Acute and Critical Care

Original Article

Neurosurgery
Role of serum magnesium in post-aneurysmal subarachnoid hemorrhagic hydrocephalus: Moinay Kim, Hyunchul Jung, Seung Bin Kim, Jun Ha Hwang, Hanwool Jeon, Yeongu Chung, Youngbo Shim, Jae Hyun Kim, Joonho Byun, Aiden Cousins, Wonhyoung Park, Jung Cheol Park, Jae Sung Ahn, Seungjoo Lee; Acute Crit Care. 2025;40(4):582-593. Published online November 28, 2025; DOI: https://doi.org/10.4266/acc.003550

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Abstract PDF: Background
Post-hemorrhagic hydrocephalus (PHH) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), yet the relationship between serum magnesium (Mg) level and PHH remains unclear. To our knowledge, this is the first prospective study to specifically examine the association between admission serum Mg level and PHH in aSAH patients.
Methods
In this prospective, multicenter study (October 2019–October 2024), 131 patients with confirmed aSAH were enrolled from four neuro-intensive care units. Patients were stratified by admission serum Mg level as <2.2 mg/dL or ≥2.2 mg/dL. The primary outcome was PHH incidence; secondary outcomes were cerebral vasospasm (CV), delayed cerebral ischemia (DCI), and 30-day modified Rankin Scale (mRS) score.
Results
Baseline characteristics were similar between groups. Serum Mg ≥2.2 mg/dL was not significantly associated with reduced vasospasm, DCI, or poor functional outcome. However, serum Mg >2.5 mg/dL correlated with lower PHH incidence in univariate analysis (odds ratio, 0.36; P=0.027) but not in multivariate analysis (P=0.136). Independent predictors of PHH were posterior circulation aneurysm, high Fisher grade, and high Hunt and Hess grade. Poor 30-day mRS was independently associated with high Fisher and Hunt and Hess grades.
Conclusions
Admission serum Mg level was not independently associated with PHH, although a potential protective trend was noted at higher levels (>2.5 mg/dL). These findings suggest a possible role of Mg in PHH prevention. Further prospective trials are warranted to clarify the therapeutic potential of Mg and to establish optimal monitoring and correction strategies in aSAH management.

Review Article

Neurosurgery
The role of catecholamines in aneurysmal subarachnoid hemorrhage: a narrative review: Samantha Nalliah, Tariq Janjua, Luis Rafael Moscote-Salazar, Md Yunus, Amit Agrawal; Acute Crit Care. 2025;40(4):513-520. Published online November 24, 2025; DOI: https://doi.org/10.4266/acc.001525

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The marked release of catecholamines during subarachnoid hemorrhage is an important aspect of the pathobiology following aneurysmal rupture. This narrative review aims to identify how catecholamines influence aneurysmal subarachnoid hemorrhage (aSAH) outcomes. aSAH is a critical neurological condition characterized by hemorrhage into the subarachnoid space, leading to severe neurological deficits and mortality. Catecholamines, including epinephrine, norepinephrine, and dopamine, are the body's stress responses, which can lead to secondary injuries following aSAH. This review was conducted through a targeted literature search of relevant studies examining the relationship between aSAH, catecholamines, and clinical outcomes. Searches were performed in PubMed, Scopus, The Cochrane Library, Medline (Ovid), Embase (Ovid), and CINAHL, including publications up to July 2024. Search terms combined keywords and subject headings related to “subarachnoid hemorrhage” or “aSAH,” “catecholamines,” “epinephrine,” “norepinephrine,” “dopamine,” and outcome-related terms such as “prognosis,” “mortality,” and “neurological outcome.” Articles were selected based on relevance, and key findings were synthesized descriptively to provide a comprehensive overview of current knowledge in this area. Elevated levels of catecholamines are observed following aSAH and are associated with increased sympathetic nervous system activity. This catecholamine surge contributes to pathological processes, including vasospasm, blood-brain barrier disruption, cerebral edema, and neuronal damage. The review highlights the implications of catecholamine levels; where higher concentrations correlate with poorer outcomes and higher mortality rates. Understanding the mechanisms responsible for secondary injury due to catecholamines surge following aSAH shall facilitate the development of therapeutic approaches to prevent secondary brain injury and improve outcomes.

Citations

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Glucose/Potassium Ratio, a Novel Biomarker for the Prognosis of Patients with Subarachnoid Hemorrhage: A Review
Luis E. Fernández-Garza, Valeria A. Fernández-Garza, Daniela Mares-Custodio, Victor Gutiérrez-Ruano, Alexandro Navarrete-Rodríguez, Juan J. Arias-Alzate
Journal of Vascular Diseases.2025; 4(4): 48. CrossRef

Original Article

Neurosurgery
The efficacy of therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis: Seungjoo Lee, Moinay Kim, Min-Yong Kwon, Sae Min Kwon, Young San Ko, Yeongu Chung, Wonhyoung Park, Jung Cheol Park, Jae Sung Ahn, Hanwool Jeon, Jihyun Im, Jae Hyun Kim; Acute Crit Care. 2024;39(2):282-293. Published online May 30, 2024; DOI: https://doi.org/10.4266/acc.2024.00612

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Abstract PDF Supplementary Material

Background
This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus.
Methods
Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed.
Results
The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups.
Conclusions
TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.

Citations

Citations to this article as recorded by

Progress of Brain Hypothermia Treatment for Severe Subarachnoid Hemorrhage—177 Cases Experienced and a Narrative Review
Hitoshi Kobata
Therapeutic Hypothermia and Temperature Management.2025; 15(3): 113. CrossRef
State-of-the-art for automated machine learning predicts outcomes in poor-grade aneurysmal subarachnoid hemorrhage using routinely measured laboratory & radiological parameters: coagulation parameters and liver function as key prognosticators
Ali Haider Bangash, Jayro Toledo, Muhammed Amir Essibayi, Neil Haranhalli, Rafael De la Garza Ramos, David J. Altschul, Stavropoula Tjoumakaris, Reza Yassari, Robert M. Starke, Redi Rahmani
Neurosurgical Review.2025;[Epub] CrossRef
Targeted temperature management in acute brain injury
Arjun Joshi, Mark Earl
Anaesthesia & Intensive Care Medicine.2025; 26(10): 639. CrossRef

Case Report

Neurosurgery
A point-of-care evaluation after visual loss following paraclinoid aneurysm repair: the role of sonographic and pupillometer assessment: Giacomo Bertolini, Ernesto Migliorino, Diego Mazzatenta, Carlo Bortolotti, Raffaele Aspide; Acute Crit Care. 2025;40(1):144-149. Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00045

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Abstract PDF: Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent devastating consequences. Herein we present a point-of-care evaluation to investigate sudden visual loss after coiling of paraclinoid aneurysms. A 20-year-old male was admitted for a sudden headache. Head computed tomography showed a subarachnoid hemorrhage and subsequent angiography revealed a 9-mm left supraclinoid aneurysm of the internal carotid artery treated with endovascular coil embolization. Thirty minutes after intensive care unit admission, the patient reported a left amaurosis. To exclude secondary etiologies, an immediate evaluation with point-of-care devices (color-doppler and B-mode ultrasound and automated pupillometry) was performed. Sonographic evaluations were negative for ischemic/thrombotic events and neurologic pupil index within physiological ranges provide evidence of third cranial nerve responsiveness. The symptomatology resolved progressively over 120 minutes with low-dose steroid therapy, 30° head-of-bed elevation, and blood pressure management. Visual deficits can occur after endovascular procedure and should be investigated. Suspected visual loss is a neurological emergency that deserves a prompt evaluation. Ultrasound and automated pupillometry have proved to be an effective, rapid, reliable, and non-invasive combination for a clinical decision-making strategy in the management of post-procedural acute visual deficits.

Original Articles

Neurosurgery
The RAP Index during Intracranial Pressure Monitoring as a Clinical Guiding for Surgically Treated Aneurysmal Subarachnoid Hemorrhage: Consecutive Series of Single Surgeon: Sung-Chul Jin, Byung Sam Choi, Jung-Soo Kim; Acute Crit Care. 2019;34(1):71-78. Published online February 28, 2019; DOI: https://doi.org/10.4266/acc.2019.00437

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Abstract PDF

Background
It is well known that assessing the RAP index along with intracranial pressure (ICP) monitoring in traumatic brain injury patients is helpful. We will discuss the usefulness of this assessment tool as a clinical guide for surgically treated poor grade aneurysmal subarachnoid hemorrhage (SAH).
Methods
This retrospective study included 35 patients with aneurysmal SAH who presented with World Federation of Neurosurgical Societies (WFNS) grade V SAH and received surgical treatment from January 2013 to December 2018. Emergency surgical clipping, hematoma removal, extraventricular drainage, and if needed, wide decompressive craniectomy were combined as the proper surgical treatments. Outcomes were assessed based on in-hospital survival and the Glasgow outcome scale score at 14-day follow-up. We compared the mortality rate of two groups of seven patients: ICP monitoring only (n=5) and ICP monitoring combined with the RAP index (n=2).
Results
The in-hospital 14-day mortality rate by brain lesion was 48.5% (n=17). Seven patients had real-time ICP monitoring. Before 2018, three of five patients with poor WFNS grade who received real-time ICP monitoring only died. There were no deaths in the group of two patients receiving real-time ICP monitoring and the RAP index.
Conclusions
Our data indicate that combining the RAP index and ICP monitoring can be used as markers for critical intracranial physiological parameters in poor grade WFNS patients.

Citations

Citations to this article as recorded by

Exploring Cerebrospinal Compensatory Zones Using a Noninvasive Approach
Sérgio Brasil, Marek Czosnyka, Wellingson S. Paiva, Gustavo Frigieri
Neurocritical Care.2025; 43(3): 834. CrossRef
Continuous monitoring methods of cerebral compliance and compensatory reserve: a scoping review of human literature
Abrar Islam, Logan Froese, Tobias Bergmann, Alwyn Gomez, Amanjyot Singh Sainbhi, Nuray Vakitbilir, Kevin Y Stein, Izabella Marquez, Younis Ibrahim, Frederick A Zeiler
Physiological Measurement.2024; 45(6): 06TR01. CrossRef
Multimodal Neurologic Monitoring in Children With Acute Brain Injury
Jennifer C. Laws, Lori C. Jordan, Lindsay M. Pagano, John C. Wellons, Michael S. Wolf
Pediatric Neurology.2022; 129: 62. CrossRef
Intracranial pressure: current perspectives on physiology and monitoring
Gregory W. J. Hawryluk, Giuseppe Citerio, Peter Hutchinson, Angelos Kolias, Geert Meyfroidt, Chiara Robba, Nino Stocchetti, Randall Chesnut
Intensive Care Medicine.2022; 48(10): 1471. CrossRef
The application value of CT radiomics features in predicting pressure amplitude correlation index in patients with severe traumatic brain injury
Jiaqi Liu, Yingchi Shan, Guoyi Gao
Frontiers in Neurology.2022;[Epub] CrossRef

Neurosurgery
Acute Cholecystitis as a Cause of Fever in Aneurysmal Subarachnoid Hemorrhage: Na Rae Yang, Kyung Sook Hong, Eui Kyo Seo; Korean J Crit Care Med. 2017;32(2):190-196. Published online May 31, 2017; DOI: https://doi.org/10.4266/kjccm.2016.00857

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Abstract PDF

Background
Fever is a very common complication that has been related to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The incidence of acalculous cholecystitis is reportedly 0.5%–5% in critically ill patients, and cerebrovascular disease is a risk factor for acute cholecystitis (AC). However, abdominal evaluations are not typically performed for febrile patients who have recently undergone aSAH surgeries. In this study, we discuss our experiences with febrile aSAH patients who were eventually diagnosed with AC.
Methods
We retrospectively reviewed 192 consecutive patients who underwent aSAH from January 2009 to December 2012. We evaluated their characteristics, vital signs, laboratory findings, radiologic images, and pathological data from hospitalization. We defined fever as a body temperature of >38.3°C, according to the Society of Critical Care Medicine guidelines. We categorized the causes of fever and compared them between patients with and without AC.
Results
Of the 192 enrolled patients, two had a history of cholecystectomy, and eight (4.2%) were eventually diagnosed with AC. Among them, six patients had undergone laparoscopic cholecystectomy. In their pathological findings, two patients showed findings consistent with coexistent chronic cholecystitis, and two showed necrotic changes to the gall bladder. Patients with AC tended to have higher white blood cell counts, aspartame aminotransferase levels, and C-reactive protein levels than patients with fevers from other causes. Predictors of AC in the aSAH group were diabetes mellitus (odds ratio [OR], 8.758; P = 0.033) and the initial consecutive fasting time (OR, 1.325; P = 0.024).
Conclusions
AC may cause fever in patients with aSAH. When patients with aSAH have a fever, diabetes mellitus and a long fasting time, AC should be suspected. A high degree of suspicion and a thorough abdominal examination of febrile aSAH patients allow for prompt diagnosis and treatment of this condition. Additionally, physicians should attempt to decrease the fasting time in aSAH patients.

Citations

Citations to this article as recorded by

Rare or Overlooked Cases of Acute Acalculous Cholecystitis in Young Patients with Central Nervous System Lesion
Seong-Hun Kim, Min-Gyu Lim, Jun-Sang Han, Chang-Hwan Ahn, Tae-Du Jung
Healthcare.2023; 11(10): 1378. CrossRef
Acute cholecystitis as a rare and overlooked complication in stroke patients
Myung Chul Yoo, Seung Don Yoo, Jinmann Chon, Young Rok Han, Seung Ah Lee
Medicine.2019; 98(9): e14492. CrossRef
Acute Acalculous Cholecystitis in Neurological Patients; Clinical Review, Risk Factors, and Possible Mechanism
See Won Um, Hak Cheol Ko, Seung Hwan Lee, Hee Sup Shin, Jun Seok Koh
Journal of Neurointensive Care.2019; 2(2): 77. CrossRef

Case Report

Neurosurgery
Delayed Traumatic Subarachnoid Hemorrhage in a Polytraumatized Patient with Disseminated Intravascular Coagulation: Jiwoong Oh, Wonyeon Lee, Ji Young Jang, Pilyoung Jung, Sohyun Kim, Jongyeon Kim, Jinsu Pyen, Kum Whang, Sungmin Cho; Korean J Crit Care Med. 2015;30(4):336-342. Published online November 30, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.4.336

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Abstract PDF

The precise mechanism involved in DIC and delayed traumatic subarachnoid hemorrhage (DT-SAH) remains unclear in multipletrauma patients. Hereby, we describe a polytraumatized patient with DIC who died due to DT-SAH. A 75-year-old female patient was admitted to our Emergency Department complaining of abdominal pain and drowsiness after a pedestrian accident. Her initial brain computerized tomography (CT) finding was negative for intracranial injury. However, her abdominal CT scan revealed a collection of retroperitoneal hematomas from internal iliac artery bleeding after a compressive pelvic fracture. This event eventually resulted in shock and DIC. An immediate angiographic embolization of the bleeding artery was performed along with transfusion and antithrombin III. Her vital signs were stabilized without neurological change. Fourteen hours after admission, she suddenly became comatose, and her follow-up brain CT scan revealed a dense DT-SAH along the basal cisterns with acute hydrocephalus. This event rapidly prompted brain CT angiography and digital subtraction angiography, which both confirmed the absence of any cerebrovascular abnormality. Despite emergency extraventricular drainage to reverse the hydrocephalus, the patient died three days after the trauma. This paper presents an unusual case of DT-SAH in a polytraumatized patient with DIC.

Citations

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Is initial optic nerve sheath diameter prognostic of specific head injury in emergency departments?
Bedriye Müge Sönmez, Emirhan Temel, Murat Doğan İşcanlı, Fevzi Yılmaz, Uğur Gülöksüz, Selçuk Parlak, Özhan Merzuk Uçkun
Journal of the National Medical Association.2019; 111(2): 210. CrossRef

Original Article

A Retrospective Study about Characteristics of Out-of-hospital Cardiac Arrest Caused by Non-traumatic Subarachnoid Hemorrhage: Min Seob Sim, Ki Dong Sung, Mun Ju Kang, Ji Ung Na, Tae Gun Shin, Ik Joon Jo, Hyoung Gon Song, Keun Jeong Song, Yeon Kwon Jeong; Korean J Crit Care Med. 2011;26(3):151-156.; DOI: https://doi.org/10.4266/kjccm.2011.26.3.151

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Abstract PDF: BACKGROUND
Subarachnoid hemorrhage is a fatal disease relatively common in the East Asian population. It can lead to cardiac arrest in several pathologic processes. We attempted to elucidate the characteristics of out-of-hospital cardiac arrest caused by non-traumatic subarachnoid hemorrhage.
METHODS
We conducted a retrospective, observational study in which patients who had visited Samsung medical center emergency room for out-of-hospital cardiac arrest from January, 1999 to December 2008 were enrolled. A total of 218 OHCA patients who had achieved ROSC were investigated by review of medical charts. Excluding those who had worn trauma, we analyzed 22 patients who had been diagnosed for SAH by brain non-contrast CT scan.
RESULTS
Median age of aneurysmal SAH-induced OHCA patients was 61 (IQR 54-67) years. Fourteen patients (64%) were female and 15 patients (68%) were witnessed. Besides, 7 patients (32%) had complained of headache before collapse. We also found 11 patients (50%) had been diagnosed with hypertension previously. All of them showed unshockable rhythm (asystole 60%, PEA 40%) initially. Their median duration of ACLS was 10 minutes. Majority of patients died within 24 hours and survivors showed poor neurologic outcome.
CONCLUSIONS
Subarachnoid hemorrhage is a relatively uncommon cause of cardiac arrest, and the outcome of OHCA induced by SAH is very poor. However, emergency physicians have to consider the possibility of SAH when trying to determine the cause of arrest, especially when treating patients who have the characteristics described above.

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