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Hernández-Durán S, Mielke D, Rohde V, Malinova V. Does Nimodipine Interruption due to High Catecholamine Doses Lead to a Greater Incidence of Delayed Cerebral Ischemia in the Setting of Aneurysmal Subarachnoid Hemorrhage? World Neurosurg 2019; 132:e834-e840. [DOI: 10.1016/j.wneu.2019.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 10/26/2022]
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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Effect of HHH-Therapy on Regional CBF after Severe Subarachnoid Hemorrhage Studied by Bedside Xenon-Enhanced CT. Neurocrit Care 2019; 28:143-151. [PMID: 28983856 PMCID: PMC5948237 DOI: 10.1007/s12028-017-0439-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Management of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) is difficult and still carries controversies. In this study, the effect of therapeutic hypervolemia, hemodilution, and hypertension (HHH-therapy) on cerebral blood flow (CBF) was assessed by xenon-enhanced computerized tomography (XeCT) hypothesizing an increase in CBF in poorly perfused regions. Methods Bedside XeCT measurements of regional CBF in mechanically ventilated SAH patients were routinely scheduled for day 0–3, 4–7, and 8–12. At clinical suspicion of DCI, patients received 5-day HHH-therapy. For inclusion, XeCT was required at 0–48 h before start of HHH (baseline) and during therapy. Data from corresponding time-windows were also collected for non-DCI patients. Results Twenty patients who later developed DCI were included, and twenty-eight patients without DCI were identified for comparison. During HHH, there was a slight nonsignificant increase in systolic blood pressure (SBP) and a significant reduction in hematocrit. Median global cortical CBF for the DCI group increased from 29.5 (IQR 24.6–33.9) to 38.4 (IQR 27.0–41.2) ml/100 g/min (P = 0.001). There was a concomitant increase in regional CBF of the worst vascular territories, and the proportion of area with blood flow below 20 ml/100 g/min was significantly reduced. Non-DCI patients showed higher CBF at baseline, and no significant change over time. Conclusions HHH-therapy appeared to increase global and regional CBF in DCI patients. The increase in SBP was small, while the decrease in hematocrit was more pronounced, which may suggest that intravascular volume status and rheological effects are of importance. XeCT may be potentially helpful in managing poor-grade SAH patients.
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Zhang T, Wang X, Wen C, Zhou F, Gao S, Zhang X, Lin S, Shi J, Li W. Effect of short-term blood pressure variability on functional outcome after intra-arterial treatment in acute stroke patients with large-vessel occlusion. BMC Neurol 2019; 19:228. [PMID: 31558167 PMCID: PMC6764143 DOI: 10.1186/s12883-019-1457-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/04/2019] [Indexed: 01/01/2023] Open
Abstract
Background Endovascular treatment (EVT) is advocated for acute ischaemic stroke with large-vessel occlusion (LVO), but perioperative periods are challenging. This study investigated the relationship between post-EVT short-term blood pressure variability (BPV) and early outcomes in LVO patients. Methods We retrospectively reviewed 72 LVO patients undergoing EVT between June 2015 and June 2018. Hourly systolic and diastolic blood pressures (SBP and DBP, respectively) were recorded in the first 24 h post-EVT. BPV were evaluated as standard deviation (SD), coefficient of variation (CV), and successive variation (SV) separately for SBP and DBP. Functional independence at 3 months was defined as a modified Rankin Scale (mRS) score of 0–2. Results For 58.3% patients with favorable outcomes, the median National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores on admission were 14 and 8, respectively. The maximum SBP ([154.3 ± 16.8] vs. [163.5 ± 15.6], P = 0.02), systolic CV ([8. 8% ± 2.0%] vs. [11.0% ± 1.8], P < 0.001), SV ([11.4 ± 2.3] vs. [14.6 ± 2.0], P < 0.001), and SD ([10.5 ± 2.4] vs. [13.8 ± 3.9], P < 0.001) were lower in patients with favorable outcomes. On multivariable logistic regression analysis, systolic SV (OR: 4.273, 95% CI: 1.030 to 17.727, P = 0.045) independently predicted unfavorable prognosis. The area under the curve was 0.868 (95% CI: 0.781 to 0.955, P < 0.001), and sensitivity and specificity were 93.3% and 73.8%, respectively, showing excellent predictive value for 3-month poor-outcomes. Conclusions Decreased systolic SV following intra-arterial therapies result in favorable outcomes at 3 months. Systolic SV may be a novel predictor of functional prognosis in LVO patients. Supplementary information Supplementary information accompanies this paper at 10.1186/s12883-019-1457-5.
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Affiliation(s)
- Tianli Zhang
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Xiaolong Wang
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Chao Wen
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Feng Zhou
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Shengwei Gao
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Xiaodong Zhang
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Shiqin Lin
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Jing Shi
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China
| | - Weirong Li
- Department of Neurology, Taiyuan Central Hospital, Taiyuan city, 030009, Shanxi Province, China.
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Haegens NM, Gathier CS, Horn J, Coert BA, Verbaan D, van den Bergh WM. Induced Hypertension in Preventing Cerebral Infarction in Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Stroke 2019; 49:2630-2636. [PMID: 30355184 DOI: 10.1161/strokeaha.118.022310] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose- Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage. If clinical signs of DCI occur, induced hypertension is a plausible but unproven therapeutic intervention. There is clinical equipoise if the use of hypertension induction is useful or not with the consequence that this strategy is irregularly used. We explored the effect of blood pressure augmentation in preventing cerebral infarction in patients with clinical signs of DCI. Methods- We performed a retrospective observational study, totaling 1647 patients with aneurysmal subarachnoid hemorrhage admitted at 3 academic hospitals in the Netherlands between 2006 and 2015. To study the primary outcome DCI related cerebral infarcts, we only included patients with no cerebral infarct at the time of onset of clinical signs of DCI. Cox regression was used to test the association between induced hypertension after onset of clinical signs of DCI and the occurrence of DCI related cerebral infarcts. Logistic regression was used to relate hypertension induction with poor outcome after 3 months, defined as a modified Rankin score >3. Results were adjusted for treatment center and baseline characteristics. Results- Clinical signs of DCI occurred in 479 (29%) patients of whom 300 without cerebral infarction on computed tomography scan at that time. Of these 300 patients, 201 (67%) were treated with hypertension induction and 99 were not. Of the patients treated with hypertension induction, 41 (20%) developed a DCI related cerebral infarct compared with 33 (33%) with no induced hypertension: adjusted hazard ratio, 0.59; 95% CI, 0.35 to 0.99. Hypertension induction also prevented poor outcome: adjusted odds ratio, 0.27; 95% CI, 0.14 to 0.55. Conclusions- Hypertension induction seems an effective strategy for preventing DCI related cerebral infarcts if not already present at the time of onset of clinical signs of DCI. This may lead to a reduction in poor clinical outcome.
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Affiliation(s)
- N Marlou Haegens
- From the Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (N.M.H., W.M.v.d.B.)
| | - Celine S Gathier
- Department of Intensive Care Medicine (C.S.G.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands.,Department of Neurology and Neurosurgery (C.S.G.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Janneke Horn
- Department of Intensive Care (J.H.), Academic Medical Center, University of Amsterdam, the Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam (B.A.C., D.V.), Academic Medical Center, University of Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam (B.A.C., D.V.), Academic Medical Center, University of Amsterdam, the Netherlands
| | - Walter M van den Bergh
- From the Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (N.M.H., W.M.v.d.B.)
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Mattingly T. CTP and DCI: We Need Clarification. Neurocrit Care 2019; 27:1-2. [PMID: 28721662 DOI: 10.1007/s12028-017-0434-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas Mattingly
- Neurosurgical Associates, Johnston Willis Hospital, Richmond, VA, USA.
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Shikata E, Tamura T, Shinno K, Okayama Y, Shinohara N, Shimada K, Kanematsu Y, Kitazato KT, Nagahiro S, Takagi Y. Importance of Managing the Water-Electrolyte Balance by Delivering the Optimal Minimum Amount of Water and Sodium After Subarachnoid Hemorrhage. World Neurosurg 2019; 129:e352-e360. [PMID: 31132492 DOI: 10.1016/j.wneu.2019.05.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND After aneurysmal subarachnoid hemorrhage (aSAH), crystalloid fluids with a relatively high sodium concentration have been used to maintain the cerebral blood flow. However, the prophylactic delivery of water and sodium by intravenous (IV) infusion will not necessarily improve the prognosis of patients after aSAH, and the excessive supply of water and sodium can negatively affect the outcome. We hypothesized that the delivery of an optimal amount of water and sodium separately might improve the outcome after aSAH. METHODS We recruited 55 consecutive patients who had undergone clipping or endovascular coil embolization after aSAH. Group 1 (n = 33) received conventional therapy (i.e., prophylactic IV sodium and water [protocol 1]). Group 2 (n = 22) received the optimal amount of water and sodium separately (protocol 2). RESULTS The median total of water and sodium chloride supplied in group 1 was significantly greater than that supplied in group 2 (P < 0.01). The modified Rankin scale score at discharge was 0-2 in 15 patients (95%) in group 2 and 23 patients (55%) in group 1 (P < 0.001). On multivariate logistic regression analysis, the odds ratio for a discharge modified Rankin scale score of 0-2 or 3-6 was significantly associated with the treatment protocol (P < 0.05) and the net fluid balance on days 4-8 (P < 0.05). CONCLUSION The separate delivery of optimal amounts of water and sodium could be a promising therapeutic strategy to improve the prognosis after aSAH.
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Affiliation(s)
- Eiji Shikata
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan.
| | - Tetsuya Tamura
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Kiyohito Shinno
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Yoshihiro Okayama
- Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Naoki Shinohara
- Department of Neurosurgery, HITO Medical Center, Ehime, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Keiko T Kitazato
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Shinji Nagahiro
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
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Bartt R, Jarvis S, Cittadino L, Atchie B, McCarthy K, van Vliet R, Bennett A, Wagner J, Orlando A, Bar-Or D. Decreased Odds for Vasospasm Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage after Transitioning from Neurosurgery Led Care to a Neurology Led Multidisciplinary Approach. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2019; 10:30-33. [PMID: 31308868 PMCID: PMC6613482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION The limited research on the management of aneurysmal subarachnoid hemorrhages (aSAHs) has not assessed the efficacy of neurology-led care. Our objective was to describe aSAH patients' outcomes after transitioning from a neurosurgery-led intensive care unit (ICU) to a neurology-led multidisciplinary care neurocritical care unit (NCCU). The study hypothesis was that the neurology-led multidisciplinary care would improve patient outcomes. METHODS This was a retrospective cohort study. We included patients (≥ 18) with aSAHs from 1/16 to 8/16 (pregroup) and from 3/17 to 11/17 (postgroup). The pregroup care was led by a neurosurgeon. The postgroup care included a neurologist, a pulmonary intensivist, a neurocritical care clinical nurse specialist, a neurosurgeon, and euvolemia protocol. The primary outcome was trips to interventional radiology (IR) for vasospasm treatment. Univariate analyses and multivariable ordinal logistic regression were used. RESULTS There were 99 patients included: 50 in the pregroup and 49 in the postgroup. On average, postgroup patients were 7 years older than the pregroup (p = 0.05); no other demographic or clinical characteristics significantly differed. The 62% higher number of trips to IR for vasospasm treatment, when compared to the pregroup, p < 0.001. CONCLUSIONS In aSAH patients, the neurology-led multidisciplinary care in the NCCU decreased the odds of repeated procedures for vasospasm treatment. Neurology-led multidisciplinary care could be more cost-effective than the neurosurgical-led care.
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Affiliation(s)
- Russell Bartt
- Blue Sky Neurology, Swedish Medical Center
- Neurology, Swedish Medical Center
| | | | | | | | | | | | - Alicia Bennett
- Blue Sky Neurology, Swedish Medical Center
- Neurology, Swedish Medical Center
| | - Jeffrey Wagner
- Blue Sky Neurology, Swedish Medical Center
- Neurology, Swedish Medical Center
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Neuro Intensive Care Unit. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Der-Nigoghossian C, Levasseur-Franklin K, Makii J. Acute Blood Pressure Management in Neurocritically Ill Patients. Pharmacotherapy 2019; 39:335-345. [PMID: 30734342 DOI: 10.1002/phar.2233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Optimal blood pressure (BP) management is controversial in neurocritically ill patients due to conflicting concerns of worsening ischemia with decreased BP versus cerebral edema and increased intracranial pressure with elevated BP. In addition, high-quality evidence is lacking regarding optimal BP goals in patients with most of these conditions. This review summarizes guideline recommendations and examines the literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury.
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Affiliation(s)
| | | | - Jason Makii
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Kieninger M, Gruber M, Knott I, Dettmer K, Oefner PJ, Bele S, Wendl C, Tuemmler S, Graf B, Eissnert C. Incidence of Arterial Hypotension in Patients Receiving Peroral or Continuous Intra-arterial Nimodipine After Aneurysmal or Perimesencephalic Subarachnoid Hemorrhage. Neurocrit Care 2019; 31:32-39. [DOI: 10.1007/s12028-019-00676-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
This review provides a summary of the literature pertaining to the perioperative care of neurosurgical patients and patients with neurological diseases. General topics addressed in this review include general neurosurgical considerations, stroke, traumatic brain injury, neuromonitoring, neurotoxicity, and perioperative disorders of cognitive function.
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The Rise and Fall of Transcranial Doppler Ultrasonography for the Diagnosis of Vasospasm in Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2019; 31:79-80. [DOI: 10.1097/ana.0000000000000490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Imamura H, Sakai N, Satow T, Iihara K. Endovascular Treatment for Vasospasm after Aneurysmal Subarachnoid Hemorrhage Based on Data of JR-NET3. Neurol Med Chir (Tokyo) 2018; 58:495-502. [PMID: 30464151 PMCID: PMC6300693 DOI: 10.2176/nmc.oa.2018-0212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Endovascular treatments for vasospasm after subarachnoid hemorrhage are typically performed for patients who are refractory to recommended medical therapies. We analyzed the current status of endovascular treatments based on the data of Japanese Registry of Neuroendovascular Therapy (JR-NET)3, and evaluated factors related to improvement of imaging findings and neurological condition, and to mechanical hemorrhage complications. We collected data of 1211 treatments performed from 2010 to 2014. Target vessels for treatments were anterior circulation (n = 1079), posterior circulation (n = 91), and both (n = 32); the distribution of vasospasm was the proximal vessel (n = 754) to the Circle of Willis, distal vessel (n = 329), and both (n = 119). Of the treatments, 948 cases (78.3%) were intra-arterial administration of vasodilators and 259 (21.4%) were percutaneous transluminal angioplasty (PTA); 879 cases were the first intervention. The treatment time from onset was within 3 h in 378 (31.2%) cases, between 3 and 6 h in 349 (28.8%) cases, and over 6 h in 245 (20.2%) cases. The statistically significant factors associated with improvement on imaging findings was the first treatment, and treatment within 3 h from onset compared with that after 6 h. Additionally, the first and early treatments after the symptoms were associated with significantly improved neurological condition. All complications of mechanical hemorrhage occurred along with PTA. The findings show that endovascular treatment for vasospasm was effective, especially for cases who suffered from symptomatic vasospasm with a short interval after onset.
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Affiliation(s)
- Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
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Affiliation(s)
- Daniel Horner
- Royal College of Emergency Medicine, London, UK
- Salford Royal NHS Foundation Trust, Salford, UK
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Maagaard M, Karlsson WK, Ovesen C, Gluud C, Jakobsen JC. Interventions for altering blood pressure in people with acute subarachnoid haemorrhage. Hippokratia 2018. [DOI: 10.1002/14651858.cd013096] [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)
- Mathias Maagaard
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - William K Karlsson
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Christian Ovesen
- Bispebjerg Hospital, University of Copenhagen; Department of Neurology; Bispebjerg Bakke 23 Copenhagen NV Denmark 2400
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Das AS, Lerner DP, Mason XL, Aziz-Sultan MA, Vaitkevicius H, Feske SK, Izzy S. Clinical Reasoning: Moyamoya disease masquerading as acute refractory cerebral vasospasm. Neurology 2018; 91:e594-e598. [DOI: 10.1212/wnl.0000000000005952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Cai J, Fang W, Chen F, Lin Z, Lin Y, Yu L, Yao P, Kang D. Cerebral perfusion pressure threshold to prevent delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2018; 54:29-32. [DOI: 10.1016/j.jocn.2018.04.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 01/26/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022]
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Hosmann A, Rauscher S, Wang WT, Dodier P, Bavinzski G, Knosp E, Gruber A. Intra-Arterial Papaverine-Hydrochloride and Transluminal Balloon Angioplasty for Neurointerventional Management of Delayed-Onset Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm. World Neurosurg 2018; 119:e301-e312. [PMID: 30053563 DOI: 10.1016/j.wneu.2018.07.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE After subarachnoid hemorrhage, delayed onset vasospasm can result in devastating ischemic stroke. The phenomenon of delayed cerebral ischemia (DCI) is not yet fully understood, and the correlation of angiographic vasospasm and cerebral infarction is still unclear. Therefore, we investigated the effect of endovascular treatment on the angiographic response and occurrence of DCI. METHODS Eighty patients with subarachnoid hemorrhage and serious cerebral vasospasm underwent endovascular treatment using intra-arterial papaverine-hydrochloride (IAP) or transluminal balloon angioplasty (TBA). The angiographic response and infarction rate were classified using the pre- and postinterventional angiographic images and computed tomography scans. RESULTS In 90% of patients, vasospasm could be improved. In most cases (78.8%), IAP was used. Retreatment after IAP was necessary in 32.9% of patients but never after TBA. A total of 233 vascular territories were treated in 128 procedures. Angiographic improvement was observed in 66.5% of territories, which was significantly associated with early intervention (P = 0.02), the use of TBA (P = 0.01), and the dose of papaverine-hydrochloride (P = 0.01). DCI occurred in 47.5% of the patients. Territorial infarction was associated with a poor Hunt and Hess grade (P = 0.03), day of aneurysm treatment (P = 0.01), severe vasospasm before (P = 0.02) and after (P = 0.03) treatment, and number of interventions (P = 0.01). However, the infarction rate was independent of the angiographic response. CONCLUSION The discrepancy of excellent angiographic results and the high incidence of DCI might stem from an inaccurate or a delayed diagnosis of impending ischemia. In view of the limited time window, optimized peri-interventional management and continuous cerebral multimodality neuromonitoring might be crucial for the ideal timing of endovascular procedures to prevent cerebral infarctions.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Steffen Rauscher
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
| | - Andreas Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Kepler Universitätsklinikum, Johannes Kepler University Linz, Linz, Austria
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English SW, Chassé M, Turgeon AF, Lauzier F, Griesdale D, Garland A, Fergusson D, Zarychanski R, van Walraven C, Montroy K, Ziegler J, Dupont-Chouinard R, Carignan R, Dhaliwal A, Mallick R, Sinclair J, Boutin A, Pagliarello G, Tinmouth A, McIntyre L. Anemia prevalence and incidence and red blood cell transfusion practices in aneurysmal subarachnoid hemorrhage: results of a multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:169. [PMID: 29973245 PMCID: PMC6031110 DOI: 10.1186/s13054-018-2089-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/07/2018] [Indexed: 11/16/2022]
Abstract
Background Whether a restrictive strategy for red blood cell (RBC) transfusion is applied to patients with aneurysmal subarachnoid hemorrhage (aSAH) is unclear. To inform the design and conduct of a future clinical trial, we sought to describe transfusion practices, hemoglobin (Hb) triggers, and predictors of RBC transfusion in patients with aSAH. Methods This is a retrospective cohort study of all consecutively admitted adult patients with aSAH at four tertiary care centers from January 1, 2012, to December 31, 2013. Patients were identified from hospital administrative discharge records and existing local aSAH databases. Data collection by trained abstractors included demographic data, aSAH characteristics, Hb and transfusion data, other major aSAH cointerventions, and outcomes using a pretested case report form with standardized procedures. Descriptive statistics were used to summarize data, and regression models were used to identify associations between anemia, transfusion, and other relevant predictors and outcome. Results A total of 527 patients met inclusion eligibility. Mean (±SD) age was 57 ± 13 years, and 357 patients (67.7%) were female. The median modified Fisher grade was 4 (IQR 3–4). Mean nadir Hb was 98 ± 20 g/L and occurred on median admission day 4 (IQR 2–11). RBC transfusion occurred in 100 patients (19.0%). Transfusion rates varied across centers (12.1–27.4%, p = 0.02). Patients received a median of 1 RBC unit (IQR 1–2) per transfusion episode and a median total of 2 units (IQR 1–4). Median pretransfusion Hb for first transfusion was 79 g/L (IQR 74–93) and did not vary substantially across centers (78–82 g/L, p = 0.37). Of patients with nadir Hb < 80 g/L, 66.3% received a transfusion compared with 2.0% with Hb nadir ≥ 100 g/L (p < 0.0001). Predictors of transfusion were history of oral anticoagulant use, anterior circulation aneurysm, neurosurgical clipping, and lower Hb. Controlling for numerous potential confounders, transfusion was not independently associated with poor outcome. Conclusions We observed that moderate anemia remains very common early in admission following SAH. Only one-fifth of patients with SAH received RBC transfusions, mostly in cases of significant anemia (Hb < 80 g/L), and this did not appear to be associated with outcome. Electronic supplementary material The online version of this article (10.1186/s13054-018-2089-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Michaël Chassé
- Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology & Critical Care, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- Department of Anesthesiology & Critical Care, Université Laval, Quebec City, QC, Canada.,Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Donald Griesdale
- Deparment of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Allan Garland
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ryan Zarychanski
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Kaitlyn Montroy
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jennifer Ziegler
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Raphaëlle Carignan
- Department of Anesthesiology & Critical Care, Université Laval, Quebec City, QC, Canada
| | - Andy Dhaliwal
- Department of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - John Sinclair
- Department of Surgery (Neurosurgery), University of Ottawa, Ottawa, ON, Canada
| | - Amélie Boutin
- Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | | | - Alan Tinmouth
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.,Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Al-Mufti F, Amuluru K, Damodara N, El-Ghanem M, Nuoman R, Kamal N, Al-Marsoummi S, Morris NA, Dangayach NS, Mayer SA. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2018; 390:44-51. [DOI: 10.1016/j.jns.2018.02.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 11/27/2022]
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Burns SK, Brewer KJ, Jenkins C, Miller S. Aneurysmal Subarachnoid Hemorrhage and Vasospasm. AACN Adv Crit Care 2018; 29:163-174. [DOI: 10.4037/aacnacc2018491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Aneurysmal subarachnoid hemorrhage is potentially fatal and is associated with poor outcomes in many patients. Advances in neurosurgical and medical management of ruptured aneurysms have improved mortality rates in patients with aneurysmal subarachnoid hemorrhage. Surgical and endovascular interventions, such as external ventricular drain placement, aneurysm clipping, and endovascular coiling, have been developed over the past few decades. Patients with aneurysmal subarachnoid hemorrhage are also at risk for cerebral vasospasm and delayed cerebral ischemia. This article describes the diagnosis and treatment of aneurysmal subarachnoid hemorrhage, vasospasm, and cerebral ischemia. Concurrent medical considerations and ideas for future neuroinflammatory vasospasm research are also discussed.
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Affiliation(s)
- Shannon K. Burns
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
| | - Kacie J. Brewer
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
| | - Courtney Jenkins
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
| | - Sally Miller
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
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Allen ML, Kulik T, Keyrouz SG, Dhar R. Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study. Neurosurgery 2018; 85:223-230. [DOI: 10.1093/neuros/nyy240] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/10/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Induced hypertension (IH) remains the mainstay of medical management for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized.
OBJECTIVE
To ascertain the frequency and predisposing factors for PRES during IH therapy.
METHODS
We identified 68 patients treated with IH from 345 SAH patients over a 3-yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls.
RESULTS
Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, both MAP immediately prior to IH (112 vs 90) and highest MAP targeted were greater (140 vs 120 mm Hg, both P < .01). Magnitude of MAP elevation was greater (54 vs 34 above baseline, P = .004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation.
CONCLUSION
PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most often when MAP was raised well above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.
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Affiliation(s)
- Michelle L Allen
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Tobias Kulik
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Salah G Keyrouz
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Rajat Dhar
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Hendrix P, Foreman PM, Harrigan MR, Fisher WS, Vyas NA, Lipsky RH, Lin M, Walters BC, Tubbs RS, Shoja MM, Pittet JF, Mathru M, Griessenauer CJ. Association of cystathionine beta-synthase polymorphisms and aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 128:1771-1777. [DOI: 10.3171/2017.2.jns162933] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVECystathionine β-synthase (CBS) is involved in homocysteine and hydrogen sulfide (H2S) metabolism. Both products have been implicated in the pathophysiology of cerebrovascular diseases. The impact of CBS polymorphisms on aneurysmal subarachnoid hemorrhage (aSAH) and its clinical sequelae is poorly understood.METHODSBlood samples from all patients enrolled in the CARAS (Cerebral Aneurysm Renin Angiotensin System) study were used for genetic evaluation. The CARAS study prospectively enrolled aSAH patients at 2 academic institutions in the United States from 2012 to 2015. Common CBS polymorphisms were detected using 5′exonuclease genotyping assays. Analysis of associations between CBS polymorphisms and aSAH was performed.RESULTSSamples from 149 aSAH patients and 50 controls were available for analysis. In multivariate logistic regression analysis, the insertion allele of the 844ins68 CBS insertion polymorphism showed a dominant effect on aSAH. The GG genotype of the CBS G/A single nucleotide polymorphism (rs234706) was independently associated with unfavorable functional outcome (modified Rankin Scale Score 3–6) at discharge and last follow-up, but not clinical vasospasm or delayed cerebral ischemia (DCI).CONCLUSIONSThe insertion allele of the 844ins68 CBS insertion polymorphism was independently associated with aSAH while the GG genotype of rs234706 was associated with an unfavorable outcome both at discharge and last follow-up. Increased CBS activity may exert its neuroprotective effects through alteration of H2S levels, and independent of clinical vasospasm and DCI.
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Affiliation(s)
- Philipp Hendrix
- 1Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Paul M. Foreman
- 2Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Mark R. Harrigan
- 2Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Winfield S. Fisher
- 2Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Nilesh A. Vyas
- 3Department of Neurosciences, Inova Health System, Falls Church
| | - Robert H. Lipsky
- 3Department of Neurosciences, Inova Health System, Falls Church
- 4Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Mingkuan Lin
- 4Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Beverly C. Walters
- 2Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 4Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | | | - Mohammadali M. Shoja
- 6Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mali Mathru
- 7Department of Anesthesiology, University of Alabama at Birmingham, Alabama
| | - Christoph J. Griessenauer
- 8Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
- 9Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
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Griessenauer CJ, Starke RM, Foreman PM, Hendrix P, Harrigan MR, Fisher WS, Vyas NA, Lipsky RH, Lin M, Walters BC, Pittet JF, Mathru M. Associations between endothelin polymorphisms and aneurysmal subarachnoid hemorrhage, clinical vasospasm, delayed cerebral ischemia, and functional outcome. J Neurosurg 2018; 128:1311-1317. [DOI: 10.3171/2016.12.jns162594] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEndothelin-1, a potent vasoconstrictor, and its receptors may be involved in the pathogenesis of aneurysmal subarachnoid hemorrhage (aSAH), clinical vasospasm, delayed cerebral ischemia (DCI), and functional outcome following aSAH. In the present study, common endothelin single nucleotide polymorphisms (SNPs) and their relation to aSAH were evaluated.METHODSBlood samples from all patients enrolled in the Cerebral Aneurysm Renin Angiotensin System (CARAS) study were used for genetic evaluation. The CARAS study prospectively enrolled patients with aSAH at 2 academic institutions in the US from 2012 to 2015. Common endothelin SNPs were detected using 5′ exonnuclease (TaqMan) genotyping assays. Analysis of associations between endothelin SNPs and aSAH and its clinical sequelae was performed.RESULTSSamples from 149 patients with aSAH and 50 controls were available for analysis. In multivariate logistic regression analysis, the TG (odds ratio [OR] 2.102, 95% confidence interval [CI] 1.048–4.218, p = 0.036) and TT genotypes (OR 7.884, 95% CI 1.003–61.995, p = 0.05) of the endothelin-1 T/G SNP (rs1800541) were significantly associated with aSAH. There was a dominant effect of the G allele (CG/GG genotypes; OR 4.617, 95% CI 1.311–16.262, p = 0.017) of the endothelin receptor A G/C SNP (rs5335) on clinical vasospasm. Endothelin SNPs were not associated with DCI or functional outcome.CONCLUSIONSCommon endothelin SNPs were found to be associated with presentation with aSAH and clinical vasospasm. Further studies are required to elucidate the relevant pathophysiology and its potential implications in the treatment of patients with aSAH.
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Affiliation(s)
| | - Robert M. Starke
- 2Department of Neurosurgery and Radiology, University of Miami, Florida
| | - Paul M. Foreman
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Philipp Hendrix
- 4Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Mark R. Harrigan
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Winfield S. Fisher
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Nilesh A. Vyas
- 5Department of Neurosciences, Inova Health System, Falls Church, Virginia
| | - Robert H. Lipsky
- 5Department of Neurosciences, Inova Health System, Falls Church, Virginia
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia; and
| | - Mingkuan Lin
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia; and
| | - Beverly C. Walters
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 5Department of Neurosciences, Inova Health System, Falls Church, Virginia
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia; and
| | | | - Mali Mathru
- 7Department of Anesthesiology, University of Alabama at Birmingham, Alabama
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Murphy A, de Oliveira Manoel AL, Macdonald RL, Baker A, Lee TY, Marotta T, Montanera W, Aviv R, Bharatha A. Changes in Cerebral Perfusion with Induced Hypertension in Aneurysmal Subarachnoid Hemorrhage: A Pilot and Feasibility Study. Neurocrit Care 2018; 27:3-10. [PMID: 28244000 DOI: 10.1007/s12028-017-0379-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The effects of induced hypertension (IH) on cerebral perfusion after subarachnoid hemorrhage (SAH) are unclear. The objectives of this investigation are to: (1) determine whether there are differences in cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) measured with computed tomography perfusion (CTP) before and after IH; (2) evaluate differences in the presence of infarction and clinical outcome between patients with and without IH. METHODS We performed a retrospective cohort analysis of 25 aneurysmal SAH patients. IH was initiated as per the standard institutional protocol when patients showed clinical symptoms of delayed cerebral ischemia (DCI). Differences in CBF, CBV, and MTT between early (<72 h after aneurysm rupture) and late (7-10 days after aneurysm rupture) CTP were quantified in patients with (n = 13) and without IH (n = 12). Outcome measures included cerebral infarction and clinical outcome at 3 months. RESULTS Early MTT was significantly greater in the IH group compared to the no-IH group. There was no difference in early or late CBV or CBF between the two groups. In patients that received IH, there was a significant decrease in MTT between the early (7.0 ± 1.2 s) and late scans (5.8 ± 1.6 s; p = 0.005). There was no difference in the incidence of infarction (5/13 vs. 2/11) or poor outcome (3/11 vs. 6/13) between the IH and no-IH groups, respectively (p > 0.05). CONCLUSIONS Elevated MTT is a significant factor for the development of DCI in patients eventually requiring IH therapy and is improved by IH treatment. Therapies to prevent DCI and improve clinical outcome may need to be initiated earlier, when cerebral perfusion abnormalities are first identified.
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Affiliation(s)
- Amanda Murphy
- Department of Medical Imaging, University of Toronto, 30 Bond Street, Room 3-077CC, Toronto, ON, M5B 1W8, Canada.
| | | | - R Loch Macdonald
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew Baker
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Tom Marotta
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Walter Montanera
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Nijboer CH, Kooijman E, van Velthoven CT, van Tilborg E, Tiebosch IA, Eijkelkamp N, Dijkhuizen RM, Kesecioglu J, Heijnen CJ. Intranasal Stem Cell Treatment as a Novel Therapy for Subarachnoid Hemorrhage. Stem Cells Dev 2018; 27:313-325. [PMID: 29310519 DOI: 10.1089/scd.2017.0148] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) represents a major health problem in Western society due to high mortality and morbidity, and the relative young age of patients. Currently, efficacious therapeutic options are very limited. Mesenchymal stem cell (MSC) administration has been shown to improve functional outcome and lesion size in experimental models of stroke and neonatal hypoxic-ischemic brain injury. Here, we studied the therapeutic potential of intranasally administered bone marrow-derived MSCs relatively late postinsult using a rat endovascular puncture model for SAH. Six days after induction of SAH, rats were treated with MSCs or vehicle through nasal administration. Intranasal MSC treatment significantly improved sensorimotor and mechanosensory function at 21 days after SAH. Gray and white matter loss was significantly reduced by MSC treatment and the number of NeuN+ neurons around the lesion increased due to MSC treatment. Moreover, intranasal MSC administration led to a sharp decrease in SAH-induced activation of astrocytes and microglia/macrophages in the lesioned hemisphere, especially of M2-like (CD206+) microglia/macrophages. Interestingly, MSC administration also decreased SAH-induced depression-like behavior in association with a restoration of tyrosine hydroxylase expression in the substantia nigra and striatum. We show here for the first time that intranasal MSC administration reverses the devastating consequences of SAH, including regeneration of the cerebral lesion, functional recovery, and treatment of comorbid depression-like behavior.
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Affiliation(s)
- Cora H Nijboer
- 1 Laboratory of Neuroimmunology and Developmental Origins of Disease, Division Woman and Baby, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Elke Kooijman
- 1 Laboratory of Neuroimmunology and Developmental Origins of Disease, Division Woman and Baby, University Medical Center Utrecht , Utrecht, the Netherlands .,2 Department of Intensive Care Medicine, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Cindy T van Velthoven
- 1 Laboratory of Neuroimmunology and Developmental Origins of Disease, Division Woman and Baby, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Erik van Tilborg
- 1 Laboratory of Neuroimmunology and Developmental Origins of Disease, Division Woman and Baby, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Ivo A Tiebosch
- 3 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Niels Eijkelkamp
- 1 Laboratory of Neuroimmunology and Developmental Origins of Disease, Division Woman and Baby, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Rick M Dijkhuizen
- 3 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Jozef Kesecioglu
- 2 Department of Intensive Care Medicine, University Medical Center Utrecht , Utrecht, the Netherlands
| | - Cobi J Heijnen
- 4 Laboratory of Neuroimmunology, Department of Symptom Research, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
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Lidington D, Kroetsch JT, Bolz SS. Cerebral artery myogenic reactivity: The next frontier in developing effective interventions for subarachnoid hemorrhage. J Cereb Blood Flow Metab 2018; 38:17-37. [PMID: 29135346 PMCID: PMC5757446 DOI: 10.1177/0271678x17742548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating cerebral event that kills or debilitates the majority of those afflicted. The blood that spills into the subarachnoid space stimulates profound cerebral artery vasoconstriction and consequently, cerebral ischemia. Thus, once the initial bleeding in SAH is appropriately managed, the clinical focus shifts to maintaining/improving cerebral perfusion. However, current therapeutic interventions largely fail to improve clinical outcome, because they do not effectively restore normal cerebral artery function. This review discusses emerging evidence that perturbed cerebrovascular "myogenic reactivity," a crucial microvascular process that potently dictates cerebral perfusion, is the critical element underlying cerebral ischemia in SAH. In fact, the myogenic mechanism could be the reason why many therapeutic interventions, including "Triple H" therapy, fail to deliver benefit to patients. Understanding the molecular basis for myogenic reactivity changes in SAH holds the key to develop more effective therapeutic interventions; indeed, promising recent advancements fuel optimism that vascular dysfunction in SAH can be corrected to improve outcome.
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Affiliation(s)
- Darcy Lidington
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada
| | - Jeffrey T Kroetsch
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada
| | - Steffen-Sebastian Bolz
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada.,3 Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, Canada
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Gathier CS, van den Bergh WM, van der Jagt M, Verweij BH, Dankbaar JW, Müller MC, Oldenbeuving AW, Rinkel GJE, Slooter AJC. Induced Hypertension for Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial. Stroke 2017; 49:76-83. [PMID: 29158449 DOI: 10.1161/strokeaha.117.017956] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Induced hypertension is widely used to treat delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but a literature review shows that its presumed effectiveness is based on uncontrolled case-series only. We here report clinical outcome of aneurysmal subarachnoid hemorrhage patients with DCI included in a randomized trial on the effectiveness of induced hypertension. METHODS Aneurysmal subarachnoid hemorrhage patients with clinical symptoms of DCI were randomized to induced hypertension or no induced hypertension. Risk ratios for poor outcome (modified Rankin Scale score >3) at 3 months, with 95% confidence intervals, were calculated and adjusted for age, clinical condition at admission and at time of DCI, and amount of blood on initial computed tomographic scan with Poisson regression analysis. RESULTS The trial aiming to include 240 patients was ended, based on lack of effect on cerebral perfusion and slow recruitment, when 21 patients had been randomized to induced hypertension, and 20 patients to no hypertension. With induced hypertension, the adjusted risk ratio for poor outcome was 1.0 (95% confidence interval, 0.6-1.8) and the risk ratio for serious adverse events 2.1 (95% confidence interval, 0.9-5.0). CONCLUSIONS Before this trial, the effectiveness of induced hypertension for DCI in aneurysmal subarachnoid hemorrhage patients was unknown because current literature consists only of uncontrolled case series. The results from our premature halted trial do not add any evidence to support induced hypertension and show that this treatment can lead to serious adverse events. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01613235.
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Affiliation(s)
- Celine S Gathier
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.).
| | - Walter M van den Bergh
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Mathieu van der Jagt
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Bon H Verweij
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Jan Willem Dankbaar
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Marcella C Müller
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Annemarie W Oldenbeuving
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Gabriel J E Rinkel
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
| | - Arjen J C Slooter
- From the Department of Intensive Care Medicine, Brain Center Rudolf Magnus (C.S.G., A.J.C.S.), Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (C.S.G., B.H.V., G.J.E.R.), and Department of Radiology (J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, the Netherlands (W.M.v.d.B.); Department of Intensive Care and Erasmus MC Stroke Center, Erasmus MC University Medical Center, Rotterdam, the Netherlands (M.v.d.J.); Department of Intensive Care, Academic Medical Center Amsterdam, University of Amsterdam, the Netherlands (M.C.M.); and Department of Intensive Care, Elisabeth-TweeSteden Hospital (ETZ), Tilburg, the Netherlands (A.W.O.)
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Van Haren F, Velloza P, Chan S, Mews P, Lueck CJ. Induced hypertension for preventing complications of delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage. Hippokratia 2017. [DOI: 10.1002/14651858.cd012842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Frank Van Haren
- Canberra Hospital; ICU; PO Box 11 Woden ACT Australia 2606
- Australian National University; Canberra Australia
- University of Canberra; Canberra Australia
| | - Peter Velloza
- Canberra Hospital; ICU; PO Box 11 Woden ACT Australia 2606
| | - Sean Chan
- Canberra Hospital; ICU; PO Box 11 Woden ACT Australia 2606
| | - Peter Mews
- Canberra Hospital; Department of Neurosurgery; PO Box 11 Woden ACT Australia 2606
| | - Christian J Lueck
- Australian National University; Canberra Australia
- Canberra Hospital; Department of Neurology; P.O Box 11 Woden Australia 2606
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Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Beyond Vasospasm and Towards a Multifactorial Pathophysiology. Curr Atheroscler Rep 2017; 19:50. [PMID: 29063300 DOI: 10.1007/s11883-017-0690-x] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischemia (DCI) is common after subarachnoid hemorrhage (SAH) and represents a significant cause of poor functional outcome. DCI was mainly thought to be caused by cerebral vasospasm; however, recent clinical trials have been unable to confirm this hypothesis. Studies in humans and animal models have since supported the notion of a multifactorial pathophysiology of DCI. This review summarizes some of the main mechanisms under investigation including cerebral vascular dysregulation, microthrombosis, cortical spreading depolarizations, and neuroinflammation. RECENT FINDINGS Recent guidelines have differentiated between DCI and angiographic vasospasm and have highlighted roles of the microvasculature, coagulation and fibrinolytic systems, cortical spreading depressions, and the contribution of the immune system to DCI. Many therapeutic interventions are underway in both preclinical and clinical studies to target these novel mechanisms as well as studies connecting these mechanisms to one another. Clinical trials to date have been largely unsuccessful at preventing or treating DCI after SAH. The only successful pharmacologic intervention is the calcium channel antagonist, nimodipine. Recent studies have provided evidence that cerebral vasospasm is not the sole contributor to DCI and that additional mechanisms may play equal if not more important roles.
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83
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Cai K, Zhang Y, Shen L, Ji Q, Xu T, Cao M. Characteristics of Blood Pressure Profiles After Endovascular Coiling as Predictors of Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 104:459-466. [DOI: 10.1016/j.wneu.2017.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
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Drevet CM, Opprecht N, Nadji A, Mirek S, Aho S, Ricolfi F, Girard C, Bouhemad B. Impact of restrictive fluid protocol on hypoxemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2017; 42:152-156. [PMID: 28735155 DOI: 10.1016/j.jcrc.2017.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/19/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In patients with aneurysmal subarachnoid hemorrhage (aSAH), acute cardiac dysfunction and triple-H-therapy, can lead to hypoxemia. Our aim was to assess impact of a protocoled fluid restrictive approach on hypoxemia in these patients. METHODS We included prospectively ICU patients with aSAH admitted within 24h after the bleed. The study was divided into 2 phases. The first phase, from January to December 2012, was designated as control group (group C). The second phase, from February 2014 to January 2015, was designated as study group (group S). Between these periods, a protocoled fluid intake approach was implemented to maintain as low as possible the cumulative fluid balances. RESULTS Effective fluid restriction was obtained: at day 3 cumulative fluid balances were respectively for group C and group S, 1559±2402ml and 759±1855ml (p=0.04); and 2211±4918ml vs 529±2806ml (p=0.04) at day 7. We observed reduction in proportion of hypoxemic patient in group S compared to group C, at day 3 (22% vs 40%, p=0.047) and at day 7 (28% vs 57%, p=0.007). CONCLUSIONS Fluid restrictive management of patients with aSAH decreases number of hypoxemic patients at day 3 and day 7.
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Affiliation(s)
- Claire-Marie Drevet
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Nicolas Opprecht
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Abdelouaïd Nadji
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Sebastien Mirek
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Serge Aho
- Service d'Epidémiologie et d'Hygiène Hospitalières, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Frederic Ricolfi
- Service d'imagerie diagnostique et thérapeutique Neuroradiologie et Urgences CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Claude Girard
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Bélaïd Bouhemad
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France.
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Yousef KM, Crago E, Lagattuta TF, Hravnak M. Clinical Presentation to the Emergency Department Predicts Subarachnoid Hemorrhage-Associated Myocardial Injury. J Emerg Nurs 2017; 44:132-138. [PMID: 28712527 DOI: 10.1016/j.jen.2017.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 05/30/2017] [Accepted: 06/15/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is frequently seen in emergency departments. Secondary injury, such as subarachnoid hemorrhage-associated myocardial injury (SAHMI), affects one third of survivors and contributes to poor outcomes. SAHMI is not attributed to ischemia from myocardial disease but can result in hypotension and arrhythmias. It is important that emergency nurses recognize which clinical presentation characteristics are predictive of SAHMI to initiate proper interventions. The aim of this study was to determine whether patients who present to the emergency department with clinical aSAH are likely to develop SAHMI, as defined by troponin I ≥0.3 ng/mL. METHODS This was a prospective descriptive study. SAHMI was defined as troponin I ≥0.3 ng/mL. Predictors included demographics and clinical characteristics, severity of injury, admission 12-lead electrogardiogram (ECG), initial emergency department vital signs, and pre-hospital symptoms at time of aneurysm rupture. RESULTS Of 449 patients, 126 (28%) had SAHMI. Patients with SAHMI were more likely to report seizures and unresponsiveness with significantly lower Glasgow coma score and higher proportion of Hunt and Hess grades 3 to 5 and Fisher grades III and IV (all P < .05). Patients with SAHMI had higher atrial and ventricular rates and longer QTc intervals on initial ECG (P < .05). On multivariable logistic regression, poor Hunt and Hess grade, report of prehospital unresponsiveness, lower admission Glasgow coma score, and longer QTc interval were significantly and independently predictive of SAHMI (P < .05). DISCUSSION Components of the clinical presentation of subarachnoid hemorrhage to the emergency department predict SAHMI. Identifying patients with SAHMI in the emergency department can be helpful in determining surveillance and care needs and informing transfer unit care. Contribution to Emergency Nursing Practice.
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Affiliation(s)
- Khalil M Yousef
- University of Jordan, School of Nursing, Amman, Jordan; University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA.
| | - Elizabeth Crago
- University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA
| | | | - Marilyn Hravnak
- University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA
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Xu B, Ji Q, Zhang Y, Shen L, Cao M, Cai K. Postoperative blood pressure variability exerts an influence on clinical outcome after coil embolization of ruptured intracranial aneurysms. Neurol Res 2017; 39:813-818. [PMID: 28675964 DOI: 10.1080/01616412.2017.1348653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Bin Xu
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Qiuhong Ji
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yunfeng Zhang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Lihua Shen
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Maohong Cao
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kefu Cai
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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Venkatraman A, Khawaja AM, Gupta S, Hardas S, Deveikis JP, Harrigan MR, Kumar G. Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis. J Neurointerv Surg 2017; 10:380-387. [DOI: 10.1136/neurintsurg-2017-013128] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveThe efficacy of intra-arterial vasodilators (IADs) for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) remains debatable. The objective of this meta-analysis was to pool estimates of angiographic and neurological response, clinical outcome, and mortality following treatment of vasospasm with IADs.MethodsWe searched PubMed, Embase, Scopus, Clinicaltrials.gov, Cochrane database, and CINAHL in December 2015 and August 2016. Studies reporting angiographic and neurological response, clinical outcome, and mortality following IAD treatment of vasospasm in 10 or more adults with aSAH were included. All established IADs were allowed. Two authors independently selected studies and abstracted the data. Mean weighted probabilities (MWP) were calculated using random effects model.ResultsInclusion criteria were met by 55 studies (n=1571). MWP for immediate angiographic response to IAD treatment was 89% (95% CI 83% to 94%), post-IAD neurological improvement 57% (95% CI 49% to 65%), good outcome 66% (95% CI 60% to 71%), and mortality was 9% (95% CI 7% to 12%). After adjusting for publication bias, MWP for mortality was 5% (95% CI 4% to 7%). When transcranial Doppler (TCD) was used along with clinical deterioration for patient selection, rates of neurological response (64%) and good outcome (72%) were better. IADs were not superior to controls (balloon angioplasty or medical management).ConclusionIAD treatment leads to a robust angiographic response and fair (but lower) rates of neurological response and good clinical outcome. Mortality was lower than the average reported in the literature. Rates of neurological response and good outcome were better when TCD was used for patient selection. Carefully designed studies are needed to compare IADs against medical management and balloon angioplasty.
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Griessenauer CJ, Tubbs RS, Foreman PM, Chua MH, Vyas NA, Lipsky RH, Lin M, Iyer R, Haridas R, Walters BC, Chaudry S, Malieva A, Wilkins S, Harrigan MR, Fisher WS, Shoja MM. Associations of renin-angiotensin system genetic polymorphisms and clinical course after aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 126:1585-1597. [DOI: 10.3171/2016.4.jns16409] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVERenin-angiotensin system (RAS) genetic polymorphisms are thought to play a role in cerebral aneurysm formation and rupture. The Cerebral Aneurysm Renin Angiotensin System (CARAS) study prospectively evaluated associations of common RAS polymorphisms and clinical course after aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe CARAS study prospectively enrolled aSAH patients at 2 academic centers in the United States. A blood sample was obtained from all patients for genetic evaluation and measurement of plasma angiotensin converting enzyme (ACE) concentration. Common RAS polymorphisms were detected using 5′exonuclease genotyping assays and pyrosequencing. Analysis of associations of RAS polymorphisms and clinical course after aSAH were performed.RESULTSA total of 166 patients were screened, and 149 aSAH patients were included for analysis. A recessive effect of allele I (insertion) of the ACE I/D (insertion/deletion) polymorphism was identified for Hunt and Hess grade in all patients (OR 2.76, 95% CI 1.17–6.50; p = 0.0206) with subsequent poor functional outcome. There was a similar effect on delayed cerebral ischemia (DCI) in patients 55 years or younger (OR 3.63, 95% CI 1.04–12.7; p = 0.0439). In patients older than 55 years, there was a recessive effect of allele A of the angiotensin II receptor Type 2 (AT2) A/C single nucleotide polymorphism (SNP) on DCI (OR 4.70, 95% CI 1.43–15.4; p = 0.0111).CONCLUSIONSBoth the ACE I/D polymorphism and the AT2 A/C single nucleotide polymorphism were associated with an age-dependent risk of delayed cerebral ischemia, whereas only the ACE I/D polymorphism was associated with poor clinical grade at presentation. Further studies are required to elucidate the relevant pathophysiology and its potential implication in the treatment of patients with aSAH.
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Affiliation(s)
- Christoph J. Griessenauer
- 1Beth Israel Deaconess Medical Center, Harvard Medical School
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | | | - Paul M. Foreman
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | | | | | - Robert H. Lipsky
- 5Department of Neurosciences and
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Mingkuan Lin
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Ramaswamy Iyer
- 7Inova Translational Medicine Institute, Inova Health System, Falls Church; and
| | - Rishikesh Haridas
- 7Inova Translational Medicine Institute, Inova Health System, Falls Church; and
| | - Beverly C. Walters
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 5Department of Neurosciences and
| | - Salman Chaudry
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Aisana Malieva
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Samantha Wilkins
- 6Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia
| | - Mark R. Harrigan
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Winfield S. Fisher
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
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[Intensive care treatment after aneurysmal subarachnoid hemorrhage]. Anaesthesist 2017; 65:951-970. [PMID: 27900416 DOI: 10.1007/s00101-016-0242-8] [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: 10/20/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease and nearly one third of patients die in the acute phase. Due to the bleeding event, a hyperactive sympathetic nervous system and an uncontrolled inflammatory response have a profound local and systemic impact on other organ functions. Neuroendocrinological disorders and cardiopulmonary morbidity are dominant. Despite a decrease in hospital mortality for high volume centers, a high proportion of survivors suffer from neurological deficits. Knowledge of the pathophysiology of vasospasms in the later stages of the disease has increased. Anti-inflammatory treatment does not improve the outcome. Nimodipine prophylaxis in the first 96 h after SAH seems to be the only intervention which has been proven to be advantageous in studies; however, nearly every second survivor of SAH suffers from some neurological deficits and more than one third of survivors report depressive episodes or symptoms of posttraumatic stress disorder.
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Abstract
Subarachnoid hemorrhage (SAH) is a debilitating, although uncommon, type of stroke with high morbidity, mortality, and economic impact. Modern 30-day mortality is as high as 40%, and about 50% of survivors have permanent disability. Care at high-volume centers with dedicated neurointensive care units is recommended. Euvolemia, not hypervolemia, should be targeted, and the aneurysm should be secured early. Neither statin therapy nor magnesium infusions should be initiated for delayed cerebral ischemia. Cerebral vasospasm is just one component of delayed cerebral edema. Hyponatremia is common in subarachnoid hemorrhage and is associated with longer length of stay, but not increased mortality.
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Affiliation(s)
- Jeremy S Dority
- Department of Anesthesiology, University of Kentucky College of Medicine, 800 Rose Street, Suite N202, Lexington, KY 40536-0293, USA.
| | - Jeffrey S Oldham
- Department of Anesthesiology, University of Kentucky College of Medicine, 800 Rose Street, Suite N202, Lexington, KY 40536-0293, USA
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91
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Kumar A, Kumar A, Singh PK, Mishra S, Garg K, Sharma BS. Letter to the Editor: Beta-blocker therapy. J Neurosurg 2017; 126:1026-1027. [DOI: 10.3171/2016.10.jns162509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Endothelial Nitric Oxide Synthase Polymorphism Is Associated with Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 101:514-519. [PMID: 28254540 DOI: 10.1016/j.wneu.2017.02.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Nitric oxide is critical in the regulation of cerebral blood flow and smooth muscle proliferation. It is synthesized by 3 nitric oxide synthase (NOS) isoforms: neuronal, inducible, and endothelial NOS (eNOS). Aneurysmal subarachnoid hemorrhage (aSAH) causes endothelial dysfunction that, in turn, contributes to pathophysiologic processes surrounding aSAH. Previous studies reported an association of an eNOS single nucleotide polymorphism (SNP) with the clinical sequelae of aSAH. Here, we further elucidate the impact of this eNOS SNP on the clinical course after aSAH. METHODS The Cerebral Aneurysm Renin Angiotensin System study prospectively enrolled aSAH patients at 2 academic institutions in the United States from 2012-2015. Blood samples from all patients enrolled in the study were used for genetic evaluation using 5'exonuclease (Taqman) genotyping assays. Associations between the eNOS SNP rs2070744 (786 T->C) and clinical course after aSAH were analyzed. RESULTS Samples from 149 aSAH patients were available for analysis. The C allele of the eNOS SNP independently predicted an increased risk for delayed cerebral ischemia (OR = 2.936, 95% CI 1.048-8.226, P = 0.040). The eNOS SNP rs2070744 was not associated with functional outcome or size of aneurysm at the time of rupture. CONCLUSIONS The present study is the first to demonstrate that the C allele of the eNOS SNP 786 T->C rs2070744 is independently associated with an increased risk for delayed cerebral ischemia following aSAH.
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Hendrix P, Foreman PM, Harrigan MR, Fisher WS, Vyas NA, Lipsky RH, Lin M, Walters BC, Tubbs RS, Shoja MM, Pittet JF, Mathru M, Griessenauer CJ. Impact of High-Mobility Group Box 1 Polymorphism on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 101:325-330. [PMID: 28189859 DOI: 10.1016/j.wneu.2017.01.121] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/29/2017] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The high-mobility group box 1 (HMGB1) protein is a eukaryotic, ubiquitously expressed protein that serves as a biomarker for various diseases and is involved in the promotion of a proinflammatory response to cell injury. In aneurysmal subarachnoid hemorrhage (aSAH), increased HMGB1 levels have been linked to poor outcome and an increased risk for cerebral vasospasm. The role of HMGB1 polymorphisms in aSAH has not been previously investigated. METHODS Patients with aSAH and controls enrolled in the prospective, 2-center CARAS (Cerebral Aneurysm Renin Angiotensin System) study were evaluated. The 3814 C/G HMGB1 single nucleotide polymorphism (SNP) rs2249825 was detected using 5'exonuclease (Taqman) genotyping assays from blood samples from patients with aSAH and controls. Associations between aSAH and its clinical sequelae with the HMGB1 SNP were assessed. RESULTS Samples from 149 patients with aSAH and 50 controls were available for analysis. No increased risk for aSAH associated with the SNP was found compared with the control group. Delayed cerebral ischemia (DCI) was defined as a cerebral infarction at the time of discharge from the intensive care unit and identified in 21.2% of patients with aSAH. In multivariable logistic regression analysis, the G allele of rs2249825 was independently associated with DCI (odds ratio, 5.695; 95% confidence interval, 1.804-17.975; P = 0.003). CONCLUSIONS The minor allele G of rs2249825 was associated with an increased risk for DCI, or cerebral infarction, after aSAH. This finding may be attributable to an increased HMGB1 protein expression in these patients.
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Affiliation(s)
- Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany.
| | - Paul M Foreman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nilesh A Vyas
- Department of Neurosciences, Inova Health System, Falls Church, Virginia, USA
| | - Robert H Lipsky
- Department of Neurosciences, Inova Health System, Falls Church, Virginia, USA; Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia, USA
| | - Minkuan Lin
- Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia, USA
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Neurosciences, Inova Health System, Falls Church, Virginia, USA; Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia, USA
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA
| | - Mohammadali M Shoja
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jean-Francois Pittet
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mali Mathru
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christoph J Griessenauer
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
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Continuous EEG Monitoring for Early Detection of Delayed Cerebral Ischemia in Subarachnoid Hemorrhage: A Pilot Study. Neurocrit Care 2017; 24:207-16. [PMID: 26432793 DOI: 10.1007/s12028-015-0205-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Early identification of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is a major challenge. The aim of this study was to investigate whether quantitative EEG (qEEG) features can detect DCI prior to clinical or radiographic findings. METHODS A prospective cohort study was performed in aSAH patients in whom continuous EEG (cEEG) was recorded. We studied 12 qEEG features. We compared the time point at which qEEG changed with the time point that clinical deterioration occurred or new ischemia was noted on CT scan. RESULTS Twenty aSAH patients were included of whom 11 developed DCI. The alpha/delta ratio (ADR) was the most promising feature that showed a significant difference in change over time in the DCI group (median -62% with IQR -87 to -39%) compared to the control group (median +27% with IQR -32 to +104%, p = 0.013). Based on the ROC curve, a threshold was chosen for a combined measure of ADR and alpha variability (AUC: 91.7, 95% CI 74.2-100). The median time that elapsed between change of qEEG and clinical DCI diagnosis was seven hours (IQR -11-25). Delay between qEEG and CT scan changes was 44 h (median, IQR 14-117). CONCLUSION In this study, ADR and alpha variability could detect DCI development before ischemic changes on CT scan was apparent and before clinical deterioration was noted. Implementation of cEEG in aSAH patients can probably improve early detection of DCI.
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Hendrix P, Foreman PM, Harrigan MR, Fisher WS, Vyas NA, Lipsky RH, Lin M, Walters BC, Tubbs RS, Shoja MM, Pittet JF, Mathru M, Griessenauer CJ. Ryanodine Receptor 1 Polymorphism Is Not Associated with Aneurysmal Subarachnoid Hemorrhage or its Clinical Sequelae. World Neurosurg 2017; 100:190-194. [PMID: 28087430 DOI: 10.1016/j.wneu.2016.12.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The pathophysiologic mechanisms underlying cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) remain poorly understand. Ryanodine receptors (RYR) are intracellular calcium channels involved in the regulation of vascular smooth muscle cells and cerebrovascular tone and diameter. Previous work reported an association between an RYR polymorphism and cerebral vasospasm. Here, we sought to assess the impact of that RYR polymorphism on aSAH and its clinical sequelae. METHODS Blood samples from all patients enrolled in the CARAS (Cerebral Aneurysm Renin Angiotensin System) study were used for genetic evaluation. The RYR1 single nucleotide polymorphism (SNP) rs35364374 was detected using 5'exonuclease (Taqman) genotyping assays. Associations between the RYR1 polymorphism and aSAH and its clinical sequelae were analyzed. RESULTS Samples from 149 patients with aSAH and 50 controls were available for analysis. Multivariable regression analysis did not show an association of RYR1 SNP rs35364374 with aSAH. Moreover, there was no association of RYR1 SNP rs35364374 with clinical vasospasm, delayed cerebral ischemia, functional outcome at discharge, or functional outcome at last follow-up. CONCLUSIONS Contrary to a previous report, the RYR1 SNP rs35364374 was not associated with aSAH or its clinical sequelae.
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Affiliation(s)
- Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany.
| | - Paul M Foreman
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Nilesh A Vyas
- Department of Neurosciences, Inova Health System, Falls Church, Virginia, USA
| | - Robert H Lipsky
- Department of Neurosciences, Inova Health System, Falls Church, Virginia, USA; Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia, USA
| | - Minkuan Lin
- Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia, USA
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA; Department of Neurosciences, Inova Health System, Falls Church, Virginia, USA; Department of Molecular Neuroscience, George Mason University, Fairfax, Virginia, USA
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA
| | - Mohammadali M Shoja
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mali Mathru
- Department of Anesthesiology, University of Alabama at Birmingham, Alabama, USA
| | - Christoph J Griessenauer
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Krömker M, Lauscher P, Kertscho H, Zacharowski K, Rosenberger P, Meier J. Anemia tolerance during normo-, hypo-, and hypervolemia. Transfusion 2016; 57:613-621. [PMID: 27990642 DOI: 10.1111/trf.13942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Restrictive intraoperative fluid management has been demonstrated to improve outcome of visceral and lung surgery in several studies. However, subsequent hypovolemia (HOV) may be accompanied by a decrease of anemia tolerance, resulting in increased transfusion needs. We therefore investigated the effect of volume status on anemia tolerance. STUDY DESIGN AND METHODS Eighteen domestic pigs of either sex (mean weight, 23.5 ± 4.8 kg) were anesthetized, ventilated, and randomized into three experimental groups: normovolemia (no intervention), HOV (blood loss of 40% of blood volume), and hypervolemia (HEV; volume infusion of 40% of blood volume). The animals were then hemodiluted until their individual critical hemoglobin concentrations (Hbcrit ) were reached by the exchange of whole blood for hydroxyethyl starch (HES; 130:0.4). Subsequently, organ-specific hypoxia was assessed using pimonidazole tissue staining in relevant organs. Hemodynamic and metabolic variables were also investigated. RESULTS Despite significant differences in exchangeable blood volume, Hbcrit was the same in all groups (2.3 g/dL, NS). During HOV, tissue hypoxia was aggravated in the myocardium, brain, and kidneys, whereas tissue oxygenation of the liver and intestine was not influenced by volume status. HEV increased tissue hypoxia in the lungs, but did not impact tissue oxygenation of other organs. CONCLUSIONS The combination of hemorrhagic HOV with subsequent anemia leads to accentuated tissue hypoxia, revealed by a significant increase in pimonidazole binding at Hbcrit , in heart, lungs, brain, and kidney. The lungs were the only organ that showed increased tissue hypoxia after pretreatment of HES infusion and subsequent anemia by normovolemic hemodilution.
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Affiliation(s)
- Malte Krömker
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Sana Klinikum Offenbach, Offenbach, Germany
| | - Patrick Lauscher
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Sana Klinikum Offenbach, Offenbach, Germany
| | - Harry Kertscho
- Department of Anesthesiology and Critical Care Medicine, University Hospital Mannheim, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Peter Rosenberger
- Clinic for Anesthesiology and Intensive Care Medicine, Eberhard Karls University, Tübingen, Germany
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine of the Kepler University, Linz, Austria
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Hänggi D, Etminan N, Aldrich F, Steiger HJ, Mayer SA, Diringer MN, Hoh BL, Mocco J, Faleck HJ, Macdonald RL. Randomized, Open-Label, Phase 1/2a Study to Determine the Maximum Tolerated Dose of Intraventricular Sustained Release Nimodipine for Subarachnoid Hemorrhage (NEWTON [Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage]). Stroke 2016; 48:145-151. [PMID: 27932607 PMCID: PMC5176000 DOI: 10.1161/strokeaha.116.014250] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/17/2016] [Accepted: 11/08/2016] [Indexed: 11/17/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— We conducted a randomized, open-label, phase 1/2a, dose-escalation study of intraventricular sustained-release nimodipine (EG-1962) to determine safety, tolerability, pharmacokinetics, and clinical effects in aneurysmal subarachnoid hemorrhage. Methods— Subjects with aneurysmal subarachnoid hemorrhage repaired by clipping or coiling were randomized to EG-1962 or enteral nimodipine. Subjects were World Federation of Neurological Surgeons grade 2 to 4 and had an external ventricular drain. Cohorts of 12 subjects received 100 to 1200 mg EG-1962 (9 per cohort) or enteral nimodipine (3 per cohort). The primary objective was to determine the maximum tolerated dose. Results— Fifty-four subjects in North America were randomized to EG-1962, and 18 subjects were randomized to enteral nimodipine. The maximum tolerated dose was 800 mg. One serious adverse event related to EG-1962 (400 mg) and 2 EG-1962 dose-limiting toxicities were without clinical sequelae. There was no EG-1962-related hypotension compared with 17% (3/18) with enteral nimodipine. Favorable outcome at 90 days on the extended Glasgow outcome scale occurred in 27/45 (60%, 95% confidence interval 46%–74%) EG-1962 subjects (5/9 with 100, 6/9 with 200, 7/9 with 400, 4/9 with 600, and 5/9 with 800 mg) and 5/18 (28%, 95% confidence interval 7%–48%, relative risk reduction of unfavorable outcome; 1.45, 95% confidence interval 1.04–2.03; P=0.027) enteral nimodipine subjects. EG-1962 reduced delayed cerebral ischemia (14/45 [31%] EG-1962 versus 11/18 [61%] enteral nimodipine) and rescue therapy (11/45 [24%] versus 10/18 [56%]). Conclusions— EG-1962 was safe and tolerable to 800 mg, and in this, aneurysmal subarachnoid hemorrhage population was associated with reduced delayed cerebral ischemia and rescue therapy. Overall, the rate of favorable clinical outcome was greater in the EG-1962-treated group. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01893190.
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Affiliation(s)
- Daniel Hänggi
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.).
| | - Nima Etminan
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Francois Aldrich
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Hans Jakob Steiger
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Stephan A Mayer
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Michael N Diringer
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Brian L Hoh
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - J Mocco
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Herbert J Faleck
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - R Loch Macdonald
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
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The Use of Milrinone in Patients with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Systematic Review. Can J Neurol Sci 2016; 44:152-160. [PMID: 27842615 DOI: 10.1017/cjn.2016.316] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a systematic review of the evidence supporting the use of milrinone for the management of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). DESIGN Primary outcomes were functional neurological status and the incidence of cerebral infarction. Search strategies adapted to the different databases were developed by a professional librarian. Medline, EMBASE, the Cochrane Library database, Web of Science, SCOPUS, BIOSIS, Global Health, Health Star, Open SIGLE, Google Scholar and the New York Academy of Medicine Gray Literature were searched as well as clinical trials databases and the proceedings of several scientific meetings. Quality of the evidence for these outcomes across studies was adjudicated using the GRADE Working Group criteria. RESULTS The search resulted in 284 citations after elimination of duplicates. Of those 9 conference proceedings and 15 studies met inclusion criteria and consisted of case reports, case series and two comparative studies: one non-randomized study with physiological outcomes only and a case series with historical controls. There was considerable variation in dosing and in co-interventions and no case control or randomized controlled studies were found. CONCLUSION There is currently only very low quality evidence to support the use of milrinone to improve important outcomes in patients with delayed cerebral ischemia secondary to subarachnoid hemorrhage. Further research is needed to clarify the value and risks of this medication in patients with SAH.
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Chalouhi N, Daou B, Okabe T, Starke RM, Dalyai R, Bovenzi CD, Anderson EC, Barros G, Reese A, Jabbour P, Tjoumakaris S, Rosenwasser R, Kraft WK, Rincon F. Beta-blocker therapy and impact on outcome after aneurysmal subarachnoid hemorrhage: a cohort study. J Neurosurg 2016; 125:730-6. [DOI: 10.3171/2015.7.jns15956] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Cerebral vasospasm (cVSP) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on outcome. Beta blockers (BBs) may blunt the sympathetic effect and catecholamine surge associated with ruptured cerebral aneurysms and prevent cardiac dysfunction. The purpose of this study was to investigate the association between preadmission BB therapy and cVSP, cardiac dysfunction, and in-hospital mortality following aSAH.
METHODS
This was a retrospective cohort study of patients with aSAH who were treated at a tertiary high-volume neurovascular referral center. The exposure was defined as any preadmission BB therapy. The primary outcome was cVSP assessed by serial transcranial Doppler with any mean flow velocity ≥ 120 cm/sec and/or need for endovascular intervention for medically refractory cVSP. Secondary outcomes were cardiac dysfunction (defined as cardiac troponin-I elevation > 0.05 μg/L, low left ventricular ejection fraction [LVEF] < 40%, or LV wall motion abnormalities [LVWMA]) and in-hospital mortality.
RESULTS
The cohort consisted of 210 patients treated between February 2009 and September 2010 (55% were women), with a mean age of 53.4 ± 13 years and median Hunt and Hess Grade III (interquartile range III–IV). Only 13% (27/210) of patients were exposed to preadmission BB therapy. Compared with these patients, a higher percentage of patients not exposed to preadmission BBs had transcranial Doppler-mean flow velocity ≥ 120 cm/sec (59% vs 22%; p = 0.003). In multivariate analyses, lower Hunt and Hess grade (OR 3.9; p < 0.001) and preadmission BBs (OR 4.5; p = 0.002) were negatively associated with cVSP. In multivariate analysis, LVWMA (OR 2.7; p = 0.002) and low LVEF (OR 1.1; p = 0.05) were independent predictors of in-hospital mortality. Low LVEF (OR 3.9; p = 0.05) independently predicted medically refractory cVSP. The in-hospital mortality rate was higher in patients with LVWMA (47.4% vs 14.8%; p < 0.001).
CONCLUSIONS
The study data suggest that preadmission therapy with BBs is associated with lower incidence of cVSP after aSAH. LV dysfunction was associated with higher medically refractory cVSP and in-hospital mortality. BB therapy may be considered after aSAH as a cardioprotective and cVSP preventive therapy.
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Affiliation(s)
| | | | | | - Robert M. Starke
- Departments of 1Neurosurgery,
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | | | | | | | | | | | | | | | | | - Fred Rincon
- Departments of 1Neurosurgery,
- 4Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania; and
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