A preliminary study of relationship among the degree of internal carotid artery stenosis, wall shear stress on MR angiography and 18F-FDG uptake on PET/CT.

BACKGROUND: This preliminary study was undertaken to evaluate relationship among the degree of internal carotid artery (ICA) stenosis, wall shear stress (WSS) by computational fluid dynamics (CFD) on magnetic resonance angiography (MRA) and 18F-FDG uptake of ICA on PET/CT. METHODS: A total of 40 carotid arteries in 20 patients with carotid atherosclerotic disease were examined with MRA and 18F-FDG PET/CT. Atherosclerotic risk factors were assessed in all patients. Degree of ICA stenosis was calculated according to NASCET method. CFD analysis was performed and maximum WSS (WSSmax) was measured. 18F-FDG uptake in ICA was quantified using maximum target-to-blood pool ratio (TBRmax). RESULTS: Atherosclerotic risk factors did not affect imaging findings. There were significant correlations between WSSmax and degree of ICA stenosis (ρ = .81, P < .001), WSSmax and TBRmax (ρ = .64, P < .001), and TBRmax and degree of ICA stenosis (ρ = .50, P = .001). CONCLUSIONS: These preliminary results indicate that there may be significant correlations among the degree of ICA stenosis, WSSmax and TBRmax in patients with carotid artery stenosis.

Validity of identification algorithms combining diagnostic codes with other measures for acute ischemic stroke in MID-NET®.

PURPOSE: We aimed to develop a reliable identification algorithm combining diagnostic codes with several treatment factors for inpatients with acute ischemic stroke (AIS) to conduct pharmacoepidemiological studies using the administrative database MID-NET® in Japan. METHODS: We validated 11 identification algorithms based on 56 different diagnostic codes (International Classification of Diseases, Tenth Revision; ICD-10) using Diagnosis Procedure Combination (DPC) data combined with information on AIS therapeutic procedures added as "AND" condition or "OR" condition. The target population for this study was 366 randomly selected hospitalized patients with possible cases of AIS, defined as relevant ICD-10 codes and diagnostic imaging and prescription or surgical procedure, in three institutions between April 1, 2015 and March 31, 2017. We determined the positive predictive values (PPVs) of these identification algorithms based on comparisons with a gold standard consisting of chart reviews by experienced specialist physicians. Additionally, the sensitivities of them among 166 patients with the possible cases of AIS at a single institution were evaluated. RESULTS: The PPVs were 0.618 (95% confidence interval [CI]: 0.566-0.667) to 0.909 (95% CI: 0.708-0.989) and progressively increased with adding or limiting information on AIS therapeutic procedures as "AND" condition in the identification algorithms. The PPVs for identification algorithms based on diagnostic codes I63.x were >0.8. However, the sensitivities progressively decreased to a maximum of ~0.2 after adding information on AIS therapeutic procedures as "AND" condition. CONCLUSIONS: The identification algorithms based on the combination of appropriate ICD-10 diagnostic codes in DPC data and other AIS treatment factors may be useful to studies for AIS at a national level using MID-NET®.

Blood Glucose Variability: A Strong Independent Predictor of Neurological Outcomes in Aneurysmal Subarachnoid Hemorrhage.

PURPOSE: In patients with aneurysmal subarachnoid hemorrhage (SAH), increased glucose variability (GV) is associated with increased mortality and cerebral infarction; however, there are no reports demonstrating an association between GV and neurological outcome. This study investigated whether GV had an independent effect on neurological outcomes in patients with SAH in the intensive care unit. MATERIALS AND METHODS: Consecutive adult patients hospitalized with SAH between January 1, 2009, and May 31, 2015 (N = 122) were retrospectively reviewed. Univariate/multivariate analyses were performed to identify independent predictors of poor neurological outcome. Patients were divided according to the mean glucose level (80-139 vs 140-200 mg/dL) and further subdivided using quartiles (Q) of the standard deviation (SD, representing variability) of the glucose level (Q1, Q2 + 3, and Q4). RESULTS: Unfavorable neurological outcomes occurred in 44.2% of the patients. On multiple regression analysis, age, Hunt and Kosnik grade, SD of glucose (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.02-1.17; P < .01), and minimum blood glucose level (OR, 0.95; 95% CI, 0.91-0.99; P < .01) were significantly associated with unfavorable neurological outcomes. Both groups (mean glucose levels: 80-139 and 140-200 mg/dL groups) had increasing unfavorable neurological outcomes with increasing SD of glucose (Q1, 15.0%; Q2 + 3, 40.0%; Q4, 52.4% and Q1, 44.4%; Q2 + 3, 50%; Q4, 88.9% in the 80-139 and 140-200 mg/dL groups, respectively). Patients with minimum glucose of <90 mg/dL comprised >50% of unfavorable neurological outcome. CONCLUSION: Increased GV was an independent predictor of unfavorable neurological outcomes in patients with SAH.

Cerebral blood flow and oxygen metabolism measurements using positron emission tomography on the first day after carotid artery stenting.

BACKGROUND: The aim of the present study is the characterization of hemodynamics to predict hyperperfusion syndrome (HPS) after carotid artery stenting (CAS) with positron emission tomography (PET) obtained before and on the first day after the treatment. METHODS: Cerebral perfusion and oxygen metabolism were evaluated by (15)O-gas PET in 18 patients with symptomatic internal carotid artery (ICA) stenosis before and on the first day after CAS. Regional cerebral blood flow (CBF), oxygen extraction fraction (OEF), cerebral metabolic rate of oxygen (CMRO2), and cerebral blood volume (CBV) were measured in the ipsilateral and contralateral middle cerebral artery territories and compared between before and after CAS. RESULTS: CBF increased in 16 of 18 patients on the first day after CAS and postoperative CBF was significantly higher than preoperative CBF bilaterally. OEF decreased in 15 of 18 patients on the first day after CAS and postoperative OEF was significantly lower than preoperative OEF in the ipsilateral hemisphere. CMRO2 and CBV did not change significantly. None of the patients showed HPS after CAS. All patients who had preoperative OEF of 53% or more (misery perfusion) in the ipsilateral hemisphere showed 50% or more increase in CBF postoperatively. The preoperative OEF value significantly correlated with the rate of postoperative increase in CBF bilaterally. CONCLUSIONS: CAS increases cerebral perfusion and improves hemodynamic compromise in patients with symptomatic ICA stenosis. Although we could not clarify the usefulness of PET before and on the first day after CAS in predicting HPS, a high preoperative OEF is related to postoperative marked CBF increase and might be used as a predictor of HPS. Patients with greater hemodynamic compromise with a high preoperative OEF should be managed carefully to prevent HPS, but they have a greater chance of CBF increase after CAS.

[Intrapituitary adenoma metastasis from lung cancer with progressive cranial nerve palsies: a case report and literature review].

We report a rare case of metastasis to a preexisting pituitary adenoma. An 80-year-old man with a history of pituitary adenoma and lung cancer presented with recent onset of bilateral visual impairment, oculomotor nerve palsies, and severe headache. A CT scan revealed a pituitary tumor expanding into the suprasellar region and infiltrating the bilateral cavernous sinuses. We performed transsphenoidal surgery and diagnosed the tumor as lung cancer metastasis to the pituitary adenoma. After the surgery, visual impairment and severe headache were resolved, and the patient underwent radiation therapy for the residual tumor. To the best of our knowledge, 20 cases of metastases to pituitary adenomas have been reported in the literature. Clinical features of metastasis to a pituitary adenoma are different from those of metastasis to normal pituitary gland. In the case of a pituitary lesion with acute aggravation, one should be aware of the possibility of metastasis to preexisting pituitary adenomas.

Revealing subependymal giant cell astrocytoma with multimodal positron emission tomography: illustrative cases.

BACKGROUND: There is limited literature on the use of positron emission tomography (PET) for benign tumors originating in the brain ventricles, and the use of multiple tracers for subependymal giant cell astrocytoma (SEGA) has not been reported. The authors compared the PET findings in two SEGA cases with past reports and literature, exploring the distinctive characteristics of SEGA on PET. OBSERVATIONS: In a 21-year-old female with SEGA, the authors utilized 18F-fluorodeoxyglucose (18F-FDG), 11C-methionine (11C-MET), 18F-fluorothymidine (18F-FLT), 18F-fluoromisonidazole, and 18F-THK5351 tracers. Additionally, in a 6-year-old girl, the authors performed 11C-MET PET. LESSONS: The results indicated the accumulation of all tracers except 18F-FDG, with particularly intense accumulation noted with 18F-FLT. In particular, 18F-FLT demonstrated accumulation comparable to that observed in malignant tumors. This study suggests that multiple PET tracers can provide valuable insights into the characterization of SEGA, with 18F-FLT showing particular promise as a distinctive marker of blood-brain barrier disruption. Further research in larger cohorts may enhance our understanding of metabolic patterns in SEGA and aid in its diagnosis and treatment. https://thejns.org/doi/10.3171/CASE24111.

Endovascular Treatment for Posterior Communicating Artery Aneurysms with Oculomotor Nerve Palsy.

Objective: Coil embolization for the treatment of internal carotid artery-posterior communicating artery aneurysms (PComAAn) associated with oculomotor nerve palsy (ONP) remains controversial in terms of the therapeutic effect to improve ONP. Patients with PComAAn treated in our hospital were retrospectively analyzed to evaluate the effectiveness of coil embolization on ONP. Methods: Twenty-three patients who had coil embolization for PComAAn with ONP were included in the analysis. In the evaluation of postoperative outcome of ONP, complete resolution of all symptoms was considered as a total recovery. ONP with a few residual symptoms that are stable and not disabling was considered as a subtotal recovery and that with only a slight improvement as a partial recovery. Results: Preoperative ONP was complete palsy in 14 and partial palsy in nine cases. The mean maximum diameter of the aneurysms was 9.1 ± 3.5 mm (3-17 mm), and the mean time from the onset to treatment was 46.3 ± 98.4 days (0-300 days). The embolization state immediately after the procedure was complete occlusion in seven, neck remnant in eight, and body filling (BF) in eight cases. Total recovery was observed in nine, subtotal recovery in 11, and partial recovery in three cases. The mean time to any improvement in ONP was 6.0 ± 6.0 months (0.5-25 months). Comparing 20 cases with total plus subtotal recovery and three cases with partial recovery, five (25.0%) and three (100%) cases showed BF immediately after the procedure, respectively, which was statistically significant (P = 0.015). Conclusion: The analysis indicated that coil embolization for the treatment of PComAAn with ONP resulted in satisfactory recovery of ONP in 87% of the cases and the outcome of aneurysm embolization was related to improvement in ONP.

Case Series of Endovascular Therapy for Blood Blister-Like Aneurysm in Acute Phase.

Objective: Blood blister-like aneurysms (BBAs) of the internal carotid artery are highly challenging to treat due to their variable morphology and tendency for rupture and regrowth. Here, we report a single-institution experience of endovascular therapy (EVT) for BBA treatment. Methods: We retrospectively reviewed patients with ruptured BBA from 2006 to 2019. All patients in whom BBA was treated with EVT were included. Patients' aneurysmal characteristics, progression status, aneurysm occlusion on follow-up angiography, and modified Rankin Scale (mRS) score were recorded. Results: A total of 11 patients (5 women and 6 men) with the mean age of 46 ± 10 years were included in this study. As initial treatment, 9 patients were treated with stent-assisted coiling (SAC). Immediate angiographic results showed that 2 cases were body filling, 4 were neck remnant, and 3 were complete obliteration. Perioperative ischemic complications were not observed. On postoperative day 1, 2 patients suffered from rerupture, and their prognoses were poor. Retreatments were performed in 5 patients. Parent artery occlusion (PAO) was performed in 6 patients including 2 initial treatments and 4 retreatments. Symptomatic infarction developed in 2 patients. In 3 patients, bypass in combination with PAO was performed. Clinical data revealed discharge mRS scores of 0-2 and 3-6 in 4 and 7 patients, respectively. Conclusion: SAC is effective for the management of BBA. Careful follow-up and response are necessary after treatment with SAC.

Deferoxamine reduces cavity size in the brain after intracerebral hemorrhage in aged rats.

This study investigated whether deferoxamine (DFX), an iron chelator, reduces cavity size after ICH in aged rats. Aged male Fischer rats (18 months old) had an intracaudate injection of 100 µL autologous blood and were treated with DFX or vehicle. Rats were euthanized at day 56 and brains were perfused for histology and immunohistochemistry. Hematoxylin and eosin staining was used to examine hematoma cavity presence and size. Immunohistochemistry was performed to measure the number of cells positive for ferritin, heme oxygenase-1 (HO-1), glial fibrillary acidic protein (GFAP) and OX-6. Neurological deficits were also examined. In aged rats with ICH, a cavity formed in the caudate in 7 out of 12 vehicle-treated rats and 1 out of 9 DFX-treated rats. DFX treatment significantly reduced the size of the ICH-induced cavity (p<0.05) as well as neurological deficits (p<0.05). DFX also reduced the number of ferritin (p<0.05) and HO-1 (p<0.01) positive cells in the ipsilateral basal ganglia. However, DFX had no effect on brain GFAP and OX-6 immunoreactivity 2 months after ICH.In conclusion, DFX reduces cavity size, neurological deficits, and immunoreactivity for ferritin and HO-1 after ICH in aged rats, supporting the suggestion that DFX may reduce brain injury in ICH patients.

Deferoxamine affects heat shock protein expression in heart after intracerebral hemorrhage in aged rats.

Cardiac dysfunction can occur after intracerebral hemorrhage (ICH). This study examined the expression of heat shock proteins (HSPs) in the heart after ICH in aged rats and whether deferoxamine (DFX), an iron chelator, affects HSP expression. Male Fischer 344 rats (18 months old) received an injection of 100 µl autologous blood into the right caudate, whereas sham-operated rats had a needle insertion. The rats were treated with DFX or vehicle at 2 and 6 h after ICH and then every 12 h for 3 days. Rats were killed 3 days after ICH, and the hearts were sampled for Western blot analysis of HSP-27 and HSP-32. Western blotting showed that levels of HSP-32 were reduced in the heart after ICH (p<0.05), and this reduction was normalized by DFX (p<0.05). DFX had no effects on heart HSP-32 levels in sham-operated rats. ICH also resulted in a reduction in HSP-27 (p<0.05), but DFX treatment reduced HSP-27 further (p<0.05). In addition, DFX reduced HSP-27 levels in sham rats. In conclusion, ICH causes HSP-27 and -32 reductions in the heart of aged rats. Deferoxamine treatment has different effects on the expression of HSP-27 and HSP-32.

Clinicopathologic Factors Associated with Tumor Necrosis after Preoperative Embolization of Meningiomas.

Objective: Preoperative embolization of meningiomas induces necrosis prior to surgery and facilitates resection. Lack of contrast enhancement on postembolization MRI correlates with pathological findings of necrosis and can be used to assess embolization efficacy. This study aimed to examine clinicopathologic factors associated with tumor necrosis after embolization. Methods: A total of 119 patients with intracranial meningioma who underwent 145 surgical resections between 2010 and 2019 at our institute were reviewed. Inclusion criteria for the study were preoperative embolization with trisacryl gelatin microspheres (Embosphere) or absorbable gelatine sponge (Gelfoam). Postembolization Gd-enhanced T1-weighted and angiographic imaging, and histopathologic examination results were reviewed to evaluate the effectiveness of embolization. Results: In all, 66 patients satisfied the inclusion criteria. In total, 36 patients were embolized with Embosphere and 30 patients were embolized with Gelfoam. Patients embolized with Embosphere had a significantly higher necrosis rate (NR) than patients with Gelfoam (21% vs. 7.1%, P <0.01). The 36 Embosphere patients were analyzed regarding clinicopathologic factors associated with NR. Tumors in 12 patients were located in the parasagittal/falx region; these patients had a significantly lower NR compared with tumors in other locations (10.6% vs. 26.2%, P = 0.016). In all, 13 patients had feeders arising from only the middle meningeal artery (MMA), which was associated with a significantly higher NR (29.3% vs. 14.4%, P = 0.015). In total, 11 patients had meningeal feeders arising from internal carotid artery (ICA), which was associated with a significantly lower NR (9.0% vs. 26.3%, P <0.01). Conclusion: This study showed embolization agent, tumor location, and blood supply were important factors predicting necrosis after preoperative embolization.

Deferoxamine treatment for intracerebral hemorrhage in aged rats: therapeutic time window and optimal duration.

BACKGROUND AND PURPOSE: Deferoxamine (DFX) reduces brain edema, neurological deficits, and brain atrophy after intracerebral hemorrhage (ICH) in aged and young rats. Our previous study found that 50 mg/kg is an effective dose in aged rats. In the present study, we explored potential therapeutic time windows and optimal therapeutic durations. METHODS: Aged male Fischer 344 rats (18 months old) sustained an intracaudate injection of 100 microL autologous whole blood, followed by intramuscular DFX or vehicle beginning at different time points, or continuing for different durations. Subgroups of rats were euthanized at day 3 for brain edema measurement and day 56 for brain atrophy determination. Behavioral tests were performed on days 1, 28, and 56 after ICH. RESULTS: Systemic administration of DFX, when begun within 12 hours after ICH, reduced brain edema. DFX treatment started 2 hours after ICH and administered for >or=7 days attenuated ICH-induced ventricle enlargement, caudate atrophy, and neurological deficits. DFX attenuated ICH-induced brain atrophy and neurological deficits without detectable side effects when begun within 24 hours and administered for 7 days. CONCLUSIONS: To the extent that these results can be translated to humans, the therapeutic time window and the optimal duration for DFX in this aged rat model of ICH may provide useful information for an ongoing DFX-ICH clinical trial.

[11C-methionine positron emission tomography in nontumorous brain lesions].

Positron emission tomography (PET) with L-[methyl-11C]methionine (MET) provides information on the metabolism of brain tumor. MET uptake reflects amino acid active transport and protein synthesis and is proportional to the amount of viable tumor cells. However, MET uptake can be increased as a result of increased density of inflammatory cells and disruption of the blood brain barrier (BBB) in nontumorous brain lesions. From October 2005 through November 2009, 438 MET-PET studies were performed for various brain lesions at our institution. Among them, 27 (6%) were finally diagnosed to be nontumorous by surgical exploration or their clinical course. Nine of 10 intracerebral hemorrhages and all 4 cerebral infarctions demonstrated mild to moderate MET uptake in or surrounding the lesions in the subacute or chronic stage after the ictus. Moderately increased MET uptake was observed in all 3 patients with brain abscess. Active lesions in multiple sclerosis and Beçhet disease showed mild MET uptake. Idiopathic orbital and optic inflammations showed mildly increased MET uptake in the lesions. Finally, a case of hypertrophic cranial pachymeningitis exhibited strong MET uptake in the lesions. We should keep in mind that high MET uptake is frequently observed in nontumorous brain lesions. Although differentiation from tumorous lesions is usually possible by laboratory and morphological examinations, nontumorous lesions should be included in the differential diagnosis when encountering patients with high MET uptake.

Effects of deferoxamine on intracerebral hemorrhage-induced brain injury in aged rats.

BACKGROUND AND PURPOSE: Deferoxamine (DFX) reduces brain edema, neuronal death, and neurological deficits after intracerebral hemorrhage (ICH) in young rats. In the present study, we investigated whether DFX is effective on brain injury after ICH in aged rats and examined dose dependency. METHODS: Male Fischer 344 rats (18 months old) had an intracaudate injection of 100 microL autologous whole blood and were treated with different doses of DFX (10, 50, and 100 mg/kg) or vehicle 2 and 6 hours post-ICH and then every 12 hours up to 7 days. Rats were euthanized at Day 3 for brain edema determination and Day 56 for brain atrophy measurement. Behavioral tests were performed during the experiments. RESULTS: All 3 doses of DFX attenuated perihematomal brain edema at 3 days (eg, at dose 50 mg/kg, 80.4+/-0.5 versus 81.6+/-0.9% in the vehicle-treated group, P<0.01). Fifty and 100 mg/kg DFX also reduced ICH-induced ventricle enlargement, caudate atrophy, and ICH-induced neurological deficits in aged rats. However, although 10 mg/kg DFX reduced ventricle enlargement and forelimb-placing deficits, it did not reduce caudate atrophy and corner turn deficits. CONCLUSIONS: These results indicate that DFX can reduce ICH-induced brain injury in aged as well as young rats and that a dose >10 mg/kg is the optimal dose of DFX in this model.

A Rare Case of Postoperative Symptomatic Cyst Formation After Resection of a Large Convexity Meningioma.

BACKGROUND: Symptomatic cyst formation after brain tumor resection is a rare complication of the early postoperative phase. We describe a complicated case of postoperative symptomatic cyst formation after gross total removal of a convexity meningioma. CASE DESCRIPTION: A 59-year-old woman presented with recent onset motor aphasia. Magnetic resonance imaging revealed a left convexity tumor. We performed gross total resection of the tumor, which was pathologically diagnosed as an atypical meningioma. Tumor resection and decompression of the normal cerebral hemisphere improved aphasia. However, 3 days after surgery, her motor aphasia worsened. Computed tomography scan confirmed that the frontal lobe was being compressed by an enlargement of the postoperative tumor cavity. Conservative therapy did not shrink the cavity, and her motor aphasia persisted. Therefore, 21 days after surgery, a drainage tube was inserted into the enlarged cavity using a neuroendoscope, which promoted shrinkage of the cavity and improved her motor aphasia. We suspected that the enlargement of the postoperative cavity was because of the presence of a valve-like structure. CONCLUSIONS: Even though formation of symptomatic cystic lesions after brain tumor resection is rare, neurosurgeons should be aware of such early postoperative complications and their management strategies.

Association between dexmedetomidine use and neurological outcomes in aneurysmal subarachnoid hemorrhage patients: A retrospective observational study.

PURPOSE: Recent studies in animal subarachnoid hemorrhage (SAH) models have reported that dexmedetomidine (DEX) use demonstrates significantly better neurological outcomes. This study aimed to evaluate whether DEX use is associated with favorable neurological outcomes (FO) in SAH patients. MATERIALS AND METHODS: We retrospectively reviewed all SAH patients between 2009 and 2017. We calculated the total dosage of DEX administered for the first 24h after admission. All patients were classified into no use, low dosage, and standard dosage group. Multivariate analysis was performed to clarify the association between DEX use and FO (modified Ranking Scale score of 0-2 at hospital discharge). RESULTS: There were 161 patients with 55.3% of FO. On univariate analysis, there were significant differences with regard to age, Hunt and Kosnik (H&K) grade, and DEX use. Multivariate analysis showed that age, H&K grade, and low dosage DEX (rather than no use) (odds ratio (OR) 3.17; 95% confidence interval (CI), 1.24-8.53; p=0.02) were significantly associated with FO. However, standard dosage DEX was not a significant factor (OR, 0.75; 95% CI, 0.25-2.16; p=0.59). CONCLUSIONS: Low dosage DEX during the first 24h after admission was associated with FO in SAH patients.

Cavernous sinus dural arteriovenous fistula treated by facial vein direct puncture: Case report and review of the literature.

Introduction In case of cavernous sinus dural arteriovenous fistula (CSDAVF), transvenous embolization (TVE) of the cavernous sinus (CS) via the inferior petrosal sinus (IPS) is generally performed. However, various approach routes have been reported when the accessibility of the IPS is challenging. We herein report a case of CSDAVF treated by TVE with direct puncture of the facial vein. Case report A 70-year-old woman who suffered from tinnitus, chemosis, diplopia and bruit was referred to our hospital. Digital subtraction angiography (DSA) demonstrated CSDAVF. We initially attempted to perform TVE via the IPS route; however, we could not guide a catheter to the CS because of an anatomical difficulty. Then, we performed percutaneous direct puncture of the dilated facial vein, and successfully treated the patient. Conclusion When navigating microcatheter to the CS is difficult because of an anatomical difficulty of the IPS, direct puncture of the facial vein is a feasible route.

Target Serum Sodium Levels During Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Dysnatremia commonly occur in the intensive care unit (ICU) management of patients with aneurysmal subarachnoid hemorrhage (SAH). However, detailed management strategies have not been provided even by current guidelines. The purposes of this study were to examine the association of abnormal serum sodium levels with unfavorable neurologic outcomes and to identify the target range of serum sodium in patients with SAH. METHODS: We retrospectively reviewed all patients who were consecutively hospitalized with a confirmed diagnosis of SAH between January 2009 and December 2015. Univariate/multivariate analyses were performed to identify the independent predictors of an unfavorable neurologic outcome (modified Rankin scale of 3-6 upon hospital discharge). RESULTS: There were 131 patients included in this study. Unfavorable neurologic outcomes occurred in 45% of patients. On multiple regression analysis, age, Hunt and Kosnik grade, and serum sodium levels in the ICU at the maximum [odds ratio (OR), 1.18; 95% CI, 1.05-1.35; P < 0.01] and minimum (OR, 0.88; 95% CI, 0.77-0.99; P = 0.048) values were significantly associated with unfavorable neurologic outcomes. The receiver operating characteristic curve analysis showed that the cut-off serum sodium levels were 145 mmol/L for maximum value and 132 mmol/L for minimum value. Patients with hyponatremia and hypernatremia during the first 2 weeks in the ICU accounted for 88.2% of patients with an unfavorable neurologic outcome; whereas, those with normal sodium levels accounted for only 15.6%. CONCLUSIONS: In patients with SAH, both hyponatremia and hypernatremia during ICU management were significantly associated with unfavorable neurologic outcomes.

Serial blood lactate measurements and its prognostic significance in intensive care unit management of aneurysmal subarachnoid hemorrhage patients.

PURPOSE: This study assesses the behavior of serial blood lactate measurements during intensive care unit (ICU) stay to identify prognostic factors of unfavorable neurological outcomes (UO) in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: We retrospectively reviewed all patients who were consecutively hospitalized with SAH between 2009 and 2016. Arterial blood lactate levels were routinely obtained on admission and every 6h in the ICU. Univariate/multivariate analyses were performed to identify independent predictors of UO (modified Rankin scale of 3-6 upon hospital discharge). RESULTS: There were 145 patients with 46% of UO. Initially, increased lactate levels reached maximum levels during the first 24h and then decreased to within the normal range. Then, the levels slightly increased again to within the normal range for the next 24h, especially in UO. On multiple regression analysis, lactate levels measured at 24h, and 48h after admission were strong predictors of UO. Lactate level measured at 48h after admission demonstrated the greatest accuracy and the highest specificity (area under the curve, 0.716; sensitivity, 40%; specificity, 92.1%). CONCLUSIONS: The lactate level at 48h after admission was the most accurate predictor of UO with a high specificity in SAH patients.