Introduction Precision medicine is an emerging paradigm aimed at providing individualized prevention and treatment of diseases through understanding and leveraging patient-to-patient variation. Aneurysmal subarachnoid hemorrhage (aSAH) carries tremendous morbidity and mortality with subsequent cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) proving devastating and unpredictable. The paucity of effective treatment or prevention measures for these conditions could potentially be improved through implementation of precision medicine. Areas covered This review presents the basic pathophysiology of CV and DCI, current treatment guidelines, and evidence for the use of precision medicine in the prediction and prevention of poor outcomes following aSAH. An extensive PubMed literature search was performed using keywords cerebral vasospasm or delayed cerebral ischemia and either biomarkers, precision medicine, metabolomics, proteomics, or genomics. Over 200 peer-reviewed articles were reviewed. The studies presented focus on biomarkers identified as predictive markers or therapeutic targets following aSAH. Expert Commentary The array of novel biomarkers reviewed here, ranging from genotypes to metabolites, has been found to correlate with CV, DCI, and neurologic outcomes after aSAH. Though their practical use in the clinical management of aSAH is not well established, using these biomarkers as predictive tools or therapeutic targets demonstrates the potential of precision medicine in the treatment of aSAH.

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Introduction: Intraarterial therapy (IAT) is the standard of care for all AIS patients, even those with active cancer. However, there is little information on the characteristics that may contribute to a functional 90-day modified Rankin scale (mRS 0-2) score for AIS patients with active cancer undergoing IAT. Methods: This retrospective study included patients (age ≥ 18) admitted from 07/18-10/20 with AIS and were treated by IAT. AIS patients with large artery occlusion who had active cancer were identified. Baseline characteristics and outcomes were evaluated to determine predictors of a functional outcome at 90 days. Outcomes were also compared to those without active cancer during the same period. The receiver operating characteristic area under the curve (AUC) was used to determine optimal admission national institutes of health scores (NIHSS) to obtain a 90-day mRS of 0-2. Results: Of the 453 patients who received IAT, 12% had active cancer. Overall, patients were a majority male (50%), a median of 70 (60-81) years of age and had an admission NIHSS of 14 (7-20). Compared to patients without cancer, patients with cancer experienced significantly more thromboembolic events during their hospital stay (40% vs. 11%, p<0.001), but functional outcomes at 90-days were not different between groups. In active cancer patients, an admission NIHSS cut-off of 8.2 (AUC:0.72 (confidence interval (CI): 0.58-0.86), p=0.001) indicating strong fit, and experiencing less thromboembolic events, were significantly associated with functional independency at 90 days. However, the admission NIHSS cut-off for patients without cancer for predicting a functional outcome was 10.5 (AUC: 0.66 (CI: 0.60-.71), p<0.001), indicating moderate fit. Receiving intravenous tissue type plasminogen activator (IV-tPA) and successful reperfusion were other significant predictors of a functional outcome for non-cancer patients. Conclusions: In our population, using an NIHSS cut-off of 8.2 for patients with active cancer in determining who should receive IAT may increase the probability of a favorable 90-day outcome. An admission NIHSS of 10.5 was moderately associated with functional outcome at 90 days, in addition to successful reperfusion and receiving IV-tPA in non-cancer patients.