-1-producing Klebsiella pneumoniae, for which intrathecal administration of colistin was curative. A previously healthy 38-year-old Japanese man, who lived in Hyderabad, India, suddenly collapsed and was brought to a local hospital. He was diagnosed with subarachnoid hemorrhage and underwent emergency surgery which included partial skull removal. Approximately 1 month after surgery, he was repatriated to Japan and was admitted to our institution with information that he had been treated for multi-drug resistant Acinetobacter infection with colistin. A week after admission, he developed aspiration pneumonia due to NDM-1-producing K. pneumoniae, which was successfully treated by intravenous (IV) administration of colistin. Subsequently, he underwent a surgical procedure to repair his skull defect. He developed high-grade fever and altered mental status on postoperative day 2. NDM-1-producing K. pneumoniae was identified in the cerebrospinal fluid, establishing the diagnosis of meningitis. Although IV colistin was only partially effective, intrathecal colistin (10 mg daily by lumbar puncture for 14 days) successfully eradicated the meningitis. Because of economic globalization, NDM-1-producing bacteria may be brought to Japan by those who are repatriated after sustaining critical illnesses and being treated in foreign countries. This report may provide useful information on the treatment of central nervous system infection by NDM-1-producing bacteria.

Cerebellopontine angle epidermoid cysts: clinical presentations and surgical outcome.

Epidermoid cysts constitute less than 1% of intracranial tumors with the majority of them involving cerebellopontine angle (CPA). Although several mechanisms for cranial nerve dysfunction due to these tumors have been proposed, no direct evaluation for hyper- or hypoactive dysfunction has been done. In this case series, pathophysiology of cranial nerve dysfunction in CPA epidermoid cysts was evaluated with special attention to a new mechanism of capsule strangulation caused by stratified tumor capsule. Twenty-two cases with epidermoid cysts of CPA micro-neurosurgically treated in our departments since 2005 were reviewed. Clinical status of the patients before the surgery and post-operative functional outcome were recorded. Available data from the English literature were summarized for comparison. Mass reduction of cyst contents in most cases was usually associated with prompt and marked improvement of the symptoms suggesting neuroapraxia caused by compression of the tumor content and/or mild ischemia. Among them, two cases showed strangulation of the affected nerves by the tumor capsule whose preoperative dysfunction did not improve after surgery in spite of meticulous microsurgical removal of the lesion. Involved facial and abducent nerves in these two cases showed distortion of nerve axis and nerve atrophy distal to the strangulation site. We report the first direct evidence of etiology of cranial nerve dysfunction caused by cerebellopontine angle epidermoid tumors. Young age and rapidly progressive neurological deficit might be the characteristics for strangulation of the affected nerves by the cyst capsule. Even though the number of cases might be limited, immediate decompression and release of the strangulating band might be urged in such patients to prevent irreversible deficits.

Therapeutic outcomes for patients with aneurysmal subarachnoid hemorrhage complicated by Takotsubo cardiomyopathy.

BACKGROUND: There are no guidelines regarding the optimal treatment of subarachnoid hemorrhage (SAH) patients complicated by Takotsubo cardiomyopathy (TCM). Although coiling has been favored as the first-line treatment, clipping may also be indicated in patients with ruptured middle cerebral artery aneurysms or in those with massive intracerebral hemorrhage. The study objective is (1) to report the feasibility/safety of clipping/coiling and (2) to identify possible prognosticators in that population. METHODS: Between January 2008 and December 2014, 371 consecutive patients with aneurysmal SAH underwent transthoracic echocardiography after admission, and 30 with TCM (7.7 %) were identified. We reviewed the incidence and type of perioperative complications among clipped (n = 11) and coiled (n = 19) patients. The 30 patients were dichotomized based on their 90-day modified Rankin scale (mRS) scores into favorable (mRS: 0-2) and unfavorable (mRS: 3-6) groups, and their demographic, laboratory and echocardiographic variables were compared. RESULTS: Neither clipped nor coiled patients developed serious perioperative cardiopulmonary complications, but coiled patients had a higher incidence of fatal procedure-related complications. Among the 30 patients, 13 (43 %) had favorable 90-day outcomes, and the favorable group was significantly younger. Age, but not the degree of cardiac dysfunction, correlated with outcomes by multivariate regression analysis. CONCLUSIONS: Clipping was shown to be a safe treatment modality in our cohort, and treatment selection may better be made on a case-by-case basis in most patients with SAH-induced TCM. The lack of correlation between the degree of cardiac dysfunction and outcomes indicates that aggressive intervention is justified in patients with severely impaired cardiac function.

Concurrence of Aneurysmal Subarachnoid Hemorrhage and Stanford Type A Acute Aortic Dissection.

We report a rare case of concurrent aneurysmal subarachnoid hemorrhage (SAH) and acute aortic dissection (AAD). A 38-year-old man visited our hospital complaining of severe headache, and brain computed tomography (CT) revealed the presence of SAH. Thoracic to neck computed tomography angiography (CTA), performed in addition to brain CTA, suggested a tear in the aortic arch, and subsequent CT aortography established the diagnosis of Stanford type A AAD. The AAD in our patient, who reported no episodes of chest or back pain, was detected incidentally by thoracic to neck CTA. The imaging study has rarely been indicated for SAH except that it provides additional anatomical information in patients for whom extracranial-intracranial bypass surgery or endovascular treatment is considered. Nevertheless, our experience may highlight additional diagnostic value of thoracic to neck CTA in SAH patients.

Ischemic Event and Risk Factors of Embolic Stroke in Atherosclerotic Cerebral Aneurysm Patients Treated with a New Clipping Technique.

BACKGROUND: We would like to know the exact rate of ischemic event and the risk factors associated with embolic stroke by treatment of atherosclerotic cerebral aneurysm with a new technique. METHODS: This is a retrospective cohort study in patients diagnosed as unruptured atherosclerotic cerebral aneurysm who underwent microsurgical clipping between January 2012 and August 2014. All intraoperative video recordings were reviewed and chosen in patients who were identified as atherosclerotic lesion on the dome, neck, or parent artery of the aneurysm. The demographic, radiographic, operative, and postoperative data were collected. The primary end point was the incidence of cerebral infarction and the neurologic outcomes using the discharge modified Rankin Scale (mRS) score at postoperation time. A statistical analysis of the factors associated with embolic stroke was done by Fisher exact and Wilcoxon rank-sum tests. The individual surgical technique was demonstrated as an illustration for use as a guide. RESULTS: Among 103 atherosclerotic cerebral aneurysms, only 3 patients (2.9%) were associated with postoperative cerebral infarction and 1 of them had permanent neurologic deficit. A good mRS score (0-2) was found in 99% of patients and only 1% had a fair mRS score (3-4). A factor associated with ischemic outcome was duration of operation (P = .046). The differences in the atherosclerotic location showed no statistical significance. CONCLUSIONS: We found a very low incidence of embolic infarction after clipping of an atherosclerotic cerebral aneurysm with our new technique. Only duration of the operation time was a dependent risk factor for embolic infarction.

Does dabigatran increase the risk of delayed hematoma expansion in a rat model of collagenase-induced intracerebral hemorrhage?

BACKGROUND: Delayed hematoma expansion is common in intracerebral hemorrhage (ICH) patients using warfarin. Dabigatran induces fewer hemorrhagic complications compared with warfarin. However, the natural history of dabigatran-related ICH remains unclear. This study aims to clarify whether dabigatran increases the risk of delayed hematoma expansion in a rat ICH model. METHODS: Male Wistar rats were treated with 2 dosages of dabigatran etexilate (DE: 10 mg/kg, n = 4; 20 mg/kg, n = 3) 30 minutes before ICH induction using intraparenchymal collagenase infusion. Five rats that received saline were used as controls. Magnetic resonance imaging was performed 24 and 48 hours after ICH induction, and serial hematoma volume measurements were obtained using T2-weighted images. Expanded hematoma volumes were calculated by subtracting hematoma volumes at 48 hours from those at 24 hours; the hematoma expansion rate was defined as the ratio of the expanded hematoma volume to that at 24 hours. RESULTS: The mean hematoma volumes (mm(3)) at 24 hours were 13.3 ± 3.3 in the control group, 14.9 ± 2.0 in the 10 mg/kg DE group, and 18.9 ± 7.6 in the 20 mg/kg DE group with no significant intergroup differences (P = .26). The mean hematoma volumes at 48 hours (mm(3)) were 21.7 ± 4.9 in the control group, 22.1 ± 5.0 in the 10 mg/kg DE group, and 23.4 ± 5.8 in the 20 mg/kg DE group with no significant intergroup differences (P = .90). Consequently, there were no significant intergroup differences in the hematoma expansion rates (P = .33). CONCLUSIONS: This experimental study of a rat ICH model indicates that dabigatran-related ICH may not increase the risk of delayed hematoma expansion.

Cardiac wall motion abnormality after bleeding from vertebral artery aneurysms.

OBJECTIVE: Lesions in the medulla oblongata may be causally associated with cardiac wall motion abnormality (WMA). Although subarachnoid hemorrhage (SAH) patients occasionally develop WMA, the relationship between aneurysmal locations and the frequency of WMA has rarely been investigated. The objective of this study was to evaluate whether the frequency of WMA was higher after the rupture of vertebral artery (VA) aneurysms than that of non-VA aneurysms. METHODS: We performed a retrospective chart analysis of 244 SAH patients who underwent transthoracic echocardiography and plasma catecholamine measurements. The frequencies of WMA and electrocardiographic (ECG) abnormalities were compared among patients classified by the location of aneurysms. Multivariate regression analysis was conducted to identify variables correlated with WMA. Furthermore, the relationship between plasma catecholamine levels and aneurysmal locations was evaluated. RESULTS: The frequency of WMA was significantly higher in patients with VA aneurysms than in those with non-VA aneurysms (45 vs. 22 %, p = 0.01). However, there was no significant difference in the frequency of ECG abnormalities. Multivariate regression analysis showed that VA aneurysms (OR, 3.317; 95 % CI, 1.129-9.745), poor-grade SAH (OR, 2.733; 95 % CI, 1.320-5.658) and concomitant hydrocephalus (OR, 3.658; 95 % CI, 1.690-7.917) correlated with WMA. There were no significant intergroup differences in plasma catecholamine levels. CONCLUSION: VA aneurysms are close to several medullary nuclei that integrate autonomic inputs. A transient deformation and ischemia of the medulla oblongata caused by the mechanical stress related to the rupture of a VA aneurysm and/or a concomitant hydrocephalus may be responsible for the disproportionately high frequency of WMA.

Hemispheric differences in the surgical outcomes of patients with traumatic acute subdural hematoma.

BACKGROUND: Our assumption that prognosis of patients with traumatic acute subdural hematoma (ASDH) does not differ significantly according to the hemispheric laterality has never been verified. METHODS: A review of the charts/radiographic images of 61 adult traumatic ASDH patients (33 left/28 right) was conducted. Intergroup comparison was made on the demographics, autonomic/laboratory data, and outcomes (90-day mortality rate). Based on the presence of concomitant brain contusion, patients were further quadrichotomized as: left ASDH with contusion (n = 14), right ASDH with contusion (n = 16), left ASDH without contusion (n = 19), and right ASDH without contusion (n = 12). Comparisons were made on demographic and outcome variables between the left ASDH with contusion and right ASDH with contusion, and between the left ASDH without contusion and right ASDH without contusion. Multivariate regression analysis was conducted to identify clinical variables correlated with fatality. RESULTS: There were no significant differences in the demographic, autonomic, and laboratory data between the left and right ASDH patients. However, 90-day mortality rate was significantly higher in the left ASDH patients when concomitant contusion was present (79% vs. 25%, p = 0.009). However, there were no significant hemispheric differences in the mortality rate among those without contusion (32% vs. 33%, p = 0.77). Multivariate regression analysis showed that left ASDH was correlated with fatality among those with contusion (OR: 6.620; 95% CI: 1.219-46.249). CONCLUSIONS: This study is probably the first to report that the left ASDH patients fared substantially worse than the right-sided counterparts. Future trials on traumatic ASDHs may benefit from considering hemispheric differences in the outcomes.

Clinical Characteristics and Outcomes of Aneurysmal Subarachnoid Hemorrhage Patients Who Live Alone.

It has been shown that living alone is one of the risk factors for unfavorable outcomes in ischemic stroke patients, mostly due to delay in receiving appropriate treatment. A single-center retrospective observational study was conducted to evaluate whether living alone was associated with unfavorable outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Among 451 SAH patients admitted to our institution between January 2013 and December 2022, 43 patients who lived alone had sustained SAH at home (group A) and 329 patients who lived with family had sustained SAH at home (group F). The mortality rate (46.5% vs. 29.8%, p = 0.04) and a tendency for having unfavorable outcomes were higher in group A than in group F. The incidence of concomitant hydrocephalus was significantly higher in the former (37.2% vs. 21.3%, p = 0.03). Group A was further classified to the Able to Call (n = 15, group AC) and Unable to Call (n = 28, group UC) subgroups based on their ability to call for help by themselves. Group AC tended to have favorable outcomes (27% vs. 4%, p = 0.04). Treatment to obliterate a ruptured aneurysm had particularly been challenging in group UC, in which the accurate time of onset often remained unidentifiable: Their overall mortality was as high as 57% and their capability to undergo surgical/interventional treatment was only 67%. Perioperative complications resulting from delayed presentation had been common. Considering the present finding that most of those who lived alone could not call for help, further effort is warranted to facilitate early detection of those patients.

Effect of insular injury on autonomic functions in patients with ruptured middle cerebral artery aneurysms.

BACKGROUND AND PURPOSE: Insular injuries are known to cause autonomic derangements. Patients with ruptured middle cerebral artery aneurysms frequently develop temporal hematomas (THs) in addition to subarachnoid hemorrhages, and those with TH may sustain autonomic derangements more frequently than those without TH. Hemispheric lateralization in autonomic derangements has been reported in patients with insular ischemic stroke, and this study was conducted to clarify whether such lateralization was also observed in patients with TH resulting from middle cerebral artery aneurysm rupture. METHODS: A retrospective analysis on the medical records of 79 patients with ruptured middle cerebral artery aneurysms was performed on the basis of lateralization and presence of TH. They were quadrichotomized as left TH+ (LTH+; n=17), right TH+ (n=25), left TH- (n=15), and right TH- (n=22). Comparisons, mainly between LTH+ and right TH+, were made on demographic variables, autonomic/cardiac parameters, plasma catecholamine and glucose levels, and outcomes. RESULTS: There were no significant differences in demographic or cardiac parameters between the 2 groups. Systolic blood pressures were lower in LTH+ (139±34 versus 174±47 mm Hg; P=0.05). The LTH+ group also tended to be more bradycardiac (80±19 versus 101±22 bpm; P=0.13). The LTH+ group exhibited significantly lower plasma norepinephrine (1008±975 versus 2549±2133 pg/mL; P=0.03) and glucose levels (9.3±1.8 versus 12.2±4.5 mmol/L; P=0.04). However, in-hospital mortality did not differ significantly (41% versus 44%; P=1.00). CONCLUSIONS: Lateralization of autonomic derangements observed might not have had a significant effect on the outcomes. Nevertheless, autonomic derangements associated with insular injury should be considered in the management of subarachnoid hemorrhage patients with TH.