Search Results (12)

Background: The Glasgow Coma Scale (GCS) is a cornerstone in neurological assessment, providing critical insights into consciousness levels in patients with traumatic brain injuries and other neurological conditions. Despite its clinical importance, traditional methods for predicting GCS scores often fail to capture the complex, multi-dimensional nature of patient data. This study aims to address this gap by leveraging machine learning (ML) techniques to develop accurate, interpretable models for GCS prediction, enhancing decision making in critical care. Methods: A comprehensive dataset of 759 patients, encompassing 25 features spanning pre-, intra-, and post-operative stages, was used to develop predictive models. The dataset included key variables such as cognitive impairments, Hunt and Hess scores, and aneurysm dimensions. Six ML algorithms, including random forest (RF), XGBoost, and artificial neural networks (ANN), were trained and rigorously evaluated. Data preprocessing involved numerical encoding, standardization, and stratified splitting into training and validation subsets. Model performance was assessed using accuracy and receiver operating characteristic area under the curve (ROC AUC) metrics. Results: The RF model achieved the highest accuracy (86.4%) and mean ROC AUC (0.9592 ± 0.0386, standard deviation), highlighting its robustness and reliability in handling heterogeneous clinical datasets. XGBoost and SVM models also demonstrated strong performance (ROC AUC = 0.9502 and 0.9462, respectively). Key predictors identified included the Hunt and Hess score, aneurysm dimensions, and post-operative factors such as prolonged intubation. Ensemble methods outperformed simpler models, such as K-nearest neighbors (KNN), which struggled with high-dimensional data. Conclusions: This study demonstrates the transformative potential of ML in GCS prediction, offering accurate and interpretable tools that go beyond traditional methods. By integrating advanced algorithms with clinically relevant features, this work provides a dynamic, data-driven framework for critical care decision making. The findings lay the groundwork for future advancements, including multi-modal data integration and broader validation, positioning ML as a vital tool in personalized neurological care. Full article

Background and Objectives: The anterior communicating artery is a common location for intracranial aneurysms. Anterior communicating artery aneurysms (AcomA) pose a significant risk of rupture. Treatment options include microsurgical clipping and endovascular techniques, but the optimal approach remains controversial. This study aims to compare the outcomes of these two treatment modalities in a single-center patient cohort using a comprehensive matching process based on clinical and morphological parameters. Materials and Methods: A retrospective analysis was conducted on 1026 patients with 1496 intracranial aneurysms treated between 2000 and 2018. After excluding cases lacking 3D angiography or aneurysms in other locations or without treatment, 140 AcomA were selected. The study matched 24 surgically treated AcomA cases with 116 endovascularly treated cases based on 21 morphological and clinical criteria, including age, sex, Hunt and Hess score, and Fisher grade. Results: The microsurgical clipping group demonstrated a significantly higher rate of complete aneurysm occlusion compared to the endovascular group (p = 0.007). However, this was associated with a higher incidence of postoperative ischemic complications in the surgical group (13 out of 24 cases) compared to the endovascular group (2 out of 116 cases). Despite these complications, no significant differences were found in clinical outcomes at discharge or follow-up, as measured by the modified Rankin Scale (p > 0.999). Both groups had comparable rates of hydrocephalus, vasospasm, and delayed cerebral ischemia. Conclusions: Microsurgical clipping resulted in higher aneurysm occlusion rates but carried an increased risk of ischemic complications compared to endovascular treatment. Clinical outcomes were comparable between the two modalities, suggesting that treatment decisions should be individualized based on aneurysm characteristics and patient factors. Further prospective studies are warranted to optimize treatment strategies for AcomA. Full article

Background: Spontaneous subarachnoid haemorrhage (SAH) represents a significant cerebrovascular disease with considerable morbidity and mortality. The aim of this study was to determine the demographic/clinical characteristics of spontaneous SAH patients admitted in the intensive care unit (ICU) and factors affecting the mortality. Methods: This study was designed as a retrospective cohort study that included patients with a diagnosis of spontaneous SAH hospitalized in the ICU. The clinical and radiological parameters were compared between mortality and survival cohorts. Univariate logistic regression analyses were performed for the effect profiles of the parameters on mortality. Results: ICU mortality was 41% in patients with spontaneous SAH. A number of factors have been identified as being independently associated with mortality in the studied cohort. These factors are hospital admission with loss of consciousness (Glasgow Coma Scale score <8), a high Clinical Comorbidity Index score, stage >2 according to the Hunt and Hess grading system and complication status (meningitis and sepsis/septic shock). Conclusions: Spontaneous SAH is a condition associated with a high mortality in severe cases. Patients exhibiting these risk factors require meticulous monitoring in the ICU. Full article

Spontaneous non-aneurysmal subarachnoid haemorrhage (NAPMSAH) (addressing point 1) is a relatively rare occurrence in clinical settings as it is rarely misdiagnosed and usually involves a significantly better prognosis than the classical aneurysmal pattern. We hereby focused on a comprehensive analysis of this distinct pathological entity with the purpose of analysing possible pathophysiological entities, outcomes and treatment options involving this diagnosis with a focus on demographical, epidemiological and clinical data. The clinical setting includes focal neurological signs related to the anatomical structures, while computer tomography followed by tomographic angiography are the most common diagnosis tools, with a typical hyperdense lesion involving the midbrain, fourth ventricle and subthalamic areas without an angiographic correspondent, such as an aneurysmal pathology. Further investigations can also be used to highlight this diagnosis, such as interventional angiography or magnetic resonance imaging. Given the rarity of this condition and its relatively better prognosis, treatment options usually remain conservative. In the present review, the main characteristics of NAPMSAH are discussed. Full article

Objective: To report the preliminary safety, tolerability, and cerebral spinal fluid (CSF) sampling utility of serial injections of concentrated intraventricular nicardipine (IVN) in the treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: We report the clinical, radiographic, and laboratory safety and tolerability data of a retrospective case series from a single academic medical center. All patients with aSAH developed vasospasm despite enteral nimodipine and received serial injections of concentrated IVN (2.5 mg/mL). CSF injection safety, tolerability, and utility are defined and reported. Results: A total of 59 doses of concentrated IVN were administered to three patients with poor-grade SAH. In Case 1, a 33-year-old man with modified Fisher scale (mFS) grade 4 and Hunt-Hess scale (HH) score 4 received 26 doses; in Case 2, a 36-year-old woman with mFS grade 4 and HH score 5 received 13 doses; and in Case 3, a 70-year-old woman with mFS grade 3 and HH score 4 received 20 doses. No major safety or tolerability events occurred. Two patients were discharged to a rehabilitation facility, and one died after discharge from the hospital. Conclusions: A concentrated 4 mg IVN dose (2.5 mg/mL) in a 1.6 mL injection appears relatively safe and tolerable and potentially offers a second-line strategy for treating refractory vasospasm in poor-grade SAH without compromising intracranial pressure or cerebral perfusion pressure. Full article

(1) Background: CC chemokine ligand 23 (CCL23) is a chemokine implicated in the inflammatory response following brain damage. The aim of this study is to identify the change in serum CCL23 levels within 24 h after aSAH and whether serum CCL23 levels are associated with initial clinical severity, delayed cerebral ischemia (DCI), and functional outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). (2) Methods: 102 patients with aSAH and 61 controls were included in this prospective observational study. All clinical data were collected prospectively, and their serum CCL23 levels were measured. Initial clinical severity was reflected by the Hunt–Hess score and mFisher score. Functional outcome was evaluated in terms of the Glasgow Outcome Scale (GOS) score at 6-month follow-up. (3) Results: Patients with aSAH had higher serum CCL23 levels than controls. The temporal profile of serum CCL23 levels and neutrophils count exhibited a sustained increase within 24 h after aSAH. Serum CCL23 levels were related to blood neutrophils count, blood CRP levels, and initial clinical severity. Serum CCL23 level was an independent predictor of DCI and 6-month poor outcome in aSAH patients. (4) Conclusions: Serum CCL23 levels emerged as an independent predictor for DCI and poor outcome in patients with aSAH. Full article

In the last 20 years, substantial improvements have been made in stroke recanalization treatment. Good outcomes after modern reperfusion treatment require the rapid and accurate identification of stroke patients. Several stroke rating scales are available or have been proposed for the early recognition of stroke and the evaluation of stroke severity and outcome. This review aims to provide an overview of commonly used stroke scales in emergency and clinical settings. The most commonly used scale in a prehospital setting for stroke recognition is the Face, Arms, Speech, Time (FAST) test. Among many prehospital stroke scales, the Los Angeles Prehospital Stroke Screen has the highest sensitivity and specificity for confirming stroke diagnosis. The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for the evaluation of stroke patients in hospital settings and research, and it has two variants: the shortened NIHSS for Emergency Medical Service and the modified NIHSS. The evaluation of comatose patients usually involves assessment with the Glasgow Coma Scale, which is very useful in patients with hemorrhagic stroke or traumatic brain injury. In patients with subarachnoid hemorrhage, the outcome is usually accessed with the Hunt and Hess scale. A commonly used tool for stroke outcome evaluation in clinical/hospital settings and research is the modified Rankin scale. The tools for disability evaluation are the Barthel Index and Functional Independence Measure. Full article

Aneurysmal subarachnoid haemorrhages (aSAH) account for 5% of strokes and continues to place a great burden on patients and their families. Cerebral vasospasm (CVS) is one of the main causes of death after aSAH, and is usually diagnosed between day 3 and 14 after bleeding. Its pathogenesis remains poorly understood. To verify whether plasma concentration of amino acids have prognostic value in predicting CVS, we analysed data from 35 patients after aSAH (median age 55 years, IQR 39–62; 20 females, 57.1%), and 37 healthy volunteers (median age 50 years, IQR 38–56; 19 females, 51.4%). Fasting peripheral blood samples were collected on postoperative day one and seven. High performance liquid chromatography-mass spectrometry (HPLC-MS) analysis was performed. The results showed that plasma from patients after aSAH featured a distinctive amino acids concentration which was presented in both principal component analysis and direct comparison. No significant differences were noted between postoperative day one and seven. A total of 18 patients from the study group (51.4%) developed CVS. Hydroxyproline (AUC = 0.7042, 95%CI 0.5259–0.8826, p = 0.0248) and phenylalanine (AUC = 0.6944, 95%CI 0.5119–0.877, p = 0.0368) presented significant CVS prediction potential. Combining the Hunt-Hess Scale and plasma levels of hydroxyproline and phenylalanine provided the model with the best predictive performance and the lowest leave-one-out cross-validation of performance error. Our results suggest that plasma amino acids may improve sensitivity and specificity of Hunt-Hess scale in predicting CVS. Full article

Objective: Evoked potentials are widely used in comatose patients to evaluate neurological function; however, prognostic relevance in patients after SAH is barely investigated. Therefore, we aimed to investigate the prognostic value of the proposed Evoked Potential Score (EPS) for somatosensory (SSEP) and brainstem auditory evoked potentials (BAEP) on the neurological outcome in patients after poor-grade SAH. Methods: We retrospectively analyzed patients after poor grade SAH (Hunt and Hess (HH) grade IV and V) that were admitted to the ICU at the Department of Neurosurgery, MUV, between 2014 and 2017. Measurements of SSEP and BAEP were evaluated separately as well as in a combined model, using the EPS at admission and before ventilator weaning and correlated with the grade of the modified ranking scale at the last available follow up. Results: In total, 48 patients after SAH HH IV/V were included in this study. The EPS for SSEP at admission (p = 0.007) and both the EPS for SSEP (p = <0.0001) and BAEP (p = 0.036) before ventilator weaning were significant prognostic markers for neurological improvement at a mean follow-up period of 14.1 months. In addition, the combined model of the EPS for SSEP/BAEP performed as a prognostic marker for neurological improvement (“at admission” p = 0.007; “before ventilator weaning” p < 0.001). Conclusions: In the first series to date we found a high prognostic significance for the EPS as a combined model, as well as a separate analysis for SSEP and BAEP in patients after SAH IV and V. In the future, these findings potentially support physicians in ethically challenging decision-making processes and in advice for patients’ families under consideration of an individual evaluation of each patient. Full article

Background: Subarachnoid hemorrhage (SAH) is a devastating disease with high morbidity and mortality. Hypoxia-induced changes and hemoglobin accumulation within the subarachnoid space are thought to lead to oxidative stress, early brain injury, and delayed vasospasm. This study aimed to evaluate the antioxidant status and its impact on neurological outcome in patients with aneurysmal SAH. Methods: In this prospective observational study, 29 patients with aneurysmal SAH were included (mean age 54.7 ± 12.4). Blood and cerebrospinal fluid (CSF) samples were collected on days (d) 1, 3, and 7. In addition, 29 patients without intracranial hemorrhage served as controls. The antioxidant system was analyzed by glutathione peroxidase (GSH-Px; U/L) and total and free glutathione-sulfhydryl (GSH; mg/L) in the plasma. Superoxide dismutase (SOD, U/mL) and total antioxidant capacity (TAC, µmol/L) were measured in the serum and CSF. Clinical data were compiled on admission (Hunt and Hess grade, Fisher grade, and GCS). Neurological and cognitive outcome (modified Rankin scale (mRS), Glasgow Outcome Scale Extended (GOSE) and Montreal Cognitive Assessment (MoCA)) was assessed after 6 weeks (6 w) and 6 months (6 m). Results: Plasma levels of SOD increased from day 1 to 7 after SAH (d1: 1.22 ± 0.36 U/L; d3: 1.25 ± 0.33 U/L, p = 0.99; d7: 1.52 ± 0.4 U/L, p = 0.019) and were significantly higher compared to controls (1.11 ± 0.27 U/L) at day 7 (p < 0.001). Concordantly, CSF levels of SOD increased from day 1 to 7 after SAH (d1: 1.22 ± 0.41 U/L; d3: 1.77 ± 0.73 U/L, p = 0.10; d7: 2.37 ± 1.29 U/L, p < 0.0001) without becoming significantly different compared to controls (1.74 ± 0.8 U/L, p = 0.09). Mean plasma TAC at day 1 (d1: 77.87 ± 49.72 µmol/L) was not statistically different compared to controls (46.74 ± 32.42 µmol/L, p = 0.25). TAC remained unchanged from day 1 to 7 (d3: 92.64 ± 68.58 µmol/L, p = 0.86; d7: 74.07 ± 54.95 µmol/L, p = 0.8) in plasma. TAC in CSF steeply declined from day 1 to 7 in patients with SAH becoming significantly different from controls at days 3 and 7 (d3: 177.3 ± 108.7 µmol/L, p = 0.0046; d7: 85.35 ± 103.9 µmol/L, p < 0.0001). Decreased SOD levels in plasma and CSF are associated with a worse neurological outcome 6 weeks (mRS: CSF p = 0.0001; plasma p = 0.027/GOSE: CSF p = 0.001; plasma p = 0.001) and 6 months (mRS: CSF p = 0.001; plasma p = 0.09/GOSE: CSF p = 0.001; plasma p = 0.001) after SAH. Increased plasma TAC correlated with a worse neurological outcome 6 weeks (mRS: p = 0.001/GOSE p = 0.001) and 6 months (mRS p = 0.001/GOSE p = 0.001) after SAH. Conclusion: In our study, a reduction in the antioxidative enzyme SOD and elevated TAC were associated with a poorer neurological outcome reflected by mRS and GOSE at 6 weeks and 6 months after SAH. A lower initial SOD CSF concentration was associated with the late deterioration of cognitive ability. These findings support the mounting evidence of the role of oxidative stress in early brain injury formation and unfavorable outcome after SAH. Full article

Background and Objectives: To identify predictors of outcome after aneurysmal subarachnoid hemorrhage (aSAH) in our interdisciplinary setting. Materials and Methods: 176 patients who had been treated for aSAH by a team of neurosurgeons and neuroradiologists between 2009 and 2017 were analyzed retrospectively. Age, gender, clinical presentation according to the Hunt and Hess (H&H) grading on admission, overall clot burden, aneurysm localization, modality of aneurysm obliteration, early deterioration (ED), occurrence of vasospasm in transcranial Doppler ultrasonography, delayed cerebral ischemia (DCI), spasmolysis, decompressive craniectomy (DC), cerebrospinal fluid (CSF) shunt placement, deep vein thrombosis (DVT), pulmonary embolism (PE), severe cardiac events (SCE), mortality on Days 14, and 30 after admission, and outcome at one year after the hemorrhage according to the Glasgow Outcome Scale (GOS) were recorded. Chi square, Fisher’s exact, Welch’s t, and Wilcoxon rank sum served as statistical tests. Generalized linear models were fitted, and ordered logistic regression was performed. Results: SCE (p = 0.049) were a significant predictor of mortality at 14 days after aSAH, but not later during the first year after the hemorrhage. Clipping as opposed to coiling (p = 0.049) of ruptured aneurysms was a significant predictor of survival on Day 30 after aSAH, but not later during the first year after the hemorrhage, while coiling as opposed to clipping of ruptured aneurysms was significantly related to a lower frequency of DVT during hospitalization (p = 0.024). Aneurysms of the anterior circulation were significantly more often clipped, while aneurysms of the posterior circulation were significantly more often coiled (p < 0.001). Age over 70 years (p = 0.049), H&H grade on admission (p = 0.022), overall clot burden (p = 0.035), ED (p = 0.009), DCI (p = 0.013), DC (p = 0.0005), and CSF shunt placement (p = 0.038) proved to be predictive of long-term outcome after aSAH. Conclusion: Long-term results after clipping and coiling of ruptured aneurysms appear equal in an interdisciplinary setting that takes aneurysm localization, available staff, and equipment into account. Full article

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is still a fatal and morbid disease, although bleeding aneurysms can be secured in almost all cases. Occurrence of post-SAH complications including cerebral vasospasm, delayed cerebral ischemia, hydrocephalus, epilepsy, and infections are the main determinants of clinical outcome. Hence, it is important to search for early predictors for specific post-SAH complications to treat these complications properly. Both cellular and molecular (cytokines) inflammation play a key role after aSAH during the phase of occurrence of post-SAH complications. Interleukin-6 (IL-6) is a well-known cytokine that has been extensively analyzed in cerebrospinal fluid (CSF) of patients after aSAH, but detailed studies exploring the role of systemic IL-6 in aSAH associated complications and its impact on early clinical outcome prediction are lacking. The current study aims to analyze the systemic IL-6 levels over two weeks after bleeding and its role in post-SAH complications. Methods: We recruited 80 aSAH patients prospectively who underwent peripheral venous blood withdrawal in serum gel tubes. The blood was centrifuged to harvest the serum, which was immediately frozen at −80 °C until analysis. Serum IL-6 levels were quantified using Immulite immunoassay system. Patient records including age, gender, post-SAH complications, aneurysm treatment, and clinical outcome (modified Rankin scale and Glasgow outcome scale) were retrieved to allow different subgroup analysis. Results: Serum IL-6 levels were significantly raised after aSAH compared to healthy controls over the first two weeks after hemorrhage. Serum IL-6 levels were found to be significantly elevated in aSAH patients presenting with higher Hunt and Hess grades, increasing age, and both intraventricular and intracerebral hemorrhage. Interestingly, serum IL-6 was also significantly raised in aSAH patients who developed seizures, cerebral vasospasm (CVS), and chronic hydrocephalus. IL-6 levels were sensitive to the development of infections and showed an increase in patients who developed pneumoniae. Intriguingly, we found a delayed increase in serum IL-6 in patients developing cerebral infarction. Finally, IL-6 levels were significantly higher in patients presenting with poor clinical outcome in comparison to good clinical outcome at discharge from hospital. Conclusion: Serum IL-6 levels were elevated early after aSAH and remained high over the two weeks after initial bleeding. Serum IL-6 was elevated in different aSAH associated complications, acting as a non-specific marker for post-SAH complications and an important biomarker for clinical outcome at discharge. Full article