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Clinical Updates and Perspectives on Subarachnoid Hemorrhage
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Clinical Updates and Perspectives on Subarachnoid Hemorrhage

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: 20 September 2025 | Viewed by 1740

Special Issue Editor

Dr. Fusao Ikawa

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Guest Editor
Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
Interests: subarachnoid hemorrhage; outcome of subarachnoid hemorrhage; delayed cerebral ischemia, ruptured cerebral aneurysm; unruptured cerebral aneurysm; artificial intelligence
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Subarachnoid hemorrhage (SAH) is a severe condition with a mortality rate of approximately 35%. However, unlike ischemic stroke, the treatment outcomes for SAH have not significantly improved. The management of post-SAH brain injury and delayed cerebral ischemia (DCI) remains inadequate. The prognosis of SAH is influenced not only by the neurological severity at onset and surgical outcomes but also by the occurrence of delayed cerebral ischemia. Therefore, improving the treatment of DCI is crucial for enhancing the prognosis of SAH.

The etiology of DCI following SAH involves not only cerebral vasospasm but also primary brain injury, increased intracranial pressure, microcirculatory disturbances, microthrombosis, blood–brain barrier disruption, and cortical spreading ischemia. Therefore, a comprehensive prevention and treatment strategy is essential.

Japan has a higher incidence of SAH compared to the global average, suggesting that preventive measures against SAH in Japan may be insufficient. Risk factors for SAH include hypertension, smoking, alcohol abuse, and the use of certain drugs. Factors more prevalent among the Japanese population include genetics, aging, high smoking rates, and a higher detection rate of SAH, though these are not definitively identified.

This Special Issue calls for original research utilizing novel data to address the aforementioned issues.

Dr. Fusao Ikawa
Guest Editor

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Keywords

  • subarachnoid hemorrhage
  • outcome of subarachnoid hemorrhage
  • delayed cerebral ischemia,
  • ruptured cerebral aneurysm
  • unruptured cerebral aneurysm
  • artificial intelligence
  • epidemiology

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Published Papers (3 papers)

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Research

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12 pages, 696 KiB  
Article
Impact of Delayed Admission on Treatment Modality and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Prefecture-Wide, Multicenter Japanese Study
by Yuma Hosokawa, Hitoshi Fukuda, Yuki Hyohdoh, Takako Kawamura, Ken Shinno, Yongran Yanase, Masaki Yokodani, Yu Hoashi, Akihito Moriki, Koji Bando, Nobuhisa Matsushita, Fumihiro Hamada, Yu Kawanishi, Yusuke Ueba, Naoki Fukui, Noritaka Masahira, Yo Nishimoto and Tetsuya Ueba
J. Clin. Med. 2025, 14(10), 3537; https://doi.org/10.3390/jcm14103537 - 18 May 2025
Viewed by 245
Abstract
Background/Objectives: Aneurysmal subarachnoid hemorrhage (SAH) requires prompt treatment, yet hospital admission is occasionally delayed, and the optimal treatment strategy for such patients remains to be established. We aimed to investigate treatment modality, treatment timing, and outcomes in patients with SAH with respect [...] Read more.
Background/Objectives: Aneurysmal subarachnoid hemorrhage (SAH) requires prompt treatment, yet hospital admission is occasionally delayed, and the optimal treatment strategy for such patients remains to be established. We aimed to investigate treatment modality, treatment timing, and outcomes in patients with SAH with respect to early versus delayed admission. Methods: A total of 1080 patients with SAH and a defined onset date were included in this prefecture-wide, multicenter, registry-based study. Baseline characteristics, late SAH complications (including vasospasm), and functional outcomes were compared between early and delayed admission groups at Day 4 or later (Day 0 = SAH onset). Additionally, the association of treatment choice (endovascular therapy or direct surgery) with treatment timing was analyzed in the delayed admission group. Results: Delayed admission was observed in 69 (6.4%) patients. The neurological status upon admission was significantly better in the delayed admission group, with more World Federation of Neurological Societies grades I–II (89.8% vs. 56.2% in the early admission group). Delayed admission was significantly associated with an increased incidence of symptomatic vasospasm by multivariable logistic regression analysis (odds ratio 2.51: 95% confidence interval 1.26–5.00, p = 0.009), while a significant difference in poor functional outcomes (modified Rankin scale 3–6) was not revealed. Although endovascular therapy use did not increase in the delayed admission group, the interval from admission to endovascular therapy was significantly shorter than that in the direct surgery group (0 [0–1] days vs. 1 [1–8] days: median [interquartile range], p = 0.007, Mann–Whitney U test). Conclusions: Delayed admission was a risk factor for symptomatic vasospasm; however, functional outcomes were not exacerbated. These results were obtained under the treatment strategy of multiple institutions, where the timing of endovascular therapy was earlier than that of direct surgery in patients with delayed admission. Full article
(This article belongs to the Special Issue Clinical Updates and Perspectives on Subarachnoid Hemorrhage)
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16 pages, 478 KiB  
Article
Spinal Drainage and Combined Pharmacotherapy as Potential Strategies to Improve Outcomes for Patients with Poor-Grade Subarachnoid Hemorrhage Treated with Clipping or Coiling but Not Receiving Nimodipine
by Koichi Hakozaki, Fumihiro Kawakita, Kazuaki Aoki, Hidenori Suzuki and pSEED Group
J. Clin. Med. 2025, 14(8), 2715; https://doi.org/10.3390/jcm14082715 - 15 Apr 2025
Viewed by 356
Abstract
Background/Objectives: The outcome for aneurysmal subarachnoid hemorrhage (SAH) remains poor, particularly for patients presenting with World Federation of Neurological Surgeons (WFNS) grades IV–V. This study was designed to identify independent prognostic factors in this group of patients with poor-grade SAH. Methods: [...] Read more.
Background/Objectives: The outcome for aneurysmal subarachnoid hemorrhage (SAH) remains poor, particularly for patients presenting with World Federation of Neurological Surgeons (WFNS) grades IV–V. This study was designed to identify independent prognostic factors in this group of patients with poor-grade SAH. Methods: We prospectively analyzed 357 SAH patients with admission WFNS grades IV–V enrolled in nine primary stroke centers in Mie prefecture, Japan, from 2013 to 2022. This study compared clinical variables, including treatments for angiographic vasospasm and delayed cerebral ischemia (DCI), between patients with favorable (modified Rankin Scale [mRS] scores 0–2) and unfavorable (mRS scores 3–6) outcomes at 90 days post-onset. Multivariate analyses were then performed to identify independent determinants of favorable 90-day outcomes, followed by propensity score matching analyses. Results: The median age was 68 years, and 53.5% of patients had admission WFNS grade V. DCI occurred in 12.9% of patients, and 66.9% had unfavorable outcomes. Independent variables related to unfavorable outcomes were older age, admission WFNS grade V, ventricular drainage, edaravone administration, and delayed cerebral infarction, while those for favorable outcomes were spinal drainage (adjusted odds ratio [aOR] 6.118, 95% confidence interval [CI] 2.687–13.927, p < 0.001), modified Fisher grade 3 (aOR 2.929, 95% CI 1.668–5.143, p < 0.001), and triple prophylactic anti-DCI medication consisting of cilostazol, fasudil hydrochloride and eicosapentaenoic acid (aOR 1.869, 95% CI 1.065–3.279, p = 0.029). Nimodipine is not approved in Japan, and statin and cerebral vasospasm did not influence outcomes. As spinal drainage and the triple prophylactic anti-DCI medication were intervenable variables, propensity score matchings were performed, and they confirmed that both spinal drainage and the triple prophylactic anti-DCI medication were useful to achieve favorable outcomes. Conclusions: In poor-grade SAH, spinal drainage and the triple prophylactic anti-DCI medication may be effective in improving outcomes, possibly by suppressing DCI pathologies other than cerebral vasospasm. Full article
(This article belongs to the Special Issue Clinical Updates and Perspectives on Subarachnoid Hemorrhage)
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Review

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14 pages, 533 KiB  
Review
Emerging Advances in the Management of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Narrative Review
by Shinsuke Muraoka, Takashi Izumi, Masahiro Nishihori, Shunsaku Goto, Issei Takeuchi and Ryuta Saito
J. Clin. Med. 2025, 14(10), 3403; https://doi.org/10.3390/jcm14103403 - 13 May 2025
Viewed by 602
Abstract
Background/Objectives: Aneurysmal subarachnoid hemorrhage (aSAH) remains a life-threatening cerebrovascular event with high rates of mortality and long-term morbidity. Among its complications, delayed cerebral ischemia (DCI) is a major contributor to poor clinical outcomes. Although cerebral vasospasm has traditionally been considered the primary mechanism [...] Read more.
Background/Objectives: Aneurysmal subarachnoid hemorrhage (aSAH) remains a life-threatening cerebrovascular event with high rates of mortality and long-term morbidity. Among its complications, delayed cerebral ischemia (DCI) is a major contributor to poor clinical outcomes. Although cerebral vasospasm has traditionally been considered the primary mechanism underlying DCI, recent studies have revealed the multifactorial nature of this condition. This review aims to provide a comprehensive overview of the pathophysiology, preventive strategies, and current treatment options for DCI following aSAH. Methods: A narrative literature review was conducted using the PubMed database to identify peer-reviewed articles relevant to the prevention and treatment of DCI following aSAH. The search strategy employed the following terms: (“Subarachnoid Hemorrhage” [MeSH]) AND “Delayed Cerebral Ischemia” AND (“Prevention and Control” [Subheading] OR “Secondary Prevention” [MeSH]). This search strategy was designed to capture studies addressing both pharmacological and non-pharmacological preventive measures for DCI. Results: A comprehensive PubMed search identified a total of 113 relevant articles. Among these, 40 publications primarily addressed pharmacological interventions, while 22 focused on neuromonitoring techniques. An additional 20 articles explored the pathophysiological mechanisms underlying DCI, and 15 involved preclinical studies utilizing animal models. The remaining 16 articles encompassed diverse topics, including prophylactic endovascular therapies, newly proposed definitions of DCI, treatment algorithm development, functional outcome analyses, and entries in clinical trial registries. Emerging evidence highlights that vasospasm alone does not account for all cases of DCI. Pharmacological approaches such as nimodipine, clazosentan, and fasudil have shown varying degrees of efficacy. Circulatory management and removal of subarachnoid hematoma via CSF drainage or thrombolytics may reduce DCI risk, although their impact on long-term neurological outcomes remains controversial. Endovascular therapy and adjunctive agents such as cilostazol or anticoagulants have demonstrated potential but require further validation through large-scale trials. Conclusions: Effective DCI prevention and treatment require a multimodal approach targeting diverse pathological mechanisms beyond vasospasm. Improved risk stratification, early detection, and individualized therapy are essential for advancing the management of patients with aSAH. Full article
(This article belongs to the Special Issue Clinical Updates and Perspectives on Subarachnoid Hemorrhage)
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