Treatment of Increased Intracranial Pressure and Vasospasm after Subarachnoid Hemorrhage in a 9-Year-Old Child—A Case Report

We report a 9-year-old patient who suffered severe subarachnoid hemorrhage due to ruptured dissecting aneurysm of the left parieto-occipital artery. After endovascular occlusion of the aneurysm, increased intracranial pressure refractory to noninvasive therapy required secondary decompressive hemicraniectomy. Critical vasospasm and delayed neurological deterioration were treated by oral nimodipine and successful endovascular rescue therapy consisting of intra-arterial balloon dilatation.

Platelet-to-neutrophil Ratio after Intravenous Thrombolysis Predicts Unfavorable Outcomes in Acute Ischemic Stroke

Background and Purpose: Platelet-to-neutrophil ratio (PNR) was suggested to be an independent protective predictor for 90-days outcomes in acute ischemic stroke (AIS) patients in previous studies. This study aims to investigate the association between PNR and outcomes of AIS in intravenous thrombolysis (IVT) group. Methods: Data on acute ischemic stroke patients who received intravenous thrombolysis from April 2015 to March 2019 were collected. We defined the PNR value at admission as pre-IVT PNR and after IVT within 24 h was defined as post-IVT PNR. Clinical outcome indicators included early neurological deterioration (END), hemorrhagic transformation (HT), delayed neurological deterioration (DND), and poor 3-month outcome (3m-mRS >2). Results: A total of 581 patients were enrolled in the final analysis. The age was 61(53-69) years, and 423(72.8%) were males. Post-IVT PNR was independently associated with hemorrhagic transformation (OR = 0.974; 95%CI = 0.956-0.992; P=0.006), early neurological deterioration (OR = 0.939; 95%CI = 0.913-0.966; P = 0.01), delayed neurological deterioration (OR = 0.949; 95%CI = 0.912- 0.988; P = 0.011), and poor outcome (OR = 0.962; 95%CI = 0.948-0.976; P<0.001). PNR level was identified as high (at the cut-off value or above) or low (below the cut-off value) according to receiver operating curve (ROC) analyses on each endpoint. Comparison of early neurological deterioration, hemorrhagic transformation, delayed neurological deterioration, and poor 3-month outcome (3m-mRS >2) between patients at high and low levels for platelet-to-neutrophil ratio (PNR) showed statistical differences (p<0.001). Conclusions: Post-IVT PNR was independently associated with early neurological deterioration, hemorrhagic transformation, delayed neurological deterioration, and poor 3-month outcome. Lower PNR can predict a worse outcome.

Abstract WP308: Role of Microthrombi and Vasospasm in the Development of Delayed Neurological Deficits After Subarachnoid Hemorrhage in Mice

Rationale: Microthrombosis has been suggested as a major factor contributing to delayed neurological deterioration in patients after subarachnoid hemorrhage (SAH). However, experimental studies on the role of microthrombi in delayed deficits after SAH has not been investigated. Our hypothesis is that, following SAH, mice which develop delayed neurological deficits have a greater number of microthrombi than mice which do not develop delayed neurological deficits. Methods: SAH was induced in adult male and female C57BL/6 mice via endovascular perforation. Mice were randomly assigned into sham (n=6/sex) or SAH groups (n=22-24/sex). Neurobehavior was performed on days 1-3, 5, and 7 post-SAH using a composite neuroscore. Animals were sacrificed on the day of delayed deficits or 7 days post-SAH. Microthrombi count and vessel diameters (for vasospasm) were measured using H&E stained brain slices. All outcomes were performed and all data were analyzed by a blinded investigator. Results: Seventeen percent (4/24) of male mice and thirty-six percent (8/22) of female mice developed delayed deficits on days 3-5 post-SAH (Figures 1A and 1B). Those mice which developed delayed deficits had significantly more microthrombi in their brains than mice which did not develop delayed deficits; vasospasm did not correlate with delayed deficits. Additionally, female SAH mice develop delayed deficits at a higher frequency than males (Figure 1C). Conclusions: This work shows for the first time delayed deficits in a SAH mouse model. Further, microthrombi correlated with delayed deficits, whereas no correlation was between delayed deficits and vasospasm. The data within this study suggests that preventing microthrombi may improve functional recovery and reduce the risk of delayed deficits.

Surgical Treatment of Intracranial Aneurysms in Elderly

Introduction: Twenty years ago, elderly patients who had a diagnosis of intracerebral aneurysms were considered to have a poor prognosis and, thus, were excluded of any kind of treatment. With the rapid aging of the population, there was a consistent increase on the prevalence of subarachnoid hemorrhage and, consequently, all of its complications. Delayed neurological deterioration from cerebral arterial vasospasm is a major cause of morbidity and mortality. Thus, specific treatment strategy for intracranial aneurysms in the elderly has been developed. Materials and Methods: Analysis of medical records, office charts, and imaging studies of all elderly patients who underwent surgical treatment of intracerebral aneurysms, and review of literature. Data related to these patients, like gender, aneurysm location, rupture, and comorbidities, were recorded. Results: Between June 1996 and November 2009, among 152 patients with 209 ruptured and unruptured intracranial aneurysms treated surgically, 23 patients were 65 years of age or older. Discussion: Withholding aneurysm surgery merely because of the patient’s age is not necessarily the most appropriate decision. Early surgery, in order to avoid re-rupture, vasospasm and infection, still is the better decision, independently of the treatment modality - open surgery or endovascular.

Abstract TP428: Leukocyte Subpopulation at Day 0 in Aneurysmal Subarachnoid Hemorrhage as Predictor of Cerebral Vasospasm

Background: Aneurysmal subarachnoid hemorrhage (SAH) remains a leading cause of significant morbidity and mortality. Previous studies have shown that there is a systemic inflammatory response, characterized by leukocytosis or leukopenia in SAH. We investigated leukocyte subpopulation in serum and cerebral spinal fluid (CSF) at day 0 as a clinical predictor of delayed neurological deterioration defined as VS at any time during hospital stay. Methods: This is a retrospective study of non-traumatic SAH. Leukocyte subpopulations data in serum and CSF at day 0 were prospectively collected and compared with the development of clinical vasospasm (VS) vs no VS during the entirety of the patient’s hospital admission. Data was analyzed using univariate analysis. Clinical VS was defined as development of new focal neurological signs, deterioration in level of consciousness, or both, when the cause was felt to be ischemia attributable to VS after other possible causes of worsening (hydrocephalus, seizure, etc.). Results: A total of 47 subjects were screened and included in the analysis; 35 of these had no clinical VS and 12 had clinical VS. In those with and without VS, there was a significant difference in elevated leukocyte counts (16.9 vs. 12.5, p<.001) and neutrophils (13.3 vs. 10.4, p<.044). VS was not associated with monocytes (1.8 vs .48, p<0.30) or with lymphocytes (1.3 vs. 1.4, p<0.60). When adjusting for fever in a logistic regression model, this association held for leukocyte count (OR:1.32, p<0.012) and was borderline significant for neutrophils (OR:1.20, p<0.051). Conclusion: There was a statistically significant association between total serum leukocyte at day 0 and incidence of VS. Neutrophils may also identify potential neurological deterioration. Total serum leukocyte may be a valuable predictor of VS and neurological deterioration in general.

Delayed neurological deterioration due to progressive pneumocephalus

Pneumocephalus can develop immediately following head trauma or clinical presentation may be delayed for days. We report a case of 35 year male whose initial CT scan brain plain small specks of pneumocephalus in left para-sellar region. However the next day he was complaining of severe headache and had multiple episodes of vomiting. Repeat CT scan showed increase in the size of pneumocephalus including appearance of intraventricular air with mild cerebral edema. The patient recovered well with conservative management. The present case is a gentle reminder that in a subgroup of head injury patients, intracranial air can produce significant mass effect leading to tension pneumocephalus which can can behave like other intracranial mass lesions and causes worsening of the neurological status of these patients.