OBJECTIVE: Ischemic complications account for significant patient morbidity following aneurysmal subarachnoid hemorrhage (aSAH). The Prevention and Treatment of Vasospasm with Clazosentan (REACT) study was designed to assess the safety and efficacy of clazosentan, an endothelin receptor antagonist, in preventing clinical deterioration due to delayed cerebral ischemia (DCI) in patients with aSAH. METHODS: REACT was a prospective, multicenter, randomized, double-blind, phase 3 study. Eligible patients had aSAH secured by surgical clipping or endovascular coiling, and had presented with thick and diffuse clot on admission CT scan. Patients were randomized (1:1 ratio) to 15 mg/hour intravenous clazosentan or placebo within 96 hours of the aSAH for up to 14 days, in addition to standard of care treatment including oral or intravenous nimodipine. The primary efficacy endpoint was the occurrence of clinical deterioration due to DCI up to 14 days after initiation of the study drug. The main secondary endpoint was the occurrence of clinically relevant cerebral infarction at day 16 after study drug initiation. Other secondary endpoints included clinical outcome assessed on the modified Rankin Scale (mRS) and the Glasgow Outcome Scale-Extended (GOSE) at week 12 post-aSAH. Imaging and clinical endpoints were centrally adjudicated. RESULTS: A total of 409 patients were randomized between February 2019 and May 2022 across 74 international sites. Three patients did not start study treatment and were not included in the analysis set. The occurrence of clinical deterioration due to DCI was 15.8% (32/202 patients) in the clazosentan group and 17.2% (35/204 patients) in the placebo group, and the difference was not statistically significant (relative risk reduction [RRR] 7.2%, 95% CI -42.6% to 39.6%, p = 0.734). A nonsignificant RRR of 34.1% (95% CI -21.3% to 64.2%, p = 0.177) was observed in clinically relevant cerebral infarcts treated with clazosentan (7.4%, 15/202) versus placebo (11.3%, 23/204). Rescue therapy was less frequently needed for patients treated with clazosentan compared to placebo (10.4%, 21/202 vs 18.1%, 37/204; RRR 42.6%, 95% CI 5.4%-65.2%). A nonsignificant relative risk increase of 25.4% (95% CI -10.7% to 76.0%, p = 0.198) was reported in the risk of poor GOSE and mRS scores with clazosentan (24.8%, 50/202) versus placebo (20.1%, 41/204) at week 12 post-aSAH. Treatment-emergent adverse events were similar to those reported previously. CONCLUSIONS: Clazosentan administered for up to 14 days at 15 mg/hour had no significant effect on the occurrence of clinical deterioration due to DCI. Clinical trial registration no.: NCT03585270 (ClinicalTrials.gov) EU clinical trial registration no.: 2018-000241-39 (clinicaltrialsregister.eu).

• MeSH
• Dioxanes * therapeutic use   adverse effects   MeSH
• Adult MeSH
• Double-Blind Method MeSH
• Vasospasm, Intracranial etiology   prevention & control   drug therapy   diagnostic imaging   MeSH
• Brain Ischemia * prevention & control   etiology   MeSH
• Middle Aged MeSH
• Humans MeSH
• Prospective Studies MeSH
• Pyridines * therapeutic use   adverse effects   administration & dosage   MeSH
• Pyrimidines * therapeutic use   adverse effects   administration & dosage   MeSH
• Aged MeSH
• Subarachnoid Hemorrhage * complications   diagnostic imaging   MeSH
• Sulfonamides * therapeutic use   adverse effects   administration & dosage   MeSH
• Tetrazoles * therapeutic use   adverse effects   MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Clinical Trial, Phase III MeSH
• Multicenter Study MeSH
• Randomized Controlled Trial MeSH

BACKGROUND: We evaluated the association of reperfusion quality and different patterns of achieved reperfusion with clinical and radiological outcomes in the ESCAPE NA1 trial. METHODS: Data are from the ESCAPE-NA1 trial. Good clinical outcome [90-day modified Rankin Scale (mRS) 0-2], excellent outcome (90-day mRS0-1), isolated subarachnoid hemorrhage, symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared across different levels of reperfusion defined by expanded Treatment in Cerebral Infarction (eTICI) Scale. Comparisons were also made between patients with (a) first-pass eTICI 2c3 reperfusion vs multiple-pass eTICI 2c3; (b) final eTICI 2b reperfusion vs eTICI 2b converted-to-eTICI 2c3; (c) sudden reperfusion vs gradual reperfusion if >1 pass was required. Multivariable logistic regression was used to test associations of reperfusion grade and clinical outcomes. RESULTS: Of 1037 included patients, final eTICI 0-1 was achieved in 46 (4.4%), eTICI 2a in 76 (7.3%), eTICI 2b in 424 (40.9%), eTICI 2c in 284 (27.4%), and eTICI 3 in 207 (20%) patients. The odds for good and excellent clinical outcome gradually increased with improved reperfusion grades (adjOR ranging from 5.7-29.3 and 4.3-17.6) and decreased for sICH and death. No differences in outcomes between first-pass versus multiple-pass eTICI 2c3, eTICI 2b converted-to-eTICI 2c3 versus unchanged eTICI 2b and between sudden versus gradual eTICI 2c3 reperfusion were observed. CONCLUSION: Better reperfusion degrees significantly improved clinical outcomes and reduced mortality, independent of the number of passes and whether eTICI 2c3 was achieved suddenly or gradually.

• MeSH
• Middle Aged MeSH
• Humans MeSH
• Reperfusion * methods   MeSH
• Aged MeSH
• Subarachnoid Hemorrhage therapy   diagnostic imaging   mortality   MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Randomized Controlled Trial MeSH

BACKGROUND: In Africa, no cerebral aneurysm treatment guidelines exist. Epidemiology, management, and outcomes after aneurysmal subarachnoid hemorrhage (aSAH) remain poorly understood, with many underdiagnosed cases. Muhimbili Orthopaedic and Neurosurgery Institute (MOI) is the only neurosurgical referral center in Tanzania. The aim of this study is to describe the current aSAH management with regional outcomes and limitations. METHODS: Patients with aSAH confirmed by computed tomography/magnetic resonance angiography between February 2019 and June 2021 were retrospectively studied. The analyzed parameters included demographics, clinical/radiologic characteristics, injury characteristics, and the modified Rankin Scale (mRS) score. RESULTS: In total, 22 patients, with a female/male ratio of 1.4 and a median age of 54 years (interquartile range [IQR], 47.2-63 years) harboring 24 aneurysms were analyzed. Thirteen patients (59.1%) paid out of pocket. The median distance traveled by patients was 537 km (IQR, 34.7-635 km). The median time between admission and treatment was 12 days (IQR, 3.2-39 days). The most common symptoms were headache (n = 20; 90.9%) and high blood pressure (n = 10; 45.4%). Nine patients (40.9%) had Fisher grade 1 and 12 (54.5%) World Federation of Neurosurgical Societies grade I. The most common aneurysms were of the middle cerebral artery (7/29.2%). Fourteen patients (63.6%) underwent clipping; of those, only 4 (28.6%) were operated on within 72 hours. Mortality was 62.5% in the nonsurgical group. Among clipped patients, 78.6% showed favorable outcomes, with no mortality. Endovascular treatment is not available in Tanzania. CONCLUSIONS: To our best knowledge, this is the first study highlighting aSAH management in Tanzania, with its assets and shortcomings. Our data show pertinent differences among international treatment guidelines, with the resultant outcomes, such as high preoperative mortality resulting from delayed/postponed treatment. Regional difficult circumstances notwithstanding, our long-term goal is to significantly improve the overall management of aSAH in Tanzania.

• MeSH
• Intracranial Aneurysm * surgery   MeSH
• Middle Aged MeSH
• Humans MeSH
• Neurosurgery * MeSH
• Orthopedics * MeSH
• Retrospective Studies MeSH
• Subarachnoid Hemorrhage * diagnostic imaging   surgery   MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Geographicals
• Tanzania MeSH

OBJECTIVES: To investigate the impact of intracerebral haematoma (ICH) on the outcomes and the factors related to an ICH in patients with aneurysmal subarachnoid haemorrhage (aSAH) in a low- and middle-income country. DESIGN: A multicentre prospective cohort study. SETTING: Three central hospitals in Hanoi, Vietnam. PARTICIPANTS: This study included all patients (≥18 years) presenting with aSAH to the three central hospitals within 4 days of ictus, from August 2019 to June 2021, and excluded patients for whom the admission Glasgow Coma Scale was unable to be scored or patients who became lost at 90 days of follow-up during the study. OUTCOME MEASURES: The primary outcome was ICH after aneurysm rupture, defined as ICH detected on an admission head CT scan. The secondary outcomes were 90-day poor outcomes and 90-day death. RESULTS: Of 415 patients, 217 (52.3%) were females, and the median age was 57.0 years (IQR: 48.0-67.0). ICH was present in 20.5% (85/415) of patients with aSAH. There was a significant difference in the 90-day poor outcomes (43.5% (37/85) and 29.1% (96/330); p=0.011) and 90-day mortality (36.5% (31/85) and 20.0% (66/330); p=0.001) between patients who had ICH and patients who did not have ICH. The multivariable regression analysis showed that systolic blood pressure (SBP) ≥140 mm Hg (adjusted odds ratio (AOR): 2.674; 95% CI: 1.372 to 5.214; p=0.004), World Federation of Neurosurgical Societies (WFNS) grades II (AOR: 3.683; 95% CI: 1.250 to 10.858; p=0.018) to V (AOR: 6.912; 95% CI: 2.553 to 18.709; p<0.001) and a ruptured middle cerebral artery (MCA) aneurysm (AOR: 3.717; 95% CI: 1.848 to 7.477; p<0.001) were independently associated with ICH on admission. CONCLUSIONS: In this study, ICH was present in a substantial proportion of patients with aSAH and contributed significantly to a high rate of poor outcomes and death. Higher SBP, worse WFNS grades and ruptured MCA aneurysms were independently associated with ICH on admission.

• MeSH
• Cerebral Hemorrhage complications   MeSH
• Stroke * complications   MeSH
• Hematoma diagnostic imaging   epidemiology   etiology   MeSH
• Intracranial Aneurysm * complications   diagnostic imaging   surgery   MeSH
• Middle Aged MeSH
• Humans MeSH
• Prospective Studies MeSH
• Subarachnoid Hemorrhage * complications   diagnostic imaging   MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Geographicals
• Vietnam MeSH

I když je trombóza žilních splavů vzácná, jedná se o závažnou a často opomíjenou diagnózu. Diagnóza je častokrát těžká kvůli širokému spektru nespecifických klinických příznaků. V poslední dekádě mortalita pacientů klesá v důsledku zvýšeného povědomí o této diagnóze a pokroku v zobrazovacích metodách. V našem případu prezentujeme 70letého pacienta, u kterého se trombóza mozkových žilních splavů projevila nejdříve symptomatickým epileptickým záchvatem a byla diagnostikována na základě anamnestických dat, klinických příznaků a zobrazovacích metod. Po nasazení antikoagulační terapie a zaléčení epileptického záchvatu došlo ke stabilizaci klinického stavu a regresi bolesti hlavy. Kazuistika poukazuje na různorodost klinického obrazu trombózy mozkových splavů a dobrou prognózu pacienta, když se včasně zahájí terapie.

Although cerebral venous thrombosis is rare, it is a serious and often overlooked diagnosis. Due to the wide range of non-specific clinical symptoms, diagnosis is often difficult. In the last decade, patient mortality has been significantly reduced by improvements in treatment and diagnosis techniques and higher awareness of this diagnosis. In our case, we present a 70-year-old patient in whom cerebral venous thrombosis first manifested as a symptomatic epileptic seizure and was diagnosed thanks to anamnestic data, clinical symptoms and neuroimaging methods. The patient's conditions improved after anticoagulant therapy and treatment of the epileptic seizure. The goal of the article is to describe the diversity of the clinical picture of cerebral venous thrombosis and highlight the good prognosis of the patient if treatment is started early.

• MeSH
• Headache etiology   MeSH
• Diagnosis, Differential MeSH
• Heparin, Low-Molecular-Weight administration & dosage   MeSH
• Ischemic Stroke * diagnostic imaging   etiology   MeSH
• Humans MeSH
• Magnetic Resonance Imaging MeSH
• Brain diagnostic imaging   pathology   MeSH
• Tomography, X-Ray Computed MeSH
• Aged MeSH
• Subarachnoid Hemorrhage diagnostic imaging   etiology   MeSH
• Sinus Thrombosis, Intracranial * diagnostic imaging   drug therapy   pathology   MeSH
• Treatment Outcome MeSH
• Seizures etiology   drug therapy   MeSH
• Check Tag
• Humans MeSH
• Aged MeSH
• Publication type
• Case Reports MeSH

Diagnostika krvácivých mozkových příhod vychází na jedné straně z anamnézy a fyzikálního vyšetření, na straně druhé se neobejde ani bez zobrazovacích metod. Článek popisuje příčiny vzniku krvácivých mozkových příhod a radiologická vyšetření, která jsou nutná jednak k potvrzení přítomnosti krvácení a která jsou dále doplňována k objasnění jejich etiologie.

Diagnosis of hemorrhagic stroke is based on a medical history, physical examination and diagnostic imaging. This paper provides a description of causes of hemorrhagic stroke and radiological examinations necessaryfor both the identification of haemorrhage and the determination of the underlying aetiology.

• MeSH
• Cerebral Hemorrhage diagnostic imaging   etiology   classification   pathology   MeSH
• Hemorrhagic Stroke * diagnostic imaging   etiology   classification   pathology   prevention & control   MeSH
• Humans MeSH
• Brain diagnostic imaging   pathology   MeSH
• Tomography, X-Ray Computed MeSH
• Aneurysm, Ruptured diagnostic imaging   pathology   prevention & control   MeSH
• Prognosis MeSH
• Recurrence MeSH
• Risk Factors MeSH
• Subarachnoid Hemorrhage diagnostic imaging   etiology   pathology   prevention & control   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Research Support, Non-U.S. Gov't MeSH
• Review MeSH

• MeSH
• Headache diagnostic imaging   etiology   MeSH
• Diagnosis, Differential MeSH
• Middle Aged MeSH
• Humans MeSH
• Subarachnoid Hemorrhage * diagnostic imaging   pathology   therapy   MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Publication type
• Case Reports MeSH

• MeSH
• Antidepressive Agents therapeutic use   MeSH
• CADASIL diagnosis   therapy   MeSH
• Central Nervous System * pathology   MeSH
• Stroke diagnostic imaging   epidemiology   classification   complications   physiopathology   pathology   prevention & control   therapy   MeSH
• Depressive Disorder diagnosis   etiology   drug therapy   MeSH
• Diagnostic Techniques and Procedures classification   MeSH
• Hemorrhagic Stroke diagnostic imaging   classification   therapy   MeSH
• Hypertensive Encephalopathy diagnostic imaging   drug therapy   MeSH
• Central Nervous System Agents administration & dosage   classification   MeSH
• Humans MeSH
• Brain diagnostic imaging   pathology   MeSH
• Cerebral Amyloid Angiopathy diagnosis   therapy   MeSH
• Vascular Diseases * diagnostic imaging   epidemiology   classification   physiopathology   pathology   prevention & control   therapy   MeSH
• Subarachnoid Hemorrhage surgery   diagnostic imaging   classification   physiopathology   MeSH
• Thrombophlebitis classification   MeSH
• Dementia, Vascular diagnosis   etiology   drug therapy   classification   MeSH
• Vasculitis, Central Nervous System MeSH
• Check Tag
• Humans MeSH
• Publication type
• Review MeSH

Devětatřicetiletý muž s anamnézou plastiky bikuspidální aortální chlopně byl přijat po autonehodě do Fakultní nemocnice Ostrava pro pravostrannou hemiparézu, zpomalené psychomotorické tempo a dezorientaci. Vstupní výpočetní tomografie (CT) prokázala subarachnoidální krvácení temporo-parietálně. Magnetická rezonance (MR) mozku odhalila difuzně lokalizovaná prokrvácená ischemická ložiska. Z ostatních vážných poranění měl nemocný rupturu sleziny s následným hemoperitoneem, která si vynutila urgentní splenektomii. V klinickém obraze nemocného dominovala neurologická symptomatologie, doplněná o petechie na končetinách a průkaz Staphylococcus aureus v likvoru i v hemokulturách. Z tohoto důvodu byla stanovena pracovní diagnóza meningoencefalitidy a nemocný byl léčen kombinací antibiotik. Vstupní transtorakální i transezofageální echokardiografické vyšetření bylo negativní. Teprve kontrolní jícnová echokardiografie, provedená s odstupem dvou týdnů od první pro recidivu febrilií, detekovala vegetace na aortální, mitrální chlopni a absces prominující na síňovou stranu předního mitrálního cípu. Vzhledem k nálezu vegetací byla přehodnocena diagnóza na infekční endokarditidu se septickými embolizacemi do mozku. Pro selhání konzervativní terapie infekční endokarditidy byla provedena náhrada aortální a mitrální chlopně, následovaná protrahovanou antibiotickou léčbou dle citlivosti. Dodatečným anamnestickým šetřením bylo zjištěno, že měsíc před manifestací onemocnění pacient utrpěl řezné poranění bérce, což mohla být vstupní brána infekce. Kazuistika prezentuje případ nemocného s obtížně a opožděně diagnostikovanou infekční endokarditidou, kde razantní antibiotická i chirurgická léčba vedla k plnému vyléčení nemocného.

A 39-year-old male with a history of bicuspid aortic valvuloplasty was admitted after a car accident for right-sided hemiparesis, cognitive slowing, and disorientation to the Teaching Hospital in Ostrava. Computed tomography (CT) at admission detected subarachnoidal bleeding in the temporoparietal region. Moreover, magnetic resonance imaging (MRI) detected small diffuse ischaemic lesions surrounded by microbleeds. Amongst other major injury, the patient suffered from splenic rupture, which led to urgent splenectomy. Major symptoms were of neurological origin, accompanied by forearm petechia and confirmed presence of Staphylococcus aureus in both blood samples and cerebrospinal fluid. Therefore preliminary diagnosis of meningoencephalitis was established and the patient was treated with combination of antibiotics. Transthoracic and transesophageal echocardiography at admission was negative. Not until the second echocardiography, performed two weeks after the first one, due to elevated body temperature, vegetations on both aortic and mitral valve and the abscess on atrial side of anterior mitral valve leaflet were observed. Therefore the meaning of petechia was rethought, and a new diagnosis of infective endocarditis (IE) with septic brain emboli was established. Due to the apparent failure of conservative treatment, the patient underwent aortic and mitral valve replacement, followed by prolonged cultivation-based antibiotic therapy. In addition, one month before the presentation patient suffered from cut injury of his shank, which may have been the entrance point of infection. This case report presents an elaborate and delayed IE diagnosis where both vigorous antibiotic and surgical treatment led to full recovery of the patient.

• Keywords
• abdominalgie,
• MeSH
• Anti-Bacterial Agents therapeutic use   MeSH
• Pain etiology   MeSH
• Heart Valve Prosthesis Implantation MeSH
• Accidents, Traffic MeSH
• Adult MeSH
• Echocardiography, Transesophageal MeSH
• Endocarditis * surgery   diagnosis   etiology   pathology   MeSH
• Hemoperitoneum diagnostic imaging   MeSH
• Fever etiology   MeSH
• Intracranial Embolism MeSH
• Brain Ischemia diagnostic imaging   pathology   MeSH
• Humans MeSH
• Magnetic Resonance Imaging MeSH
• Meningoencephalitis diagnosis   MeSH
• Brain diagnostic imaging   pathology   MeSH
• Neurologic Manifestations * MeSH
• Treatment Failure MeSH
• Paresis etiology   MeSH
• Lung diagnostic imaging   pathology   MeSH
• Tomography, X-Ray Computed MeSH
• Leg Injuries complications   MeSH
• Purpura etiology   MeSH
• Splenic Rupture surgery   diagnostic imaging   MeSH
• Splenectomy MeSH
• Heart Valves surgery   pathology   MeSH
• Staphylococcal Infections etiology   blood   cerebrospinal fluid   MeSH
• Staphylococcus aureus pathogenicity   MeSH
• Subarachnoid Hemorrhage diagnostic imaging   pathology   MeSH
• Treatment Outcome MeSH
• Confusion etiology   MeSH
• Check Tag
• Adult MeSH
• Humans MeSH
• Male MeSH
• Publication type
• Case Reports MeSH

BACKGROUND: Optimal surgical treatment of blood-blister aneurysms (BBA) remains controversial. Some surgeons prefer clipping reconstruction while others favor primary bypass with trapping. OBJECTIVE: To analyze of benefit of double bypass technique to surgical outcomes in patients with ruptured BBA in poor initial neurological condition (PINC). METHODS: Retrospective analysis of clinical, radiological, and surgical data in 9 patients treated between January 2009 and December 2015. Intraoperative middle cerebral artery blood pressure (MCABP) measurement was used for selection of bypass procedure. RESULTS: Seven patients presented with World Federation of Neurosurgical Societies (WFNS) subarachnoid hemorrhage (SAH) score 4 or 5. No pulse pressure in the MCA after internal carotid artery (ICA) clamping was found in 3 patients, although their ACoA or PCoA were well visualized on preoperative angiograms. By contrast, only a minimal drop in MCABP following ICA clamping was detected in two cases, although their collaterals were slim/nonvisualized on imaging. Although angiographic vasospasms were not observed in our patients, two of them experienced cerebral infarction, attributable more to the mass effect and postoperative ICA thrombosis than to SAH-induced vasospasm. There were 2 premature intraoperative ruptures, but no perioperative mortality, aneurysm recurrence, or rebleeding. Five patients with WFNS SAH score 4 or 5 achieved favorable outcomes. CONCLUSION: Early double bypass technique guided by MCABP measurement and combined with trapping (or rarely clipping) seems to be a safe method with excellent long-term outcomes in patients in PINC. This study may thus contribute to the debate on the optimal treatment strategy for BBA.

• MeSH
• Carotid Artery, Internal diagnostic imaging   surgery   MeSH
• Adult MeSH
• Intracranial Aneurysm complications   diagnostic imaging   surgery   MeSH
• Middle Aged MeSH
• Humans MeSH
• Follow-Up Studies MeSH
• Carotid Artery Diseases complications   diagnostic imaging   surgery   MeSH
• Nervous System Diseases diagnostic imaging   etiology   surgery   MeSH
• Aneurysm, Ruptured complications   diagnostic imaging   surgery   MeSH
• Retrospective Studies MeSH
• Aged MeSH
• Subarachnoid Hemorrhage complications   diagnostic imaging   surgery   MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH