51
|
Allen JW, Prater A, Kallas O, Abidi SA, Howard BM, Tong F, Agarwal S, Yaghi S, Dehkharghani S. Diagnostic Performance of Computed Tomography Angiography and Computed Tomography Perfusion Tissue Time-to-Maximum in Vasospasm Following Aneurysmal Subarachnoid Hemorrhage. J Am Heart Assoc 2021; 11:e023828. [PMID: 34970916 PMCID: PMC9075209 DOI: 10.1161/jaha.121.023828] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Vasospasm is a treatable cause of deterioration following aneurysmal subarachnoid hemorrhage. Cerebral computed tomography perfusion mean transit times have been proposed as a predictor of vasospasm but suffer from well‐known technical limitations. We evaluated fully automated, thresholded time‐to‐maxima of the tissue residue function (Tmax) for determination of vasospasm following aneurysmal subarachnoid hemorrhage. Methods and Results Retrospective analysis of 540 arterial segments from 36 encounters in 31 consecutive patients with aneurysmal subarachnoid hemorrhage undergoing computed tomography angiography (CTA), computed tomography perfusion, and digital subtraction angiography (DSA) within 24 hours. Tmax at 4, 6, 8, and 10 s was generated using RAPID (iSchemaView Inc., Menlo Park, CA). Dual‐reader CTA and computed tomography perfusion interpretations were compared for patients with and without vasospasm on DSA (DSA+ and DSA−). Logistic regression models were developed using CTA and Tmax as input predictors and DSA vasospasm as outcome in adjusted and unadjusted models. Imaging studies from all 31 subjects (mean age 47.3±11.1, 77% female, 65% with single aneurysm with mean size of 6.0±2.9 mm) were included. Vasospasm was identified in 42 segments on DSA and 59 segments on CTA, with significant associations across individual vessel segments (P<0.001). In adjusted analyses, DSA vasospasm was associated with CTA (odds ratio [OR], 2.43; 95% CI, 0.94–6.32; P=0.068) as well as territory‐specific Tmax>6 seconds delays (OR, 3.57; 95% CI, 1.36–9.35; P=0.009). Sensitivity/specificity for DSA vasospasm was 31%/91% for CTA, 26%/89% for Tmax>6 seconds, and 12%/99% for CTA+Tmax>6 seconds. Conclusions CTA and Tmax offer high specificity for presence of vasospasm; their utility, even in combination, as screening tests is, however, limited by poor sensitivity.
Collapse
Affiliation(s)
- Jason W Allen
- Department of Radiology and Imaging Sciences Emory University Atlanta GA.,Department of Neurology Emory University Atlanta GA
| | - Adam Prater
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Omar Kallas
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Syed A Abidi
- Emory School of Medicine Emory University Atlanta GA
| | - Brian M Howard
- Department of Radiology and Imaging Sciences Emory University Atlanta GA.,Department of Neurosurgery Emory University Atlanta GA
| | - Frank Tong
- Department of Radiology and Imaging Sciences Emory University Atlanta GA.,Department of Neurosurgery Emory University Atlanta GA
| | | | - Shadi Yaghi
- Department of Neurology Brown University Providence RI
| | - Seena Dehkharghani
- Department of Neurology New York University New York NY.,Department of Radiology New York University New York NY
| |
Collapse
|
52
|
Hu P, Li Y, Zhang H, Su Z, Xu S, Li X, Gao X, Liu Y, Deng G, Xu Y, Ye L, Chen Q. Development and external validation of a dynamic nomogram for delayed cerebral ischaemia after aneurysmal subarachnoid hemorrhage: a study protocol for a multicentre retrospective cohort study. BMJ Open 2021; 11:e051956. [PMID: 34949617 PMCID: PMC8712981 DOI: 10.1136/bmjopen-2021-051956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Delayed cerebral ischaemia (DCI) caused by aneurysmal subarachnoid haemorrhage (aSAH) is the most frequent complication and typically contributes to poor neurological outcome or deterioration of patients' condition. Therefore, early accurate and effective prediction of DCI is urgently needed. This study aims to construct a dynamic nomogram for precisely calculating the risk of DCI in patients with aSAH. Internal validation of this tool is conducted using the training cohort, and independent external validation is completed by using other medical centre datasets. METHODS AND ANALYSIS This study is a multicentre, retrospective, observational cohort study using data from patients with aSAH. The participants include all adult patients who received surgical treatment in neurosurgery of multiple medical centres from 1 September 2019 to 1 April 2021, including Renmin Hospital of Wuhan University, Huzhou Central Hospital, First Affiliated Hospital of Harbin Medical University, General Hospital of Northern Theatre Command and Affiliated Hospital of Panzhihua University. Clinical information is collected via the electronic medical record system, including demographic data, clinical state on admission and serum laboratory tests. Modified Fisher grade at admission, admission subarachnoid clot and cerebral oedema density, and residual postoperative subarachnoid clot density are determined using the electronic imagine record software. The primary outcome is DCI. ETHICS AND DISSEMINATION This study protocol was reviewed and approved by the Medical Ethics Committee of Renmin Hospital of Wuhan University, which is the principal affiliation of this study (approval number: WDRM2021-K022). The other Ethics Committees, including Huzhou Central Hospital (approval number: 202108005-01), First Affiliated Hospital of Harbin Medical University (approval number: H202156), General Hospital of Northern Theater Command (approval number: Y2021060) and Affiliated Hospital of Panzhihua University (approval number: 202105002), also approved the protocol. The results of this research will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER ChiCTR2100044448.
Collapse
Affiliation(s)
- Ping Hu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, China
| | - Hongbo Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, China
| | - Shancai Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xuesong Li
- Department of Neurosurgery, Huizhou Third People's Hospital, Huizhou, China
| | - Xu Gao
- Department of Neurosurgery, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yangfan Liu
- Department of Neurosurgery, Affiliated Hospital of Panzhihua University, Panzhihua, China
| | - Gang Deng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yang Xu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liguo Ye
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
53
|
Geraghty JR, Lung TJ, Hirsch Y, Katz EA, Cheng T, Saini NS, Pandey DK, Testai FD. Systemic Immune-Inflammation Index Predicts Delayed Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 89:1071-1079. [PMID: 34560777 PMCID: PMC8600162 DOI: 10.1093/neuros/nyab354] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/31/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Delayed cerebral vasospasm is a feared complication of aneurysmal subarachnoid hemorrhage (SAH). OBJECTIVE To investigate the relationship of systemic inflammation, measured using the systemic immune-inflammation (SII) index, with delayed angiographic or sonographic vasospasm. We hypothesize that early elevations in SII index serve as an independent predictor of vasospasm. METHODS We retrospectively reviewed the medical records of 289 SAH patients for angiographic or sonographic evidence of delayed cerebral vasospasm. SII index [(neutrophils × platelets/lymphocytes)/1000] was calculated from laboratory data at admission and dichotomized based on whether or not the patient developed vasospasm. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to determine the ability of SII index to predict the development of vasospasm. RESULTS A total of 246 patients were included in our study, of which 166 (67.5%) developed angiographic or sonographic evidence of cerebral vasospasm. Admission SII index was elevated for SAH in patients with vasospasm compared to those without (P < .001). In univariate logistic regression, leukocytes, neutrophils, lymphocytes, neutrophil-lymphocyte ratio (NLR), and SII index were associated with vasospasm. After adjustment for age, aneurysm location, diabetes mellitus, hyperlipidemia, and modified Fisher scale, SII index remained an independent predictor of vasospasm (odds ratio 1.386, P = .003). ROC analysis revealed that SII index accurately distinguished between patients who develop vasospasm vs those who do not (area under the curve = 0.767, P < .001). CONCLUSION Early elevation in SII index can independently predict the development of delayed cerebral vasospasm in aneurysmal SAH.
Collapse
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tyler J Lung
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Yonatan Hirsch
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Eitan A Katz
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tiffany Cheng
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Neil S Saini
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Dilip K Pandey
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| |
Collapse
|
54
|
Akeret K, Buzzi RM, Schaer CA, Thomson BR, Vallelian F, Wang S, Willms J, Sebök M, Held U, Deuel JW, Humar R, Regli L, Keller E, Hugelshofer M, Schaer DJ. Cerebrospinal fluid hemoglobin drives subarachnoid hemorrhage-related secondary brain injury. J Cereb Blood Flow Metab 2021; 41:3000-3015. [PMID: 34102922 PMCID: PMC8545037 DOI: 10.1177/0271678x211020629] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Secondary brain injury after aneurysmal subarachnoid hemorrhage (SAH-SBI) contributes to poor outcomes in patients after rupture of an intracranial aneurysm. The lack of diagnostic biomarkers and novel drug targets represent an unmet need. The aim of this study was to investigate the clinical and pathophysiological association between cerebrospinal fluid hemoglobin (CSF-Hb) and SAH-SBI. In a cohort of 47 patients, we collected daily CSF-samples within 14 days after aneurysm rupture. There was very strong evidence for a positive association between spectrophotometrically determined CSF-Hb and SAH-SBI. The accuracy of CSF-Hb to monitor for SAH-SBI markedly exceeded that of established methods (AUC: 0.89 [0.85-0.92]). Temporal proteome analysis revealed erythrolysis accompanied by an adaptive macrophage response as the two dominant biological processes in the CSF-space after aneurysm rupture. Ex-vivo experiments on the vasoconstrictive and oxidative potential of Hb revealed critical inflection points overlapping CSF-Hb thresholds in patients with SAH-SBI. Selective depletion and in-solution neutralization by haptoglobin or hemopexin efficiently attenuated the vasoconstrictive and lipid peroxidation activities of CSF-Hb. Collectively, the clinical association between high CSF-Hb levels and SAH-SBI, the underlying pathophysiological rationale, and the favorable effects of haptoglobin and hemopexin in ex-vivo experiments position CSF-Hb as a highly attractive biomarker and potential drug target.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Christian A Schaer
- Department of Anesthesiology, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Sophie Wang
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Jan Willms
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Ulrike Held
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich; Zurich, Switzerland
| | - Jeremy W Deuel
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Rok Humar
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Emanuela Keller
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland.,Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| |
Collapse
|
55
|
Smith NM, Sweeney EM, Gupta A, Patsalides A, Sanelli P, Ivanidze J. Diagnostic accuracy of shuttle CT angiography (CTA) and helical CTA in the diagnosis of vasospasm. Clin Imaging 2021; 81:37-42. [PMID: 34598002 DOI: 10.1016/j.clinimag.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy of computed tomography angiography (CTA) acquired with shuttle technique (CTAs) and helical CTA (CTAh) for vasospasm, using digital subtraction angiography (DSA) obtained within 24 h as reference standard. METHODS Thirty-six patients with suspected vasospasm in the setting of aneurysmal subarachnoid hemorrhage (ASAH, 30/36) or acute inflammatory/infectious conditions (6/36) who underwent CTAs (17/36) or CTAh (19/36) followed by DSA within 24 h were identified retrospectively. Presence of vasospasm in the proximal cerebral arterial segments was assessed qualitatively and semi-quantitatively on CTA and subsequent DSA. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Inter-rater variability was assessed using Cohen's kappa. RESULTS On CTAs, 35% of patients had low and 65% had high vasospasm burden. On CTAh, 37% had low and 63% had high vasospasm burden. ROC analysis demonstrated an AUC of 0.87 for CTAs (95%CI 0.67-1.00, p = 0.015) and 0.88 for CTAh (0.72-1.00, p = 0.028). Cohen's kappa was 0.843 (95%CI 0.548-1.000). Thresholding with Youden's J index, CTAs had a sensitivity of 85.71% (95%CI 48.69 to 99.27) and specificity of 66.67% (35.42 to 87.94). CTAh had sensitivity of 100% (56.55 to 100.00) and specificity of 78.57% (52.41 to 92.43). CONCLUSION CTAs and CTAh yielded similar sensitivity, specificity, and AUC values on ROC analysis for the detection of vasospasm using DSA as reference standard. Our findings suggest that CTAs is a promising alternative to CTAh especially in patients requiring serial imaging, given its potential advantages of decreased radiation exposure, contrast dose, and cost-effectiveness.
Collapse
Affiliation(s)
- Natasha M Smith
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| | - Elizabeth M Sweeney
- Division of Biostatistics and Epidemiology, Department of Population Health Sciences, New York Presbyterian, Weill Cornell Medical College, 1300 York Ave., New York, NY 10065, USA.
| | - Ajay Gupta
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| | - Athos Patsalides
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Pina Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Jana Ivanidze
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| |
Collapse
|
56
|
Pang J, Wu Y, Peng J, Yang P, Chen L, Jiang Y. Association of Pericyte Loss With Microthrombosis After Subarachnoid Hemorrhage in ApoE-Deficient Mice. Front Neurol 2021; 12:726520. [PMID: 34566870 PMCID: PMC8460864 DOI: 10.3389/fneur.2021.726520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The occurrence of microthrombosis contributes to not only delayed cerebral ischemia (DCI), but also early brain injury (EBI) after SAH. However, the underlying mechanism is not completely investigated. In the current study, we explored the underlying mechanism of microthrombosis in EBI stage after SAH in ApoE-deficient mice. Methods: Experimental SAH was established by endovascular perforation in apolipoprotein E (ApoE)-deficient mice and wild type (WT) mice. Neurobehavioral, molecular biological and histopathological methods were used to assess the relationship between pericytes loss, neurobehavioral performance, and microthrombosis. Results: We found that the number of microthrombi was significantly increased and peaked 48 h after SAH in WT mice. The increased microthrombosis was related to the decreased effective microcirculation perfusion area and EBI severity. ApoE-deficient mice showed more extensive microthrombosis than that of WT mice 48 h after SAH, which was thereby associated with greater neurobehavioral deficits. Immunohistochemical staining showed that microthrombi were predominantly located in microvessels where pericytes coverage was absent. Mechanistically, ApoE deficiency caused more extensive CypA-NF-κB-MMP-9 pathway activation than that observed in WT mice, which thereby led to more degradation of N-cadherin, and subsequently more pericytes loss. Thereafter, the major adhesion molecule that promoting microthrombi formation in microvessels, P-selectin, was considerably increased in WT mice and increased to a greater extent in the ApoE-deficient mice. Conclusion: Taken together, these data suggest that pericytes loss is associated with EBI after SAH through promoting microthrombosis. Therapies that target ApoE to reduce microthrombosis may be a promising strategy for SAH treatment.
Collapse
Affiliation(s)
- Jinwei Pang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yue Wu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianhua Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ping Yang
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ligang Chen
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, China
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, China.,Luzhou Key Laboratory of Neurological Diseases and Brain Function, Luzhou, China
| |
Collapse
|
57
|
Schenck H, Netti E, Teernstra O, De Ridder I, Dings J, Niemelä M, Temel Y, Hoogland G, Haeren R. The Role of the Glycocalyx in the Pathophysiology of Subarachnoid Hemorrhage-Induced Delayed Cerebral Ischemia. Front Cell Dev Biol 2021; 9:731641. [PMID: 34540844 PMCID: PMC8446455 DOI: 10.3389/fcell.2021.731641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/06/2021] [Indexed: 12/02/2022] Open
Abstract
The glycocalyx is an important constituent of blood vessels located between the bloodstream and the endothelium. It plays a pivotal role in intercellular interactions in neuroinflammation, reduction of vascular oxidative stress, and provides a barrier regulating vascular permeability. In the brain, the glycocalyx is closely related to functions of the blood-brain barrier and neurovascular unit, both responsible for adequate neurovascular responses to potential threats to cerebral homeostasis. An aneurysmal subarachnoid hemorrhage (aSAH) occurs following rupture of an intracranial aneurysm and leads to immediate brain damage (early brain injury). In some cases, this can result in secondary brain damage, also known as delayed cerebral ischemia (DCI). DCI is a life-threatening condition that affects up to 30% of all aSAH patients. As such, it is associated with substantial societal and healthcare-related costs. Causes of DCI are multifactorial and thought to involve neuroinflammation, oxidative stress, neuroinflammation, thrombosis, and neurovascular uncoupling. To date, prediction of DCI is limited, and preventive and effective treatment strategies of DCI are scarce. There is increasing evidence that the glycocalyx is disrupted following an aSAH, and that glycocalyx disruption could precipitate or aggravate DCI. This review explores the potential role of the glycocalyx in the pathophysiological mechanisms contributing to DCI following aSAH. Understanding the role of the glycocalyx in DCI could advance the development of improved methods to predict DCI or identify patients at risk for DCI. This knowledge may also alter the methods and timing of preventive and treatment strategies of DCI. To this end, we review the potential and limitations of methods currently used to evaluate the glycocalyx, and strategies to restore or prevent glycocalyx shedding.
Collapse
Affiliation(s)
- Hanna Schenck
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Eliisa Netti
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Onno Teernstra
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Inger De Ridder
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jim Dings
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Govert Hoogland
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Roel Haeren
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
58
|
Hu P, Xu Y, Liu Y, Li Y, Ye L, Zhang S, Zhu X, Qi Y, Zhang H, Sun Q, Wang Y, Deng G, Chen Q. An Externally Validated Dynamic Nomogram for Predicting Unfavorable Prognosis in Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:683051. [PMID: 34512505 PMCID: PMC8426570 DOI: 10.3389/fneur.2021.683051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/15/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Aneurysmal subarachnoid hemorrhage (aSAH) leads to severe disability and functional dependence. However, no reliable method exists to predict the clinical prognosis after aSAH. Thus, this study aimed to develop a web-based dynamic nomogram to precisely evaluate the risk of poor outcomes in patients with aSAH. Methods: Clinical patient data were retrospectively analyzed at two medical centers. One center with 126 patients was used to develop the model. Least absolute shrinkage and selection operator (LASSO) analysis was used to select the optimal variables. Multivariable logistic regression was applied to identify independent prognostic factors and construct a nomogram based on the selected variables. The C-index and Hosmer–Lemeshow p-value and Brier score was used to reflect the discrimination and calibration capacities of the model. Receiver operating characteristic curve and calibration curve (1,000 bootstrap resamples) were generated for internal validation, while another center with 84 patients was used to validate the model externally. Decision curve analysis (DCA) and clinical impact curves (CICs) were used to evaluate the clinical usefulness of the nomogram. Results: Unfavorable prognosis was observed in 46 (37%) patients in the training cohort and 24 (29%) patients in the external validation cohort. The independent prognostic factors of the nomogram, including neutrophil-to-lymphocyte ratio (NLR) (p = 0.005), World Federation of Neurosurgical Societies (WFNS) grade (p = 0.002), and delayed cerebral ischemia (DCI) (p = 0.0003), were identified using LASSO and multivariable logistic regression. A dynamic nomogram (https://hu-ping.shinyapps.io/DynNomapp/) was developed. The nomogram model demonstrated excellent discrimination, with a bias-corrected C-index of 0.85, and calibration capacities (Hosmer–Lemeshow p-value, 0.412; Brier score, 0.12) in the training cohort. Application of the model to the external validation cohort yielded a C-index of 0.84 and a Brier score of 0.13. Both DCA and CIC showed a superior overall net benefit over the entire range of threshold probabilities. Conclusion: This study identified that NLR on admission, WFNS grade, and DCI independently predicted unfavorable prognosis in patients with aSAH. These factors were used to develop a web-based dynamic nomogram application to calculate the precise probability of a poor patient outcome. This tool will benefit personalized treatment and patient management and help neurosurgeons make better clinical decisions.
Collapse
Affiliation(s)
- Ping Hu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yang Xu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yangfan Liu
- Department of Neurosurgery, the Affiliated Hospital of Panzhihua University, Panzhihua, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liguo Ye
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Si Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xinyi Zhu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yangzhi Qi
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Huikai Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qian Sun
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yixuan Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gang Deng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
59
|
Wan H, Brathwaite S, Ai J, Hynynen K, Macdonald RL. Role of perivascular and meningeal macrophages in outcome following experimental subarachnoid hemorrhage. J Cereb Blood Flow Metab 2021; 41:1842-1857. [PMID: 33444089 PMCID: PMC8327101 DOI: 10.1177/0271678x20980296] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The distribution and clearance of erythrocytes after subarachnoid hemorrhage (SAH) is poorly understood. We aimed to characterize the distribution of erythrocytes after SAH and the cells involved in their clearance. To visualize erythrocyte distribution, we injected fluorescently-labelled erythrocytes into the prechiasmatic cistern of mice. 10 minutes after injection, we found labelled erythrocytes in the subarachnoid space and ventricular system, and also in the perivascular spaces surrounding large penetrating arterioles. 2 and 5 days after SAH, fluorescence was confined within leptomeningeal and perivascular cells. We identified the perivascular cells as perivascular macrophages based on their morphology, location, Iba-1 immunoreactivity and preferential uptake of FITC-dextran. We subsequently depleted meningeal and perivascular macrophages 2 days before or 3 hours after SAH with clodronate liposomes. At day 5 after SAH, we found increased blood deposition in mice treated prior to SAH, but not those treated after. Treatment post-SAH improved neurological scoring, reduced neuronal cell death and perivascular inflammation, whereas pre-treatment only reduced perivascular inflammation. Our data indicate that after SAH, erythrocytes are distributed throughout the subarachnoid space extending into the perivascular spaces of parenchymal arterioles. Furthermore, meningeal and perivascular macrophages are involved in erythrocyte uptake and play an important role in outcome after SAH.
Collapse
Affiliation(s)
- Hoyee Wan
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Research Institute, Sunnybrook Hospital, Toronto, Canada
| | - Shakira Brathwaite
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Canada.,Sunnybrook Health Sciences Research Institute, Sunnybrook Hospital, Toronto, Canada
| | - Jinglu Ai
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Canada.,Barrow Neurological Institute, Phoenix, AZ, USA
| | - Kullervo Hynynen
- Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Research Institute, Sunnybrook Hospital, Toronto, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Canada.,Department of Neurological Surgery, University of California San Francisco, Fresno, CA, USA
| |
Collapse
|
60
|
Admission serum high mobility group box 1 (HMGB1) protein predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2021; 45:807-817. [PMID: 34302233 DOI: 10.1007/s10143-021-01607-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
High mobility group box 1 protein (HMGB1) is a prototypical damage associated particle and acts as a key player in aseptic inflammation. HMGB1 appears critical for the crosstalk of a prothrombotic and proinflammatory state that is implicated in mediating and exacerbating ischemic brain injury. The role of HMGB1 in aneurysmal subarachnoid hemorrhage (aSAH) remains to be elucidated. A prospective, single blinded observational study was designed to investigate the role of HMGB1 in aSAH. Serial serum HMGB1 level quantification on admission day 0, 4, 8, and 12 was performed. Primary outcome measures were delayed cerebral ischemia (DCI - new infarction on CT) and poor functional outcome (90-day modified Rankin Scale 4-6). The role of HMGB1 levels for DCI, functional outcome and radiological vasospasm prediction was analyzed. Collectively, 83 aSAH patients were enrolled. Five patients died within 48 h. In 29/78 patients (37.2%), DCI was identified. In multivariable analysis, radiological vasospasm and admission HMGB1 were independent predictors for DCI. Younger age and higher white blood cell count, but not insult burden (World Federation of Neurosurgical Societies scale, modified Fisher scale, intraparenchymal or intraventricular hematoma existence) correlated with admission HMGB1 levels. Serial HMGB1 levels did not differ between patients with or without DCI, poor functional outcome or radiological vasospasm development. Admission serum HMGB1 does not reflect initial insult burden but serves as an independent biomarker predictive of DCI. Further studies are warranted to disentangle the role of HMGB1 surrounding the sequelae of aSAH.
Collapse
|
61
|
Dodd WS, Noda I, Martinez M, Hosaka K, Hoh BL. NLRP3 inhibition attenuates early brain injury and delayed cerebral vasospasm after subarachnoid hemorrhage. J Neuroinflammation 2021; 18:163. [PMID: 34284798 PMCID: PMC8293512 DOI: 10.1186/s12974-021-02207-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The NLRP3 inflammasome is a critical mediator of several vascular diseases through positive regulation of proinflammatory pathways. In this study, we defined the role of NLRP3 in both the acute and delayed phases following subarachnoid hemorrhage (SAH). SAH is associated with devastating early brain injury (EBI) in the acute phase, and those that survive remain at risk for developing delayed cerebral ischemia (DCI) due to cerebral vasospasm. Current therapies are not effective in preventing the morbidity and mortality associated with EBI and DCI. NLRP3 activation is known to drive IL-1β production and stimulate microglia reactivity, both hallmarks of SAH pathology; thus, we hypothesized that inhibition of NLRP3 could alleviate SAH-induced vascular dysfunction and functional deficits. METHODS We studied NLRP3 in an anterior circulation autologous blood injection model of SAH in mice. Mice were randomized to either sham surgery + vehicle, SAH + vehicle, or SAH + MCC950 (a selective NLRP3 inhibitor). The acute phase was studied at 1 day post-SAH and delayed phase at 5 days post-SAH. RESULTS NLRP3 inhibition improved outcomes at both 1 and 5 days post-SAH. In the acute (1 day post-SAH) phase, NLRP3 inhibition attenuated cerebral edema, tight junction disruption, microthrombosis, and microglial reactive morphology shift. Further, we observed a decrease in apoptosis of neurons in mice treated with MCC950. NLRP3 inhibition also prevented middle cerebral artery vasospasm in the delayed (5 days post-SAH) phase and blunted SAH-induced sensorimotor deficits. CONCLUSIONS We demonstrate a novel association between NLRP3-mediated neuroinflammation and cerebrovascular dysfunction in both the early and delayed phases after SAH. MCC950 and other NLRP3 inhibitors could be promising tools in the development of therapeutics for EBI and DCI.
Collapse
Affiliation(s)
- William S Dodd
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Imaray Noda
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Melanie Martinez
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Koji Hosaka
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA.
| |
Collapse
|
62
|
Vasquez HE, Prasad L, Moscote-Salazar LR, Agrawal A. Atmospheric variables and subarachnoid hemorrhage: narrative review. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Abstract
Abstract
Background
Stroke is a neurological emergency that tends to be the first cause of death in many countries. Atmospheric variables are strongly associated with stroke, in which subarachnoid hemorrhage (SAH) has been associated in many studies to meteorological risk factors such as air pollution, air pressure, weather changes, and ambient temperature. These characteristics may influence the brain circulation and cause SAH, being diagnosed as idiopathic SAH or SAH with unknown cause.
Objective
The main objective of this review is to present the most relevant meteorological risk factors that may develop subarachnoid hemorrhage according to the current evidence that supports the strong association.
Conclusion
Brain vessel circulation may be influenced by atmospheric variables such as air pollution and weather changes, generating intrinsic changes in the intima of the vessels which leads to vasospasm and with comorbidities associated may develop SAH.
Collapse
|
63
|
Wipplinger C, Griessenauer CJ. Commentary: Machine Learning-Driven Metabolomic Evaluation of Cerebrospinal Fluid: Insights Into Poor Outcomes After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 88:E412-E414. [PMID: 33582769 DOI: 10.1093/neuros/nyab033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Neuroscience Institute, Danville, Pennsylvania, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| |
Collapse
|
64
|
Stetter C, Weidner F, Lilla N, Weiland J, Kunze E, Ernestus RI, Muellenbach RM, Westermaier T. Therapeutic hypercapnia for prevention of secondary ischemia after severe subarachnoid hemorrhage: physiological responses to continuous hypercapnia. Sci Rep 2021; 11:11715. [PMID: 34083595 PMCID: PMC8175721 DOI: 10.1038/s41598-021-91007-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
Temporary hypercapnia has been shown to increase cerebral blood flow (CBF) and might be used as a therapeutical tool in patients with severe subarachnoid hemorrhage (SAH). It was the aim of this study was to investigate the optimum duration of hypercapnia. This point is assumed to be the time at which buffer systems become active, cause an adaptation to changes of the arterial partial pressure of carbon dioxide (PaCO2) and annihilate a possible therapeutic effect. In this prospective interventional study in a neurosurgical ICU the arterial partial pressure of carbon dioxide (PaCO2) was increased to a target range of 55 mmHg for 120 min by modification of the respiratory minute volume (RMV) one time a day between day 4 and 14 in 12 mechanically ventilated poor-grade SAH-patients. Arterial blood gases were measured every 15 min. CBF and brain tissue oxygen saturation (StiO2) were the primary and secondary end points. Intracranial pressure (ICP) was controlled by an external ventricular drainage. Under continuous hypercapnia (PaCO2 of 53.17 ± 5.07), CBF was significantly elevated between 15 and 120 min after the start of hypercapnia. During the course of the trial intervention, cardiac output also increased significantly. To assess the direct effect of hypercapnia on brain perfusion, the increase of CBF was corrected by the parallel increase of cardiac output. The maximum direct CBF enhancing effect of hypercapnia of 32% was noted at 45 min after the start of hypercapnia. Thereafter, the CBF enhancing slowly declined. No relevant adverse effects were observed. CBF and StiO2 reproducibly increased by controlled hypercapnia in all patients. After 45 min, the curve of CBF enhancement showed an inflection point when corrected by cardiac output. It is concluded that 45 min might be the optimum duration for a therapeutic use and may provide an optimal balance between the benefits of hypercapnia and risks of a negative rebound effect after return to normal ventilation parameters. Trial registration: The study was approved by the institutional ethics committee (AZ 230/14) and registered at ClinicalTrials.gov (Trial-ID: NCT01799525). Registered 01/01/2015.
Collapse
Affiliation(s)
- Christian Stetter
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany.
| | - Franziska Weidner
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany.,Department of Neuroradiology, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Ralf Michael Muellenbach
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany.,Department of Anesthesiology, Klinikum Kassel, Moenchebergstrasse 41-43, 34125, Kassel, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| |
Collapse
|
65
|
Neuroprotective Strategies in Aneurysmal Subarachnoid Hemorrhage (aSAH). Int J Mol Sci 2021; 22:ijms22115442. [PMID: 34064048 PMCID: PMC8196706 DOI: 10.3390/ijms22115442] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) remains a disease with high mortality and morbidity. Since treating vasospasm has not inevitably led to an improvement in outcome, the actual emphasis is on finding neuroprotective therapies in the early phase following aSAH to prevent secondary brain injury in the later phase of disease. Within the early phase, neuroinflammation, thromboinflammation, disturbances in brain metabolism and early neuroprotective therapies directed against delayed cerebral ischemia (DCI) came into focus. Herein, the role of neuroinflammation, thromboinflammation and metabolism in aSAH is depicted. Potential neuroprotective strategies regarding neuroinflammation target microglia activation, metalloproteases, autophagy and the pathway via Toll-like receptor 4 (TLR4), high mobility group box 1 (HMGB1), NF-κB and finally the release of cytokines like TNFα or IL-1. Following the link to thromboinflammation, potential neuroprotective therapies try to target microthrombus formation, platelets and platelet receptors as well as clot clearance and immune cell infiltration. Potential neuroprotective strategies regarding metabolism try to re-balance the mismatch of energy need and supply following aSAH, for example, in restoring fuel to the TCA cycle or bypassing distinct energy pathways. Overall, this review addresses current neuroprotective strategies in aSAH, hopefully leading to future translational therapy options to prevent secondary brain injury.
Collapse
|
66
|
Ivanidze J, Sanelli PC. Vasospasm: Role of Imaging in Detection and Monitoring Treatment. Neuroimaging Clin N Am 2021; 31:147-155. [PMID: 33902870 DOI: 10.1016/j.nic.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cerebral vasospasm (VS) and delayed cerebral ischemia (DCI) are important complications of aneurysmal subarachnoid hemorrhage (ASAH). Imaging approaches to VS monitoring include noninvasive bedside assessment with transcranial Doppler ultrasonography, angiographic evaluation with digital subtraction angiography, and computed tomography (CT) angiography. DCI is a clinical diagnosis and is not fully explained by the presence of angiographic VS. CT perfusion has shown clinical utility and implications for future research in the evaluation of DCI in patients with ASAH. This review article discusses the common approaches to diagnosis and monitoring of VS and DCI, current treatment strategies, and future research directions.
Collapse
Affiliation(s)
- Jana Ivanidze
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA.
| | - Pina C Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 300 Community Drive, Manhasset, NY 11030, USA
| |
Collapse
|
67
|
Role of SIRT1 in Isoflurane Conditioning-Induced Neurovascular Protection against Delayed Cerebral Ischemia Secondary to Subarachnoid Hemorrhage. Int J Mol Sci 2021; 22:ijms22084291. [PMID: 33924243 PMCID: PMC8074752 DOI: 10.3390/ijms22084291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 12/19/2022] Open
Abstract
We recently reported that isoflurane conditioning provided multifaceted protection against subarachnoid hemorrhage (SAH)-induced delayed cerebral ischemia (DCI), and this protection was through the upregulation of endothelial nitric oxide synthase (eNOS). SIRT1, an NAD-dependent deacetylase, was shown to be one of the critical regulators of eNOS. The aim of our current study is to examine the role of SIRT1 in isoflurane conditioning-induced neurovascular protection against SAH-induced DCI. Mice were divided into four groups: sham, SAH, or SAH with isoflurane conditioning (with and without EX-527). Experimental SAH via endovascular perforation was performed. Anesthetic conditioning was performed with isoflurane 2% for 1 h, 1 h after SAH. EX-527, a selective SIRT1 inhibitor, 10 mg/kg was injected intraperitoneally immediately after SAH in the EX-527 group. SIRT1 mRNA expression and activity levels were measured. Vasospasm, microvessel thrombosis, and neurological outcome were assessed. SIRT1 mRNA expression was downregulated, and no difference in SIRT1 activity was noted after isoflurane exposure. Isoflurane conditioning with and without EX-527 attenuated vasospasm, microvessel thrombosis and improved neurological outcomes. Our data validate our previous findings that isoflurane conditioning provides strong protection against both the macro and micro vascular deficits induced by SAH, but this protection is likely not mediated through the SIRT1 pathway.
Collapse
|
68
|
Interleukin 6 and Aneurysmal Subarachnoid Hemorrhage. A Narrative Review. Int J Mol Sci 2021; 22:ijms22084133. [PMID: 33923626 PMCID: PMC8073154 DOI: 10.3390/ijms22084133] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
Interleukin 6 (IL-6) is a prominent proinflammatory cytokine. Neuroinflammation in general, and IL-6 signaling in particular, appear to play a major role in the pathobiology and pathophysiology of aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Most importantly, elevated IL-6 CSF (rather than serum) levels appear to correlate with delayed cerebral ischemia (DCI, “vasospasm”) and secondary (“vasospastic”) infarctions. IL-6 CSF levels may also reflect other forms of injury to the brain following SAH, i.e., early brain damage and septic complications of SAH and aneurysm treatment. This would explain why many researchers have found an association between IL-6 levels and patient outcomes. These findings clearly suggest CSF IL-6 as a candidate biomarker in SAH patients. However, at this point, discrepant findings in variable study settings, as well as timing and other issues, e.g., defining proper clinical endpoints (i.e., secondary clinical deterioration vs. angiographic vasospasm vs. secondary vasospastic infarct) do not allow for its routine use. It is also tempting to speculate about potential therapeutic measures targeting elevated IL-6 CSF levels and neuroinflammation in SAH patients. Corticosteroids and anti-platelet drugs are indeed used in many SAH cases (not necessarily with the intention to interfere with detrimental inflammatory signaling), however, no convincing benefit has been demonstrated yet. The lack of a robust clinical perspective against the background of a relatively large body of data linking IL-6 and neuroinflammation with the pathophysiology of SAH is somewhat disappointing. One underlying reason might be that most relevant studies only report correlative data. The specific molecular pathways behind elevated IL-6 levels in SAH patients and their various interactions still remain to be delineated. We are optimistic that future research in this field will result in a better understanding of the role of neuroinflammation in the pathophysiology of SAH, which in turn, will translate into the identification of suitable biomarkers and even potential therapeutic targets.
Collapse
|
69
|
Bohara S, Garg K, Singh Rajpal PM, Kasliwal M. Role of Cilostazol in Prevention of Vasospasm After Aneurysmal Subarachnoid Hemorrhage-A Systematic Review, Meta-Analysis, and Trial Sequential Analysis. World Neurosurg 2021; 150:161-170. [PMID: 33631387 DOI: 10.1016/j.wneu.2021.02.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Cerebral vasospasm is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Many drugs have been tried to mitigate cerebral vasospasm and delayed cerebral ischemia. Cilostazol, a selective inhibitor of phosphodiesterase 3, is a promising agent in preventing cerebral vasospasm and delayed cerebral ischemia after aSAH. The objective of this article was to ascertain the effect of cilostazol on cerebral vasospasm after aSAH by performing meta-analysis and trial sequential analysis. METHODS A systematic search of the literature was performed, and all the eligible randomized controlled trials were included in the meta-analysis and trial sequential analysis. RESULTS A total of 454 articles were identified using the search criteria. Six articles were selected for systematic review and the 4 randomized controlled trials were included in the meta-analysis. The pooled odds ratio for symptomatic vasospasm, new-onset infarct, and angiographic vasospasm was 0.35 (95% confidence interval [CI], 0.21-0.59; P < 0.0001), 0.38 (95% CI, 0.21-0.66; P = 0.0007) and 0.49 (95% CI, 0.31-0.80; P = 0.004), respectively. The pooled risk ratio for unfavorable outcome was 0.52 (95% CI, 0.37-0.74; P = 0.0003). CONCLUSIONS Cilostazol decreases the prevalence of symptomatic vasospasm, new-onset infarct, and angiographic vasospasm when administered after aSAH. Trial sequential analysis increased the precision of our results because the defined thresholds of effect were met by the available studies. However, further studies involving patients from other geographic areas are required to confirm the generalization of the results.
Collapse
Affiliation(s)
- Sandeep Bohara
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Manish Kasliwal
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
70
|
Effects of post-interventional antiplatelet therapy on angiographic vasospasm, delayed cerebral ischemia, and clinical outcome after aneurysmal subarachnoid hemorrhage: a single-center experience. Neurosurg Rev 2021; 44:2899-2912. [PMID: 33492514 PMCID: PMC8490212 DOI: 10.1007/s10143-021-01477-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/22/2020] [Accepted: 01/08/2021] [Indexed: 02/08/2023]
Abstract
Platelet activation has been postulated to be involved in the pathogenesis of delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to investigate potentially beneficial effects of antiplatelet therapy (APT) on angiographic CVS, DCI-related infarction and functional outcome in endovascularly treated aSAH patients. Retrospective single-center analysis of aSAH patients treated by endovascular aneurysm obliteration. Based on the post-interventional medical regime, patients were assigned to either an APT group or a control group not receiving APT. A subgroup analysis separately investigated those APT patients with aspirin monotherapy (MAPT) and those receiving dual treatment (aspirin plus clopidogrel, DAPT). Clinical and radiological characteristics were compared between groups. Possible predictors for angiographic CVS, DCI-related infarction, and an unfavorable functional outcome (modified Rankin scale ≥ 3) were analyzed. Of 160 patients, 85 (53%) had received APT (n = 29 MAPT, n = 56 DAPT). APT was independently associated with a lower incidence of an unfavorable functional outcome (OR 0.40 [0.19-0.87], P = 0.021) after 3 months. APT did not reduce the incidence of angiographic CVS or DCI-related infarction. The pattern of angiographic CVS or DCI-related infarction as well as the rate of intracranial hemorrhage did not differ between groups. However, the lesion volume of DCI-related infarctions was significantly reduced in the DAPT subgroup (P = 0.011). Post-interventional APT in endovascularly treated aSAH patients is associated with better functional outcome at 3 months. The beneficial effect of APT might be mediated by reduction of the size of DCI-related infarctions.
Collapse
|
71
|
Barpujari A, Patel C, Zelmonovich R, Clark A, Patel D, Pierre K, Scott K, Lucke Wold B. Pharmaceutical Management for Subarachnoid Hemorrhage. RECENT TRENDS IN PHARMACEUTICAL SCIENCES AND RESEARCH 2021; 3:16-30. [PMID: 34984419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/28/2022]
Abstract
Aneurysmal subarachnoid hemorrhage can have deleterious consequences. Vasospasm, delayed cerebral ischemia, and re-hemorrhage can all cause delayed sequelae. Furthermore, severe headaches are common and require careful modulation of pain medications. Limited treatment options currently exist and are becoming more complex with the rising use of oral anticoagulants needing reversal. In this review, we highlight the current treatment options currently employed and address avenues of future discovery based on emerging preclinical data. Furthermore, we dive into the best treatment approach for managing headaches following subarachnoid hemorrhage. The review is designed to serve as a catalyst for further prospective investigation into this important topic.
Collapse
Affiliation(s)
- Arnav Barpujari
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Chhaya Patel
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Alec Clark
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Devan Patel
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kyle Scott
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | |
Collapse
|
72
|
Failed Neuroprotection of Combined Inhibition of L-Type and ASIC1a Calcium Channels with Nimodipine and Amiloride. Int J Mol Sci 2020; 21:ijms21238921. [PMID: 33255506 PMCID: PMC7727815 DOI: 10.3390/ijms21238921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 01/15/2023] Open
Abstract
Effective pharmacological neuroprotection is one of the most desired aims in modern medicine. We postulated that a combination of two clinically used drugs-nimodipine (L-Type voltage-gated calcium channel blocker) and amiloride (acid-sensing ion channel inhibitor)-might act synergistically in an experimental model of ischaemia, targeting the intracellular rise in calcium as a pathway in neuronal cell death. We used organotypic hippocampal slices of mice pups and a well-established regimen of oxygen-glucose deprivation (OGD) to assess a possible neuroprotective effect. Neither nimodipine (at 10 or 20 µM) alone or in combination with amiloride (at 100 µM) showed any amelioration. Dissolved at 2.0 Vol.% dimethyl-sulfoxide (DMSO), the combination of both components even increased cell damage (p = 0.0001), an effect not observed with amiloride alone. We conclude that neither amiloride nor nimodipine do offer neuroprotection in an in vitro ischaemia model. On a technical note, the use of DMSO should be carefully evaluated in neuroprotective experiments, since it possibly alters cell damage.
Collapse
|
73
|
Bader ER, Allam MM, Harris TGW, Suchdev N, Loke YK, Barlas R. Thrombolysis for aneurysmal subarachnoid haemorrhage. Hippokratia 2020. [DOI: 10.1002/14651858.cd013748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Edward R Bader
- Department of Neurological Surgery; Albert Einstein College of Medicine, Montefiore Medical Center; New York USA
| | - Mazen M Allam
- Foundation Programme; NHS Ayrshire and Arran; Kilmarnock UK
| | - Thomas G W Harris
- Department of Plastic and Reconstructive Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland USA
| | - Neena Suchdev
- Foundation Programme; Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - Yoon Kong Loke
- Norwich Medical School; University of East Anglia; Norwich UK
| | - Raphae Barlas
- Ageing Clinical and Experimental Research; University of Aberdeen; Aberdeen UK
| |
Collapse
|
74
|
Sun GU, Park E, Kim DW, Kang SD. Dual antiplatelet treatment associated with reduced risk of symptomatic vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2020; 22:134-140. [PMID: 32971572 PMCID: PMC7522390 DOI: 10.7461/jcen.2020.22.3.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/08/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) are considered complications after aneurysmal subarachnoid hemorrhage (aSAH). Several hypotheses involving platelet activation have been asserted in the pathophysiology of cerebral vasospasm and DCI. This study aimed to investigate the effect of dual antiplatelet treatment (DAPT) on symptomatic vasospasm and DCI in patients with aSAH. METHODS A retrospective study was conducted on patients with aSAH from 2009 to 2018. The patients are divided into 2 groups according to the treatment method such as simple or balloon-assisted coil embolization group (SB coiling), and stent-assisted coil embolization group. Patients treated by SB coiling without DAPT were classified as the control group. Patients who required dual antiplatelet treatment due to stent-assisted coil embolization were classified as DAPT group. The incidence of symptomatic vasospasm and DCI was compared between the two groups. RESULTS Of 743 patients with aSAH, 563 patients were treated with clipping, 115 patients treated with SB coiling, and 65 patients receive stent-assisted coiling. Among 115 patients underwent SB coiling, 14 patients were excluded by the exclusion criteria. Total number of control group (SB coiling) was 101, DAPT group (stent-assisted coiling) was 65. Depending on whether or not taking DAPT, the incidence of symptomatic vasospasm was lower in the DAPT group (p=0.010). DCI incidence was also lower in the DAPT group, which was statistically significant (p=0.029). CONCLUSIONS DAPT reduces the frequency of symptomatic vasospasm and DCI in patients with aSAH in our single-center study. To warranting this topic, further, larger prospective and randomized studies should be needed.
Collapse
Affiliation(s)
- Gyeong-Ung Sun
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Eunsung Park
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| |
Collapse
|
75
|
Wang HB, Wang WQ, Wu QJ, Hou YJ, Li HX, Yang HJ, Yang MF, Sun BL, Zhang ZY. Negative Allosteric Modulator of mGluR1 Improves Long-Term Neurologic Deficits after Experimental Subarachnoid Hemorrhage. ACS Chem Neurosci 2020; 11:2869-2880. [PMID: 32786302 DOI: 10.1021/acschemneuro.0c00485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) causes permanent neurological sequelae, but the underlying mechanism needs to be further clarified. Here, we show that inhibition of metabotropic glutamate receptor 1 (mGluR1) with negative allosteric modulator JNJ16259685 improves long-term neurobehavioral outcomes in an endovascular perforation model of SAH. JNJ16259685 improves cerebrovascular dysfunction through attenuation of cerebral blood flow (CBF) reduction, cerebral vasoconstrictio, and microthrombosis formation in a rat SAH model. Moreover, JNJ16259685 reduces experimental SAH-induced long-term neuronal damage through alleviation of neuronal death and degeneration. Mechanically, JNJ16259685 maintains phosphorylation of endothelial NO synthase (eNOS) and vasodilator-stimulated phosphoprotein (VASP) and decreases apoptosis-related factors Bax, active caspase-9, and active caspase-3 following experimental SAH. Altogether, our results suggest JNJ16259685 improves long-term functional impairment through neurovascular protection.
Collapse
Affiliation(s)
- Hong-Bin Wang
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| | - Wei-qi Wang
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
- Department of Neurology, Medical College of Qingdao University, Qingdao 266021, Shandong, People’s Republic of China
| | - Qing-Jian Wu
- Department of Emergency, Jining No. 1 People’s Hospital, Jining 272011, People’s Republic of China
| | - Ya-jun Hou
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| | - Han-xia Li
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| | - Hui-juan Yang
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| | - Ming-feng Yang
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| | - Bao-liang Sun
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| | - Zong-yong Zhang
- Department of Neurology, Second Affiliated Hospital; Key Laboratory of Cerebral Microcirculation, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian 271016, Shandong, People’s Republic of China
| |
Collapse
|
76
|
Wang HB, Wu QJ, Zhao SJ, Hou YJ, Li HX, Yang MF, Wang BJ, Sun BL, Zhang ZY. Early High Cerebrospinal Fluid Glutamate: A Potential Predictor for Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. ACS OMEGA 2020; 5:15385-15389. [PMID: 32637812 PMCID: PMC7331073 DOI: 10.1021/acsomega.0c01472] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/04/2020] [Indexed: 06/11/2023]
Abstract
Delayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Early identification of cerebrospinal fluid (CSF) markers is helpful for warning of impending DCI. This study assessed whether early high CSF glutamate levels can be observed in aSAH patients who later developed DCI. In this prospective clinical study, patients with normal pressure hydrocephalus or aSAH were enrolled. We found that the early CSF levels of glutamate were significantly elevated in aSAH patients compared to patients with normal pressure hydrocephalus. There was a significant difference in early CSF levels of glutamate between aSAH patients without DCI and with DCI. The early CSF levels of glutamate are significantly related to the Hunt and Hess grade, the World Federation of Neurological Surgeons (WFNS) grade, and the modified Fisher score on admission and occurrence of DCI in aSAH patients. Preliminary evidence of this study suggests that early high CSF glutamate levels are correlated with DCI in aSAH patients.
Collapse
Affiliation(s)
- Hong-Bin Wang
- School of Medicine, Shandong University, Jinan 250012, People’s
Republic of China
- Key Lab of Cerebral Microcirculation, School
of Basic Medical Sciences, Shandong First
Medical University & Shandong Academy of Medical Sciences, Taian 271016, People’s Republic of China
| | - Qing-Jian Wu
- Department
of Emergency, Jining No. 1 People’s
Hospital, Jining 272011, People’s Republic of China
| | - Shi-jun Zhao
- Department of Neurology, Baotou Central
Hospital, Baotou 014040, People’s Republic of China
| | - Ya-jun Hou
- Key Lab of Cerebral Microcirculation, School
of Basic Medical Sciences, Shandong First
Medical University & Shandong Academy of Medical Sciences, Taian 271016, People’s Republic of China
| | - Han-xia Li
- Key Lab of Cerebral Microcirculation, School
of Basic Medical Sciences, Shandong First
Medical University & Shandong Academy of Medical Sciences, Taian 271016, People’s Republic of China
| | - Ming-feng Yang
- Key Lab of Cerebral Microcirculation, School
of Basic Medical Sciences, Shandong First
Medical University & Shandong Academy of Medical Sciences, Taian 271016, People’s Republic of China
| | - Bao-Jun Wang
- Department of Neurology, Baotou Central
Hospital, Baotou 014040, People’s Republic of China
| | - Bao-liang Sun
- Key Lab of Cerebral Microcirculation, School
of Basic Medical Sciences, Shandong First
Medical University & Shandong Academy of Medical Sciences, Taian 271016, People’s Republic of China
| | - Zong-yong Zhang
- Key Lab of Cerebral Microcirculation, School
of Basic Medical Sciences, Shandong First
Medical University & Shandong Academy of Medical Sciences, Taian 271016, People’s Republic of China
| |
Collapse
|
77
|
Cerebrospinal Fluid Concentrations of Nimodipine Correlate With Long-term Outcome in Aneurysmal Subarachnoid Hemorrhage: Pilot Study. Clin Neuropharmacol 2020; 42:157-162. [PMID: 31306217 DOI: 10.1097/wnf.0000000000000356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim was to evaluate plasma and cerebrospinal fluid (CSF) nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage and their correlation with clinical outcome. METHODS Nimodipine infusion was started at 1 mg/h and increased up to 2 mg/h and continued up to 21 days in surviving patients. Arterial and CSF samples were collected at least after 24 hours of stable nimodipine dosing. Delayed cerebral ischemia and vasospasm were documented by new neurological deficits and neuroimaging. The clinical outcome was assessed at 9 months by the modified Rankin scale. RESULTS Twenty-three patients were enrolled. Nimodipine dose was 13 to 38 μg/kg per hour. Nimodipine arterial and CSF concentrations were 24.9 to 71.8 ng/mL and 37 to 530 pg/mL, respectively. Dose did not correlate with arterial or CSF concentrations. Arterial concentrations did not correlate with corresponding CSF concentrations. Doses and arterial concentrations did not correlate with the clinical outcome and were not associated with the occurrence of delayed cerebral ischemia. However, patients with no significant disability after 9 months of hemorrhage showed significantly higher CSF nimodipine concentrations (P = 0.015) and CSF-to-plasma ratios (P = 0.011) compared with patients who showed some degree of disability or who died. CONCLUSIONS Cerebrospinal fluid nimodipine concentrations measured during hospital drug infusion showed a correlation with long-term clinical outcome in patients with aneurysmal subarachnoid hemorrhage. These very preliminary data suggest that CSF concentrations monitoring may have some value in managing these patients.
Collapse
|
78
|
Hurth H, Birkenhauer U, Steiner J, Schlak D, Hennersdorf F, Ebner FH. Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage – Serum D-dimer and C-reactive Protein as Early Markers. J Stroke Cerebrovasc Dis 2020; 29:104558. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104558] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/19/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022] Open
|
79
|
Oka F, Chung DY, Suzuki M, Ayata C. Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: Experimental-Clinical Disconnect and the Unmet Need. Neurocrit Care 2020; 32:238-251. [PMID: 30671784 PMCID: PMC7387950 DOI: 10.1007/s12028-018-0650-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is among the most dreaded complications following aneurysmal subarachnoid hemorrhage (SAH). Despite advances in neurocritical care, DCI remains a significant cause of morbidity and mortality, prolonged intensive care unit and hospital stay, and high healthcare costs. Large artery vasospasm has classically been thought to lead to DCI. However, recent failure of clinical trials targeting vasospasm to improve outcomes has underscored the disconnect between large artery vasospasm and DCI. Therefore, interest has shifted onto other potential mechanisms such as microvascular dysfunction and spreading depolarizations. Animal models can be instrumental in dissecting pathophysiology, but clinical relevance can be difficult to establish. METHODS Here, we performed a systematic review of the literature on animal models of SAH, focusing specifically on DCI and neurological deficits. RESULTS We find that dog, rabbit and rodent models do not consistently lead to DCI, although some degree of delayed vascular dysfunction is common. Primate models reliably recapitulate delayed neurological deficits and ischemic brain injury; however, ethical issues and cost limit their translational utility. CONCLUSIONS To facilitate translation, clinically relevant animal models that reproduce the pathophysiology and cardinal features of DCI after SAH are urgently needed.
Collapse
Affiliation(s)
- Fumiaki Oka
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - David Y Chung
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Cenk Ayata
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| |
Collapse
|
80
|
Zhuang K, Zuo YC, Sherchan P, Wang JK, Yan XX, Liu F. Hydrogen Inhalation Attenuates Oxidative Stress Related Endothelial Cells Injury After Subarachnoid Hemorrhage in Rats. Front Neurosci 2020; 13:1441. [PMID: 32038143 PMCID: PMC6985445 DOI: 10.3389/fnins.2019.01441] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease with poor clinical outcome. Nucleotide binding and oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome serves a key role in inflammatory response, which may lead to endothelial cell injury and blood-brain barrier (BBB) disruption. Hydrogen (H2) is considered a neuroprotective antioxidant. This study was set out to explore whether hydrogen inhalation protects against SAH induced endothelial cell injury, BBB disruption, microthrombosis and vasospasm in rats. Methods: One hundred eighty-two male SD rats were used for the study. SAH was induced by endovascular perforation. H2 at a concentration of 3.3% was inhaled beginning at 0.5 h after SAH for duration of 30, 60 or 120 min, followed by single administration or once daily administration for 3 days. The temporal expression of NLRP3 and ASC in the brain was determined, with the effect of hydrogen inhalation evaluated. In addition, brain water content, oxidative stress markers, inflammasome, apoptotic markers, microthrombosis, and vasospasm were evaluated at 24 or 72 h after SAH. Results: The expression of NLRP3 and ASC were upregulated after SAH associated with elevated expression of MDA, 8-OHdG, 4-HNE, HO-1, TLR4/NF-κB, inflammatory and apoptotic makers. Hydrogen inhalation reduced the expression of these inflammatory and apoptotic makers in the vessels, brain edema, microthrombi formation, and vasospasm in rats with SAH relative to control. Hydrogen inhalation also improved short-term and long-term neurological recovery after SAH. Conclusion: Hydrogen inhalation can ameliorate oxidative stress related endothelial cells injury in the brain and improve neurobehavioral outcomes in rats following SAH. Mechanistically, the above beneficial effects might be related to, at least in part, the inhibition of activation of ROS/NLRP3 axis.
Collapse
Affiliation(s)
- Kai Zhuang
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yu-Chun Zuo
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Prativa Sherchan
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Ji-Kai Wang
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-Xin Yan
- Department of Anatomy and Neurobiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Fei Liu
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
81
|
Khattar NK, Bak E, White AC, James RF. Heparin Treatment in Aneurysmal Subarachnoid Hemorrhage: A Review of Human Studies. ACTA NEUROCHIRURGICA SUPPLEMENT 2020; 127:15-19. [DOI: 10.1007/978-3-030-04615-6_3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
82
|
Zuo Y, He T, Liao P, Zhuang K, Yan X, Liu F. 17-Allylamino-Demethoxygeldanamycin Ameliorate Microthrombosis Via HSP90/RIP3/NLRP3 Pathway After Subarachnoid Hemorrhage in Rats. ACTA NEUROCHIRURGICA. SUPPLEMENT 2020; 127:69-75. [PMID: 31407066 DOI: 10.1007/978-3-030-04615-6_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is a severe and emergent cerebrovascular disease, the prognosis of which usually very poor. Microthrombi formation highlighted with inflammation occurs early after SAH. As the main cause of DCI, microthrombosis associated with the prognosis of SAH. The aim of this study was to show HSP90 inhibitor 17-AAG effect on microthrombosis after SAH in rats. METHODS Ninety-five SD rats were used for the experiment. For time course study, the rats were randomly divided into five groups: sham group and SAH group with different time point (1d, 2d, 3d, 5d). Endovascular perforation method was conducted for SAH model. Neurological score, SAH grade, and mortality were measured after SAH. The samples of the left hemisphere brain were collected. The expression of HSP90 was detected by Western blot. The microthrombosis after SAH in rats' brain was detected by immunohistochemistry. For mechanism study, rats were randomly divided into three groups: sham, SAH + vehicle, and SAH +17-AAG (n = 6/group). 17-AAG was given by intraperitoneal injection (80 mg/kg) 1 h after SAH. Neurological function were measured at 24 h after SAH. The expression of RIP3, NLRP3, ASC, and IL-1β was measured by Western blot. Microthrombosis was detected by immunohistochemistry. RESULTS Our results showed that the HSP90 protein level increased and peaked at 2 days after SAH. Microthrombosis caused by SAH was increased in 1 day and peaked at 2 days after SAH. Administration HSP90 specific inhibitor 17-AAG reduced expression of RIP3, NLRP3, ASC, and IL-1β, reduced microthrombosis after SAH, and improved neurobehavior when compared to vehicle group. CONCLUSIONS 17-AAG can ameliorate microthrombosis via HSP90/RIP3/NLRP3 pathway and improve neurobehavior after SAH.
Collapse
Affiliation(s)
- Yuchun Zuo
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Tibiao He
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Peiqiang Liao
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Kai Zhuang
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoxin Yan
- Department of Anatomy, The XiangYa Medical School, Central South University, Changsha, China
| | - Fei Liu
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China.
| |
Collapse
|
83
|
Zhao DD, Guo ZD, He S, Yin C. High intracranial pressure may be the initial inducer of elevated plasma D-dimer level after aneurysmal subarachnoid haemorrhage. Int J Neurosci 2019; 130:694-699. [PMID: 31852390 DOI: 10.1080/00207454.2019.1702546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Dong-Dong Zhao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Zong-Duo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sen He
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Cheng Yin
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| |
Collapse
|
84
|
van der Steen WE, Marquering HA, Boers AM, Ramos LA, van den Berg R, Vergouwen MD, Majoie CB, Coert BA, Vandertop WP, Verbaan D, Roos YB. Predicting Delayed Cerebral Ischemia with Quantified Aneurysmal Subarachnoid Blood Volume. World Neurosurg 2019; 130:e613-e619. [DOI: 10.1016/j.wneu.2019.06.170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/20/2019] [Indexed: 01/27/2023]
|
85
|
Savarraj J, Parsha K, Hergenroeder G, Ahn S, Chang TR, Kim DH, Choi HA. Early Brain Injury Associated with Systemic Inflammation After Subarachnoid Hemorrhage. Neurocrit Care 2019; 28:203-211. [PMID: 29043545 DOI: 10.1007/s12028-017-0471-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH) is defined as brain injury occurring within 72 h of aneurysmal rupture. Although EBI is the most significant predictor of outcomes after aSAH, its underlying pathophysiology is not well understood. We hypothesize that EBI after aSAH is associated with an increase in peripheral inflammation measured by cytokine expression levels and changes in associations between cytokines. METHODS aSAH patients were enrolled into a prospective observational study and were assessed for markers of EBI: global cerebral edema (GCE), subarachnoid hemorrhage early brain edema score (SEBES), and Hunt-Hess grade. Serum samples collected at ≤ 48 h of admission were analyzed using multiplex bead-based assays to determine levels of 13 pro- and anti-inflammatory cytokines. Pairwise correlation coefficients between cytokines were represented as networks. Cytokine levels and differences in correlation networks were compared between EBI groups. RESULTS Of the 71 patients enrolled in the study, 17 (24%) subjects had GCE, 31 (44%) subjects had SEBES ≥ 3, and 21 (29%) had HH ≥ 4. IL-6 was elevated in groups with GCE, SEBES ≥ 3, and HH ≥ 4. MIP1β was independently associated with high-grade SEBES. Correlation network analysis suggests higher systematic inflammation in subjects with SEBES ≥ 3. CONCLUSIONS EBI after SAH is associated with increased levels of specific cytokines. Peripheral levels of IL-10, IL-6, and MIP1β may be important markers of EBI. Investigating systematic correlations in addition to expression levels of individual cytokines may offer deeper insight into the underlying mechanisms related to EBI.
Collapse
Affiliation(s)
- Jude Savarraj
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Kaushik Parsha
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Georgene Hergenroeder
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Sungho Ahn
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Tiffany R Chang
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Dong H Kim
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - H Alex Choi
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA.
| |
Collapse
|
86
|
Wang S, Li B, Yin T, Hong J, Gu J, Wei L. Cerebral venous circulation changes caused by aneurysmal subarachnoid hemorrhage. Clin Hemorheol Microcirc 2019; 74:127-138. [PMID: 31524149 DOI: 10.3233/ch-190573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aneurysmal subarachnoid hemorrhage (aSAH) is an acute severe hemorrhagic stroke with high morbidity and mortality with poor prognosis. OBJECTIVE This study aims to analyze the changes of cerebral venous circulation in patients with aneurysmal subarachnoid hemorrhage by digital subtraction angiography (DSA). MATERIALS AND METHODS Totally, 57 patients with aSAH, 48 patients with unruptured aneurysms, and 45 patients without aneurysms (control group) were enrolled. The microvascular cerebral circulation time (mCCT), venous cerebral circulation time (vCCT), cerebral arterioles and cortical veins were analyzed by DSA. RESULTS There were changes of cerebral microvessels and cortical veins in patients with aSAH. The mCCT (6.15±1.37 s) and vCCT (2.79±0.34 s) of aSAH patients significantly increased compared with control patients (3.74±0.50 s; 2.64±0.32 s) (P < 0.05). However, the mCCT increased more compared with vCCT in aSAH patients (P < 0.001), while the vCCT increased more compared with mCCT in severe aSAH cases (P < 0.01). There was no significant difference in mCCT and vCCT between patients with unruptured aneurysms and controls (P = 0.131; P = 0.621). CONCLUSIONS The mCCT increases in acute aSAH patients within 72 hours and vCCT increases in severe aSAH cases.
Collapse
Affiliation(s)
- S Wang
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fujian, China
| | - B Li
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fujian, China
| | - T Yin
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fujian, China
| | - J Hong
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fujian, China
| | - J Gu
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fujian, China
| | - L Wei
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fujian, China
| |
Collapse
|
87
|
Griffiths S, Clark J, Adamides AA, Ziogas J. The role of haptoglobin and hemopexin in the prevention of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a review of current literature. Neurosurg Rev 2019; 43:1273-1288. [PMID: 31493061 DOI: 10.1007/s10143-019-01169-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 01/01/2023]
Abstract
Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major cause of mortality and morbidity. The pathophysiology of DCI after aSAH is thought to involve toxic mediators released from lysis of red blood cells within the subarachnoid space, including free haemoglobin and haem. Haptoglobin and hemopexin are endogenously produced acute phase proteins that are involved in the clearance of these toxic mediators. The aim of this review is to investigate the pathophysiological mechanisms involved in DCI and the role of both endogenous as well as exogenously administered haptoglobin and hemopexin in the prevention of DCI.
Collapse
Affiliation(s)
- Sean Griffiths
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia. .,Western Hospital, 160 Gordon St, Footscray, 3011, Australia.
| | - Jeremy Clark
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - Alexios A Adamides
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - James Ziogas
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, 3010, Australia
| |
Collapse
|
88
|
Lai PMR, Gormley WB, Patel N, Frerichs KU, Aziz-Sultan MA, Du R. Age-Dependent Radiographic Vasospasm and Delayed Cerebral Ischemia in Women After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e230-e235. [PMID: 31203057 DOI: 10.1016/j.wneu.2019.06.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Recent literature suggests there are sex differences in delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Our study serves to compare sex differences in radiographic vasospasm, DCI, and clinical outcome after aSAH, and to determine whether there are age-dependent differences. METHODS A total of 328 patients with ruptured cerebral aneurysms were evaluated for radiographic vasospasm, clinical deterioration, cerebral infarction, and modified Rankin Scale-determined clinical outcome at 6 months to 1 year after rupture. Multivariate regression analyses were performed to evaluate the associations between these outcome measures and sex, adjusting for age, hypertension, aneurysm location, admission Hunt and Hess grade, and modified Fisher grade. RESULTS After multivariate adjustment, women had higher rates of radiographic vasospasm (β = 0.35; 95% confidence interval [CI], 0.068-0.63; P = 0.015), clinical deterioration (odds ratio [OR], 2.8; 95% CI, 1.3-6.0; P = 0.008) and cerebral infarction (OR, 2.4; 95% CI, 1.0-5.5; P = 0.039), but no difference was observed in follow-up modified Rankin Scale (mRS) outcome score at 6 months to 1 year (P = 0.96). Older women (age >55 years) have a higher rate of clinical deterioration than men in the same age group (OR, 3.5; 95% CI, 1.0-12; P = 0.043). In contrast, younger women (age ≤55 years) had increased radiographic vasospasm (β = 0.55; 95% CI, 0.17-0.93; P = 0.005) and worse mRS outcome score (β = 0.042; 95% CI, -0.021 to 1.1; P = 0.042) compared with men. CONCLUSIONS Female sex is associated with a higher risk of radiographic vasospasm, clinical deterioration, and cerebral infarction. Furthermore, this association appears to be age-dependent. This study further supports the unique role of sex, and highlights the need to better understand the possible role of female hormones in the development of complications of subarachnoid hemorrhage.
Collapse
Affiliation(s)
- Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Patel
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
89
|
Liu ZW, Zhao JJ, Pang HG, Song JN. Vascular endothelial growth factor A promotes platelet adhesion to collagen IV and causes early brain injury after subarachnoid hemorrhage. Neural Regen Res 2019; 14:1726-1733. [PMID: 31169190 PMCID: PMC6585561 DOI: 10.4103/1673-5374.257530] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The role of vascular endothelial growth factor A in platelet adhesion in cerebral microvessels in the early stage of subarachnoid hemorrhage remains unclear. In this study, the endovascular puncture method was used to produce a rat model of subarachnoid hemorrhage. Then, 30 minutes later, vascular endothelial growth factor A antagonist anti-vascular endothelial growth factor receptor 2 antibody, 10 μg, was injected into the right ventricle. Immunohistochemistry and western blot assay were used to assess expression of vascular endothelial growth factor A, occludin and claudin-5. Immunohistochemical double labeling was conducted to examine co-expression of GP Ia-II integrin and type IV collagen. TUNEL was used to detect apoptosis in the hippocampus. Neurological score was used to assess behavioral performance. After subarachnoid hemorrhage, the expression of vascular endothelial growth factor A increased in the hippocampus, while occludin and claudin-5 expression levels decreased. Co-expression of GP Ia-II integrin and type IV collagen and the number of apoptotic cells increased, whereas behavioral performance was markedly impaired. After treatment with anti-vascular endothelial growth factor receptor 2 antibody, occludin and claudin-5 expression recovered, while co-expression of GP Ia-II integrin and type IV collagen and the number of apoptotic cells decreased. Furthermore, behavioral performance improved notably. Our findings suggest that increased vascular endothelial growth factor A levels promote platelet adhesion and contribute to early brain injury after subarachnoid hemorrhage. This study was approved by the Biomedical Ethics Committee, Medical College of Xi’an Jiaotong University, China in December 2015.
Collapse
Affiliation(s)
- Zun-Wei Liu
- Department of Renal Transplantation, Nephropathy Hospital, the First Affiliated Hospital, Medical College of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Jun-Jie Zhao
- Department of Neurosurgery, the First Affiliated Hospital, Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hong-Gang Pang
- The First Affiliated Hospital, Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Jin-Ning Song
- Department of Neurosurgery, the First Affiliated Hospital, Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| |
Collapse
|
90
|
Abstract
BACKGROUND High red cell distribution width (RDW) values have been associated with increased hospital mortality in critically ill patients, but few data are available for subarachnoid hemorrhage (SAH). METHODS We analyzed an institutional database of adult (>18 y) patients admitted to the Department of Intensive Care after nontraumatic SAH between January 2011 and May 2016. RDW (normal value, 10.9% to 13.4%) was obtained daily from admission for a maximum of 7 days, from routine blood analysis. We recorded the occurrence of delayed cerebral ischemia (DCI), and neurological outcome (assessed using the Glasgow Outcome Scale [GOS]) at 3 months. RESULTS A total of 270 patients were included (median age 54 y-121/270 male [45%]), of whom 96 (36%) developed DCI and 109 (40%) had an unfavorable neurological outcome (GOS, 1 to 3). The median RDW on admission was 13.8 [13.3 to 14.5]% and the highest value during the intensive care unit (ICU) stay 14.2 [13.6 to 14.8]%. The RDW was high (>13.4%) in 177 patients (66%) on admission and in 217 (80%) at any time during the ICU stay. Patients with a high RDW on admission were more likely to have an unfavorable neurological outcome. In multivariable regression analysis, older age, a high WFNS grade on admission, presence of DCI or intracranial hypertension, previous neurological disease, vasopressor therapy and a high RDW (OR, 1.1618 [95% CI, 1.213-2.158]; P=0.001) during the ICU stay were independent predictors of unfavorable neurological outcome. CONCLUSIONS High RDW values were more likely to result in an unfavorable outcome after SAH. This information could help in the stratification of SAH patients already on ICU admission.
Collapse
|
91
|
Ischemic Lesions in Acute and Subacute Perimesencephalic Subarachnoid Hemorrhage. AJR Am J Roentgenol 2018; 212:418-424. [PMID: 30557051 DOI: 10.2214/ajr.18.19700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Perimesencephalic hemorrhage (PMH) is a subtype of nonaneurysmal subarachnoid hemorrhage (SAH). In patients with aneurysmal SAH, the occurrence of acute ischemic lesions is associated with severity and poor outcome. We investigated the frequency of ischemic lesions on DWI in patients with PMH and compared it with the frequency of ischemic lesions in patients with aneurysmal SAH. SUBJECTS AND METHODS From a prospective cohort of 80 patients with acute spontaneous SAH, we included 15 patients with PMH and 39 patients with aneurysmal SAH who were matched on the basis of their clinical condition (World Federation of Neurological Societies grade 1 or 2). MRI was performed less than 72 hours after SAH, 8-10 days after SAH, or at both points in time. The number and distribution of lesions previously seen on DWI that were also seen on a second MRI examination were assessed. Nonparametric tests were used to compare groups. RESULTS Early acute ischemic lesions (those identified < 72 hours after SAH) were found in 46.2% of patients with PMH and in 62.9% of patients with aneurysmal SAH. No significant differences in the number of acute ischemic lesions between groups were noted less than 72 hours after SAH (median, 0.5 lesion [interquartile range {IQR}, two lesions] in patients with PMH vs one lesion [IQR, three lesions] in patients with aneurysmal SAH [p = 0.48] or 8-10 days after SAH (median, 0.5 lesion [IQR, four lesions] in patients with PMH vs 1.5 lesions [IQR, three lesions] in patients with aneurysmal SAH [p = 0.26]). However, 58.3% of patients with aneurysmal SAH had new infarcts at 8-10 days, compared with 7.1% of patients with PMH. Patients with PMH had diffuse ischemic lesions, whereas patients with aneurysmal SAH in the anterior circulation had mainly supratentorial lesions. CONCLUSION Early ischemic lesions appeared on DWI both in patients with PMH and in patients with aneurysmal SAH. The number of lesions increased during the time window for vasospasm, mainly in patients with aneurysmal SAH. Further studies are required to better understand the pathophysiologic mechanisms behind early ischemia in patients with PMH and their impact on prognosis.
Collapse
|
92
|
Petridis AK, Kamp MA, Cornelius JF, Beez T, Beseoglu K, Turowski B, Steiger HJ. Aneurysmal Subarachnoid Hemorrhage. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:226-236. [PMID: 28434443 DOI: 10.3238/arztebl.2017.0226] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 08/29/2016] [Accepted: 11/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living. METHODS This article is based on a selective review of pertinent literature retrieved by a PubMed search. RESULTS Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping). CONCLUSION SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.
Collapse
Affiliation(s)
- Athanasios K Petridis
- Department of Neurosurgery, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital
| | | | | | | | | | | | | |
Collapse
|
93
|
Endothelial Cell Dysfunction and Injury in Subarachnoid Hemorrhage. Mol Neurobiol 2018; 56:1992-2006. [DOI: 10.1007/s12035-018-1213-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/27/2018] [Indexed: 01/15/2023]
|
94
|
Blackburn SL, Kumar PT, McBride D, Zeineddine HA, Leclerc J, Choi HA, Dash PK, Grotta J, Aronowski J, Cardenas JC, Doré S. Unique Contribution of Haptoglobin and Haptoglobin Genotype in Aneurysmal Subarachnoid Hemorrhage. Front Physiol 2018; 9:592. [PMID: 29904350 PMCID: PMC5991135 DOI: 10.3389/fphys.2018.00592] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/02/2018] [Indexed: 01/12/2023] Open
Abstract
Survivors of cerebral aneurysm rupture are at risk for significant morbidity and neurological deficits. Much of this is related to the effects of blood in the subarachnoid space which induces an inflammatory cascade with numerous downstream consequences. Recent clinical trials have not been able to reduce the toxic effects of free hemoglobin or improve clinical outcome. One reason for this may be the inability to identify patients at high risk for neurologic decline. Recently, haptoglobin genotype has been identified as a pertinent factor in diabetes, sickle cell, and cardiovascular disease, with the Hp 2-2 genotype contributing to increased complications. Haptoglobin is a protein synthesized by the liver that binds free hemoglobin following red blood cell lysis, and in doing so, prevents hemoglobin induced toxicity and facilitates clearance. Clinical studies in patients with subarachnoid hemorrhage indicate that Hp 2-2 patients may be a high-risk group for hemorrhage related complications and poor outcome. We review the relevance of haptoglobin in subarachnoid hemorrhage and discuss the effects of genotype and expression levels on the known mechanisms of early brain injury (EBI) and cerebral ischemia after aneurysm rupture. A better understanding of haptoglobin and its role in preventing hemoglobin related toxicity should lead to novel therapeutic avenues.
Collapse
Affiliation(s)
- Spiros L Blackburn
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Peeyush T Kumar
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Devin McBride
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Jenna Leclerc
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, FL, United States
| | - H Alex Choi
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Pramod K Dash
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - James Grotta
- Department of Neurology, The University of Texas Health Sciences Center, Houston, TX, United States
| | - Jaroslaw Aronowski
- Department of Neurology, The University of Texas Health Sciences Center, Houston, TX, United States
| | - Jessica C Cardenas
- Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, The University of Texas Health Science Center, Houston, TX, United States
| | - Sylvain Doré
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, FL, United States.,Departments of Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience, University of Florida, McKnight Brain Institute, Gainesville, FL, United States
| |
Collapse
|
95
|
James RF, Khattar NK, Aljuboori ZS, Page PS, Shao EY, Carter LM, Meyer KS, Daniels MW, Craycroft J, Gaughen JR, Chaudry MI, Rai SN, Everhart DE, Simard JM. Continuous infusion of low-dose unfractionated heparin after aneurysmal subarachnoid hemorrhage: a preliminary study of cognitive outcomes. J Neurosurg 2018; 130:1460-1467. [PMID: 29749915 DOI: 10.3171/2017.11.jns17894] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 11/29/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cognitive dysfunction occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH) survivors. Low-dose intravenous heparin (LDIVH) infusion using the Maryland protocol was recently shown to reduce clinical vasospasm and vasospasm-related infarction. In this study, the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive changes in aSAH patients treated with the Maryland LDIVH protocol compared with controls. METHODS A retrospective analysis of all patients treated for aSAH between July 2009 and April 2014 was conducted. Beginning in 2012, aSAH patients were treated with LDIVH in the postprocedural period. The MoCA was administered to all aSAH survivors prospectively during routine follow-up visits, at least 3 months after aSAH, by trained staff blinded to treatment status. Mean MoCA scores were compared between groups, and regression analyses were performed for relevant factors. RESULTS No significant differences in baseline characteristics were observed between groups. The mean MoCA score for the LDIVH group (n = 25) was 26.4 compared with 22.7 in controls (n = 22) (p = 0.013). Serious cognitive impairment (MoCA ≤ 20) was observed in 32% of controls compared with 0% in the LDIVH group (p = 0.008). Linear regression analysis demonstrated that only LDIVH was associated with a positive influence on MoCA scores (β = 3.68, p =0.019), whereas anterior communicating artery aneurysms and fevers were negatively associated with MoCA scores. Multivariable linear regression analysis resulted in all 3 factors maintaining significance. There were no treatment complications. CONCLUSIONS This preliminary study suggests that the Maryland LDIVH protocol may improve cognitive outcomes in aSAH patients. A randomized controlled trial is needed to determine the safety and potential benefit of unfractionated heparin in aSAH patients.
Collapse
Affiliation(s)
- Robert F James
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- 2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Nicolas K Khattar
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Zaid S Aljuboori
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Paul S Page
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Elaine Y Shao
- 2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Lacey M Carter
- 2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Kimberly S Meyer
- 1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michael W Daniels
- 3Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health, Louisville, Kentucky
| | - John Craycroft
- 3Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health, Louisville, Kentucky
| | - John R Gaughen
- 4Sentara Martha Jefferson Hospital, Charlottesville, Virginia
| | - M Imran Chaudry
- 5Comprehensive Stroke and Cerebrovascular Center, Medical University of South Carolina, Charleston, South Carolina
| | - Shesh N Rai
- 3Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health, Louisville, Kentucky
| | - D Erik Everhart
- Departments of6Psychology and
- 7Internal Medicine, East Carolina University, Greenville, North Carolina; and
| | - J Marc Simard
- Departments of8Neurosurgery
- 9Pathology, and
- 10Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
96
|
Adami D, Berkefeld J, Platz J, Konczalla J, Pfeilschifter W, Weidauer S, Wagner M. Complication rate of intraarterial treatment of severe cerebral vasospasm after subarachnoid hemorrhage with nimodipine and percutaneous transluminal balloon angioplasty: Worth the risk? J Neuroradiol 2018; 46:15-24. [PMID: 29733918 DOI: 10.1016/j.neurad.2018.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (SAH). Arterial cerebral vasospasm (CVS) is discussed as the main pathomechanism for DCI. Due to positive effects of per os nimodipine, intraarterial nimodipine application is used in patients with DCI. Further, percutaneous transluminal balloon angioplasty (PTA) is applied in focal high-grade spasm of intracranial arteries. However, clinical benefits of those techniques are unconfirmed in randomized trials so far, and complications might occur. We analyzed the occurrence of new infarcts in patients with severe CVS treated intra-arterially to assess benefits and risks of those techniques in a large single-center collective. MATERIALS AND METHODS All imaging and clinical data of 88 patients with CVS after SAH and 188 procedures of intraarterial nimodipine infusion and additional PTA in selected cases (18 patients, 20 PTA procedures) treated at our institution were reviewed. In the event of new infarcts after endovascular treatment of CVS, infarct patterns were analyzed to determine the most probable etiology. RESULTS Fifty-three percent of patients developed new cerebral infarction after intraarterial nimodipine and additional PTA in selected cases. Hereunder 47% were caused by persisting CVS. In 6% of patients, 3% of procedures respectively, new infarcts occurred due to complications of the intraarterial treatment including thromboembolism and arterial dissection. Of those, 3% of patients, 2% of procedures respectively, were assigned to thrombembolic complications of digital substraction angiography for intraarterial nimodipine. 17% of all patients treated with PTA (3/18=17%) showed infarction as a complication of PTA (15% of all PTA procedures). In 1% of patients, etiology of new infarction remained unclear. CONCLUSION Ischemic complications occur in about 6% of patients treated intraarterially for CVS, 3% of procedures respectively. Further, to date a benefit for patients treated with this therapy could not be proven. Therefore, intraarterial treatment of CVS should be performed only in carefully selected cases.
Collapse
Affiliation(s)
- Daniela Adami
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Johannes Platz
- Department of Neurosurgery, University Hospital Frankfurt, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Stefan Weidauer
- Neurology, Sankt Katharinen-Krankenhaus GmbH, Seckbacher Landstraße 65, 60389 Frankfurt, Germany
| | - Marlies Wagner
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany.
| |
Collapse
|
97
|
de Oliveira Manoel AL, Macdonald RL. Neuroinflammation as a Target for Intervention in Subarachnoid Hemorrhage. Front Neurol 2018; 9:292. [PMID: 29770118 PMCID: PMC5941982 DOI: 10.3389/fneur.2018.00292] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/16/2018] [Indexed: 01/09/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a sub-type of hemorrhagic stroke associated with the highest rates of mortality and long-term neurological disabilities. Despite the improvement in the management of SAH patients and the reduction in case fatality in the last decades, disability and mortality remain high in this population. Brain injury can occur immediately and in the first days after SAH. This early brain injury can be due to physical effects on the brain such as increased intracranial pressure, herniations, intracerebral, intraventricular hemorrhage, and hydrocephalus. After the first 3 days, angiographic cerebral vasospasm (ACV) is a common neurological complication that in severe cases can lead to delayed cerebral ischemia and cerebral infarction. Consequently, the prevention and treatment of ACV continue to be a major goal. However, most treatments for ACV are vasodilators since ACV is due to arterial vasoconstriction. Other targets also have included those directed at the underlying biochemical mechanisms of brain injury such as inflammation and either independently or as a consequence, cerebral microthrombosis, cortical spreading ischemia, blood–brain barrier breakdown, and cerebral ischemia. Unfortunately, no pharmacologic treatment directed at these processes has yet shown efficacy in SAH. Enteral nimodipine and the endovascular treatment of the culprit aneurysm, remain the only treatment options supported by evidence from randomized clinical trials to improve patients’ outcome. Currently, there is no intervention directly developed and approved to target neuroinflammation after SAH. The goal of this review is to provide an overview on anti-inflammatory drugs tested after aneurysmal SAH.
Collapse
Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Adult Critical Care Unit, Hospital Paulistano - United Health Group, São Paulo, Brazil.,Keenan Research Center for Biomedical Science, Department of Surgery, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science, Department of Surgery, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
98
|
Golanov EV, Bovshik EI, Wong KK, Pautler RG, Foster CH, Federley RG, Zhang JY, Mancuso J, Wong ST, Britz GW. Subarachnoid hemorrhage - Induced block of cerebrospinal fluid flow: Role of brain coagulation factor III (tissue factor). J Cereb Blood Flow Metab 2018; 38:793-808. [PMID: 28350198 PMCID: PMC5987942 DOI: 10.1177/0271678x17701157] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Subarachnoid hemorrhage (SAH) in 95% of cases results in long-term disabilities due to brain damage, pathogenesis of which remains uncertain. Hindrance of cerebrospinal fluid (CSF) circulation along glymphatic pathways is a possible mechanism interrupting drainage of damaging substances from subarachnoid space and parenchyma. We explored changes in CSF circulation at different time following SAH and possible role of brain tissue factor (TF). Fluorescent solute and fluorescent microspheres injected into cisterna magna were used to track CSF flow in mice. SAH induced by perforation of circle of Willis interrupted CSF flow for up to 30 days. Block of CSF flow did not correlate with the size of hemorrhage. Following SAH, fibrin deposits were observed on the brain surface including areas without visible blood. Block of astroglia-associated TF by intracerebroventricular administration of specific antibodies increased size of hemorrhage, decreased fibrin deposition and facilitated spread of fluorophores in sham/naïve animals. We conclude that brain TF plays an important role in localization of hemorrhage and also regulates CSF flow under normal conditions. Targeting of the TF system will allow developing of new therapeutic approaches to the treatment of SAH and pathologies related to CSF flow such as hydrocephalus.
Collapse
Affiliation(s)
- Eugene V Golanov
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Evgeniy I Bovshik
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Kelvin K Wong
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA.,2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Robia G Pautler
- 3 Departments of Molecular Physiology and Biophysics and Neuroscience and Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Chase H Foster
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Richard G Federley
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA.,2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Jonathan Y Zhang
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - James Mancuso
- 2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Stephen Tc Wong
- 2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Gavin W Britz
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| |
Collapse
|
99
|
van der Steen WE, Zijlstra IA, Verbaan D, Boers AMM, Gathier CS, van den Berg R, Rinkel GJE, Coert BA, Roos YBWEM, Majoie CBLM, Marquering HA. Association of Quantified Location-Specific Blood Volumes with Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. AJNR Am J Neuroradiol 2018; 39:1059-1064. [PMID: 29650786 DOI: 10.3174/ajnr.a5626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 02/12/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia is a severe complication of aneurysmal SAH and is associated with a high case morbidity and fatality. The total blood volume and the presence of intraventricular blood on CT after aneurysmal SAH are associated with delayed cerebral ischemia. Whether quantified location-specific (cisternal, intraventricular, parenchymal, and subdural) blood volumes are associated with delayed cerebral ischemia has been infrequently researched. This study aimed to associate quantified location-specific blood volumes with delayed cerebral ischemia. MATERIALS AND METHODS Clinical and radiologic data were collected retrospectively from consecutive patients with aneurysmal SAH with available CT scans within 24 hours after ictus admitted to 2 academic centers between January 2009 and December 2011. Total blood volume was quantified using an automatic hemorrhage-segmentation algorithm. Segmented blood was manually classified as cisternal, intraventricular, intraparenchymal, or subdural. Adjusted ORs with 95% confidence intervals for delayed cerebral ischemia per milliliter of location-specific blood were calculated using multivariable logistic regression analysis. RESULTS We included 282 patients. Per milliliter increase in blood volume, the adjusted OR for delayed cerebral ischemia was 1.02 (95% CI, 1.01-1.04) for cisternal, 1.02 (95% CI, 1.00-1.04) for intraventricular, 0.99 (95% CI, 0.97-1.02) for intraparenchymal, and 0.96 (95% CI, 0.86-1.07) for subdural blood. CONCLUSIONS Our findings suggest that in patients with aneurysmal subarachnoid hemorrhage, the cisternal blood volume has a stronger relation with delayed cerebral ischemia than the blood volumes at other locations in the brain.
Collapse
Affiliation(s)
- W E van der Steen
- From the Department of Biomedical Engineering and Physics (W.E.v.d.S., A.M.M.B., H.A.M.) .,Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M).,Neurosurgical Center Amsterdam (W.E.v.d.S., D.V., B.A.C.).,Department of Neurology (W.E.v.d.S., Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - I A Zijlstra
- Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| | - D Verbaan
- Neurosurgical Center Amsterdam (W.E.v.d.S., D.V., B.A.C.)
| | - A M M Boers
- From the Department of Biomedical Engineering and Physics (W.E.v.d.S., A.M.M.B., H.A.M.).,Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M).,Department of Robotics and Mechatronics (A.M.M.B.), University of Twente, Enschede, the Netherlands
| | - C S Gathier
- Department of Neurology and Neurosurgery (C.S.G., G.J.E.R.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - R van den Berg
- Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| | - G J E Rinkel
- Department of Neurology and Neurosurgery (C.S.G., G.J.E.R.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - B A Coert
- Neurosurgical Center Amsterdam (W.E.v.d.S., D.V., B.A.C.)
| | - Y B W E M Roos
- Department of Neurology (W.E.v.d.S., Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - C B L M Majoie
- Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| | - H A Marquering
- From the Department of Biomedical Engineering and Physics (W.E.v.d.S., A.M.M.B., H.A.M.).,Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| |
Collapse
|
100
|
Koyanagi M, Fukuda H, Lo B, Uezato M, Kurosaki Y, Sadamasa N, Handa A, Chin M, Yamagata S. Effect of intrathecal milrinone injection via lumbar catheter on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 128:717-722. [DOI: 10.3171/2016.10.jns162227] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDelayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI.METHODSThe prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables.RESULTSAfter propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups.CONCLUSIONSIn propensity score–matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.
Collapse
Affiliation(s)
- Masaomi Koyanagi
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Hitoshi Fukuda
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Benjamin Lo
- 2Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Minami Uezato
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Yoshitaka Kurosaki
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Nobutake Sadamasa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Akira Handa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Masaki Chin
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Sen Yamagata
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| |
Collapse
|