Large practice variations in diagnosis and treatment of delayed cerebral ischemia after subarachnoid hemorrhage

Tjerkstra, Maud A.; Verbaan, Dagmar; Coert, Bert A.; Post, René; Berg, René van den; Coutinho, Jonathan M.; Horn, Janneke; Vandertop, W. Peter

doi:10.1016/j.wneu.2022.01.033

Cited by 9 publications

(14 citation statements)

References 25 publications

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“…In the past decades, evidence has shown that cerebral vasospasm and DCI should be considered as two separate entities. The heterogeneity in the definition of DCI has allowed for many variations of its diagnostic and therapeutic regimen [ 20 ]. These contributing factors explain the missing predictability of our visual classification for patient outcomes.…”

Section: Discussionmentioning

confidence: 99%

Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography

Merkel

Lindner

Gaber

et al. 2022

JCM

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Background: During the last decade, cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) was a current research focus without a standardized classification in digital subtraction angiography (DSA). This study was performed to investigate a device-independent visual cerebral vasospasm classification for endovascular treatment. Methods: The analyses are DSA based rather than multimodal. Ten defined points of intracranial arteries were measured in 45 patients suffering from cerebral vasospasm after SAH at three time points (hospitalization, before spasmolysis, control after six months). Mathematical clustering of vessel diameters was performed to generate four objective grades for comparison. Six interventional neuroradiologists in two groups scored 237 DSAs after a new visual classification (grade 0–3) developed on a segmental pattern of vessel contraction. For the second group, a threshold-based criterion was amended. Results: The raters had a reproducibility of 68.4% in the first group and 75.2% in the second group. The complementary threshold-based criterion increased the reproducibility by about 6.8%, while the rating deviated more from the mathematical clustering in all grades. Conclusions: The proposed visual classification scheme of cerebral vasospasm is suitable as a standard grading procedure for endovascular treatment. There is no advantage of a threshold-based criterion that compensates for the effort involved. Automated vessel analysis is superior to compare inter-group results in research settings.

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Section: Discussionmentioning

confidence: 99%

Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography

Merkel

Lindner

Gaber

et al. 2022

JCM

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show abstract

“…Our data are retrospectively gathered from electronic files and images. In the last decade, neurosurgeons, intensivists, and neuroradiologists focused on cerebral vasospasm defined by angiography and TCD ( 4 ). Now-a-days, DCI is the recommended term to describe the post-SAH delayed clinical deterioration after other potential identifiable causes have been ruled out.…”

Section: Discussionmentioning

confidence: 99%

“…Instead, this study was focused on comparing imaging findings. Tjerkstra et al ( 4 ) showed in their nationwide, web-based survey that large variations remain in the definition, diagnosis, and treatment of DCI among intensivists, neurologists, and neurosurgeons. Many physicians still rely on angiography or TCD.…”

Section: Discussionmentioning

confidence: 99%

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Nimodipine vs. Milrinone – Equal or Complementary Use? A Retrospective Analysis

et al. 2022

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BackgroundCerebral vasospasm (CVS) continues to account for high morbidity and mortality in patients surviving the initial aneurysmal subarachnoid hemorrhage (SAH). Nimodipine is the only drug known to reduce delayed cerebral ischemia (DCI), but it is believed not to affect large vessel CVS. Milrinone has emerged as a promising option. Our retrospective study focused on the effectiveness of the intra-arterial application of both drugs in monotherapy and combined therapy.MethodsWe searched for patients with aneurysmal SAH, angiographically confirmed CVS, and at least one intra-arterial pharmacological angioplasty. Ten defined vessel sections on angiograms were assessed before and after vasodilator infusion. The improvement in vessel diameters was compared to the frequency of DCI-related cerebral infarction before hospital discharge and functional outcome reported as the modified Rankin Scale (mRS) score after 6 months.ResultsBetween 2014 and 2021, 132 intra-arterial interventions (144 vascular territories, 12 bilaterally) in 30 patients were analyzed for this study. The vasodilating effect of nimodipine was superior to milrinone in all intradural segments. There was no significant intergroup difference concerning outcome in mRS (p = 0.217). Only nimodipine or the combined approach could prevent DCI-related infarction (both 57.1%), not milrinone alone (87.5%). Both drugs induced a doubled vasopressor demand due to blood pressure decrease, but milrinone alone induced tachycardia.ConclusionsThe monotherapy with intra-arterial nimodipine was superior to milrinone. Nimodipine and milrinone may be used complementary in an escalation scheme with the administration of nimodipine first, complemented by milrinone in cases of severe CVS. Milrinone monotherapy is not recommended.

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“…The STA sign indicates self-sufficient older patients at risk for unfavorable outcome who may benefit from intensified care and monitoring after SAH. Patients suffering from severe SAH are frequently in a poor neurological condition, and the diagnosis of DCI, according to Vergouwen et al [ 22 ], is often challenging, with a broad inter-rater variance [ 23 ]. Here, the STA sign might be helpful diagnostic tool.…”

Section: Discussionmentioning

confidence: 99%

The Supratrochlear Artery Sign—A New Piece in the Puzzle of Cerebral Vasospasm

et al. 2022

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Background: Cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) has been extensively investigated, but the impact of collateralization remains unclear. We investigated the predictive value of collateral activation for delayed cerebral ischemia (DCI)-related infarctions and functional outcome. Methods: Data from 43 patients with CVS (January 2014 to August 2021) were evaluated for the angiographic presence of leptomeningeal and ophthalmic collaterals (anterior falcine artery (AFA), supratrochlear artery (STA), dorsal nasal artery (DNA)) on internal carotid artery angiograms. Vasospasm-related infarction and the modified Rankin Scale (mRS) score after six months were chosen as the endpoints. Results: 77% of the patients suffered from DCI-related infarctions. In 233 angiograms (at hospitalization, before spasmolysis, after six months), positive vessel signs were observed in 31 patients for STA, 35 for DNA, and 31 for AFA. The STA sign had the highest positive (84.6%) and negative (85.7%) predictive value for unfavorable outcome (mRS 4–6) in patients aged ≥50 years. DNA and AFA signs were not meaningful predictors for either endpoint. Leptomeningeal collaterals showed a positive Pearson’s correlation with the STA sign in 87.5% (p = 0.038) without providing any prediction for either endpoint. Conclusions: The STA sign is associated with clinical outcome in patients with CVS after SAH aged ≥50 years, and was correlated with the occurrence of leptomeningeal collaterals.

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Large practice variations in diagnosis and treatment of delayed cerebral ischemia after subarachnoid hemorrhage

Cited by 9 publications

References 25 publications

Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography

Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography

Nimodipine vs. Milrinone – Equal or Complementary Use? A Retrospective Analysis

The Supratrochlear Artery Sign—A New Piece in the Puzzle of Cerebral Vasospasm

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