Acute phase after aneurysmal subarachnoid hemorrhage (aSAH) is associated with several metabolic derangements including stress-induced hyperglycemia (SIH). The present study is designed to identify objective radiological determinants for SIH to better understand its contributory role in clinical outcomes after aSAH. A computer-aided detection tool was used to segment admission computed tomography (CT) images of aSAH patients to estimate intracranial blood and cerebrospinal fluid volumes. Modified Graeb score (mGS) was used as a semi-quantitative measure to estimate degree of hydrocephalus. The relationship between glycemic gap (GG) determined SIH, mGS, and estimated intracranial blood and cerebrospinal fluid volumes were evaluated using linear regression. Ninety-four [94/187 (50.3%)] among the study cohort had SIH (defined as GG > 26.7 mg/dl). Patients with SIH had 14.3 ml/1000 ml more intracranial blood volume as compared to those without SIH [39.6 ml (95% confidence interval, CI, 33.6 to 45.5) vs. 25.3 ml (95% CI 20.6 to 29.9), p = 0.0002]. Linear regression analysis of mGS with GG showed each unit increase in mGS resulted in 1.2 mg/dl increase in GG [p = 0.002]. Patients with SIH had higher mGS [median 4.0, interquartile range, IQR 2.0-7.0] as compared to those without SIH [median 2.0, IQR 0.0-6.0], p = 0.002. Patients with third ventricular blood on admission CT scan were more likely to develop SIH [67/118 (56.8%) vs. 27/69 (39.1%), p = 0.023]. Hence, the present study, using unbiased SIH definition and objective CT scan parameters, reports "dose-dependent" radiological features resulting in SIH. Such findings allude to a brain injury-stress response-neuroendocrine axis in etiopathogenesis of SIH.

Introduction: Post-hemorrhagic hydrocephalus is a frequent complication after aneurysmal subarachnoid hemorrhage (aSAH) that can result in homeostatic derangement including stress induced hyperglycemia (SIH). Modified Graeb score (MGS) is a semi-quantitative scoring system that can estimate extent of hydrocephalus and amount of intraventricular blood. Hypothesis: We assessed whether MGS can predict SIH after aSAH. Methods: On the basis of our previous research with this same cohort, SIH was defined as a ratio of admission serum glucose (AG) to glycated hemoglobin, HbA1c (AG:HbA1c) of 26 or higher. This retrospective study reviewed charts of aSAH patients admitted to a tertiary care hospital. MGS was calculated retrospectively using admission computed tomography (CT) scans. Exploratory loess regression was used to characterize the association between MGS and SIH. Non-parametric tests were used to investigate difference in MGS between those with and without SIH. Fisher’s exact tests assessed differences in prevalence of SIH between patient groups. Results: Average age of cohort was 52.3±13.1 years with 65% women. SIH was observed in 72/165 (43.6%) patients. One hundred and eight of the 165 patients (65.5%) were modified Fisher grade 3-4 on admission CT scans. Fifty-five patients (50.9%) with modified Fisher grade 3-4 developed SIH as compared to 17 (29.8%) of patients with modified Fisher grade 1-2 (p=0.013). Locally weighted or LOESS regression showed a positive relationship between the AG:HbA1c ratio at MGS up to about 12. MGS threshold of ≥10 predicted SIH with 88.2% specificity. Although median MGS was higher in patients developing SIH (4; interquartile range or IQR 5.5) as compared to those without SIH (2; IQR 6.0), the difference did not reach statistical significance (p=0.079). Conclusion: Higher MGS, indicative of more severe obstructive hydrocephalus, is associated with increased incidence of SIH. This alludes to contribution of hydrocephalus in neurohumoral derangement and associated dysglycemia after aSAH.

Here we present the case of a 36-year-old man who was found to have a symptomatic malignant neural sheath tumor growing from the C2 nerve root following a period of progressively worsening headaches. The patient was successfully treated with surgical resection resulting in resolution of cranial nerve deficits. Though uncommon, malignant peripheral nerve sheath tumor must be considered in the differential diagnosis of tumors involving the cervical nerve roots and carotid space.