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Golanov EV, Bovshik EI, Wong KK, Pautler RG, Foster CH, Federley RG, Zhang JY, Mancuso J, Wong ST, Britz GW. Subarachnoid hemorrhage - Induced block of cerebrospinal fluid flow: Role of brain coagulation factor III (tissue factor). J Cereb Blood Flow Metab 2018; 38:793-808. [PMID: 28350198 PMCID: PMC5987942 DOI: 10.1177/0271678x17701157] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Subarachnoid hemorrhage (SAH) in 95% of cases results in long-term disabilities due to brain damage, pathogenesis of which remains uncertain. Hindrance of cerebrospinal fluid (CSF) circulation along glymphatic pathways is a possible mechanism interrupting drainage of damaging substances from subarachnoid space and parenchyma. We explored changes in CSF circulation at different time following SAH and possible role of brain tissue factor (TF). Fluorescent solute and fluorescent microspheres injected into cisterna magna were used to track CSF flow in mice. SAH induced by perforation of circle of Willis interrupted CSF flow for up to 30 days. Block of CSF flow did not correlate with the size of hemorrhage. Following SAH, fibrin deposits were observed on the brain surface including areas without visible blood. Block of astroglia-associated TF by intracerebroventricular administration of specific antibodies increased size of hemorrhage, decreased fibrin deposition and facilitated spread of fluorophores in sham/naïve animals. We conclude that brain TF plays an important role in localization of hemorrhage and also regulates CSF flow under normal conditions. Targeting of the TF system will allow developing of new therapeutic approaches to the treatment of SAH and pathologies related to CSF flow such as hydrocephalus.
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Affiliation(s)
- Eugene V Golanov
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Evgeniy I Bovshik
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Kelvin K Wong
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA.,2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Robia G Pautler
- 3 Departments of Molecular Physiology and Biophysics and Neuroscience and Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Chase H Foster
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Richard G Federley
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA.,2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Jonathan Y Zhang
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - James Mancuso
- 2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Stephen Tc Wong
- 2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Gavin W Britz
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
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102
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van der Steen WE, Zijlstra IA, Verbaan D, Boers AMM, Gathier CS, van den Berg R, Rinkel GJE, Coert BA, Roos YBWEM, Majoie CBLM, Marquering HA. Association of Quantified Location-Specific Blood Volumes with Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. AJNR Am J Neuroradiol 2018; 39:1059-1064. [PMID: 29650786 DOI: 10.3174/ajnr.a5626] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 02/12/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia is a severe complication of aneurysmal SAH and is associated with a high case morbidity and fatality. The total blood volume and the presence of intraventricular blood on CT after aneurysmal SAH are associated with delayed cerebral ischemia. Whether quantified location-specific (cisternal, intraventricular, parenchymal, and subdural) blood volumes are associated with delayed cerebral ischemia has been infrequently researched. This study aimed to associate quantified location-specific blood volumes with delayed cerebral ischemia. MATERIALS AND METHODS Clinical and radiologic data were collected retrospectively from consecutive patients with aneurysmal SAH with available CT scans within 24 hours after ictus admitted to 2 academic centers between January 2009 and December 2011. Total blood volume was quantified using an automatic hemorrhage-segmentation algorithm. Segmented blood was manually classified as cisternal, intraventricular, intraparenchymal, or subdural. Adjusted ORs with 95% confidence intervals for delayed cerebral ischemia per milliliter of location-specific blood were calculated using multivariable logistic regression analysis. RESULTS We included 282 patients. Per milliliter increase in blood volume, the adjusted OR for delayed cerebral ischemia was 1.02 (95% CI, 1.01-1.04) for cisternal, 1.02 (95% CI, 1.00-1.04) for intraventricular, 0.99 (95% CI, 0.97-1.02) for intraparenchymal, and 0.96 (95% CI, 0.86-1.07) for subdural blood. CONCLUSIONS Our findings suggest that in patients with aneurysmal subarachnoid hemorrhage, the cisternal blood volume has a stronger relation with delayed cerebral ischemia than the blood volumes at other locations in the brain.
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Affiliation(s)
- W E van der Steen
- From the Department of Biomedical Engineering and Physics (W.E.v.d.S., A.M.M.B., H.A.M.) .,Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M).,Neurosurgical Center Amsterdam (W.E.v.d.S., D.V., B.A.C.).,Department of Neurology (W.E.v.d.S., Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - I A Zijlstra
- Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| | - D Verbaan
- Neurosurgical Center Amsterdam (W.E.v.d.S., D.V., B.A.C.)
| | - A M M Boers
- From the Department of Biomedical Engineering and Physics (W.E.v.d.S., A.M.M.B., H.A.M.).,Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M).,Department of Robotics and Mechatronics (A.M.M.B.), University of Twente, Enschede, the Netherlands
| | - C S Gathier
- Department of Neurology and Neurosurgery (C.S.G., G.J.E.R.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - R van den Berg
- Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| | - G J E Rinkel
- Department of Neurology and Neurosurgery (C.S.G., G.J.E.R.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - B A Coert
- Neurosurgical Center Amsterdam (W.E.v.d.S., D.V., B.A.C.)
| | - Y B W E M Roos
- Department of Neurology (W.E.v.d.S., Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - C B L M Majoie
- Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
| | - H A Marquering
- From the Department of Biomedical Engineering and Physics (W.E.v.d.S., A.M.M.B., H.A.M.).,Department of Radiology (W.E.v.d.S., I.A.Z., A.M.M.B., R.v.d.B., C.B.L.M.M., H.A.M)
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103
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Koyanagi M, Fukuda H, Lo B, Uezato M, Kurosaki Y, Sadamasa N, Handa A, Chin M, Yamagata S. Effect of intrathecal milrinone injection via lumbar catheter on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 128:717-722. [DOI: 10.3171/2016.10.jns162227] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDelayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI.METHODSThe prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables.RESULTSAfter propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups.CONCLUSIONSIn propensity score–matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.
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Affiliation(s)
- Masaomi Koyanagi
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Hitoshi Fukuda
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Benjamin Lo
- 2Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Minami Uezato
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Yoshitaka Kurosaki
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Nobutake Sadamasa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Akira Handa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Masaki Chin
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Sen Yamagata
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
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104
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Trends of Platelet Volume Index Predicts Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. World Neurosurg 2018; 111:e624-e631. [DOI: 10.1016/j.wneu.2017.12.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/19/2017] [Accepted: 12/20/2017] [Indexed: 12/21/2022]
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105
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Beitzke M, Enzinger C, Pichler A, Wünsch G, Fazekas F. Acute diffusion-weighted imaging lesions in cerebral amyloid angiopathy-related convexal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2018; 38:225-229. [PMID: 29168672 PMCID: PMC5951020 DOI: 10.1177/0271678x17744736] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Small acute diffusion-weighted imaging (DWI) lesions can accompany intracerebral hemorrhage due to cerebral amyloid angiopathy (CAA). We therefore examined the occurrence of such lesions in the context of CAA-related convexal subarachnoid hemorrhage (cSAH) both in a cross-sectional and longitudinal manner. DWI lesions were noted in 14/29 (48%) patients at their index cSAH and 12/21 patients (57%) showed acute small DWI lesions at follow-up MRI. Forty-four of 71 (62%) DWI lesions were spatially related to areas of cortical superficial siderosis. Clarification of the implications of our finding needs the investigation of larger patient groups.
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Affiliation(s)
- Markus Beitzke
- 1 Department of Neurology, 31475 Medical University of Graz , Graz, Austria
| | - Christian Enzinger
- 1 Department of Neurology, 31475 Medical University of Graz , Graz, Austria.,2 Department of Radiology, Division of Neuroradiology, 31475 Medical University of Graz , Graz, Austria
| | - Alexander Pichler
- 1 Department of Neurology, 31475 Medical University of Graz , Graz, Austria
| | - Gerit Wünsch
- 3 Institute for Medical Informatics, Statistics and Documentation, 31475 Medical University of Graz , Graz, Austria
| | - Franz Fazekas
- 1 Department of Neurology, 31475 Medical University of Graz , Graz, Austria
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106
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Abstract
Diseases of the central nervous system that are caused by an underlying vascular pathology typically result in either hemorrhage or ischemia. Most prominent entities include spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. For anatomic reasons, cerebrospinal fluid (CSF) qualifies as body fluid for the exploration of biomarkers in these disorders. Even though in subarachnoid hemorrhage a few CSF parameters have been established for routine diagnostic purposes, there is still an unmet need and broad interest in the identification of molecules that would allow further insight into disease mechanisms and supplement patients' medical care. This chapter provides an overview on what is presently known about CSF biomarkers in spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. We recapitulate current evidence on established diagnostic tests, discuss the role of various CSF molecules in the pathophysiology of these diseases, and illuminate their potential use in future clinical practice. Furthermore, we address methodologic aspects as well as shortcomings of research in this field.
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Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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107
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Ray B, Pandav VM, Mathews EA, Thompson DM, Ford L, Yearout LK, Bohnstedt BN, Chaudhary S, Dale GL, Prodan CI. Coated-Platelet Trends Predict Short-Term Clinical OutcomeAfter Subarachnoid Hemorrhage. Transl Stroke Res 2017; 9:459-470. [DOI: 10.1007/s12975-017-0594-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022]
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108
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Nagahama Y, Allan L, Nakagawa D, Zanaty M, Starke RM, Chalouhi N, Jabbour P, Brown RD, Derdeyn CP, Leira EC, Broderick J, Chimowitz M, Torner JC, Hasan D. Dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage: association with reduced risk of clinical vasospasm and delayed cerebral ischemia. J Neurosurg 2017; 129:702-710. [PMID: 29099296 DOI: 10.3171/2017.5.jns17831] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical vasospasm and delayed cerebral ischemia (DCI) are devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Several theories involving platelet activation have been postulated as potential explanations of the development of clinical vasospasm and DCI. However, the effects of dual antiplatelet therapy (DAPT; aspirin and clopidogrel) on clinical vasospasm and DCI have not been previously investigated. The objective of this study was to evaluate the effects of DAPT on clinical vasospasm and DCI in aSAH patients. METHODS Analysis of patients treated for aSAH during the period from July 2009 to April 2014 was performed in a single-institution retrospective study. Patients were divided into 2 groups: patients who underwent stent-assisted coiling or placement of flow diverters requiring DAPT (DAPT group) and patients who underwent coiling only without DAPT (control group). The frequency of symptomatic clinical vasospasm and DCI and of hemorrhagic complications was compared between the 2 groups, utilizing univariate and multivariate logistic regression. RESULTS Of 312 aSAH patients considered for this study, 161 met the criteria for inclusion and were included in the analysis (85 patients in the DAPT group and 76 patients in the control group). The risks of clinical vasospasm (OR 0.244, CI 95% 0.097-0.615, p = 0.003) and DCI (OR 0.056, CI 95% 0.01-0.318, p = 0.001) were significantly lower in patients receiving DAPT. The rates of hemorrhagic complications associated with placement of external ventricular drains and ventriculoperitoneal shunts were similar in both groups (4% vs 2%, p = 0.9). CONCLUSIONS The use of DAPT was associated with a lower risk of clinical vasospasm and DCI in patients treated for aSAH, without an increased risk of hemorrhagic complications.
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Affiliation(s)
| | - Lauren Allan
- 2Department of General Surgery, Mercy Medical Center, Des Moines, Iowa
| | | | | | | | - Nohra Chalouhi
- 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert D Brown
- 6Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - Enrique C Leira
- 8Department of Neurology, University of Iowa College of Medicine.,9Department of Epidemiology, University of Iowa, Iowa City
| | - Joseph Broderick
- 10Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio; and
| | - Marc Chimowitz
- 11Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - James C Torner
- 9Department of Epidemiology, University of Iowa, Iowa City
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109
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A Propensity Score-Matched Study of the Use of Non-steroidal Anti-inflammatory Agents Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 25:351-358. [PMID: 27000643 DOI: 10.1007/s12028-016-0266-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Inflammation may contribute to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Here, we compared outcomes among propensity score-matched cohorts who did and did not receive non-steroidal anti-inflammatory drug (NSAID) use after aSAH. METHODS Propensity score-matched analysis of 413 subjects enrolled in the Clazosentan to Overcome Neurological iSChemia and Infarction OccUring after Subarachnoid hemorrhage (CONSCIOUS-1) study. Propensity score matching was performed on the basis of age, sex, baseline National Institutes of Health Stroke Scale score, World Federation of Neurological Societies grade on admission, procedure used for securing aneurysm, and SAH clot burden. RESULTS 178 patients were matched (89 received NSAIDs, 89 did not). Propensity score matching was considered acceptable. Patients who had received NSAIDs during their hospital stay had significantly lower mortality rate, and reduced duration of intensive care unit stay and total length of hospital stay (P = 0.035, P = 0.009, and P = 0.053, respectively). At 6 weeks, 80.9 % of patients treated with NSAIDs had good functional outcome compared to 68.5 % of matched controls (P = 0.083). There was no significant difference in the proportions of patients who developed delayed ischemic neurological deficits, angiographic vasospasm, or required rescue therapy. CONCLUSIONS Inflammation may play a crucial role in the poor outcomes after SAH, and that NSAIDs may be a useful therapeutic option, once validated by larger prospective studies.
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110
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Siegler JE, Marcaccio C, Nawalinski K, Quattrone F, Sandsmark DK, Maloney-Wilensky E, Frangos S, Levine JM, Stein SC, Kasner SE, Kumar MA. Elevated Red Cell Distribution Width is Associated with Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 26:26-33. [PMID: 27530692 DOI: 10.1007/s12028-016-0306-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated red blood cell distribution width (RDW) has been associated with thrombotic disorders including myocardial infarction, venous thromboembolism, and ischemic stroke, independent of other inflammatory and coagulation biomarkers. The purpose of this study was to determine whether elevated RDW is associated with cerebral infarction and poor outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS In this retrospective single-center cohort of aSAH patients (October 2009-September 2014), elevated RDW was defined as a mean RDW >14.5 % during the first 14 days after aSAH. Outcomes included cerebral infarction (CI) by any mechanism and poor functional outcome, defined as discharge modified Rankin Scale (mRS) >4, indicating severe disability or death. RESULTS Of 179 patients, 27 % had a high Hunt-Hess grade (IV-V), and 76 % were women. Twenty-four patients (13.4 %) underwent red blood cell (RBC) transfusion and compared to patients with normal RDW, patients with an elevated RDW were at greater odds of RBC transfusion (OR 2.56 [95 % CI, 1.07-6.11], p = 0.035). In univariate analysis, more patients with elevated RDW experienced CI (30.8 vs. 13.7 %, p = 0.017). In the multivariable model, elevated RDW was significantly associated with CI (OR 3.08 [95 % CI, 1.30-7.32], p = 0.011), independent of known confounders including but not limited to age, sex, race, high Hunt-Hess grade, and RBC transfusion. In multivariable analysis, RDW elevation was also associated with poor functional outcome (mRS > 4) at discharge (OR 2.59 [95 % CI, 1.04-629], p = 0.040). CONCLUSIONS RDW elevation is associated with cerebral infarction and poor outcome after aSAH. Further evaluation of this association is warranted as it may shed light on mechanistic relations between anemia, inflammation, and thrombosis after aSAH.
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Affiliation(s)
- James E Siegler
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA.
| | - Christy Marcaccio
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Kelsey Nawalinski
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Francis Quattrone
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Danielle K Sandsmark
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Eileen Maloney-Wilensky
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Suzanne Frangos
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Joshua M Levine
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Sherman C Stein
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Scott E Kasner
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Monisha A Kumar
- Departments of Neurology and Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
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111
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McBride DW, Blackburn SL, Peeyush KT, Matsumura K, Zhang JH. The Role of Thromboinflammation in Delayed Cerebral Ischemia after Subarachnoid Hemorrhage. Front Neurol 2017; 8:555. [PMID: 29109695 PMCID: PMC5660311 DOI: 10.3389/fneur.2017.00555] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/02/2017] [Indexed: 01/13/2023] Open
Abstract
Delayed cerebral ischemia (DCI) is a major determinant of patient outcome following aneurysmal subarachnoid hemorrhage. Although the exact mechanisms leading to DCI are not fully known, inflammation, cerebral vasospasm, and microthrombi may all function together to mediate the onset of DCI. Indeed, inflammation is tightly linked with activation of coagulation and microthrombi formation. Thromboinflammation is the intersection at which inflammation and thrombosis regulate one another in a feedforward manner, potentiating the formation of thrombi and pro-inflammatory signaling. In this review, we will explore the role(s) of inflammation and microthrombi in subarachnoid hemorrhage (SAH) pathophysiology and DCI, and discuss the potential of targeting thromboinflammation to prevent DCI after SAH.
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Affiliation(s)
- Devin W McBride
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Spiros L Blackburn
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kumar T Peeyush
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kanako Matsumura
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda School of Medicine, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda School of Medicine, Loma Linda University, Loma Linda, CA, United States
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112
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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: 192] [Impact Index Per Article: 27.4] [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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113
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Korbakis G, Prabhakaran S, John S, Garg R, Conners JJ, Bleck TP, Lee VH. MRI Detection of Cerebral Infarction in Subarachnoid Hemorrhage. Neurocrit Care 2017; 24:428-35. [PMID: 26572141 DOI: 10.1007/s12028-015-0212-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate magnetic resonance imaging (MRI) detection of cerebral infarction (CI) in patients presenting with subarachnoid hemorrhage (SAH). BACKGROUND CI is a well-known complication of SAH that is typically detected on computed tomography (CT). MRI has improved sensitivity for acute CI over CT, particularly with multiple, small, or asymptomatic lesions. METHODS With IRB approval, 400 consecutive SAH patients admitted to our institution from August 2006 to March 2011 were retrospectively reviewed. Traumatic SAH and secondary SAH were excluded. Data were collected on demographics, cause of SAH, Hunt Hess and World Federation of Neurosurgical Societies grades, and neuroimaging results. MRIs were categorized by CI pattern as single cortical (SC), single deep (SD), multiple cortical (MC), multiple deep (MD), and multiple cortical and deep (MCD). RESULTS Among 123 (30.8 %) SAH patients who underwent MRIs during their hospitalization, 64 (52 %) demonstrated acute CI. The mean time from hospital admission to MRI was 5.7 days (range 0-29 days). Among the 64 patients with MRI infarcts, MRI CI pattern was as follows: MC in 20 (31 %), MCD in 18 (28 %), SC in 16 (25 %), SD in 3 (5 %), MD in 2 (3 %), and 5 (8 %) did not have images available for review. Most infarcts detected on MRI (39/64 or 61 %) were not visible on CT. CONCLUSIONS The use of MRI increases the detection of CI in SAH. Unlike CT studies, MRI-detected CI in SAH tends to involve multiple vascular territories. Studies that rely on CT may underestimate the burden of CI after SAH.
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Affiliation(s)
- Georgia Korbakis
- Department of Neurosurgery, University of California Los Angeles, 757 Westwood Blvd Room 6236, Los Angeles, CA, 90095, USA.
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL, 60611, US
| | - Sayona John
- Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison Street #1121, Chicago, IL, 60612, US
| | - Rajeev Garg
- Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison Street #1121, Chicago, IL, 60612, US
| | - James J Conners
- Section of Cerebrovascular Disease, Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison Street #1121, Chicago, IL, 60612, US
| | - Thomas P Bleck
- Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison Street #1121, Chicago, IL, 60612, US
| | - Vivien H Lee
- Section of Cerebrovascular Disease, Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison Street #1121, Chicago, IL, 60612, US
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114
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Bache S, Rasmussen R, Rossing M, Laigaard FP, Nielsen FC, Møller K. MicroRNA Changes in Cerebrospinal Fluid After Subarachnoid Hemorrhage. Stroke 2017; 48:2391-2398. [PMID: 28768799 PMCID: PMC5571886 DOI: 10.1161/strokeaha.117.017804] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/09/2017] [Accepted: 06/28/2017] [Indexed: 01/12/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Delayed cerebral ischemia (DCI) accounts for a major part of the morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). MicroRNAs (miRNAs) are pathophysiologically involved in acute cerebral ischemia. This study compared miRNA profiles in cerebrospinal fluid from neurologically healthy patients, as well as SAH patients with and without subsequent development of DCI. Methods— In a prospective case–control study of SAH patients treated with external ventricular drainage and neurologically healthy patients, miRNA profiles in cerebrospinal fluid were screened and validated using 2 different high-throughput real-time quantification polymerase chain reaction techniques. The occurrence of DCI was documented in patient charts and subsequently reviewed independently by 2 physicians. Results— MiRNA profiles from 27 SAH patients and 10 neurologically healthy patients passed quality control. In the validation, 66 miRNAs showed a relative increase in cerebrospinal fluid from SAH patients compared with neurologically healthy patients (P<0.001); 2 (miR-21 and miR-221) showed a relative increase in SAH patients with DCI compared with those without (P<0.05) in both the screening and validation. Conclusions— SAH is associated with marked changes in the cerebrospinal fluid miRNA profile. These changes could be associated to the development of DCI. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01791257.
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Affiliation(s)
- Søren Bache
- From the Departments of Neuroanaesthesiology (S.B., K.M.) and Neurosurgery (R.R.), The Neuroscience Centre, and Centre for Genomic Medicine (S.B., M.R., F.C.N.), Rigshospitalet, and Department of Anaesthesia, Frederiksberg Hospital (F.P.L.), University of Copenhagen, Denmark.
| | - Rune Rasmussen
- From the Departments of Neuroanaesthesiology (S.B., K.M.) and Neurosurgery (R.R.), The Neuroscience Centre, and Centre for Genomic Medicine (S.B., M.R., F.C.N.), Rigshospitalet, and Department of Anaesthesia, Frederiksberg Hospital (F.P.L.), University of Copenhagen, Denmark
| | - Maria Rossing
- From the Departments of Neuroanaesthesiology (S.B., K.M.) and Neurosurgery (R.R.), The Neuroscience Centre, and Centre for Genomic Medicine (S.B., M.R., F.C.N.), Rigshospitalet, and Department of Anaesthesia, Frederiksberg Hospital (F.P.L.), University of Copenhagen, Denmark
| | - Finn Pedersen Laigaard
- From the Departments of Neuroanaesthesiology (S.B., K.M.) and Neurosurgery (R.R.), The Neuroscience Centre, and Centre for Genomic Medicine (S.B., M.R., F.C.N.), Rigshospitalet, and Department of Anaesthesia, Frederiksberg Hospital (F.P.L.), University of Copenhagen, Denmark
| | - Finn Cilius Nielsen
- From the Departments of Neuroanaesthesiology (S.B., K.M.) and Neurosurgery (R.R.), The Neuroscience Centre, and Centre for Genomic Medicine (S.B., M.R., F.C.N.), Rigshospitalet, and Department of Anaesthesia, Frederiksberg Hospital (F.P.L.), University of Copenhagen, Denmark
| | - Kirsten Møller
- From the Departments of Neuroanaesthesiology (S.B., K.M.) and Neurosurgery (R.R.), The Neuroscience Centre, and Centre for Genomic Medicine (S.B., M.R., F.C.N.), Rigshospitalet, and Department of Anaesthesia, Frederiksberg Hospital (F.P.L.), University of Copenhagen, Denmark
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115
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Tholance Y, Barcelos GK, Perret-Liaudet A, Omar E, Carrillon R, Grousson S, Lieutaud T, Dailler F, Marinesco S. Placing intracerebral probes to optimise detection of delayed cerebral ischemia and allow for the prediction of patient outcome in aneurysmal subarachnoid haemorrhage. J Cereb Blood Flow Metab 2017; 37:2820-2832. [PMID: 27798274 PMCID: PMC5536791 DOI: 10.1177/0271678x16675880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/08/2016] [Accepted: 09/15/2016] [Indexed: 12/23/2022]
Abstract
Cerebral microdialysis could be useful to detect delayed cerebral ischemia in aneurysmal subarachnoid haemorrhage patients. The optimal location of the probes, however, remains controversial. Here, we determined the vascular territories with the highest infarct risk in relation to aneurysm location to define probe implantation guidelines. These guidelines were retrospectively validated by studying the likelihood of probe to fall in a secondary infarct area, and by analysing their influence to predict patient outcome. The vascular territories with highest risk of infarction were the anterior cerebral arteries for anterior communicating artery aneurysms and the ipsilateral middle cerebral artery for internal carotid artery, posterior communicating artery and middle cerebral artery aneurysms. When cerebral microdialysis probes had been implanted in these territories, 79% were located within an infarcted area versus 54% when they were implanted in other territories. Delayed cerebral ischemia was detected only when the probe was located within a brain area later affected by secondary infarction, which could justify the use of implantation guidelines. Moreover, individual patient outcomes could be predicted when probes were placed in the brain territories as suggested by this study. Thus, a precise probe placement algorithm can improve delayed cerebral ischemia detection sensitivity and allow for a better prediction concerning patient outcome.
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Affiliation(s)
- Yannick Tholance
- Department of Biochemistry and Molecular Genetics, Dupuytren University Hospital, Limoges, France
- TIGER Team, Lyon Neuroscience Research Center, CNRS, UMR 5292, INSERM U1028, University Lyon 1, Lyon, France
| | - Gleicy K Barcelos
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
- BioRaN Team, Lyon Neuroscience Research Center, CNRS, UMR 5292, INSERM U1028, University Lyon 1, Lyon, France
| | - Armand Perret-Liaudet
- BioRaN Team, Lyon Neuroscience Research Center, CNRS, UMR 5292, INSERM U1028, University Lyon 1, Lyon, France
- Laboratory of Neurobiology, Neurochemistry Unit, Department of Biochemistry and Molecular Biology, Hospices Civils de Lyon, Lyon, France
| | - Edris Omar
- Neuro-Intensive Care Unit, Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | - Romain Carrillon
- Neuro-Intensive Care Unit, Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | - Sébastien Grousson
- Neuro-Intensive Care Unit, Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | - Thomas Lieutaud
- TIGER Team, Lyon Neuroscience Research Center, CNRS, UMR 5292, INSERM U1028, University Lyon 1, Lyon, France
| | - Frédéric Dailler
- Neuro-Intensive Care Unit, Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | - Stéphane Marinesco
- TIGER Team, Lyon Neuroscience Research Center, CNRS, UMR 5292, INSERM U1028, University Lyon 1, Lyon, France
- AniRA-NeuroChem Technological Platform, Lyon Neuroscience Research Center, CNRS, UMR 5292, INSERM U1028, University Lyon 1, Lyon, France
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Abstract
Neurologic deterioration following acute injury to the central nervous system may be amenable to pharmacologic intervention, although, to date, no such therapy exists. Ketamine is an anesthetic and analgesic emerging as a novel therapy for a number of clinical entities in recent years, including refractory pain, depression, and drug-induced hyperalgesia due to newly discovered mechanisms of action and new application of its known pharmacodynamics. In this focused review, the evidence for ketamine as a neuroprotective agent in stroke, neurotrauma, subarachnoid hemorrhage, and status epilepticus is highlighted, with a focus on its applications for excitotoxicity, neuroinflammation, and neuronal hyperexcitability. Preclinical modeling and clinical applications are discussed.
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Affiliation(s)
- Josh D Bell
- From the Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
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117
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Wessell A, Kole MJ, Badjatia N, Parikh G, Albrecht JS, Schreibman DL, Simard JM. High Compliance with Scheduled Nimodipine Is Associated with Better Outcome in Aneurysmal Subarachnoid Hemorrhage Patients Cotreated with Heparin Infusion. Front Neurol 2017. [PMID: 28649230 PMCID: PMC5465287 DOI: 10.3389/fneur.2017.00268] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction We sought to determine whether compliance with scheduled nimodipine in subarachnoid hemorrhage patients impacted patient outcomes, with the intent of guiding future nimodipine management in patients who experience nimodipine-induced hypotension. Methods We performed a retrospective analysis of 118 consecutive aneurysmal subarachnoid hemorrhage patients treated with the Maryland Low-Dose IV Heparin Infusion Protocol. Patients were categorized into three independent nimodipine compliance groups: ≥1 dose held, ≥1 dose split, and no missed or split-doses. A split-dose was defined as 30 mg of nimodipine administered every 2 h. Our primary outcome was discharge to home. Bivariate and multivariable logistic regression analyses were used to assess predictors of discharge disposition as a function of nimodipine compliance. Results Of the 118 patients, 20 (17%) received all nimodipine doses, 6 (5%) received split-doses but never had a full dose held, and 92 (78%) had ≥1 dose held. Forty-five percent of patients were discharged to home, including 75% who received all doses, 67% who received ≥1 split-doses, and 37% with ≥1 missed doses (p = 0.003). Multivariable analysis showed that, along with age and World Federation of Neurosurgical Societies grade, nimodipine compliance was an independent predictor of clinical outcome; compared to missing one or more nimodipine doses, full dosing compliance was associated with increased odds of discharge to home (odds ratio 5.20; 95% confidence intervals 1.46–18.56). Conclusion In aneurysmal subarachnoid hemorrhage patients with modified Fisher scores 2 through 4 who are cotreated with a low-dose heparin infusion, full compliance with nimodipine dosing was associated with increased odds of discharge to home.
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Affiliation(s)
- Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Matthew J Kole
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neeraj Badjatia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gunjan Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - David L Schreibman
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, United States
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118
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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 Plasminogen Activator Inhibitor 1 (SERPINE1) Polymorphisms and Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 105:672-677. [PMID: 28599907 DOI: 10.1016/j.wneu.2017.05.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Genetic variations of the serine proteinase inhibitor family E member 1 (SERPINE1) gene, which encodes plasminogen activator inhibitor 1, correlate with serum levels of its product and are associated with thrombophilia and coronary atherosclerosis. Various SERPINE1 ;gene polymorphisms have been identified. However, only the functional 5G/4G polymorphism has been assessed in the context of aneurysmal subarachnoid hemorrhage (aSAH). We assessed associations of 6 SERPINE1 polymorphisms with the clinical sequelae of aSAH. METHODS From 2012 to 2015, patients with aSAH were prospectively enrolled into the CARAS (Cerebral Aneurysm Renin Angiotensin System) study at 2 major academic institutions. Blood samples were used to evaluate 6 common SERPINE1 single nucleotide polymorphisms via 5' exonuclease (Taqman) genotyping assays. RESULTS There was an association of the AA genotype of rs2227631 with the 4G/4G genotype and of the GG genotype of rs7242 with the AA genotype of rs2227684. In multivariable analysis, patients with the AA genotype of rs2227631 and 4G/4G genotype had an increased risk for developing delayed cerebral ischemia. Patients with the GG genotype of rs7242 and AA genotype of rs2227684 had a decreased risk for a poor functional outcome. CONCLUSIONS SERPINE1 gene polymorphisms were associated with delayed cerebral ischemia and functional outcome after aSAH. These associations may arise from alterations of plasminogen activator inhibitor 1 levels.
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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
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
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119
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Behavioral characterization of the anterior injection model of subarachnoid hemorrhage. Behav Brain Res 2017; 323:154-161. [DOI: 10.1016/j.bbr.2017.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 01/27/2017] [Accepted: 02/02/2017] [Indexed: 11/20/2022]
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120
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Daftari Besheli L, Tan CO, Bell DL, Hirsch JA, Gupta R. Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage. PLoS One 2017; 12:e0174676. [PMID: 28339483 PMCID: PMC5365119 DOI: 10.1371/journal.pone.0174676] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 03/13/2017] [Indexed: 01/03/2023] Open
Abstract
Intra-arterial (IA) vasodilator therapy is one of the recommended treatments to minimize the impact of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm refractory to standard management. However, its usefulness and efficacy is not well established. We evaluated the effect IA vasodilator therapy on middle cerebral artery blood flow and on discharge outcome. We reviewed records for 115 adults admitted to Neurointensive Care Unit to test whether there was a difference in clinical outcome (discharge mRS) in those who received IA infusions. In a subset of 19 patients (33 vessels) treated using IA therapy, we tested whether therapy was effective in reversing the trends in blood flow. All measures of MCA blood flow increased from day -2 to -1 before infusion (maximum Peak Systolic Velocity (PSV) 232.2±9.4 to 262.4±12.5 cm/s [p = 0.02]; average PSV 202.1±8.5 to 229.9±10.9 [p = 0.02]; highest Mean Flow Velocity (MFV) 154.3±8.3 to 172.9±10.5 [p = 0.10]; average MFV 125.5±6.3 to 147.8±9.5 cm/s, [p = 0.02]) but not post-infusion (maximum PSV 261.2±14.6 cm/s [p = .89]; average PSV 223.4±11.4 [p = 0.56]; highest MFV 182.9±12.4 cm/s [p = 0.38]; average MFV 153.0±10.2 cm/s [p = 0.54]). After IA therapy, flow velocities were consistently reduced (day X infusion interaction p<0.01 for all measures). However, discharge mRS was higher in IA infusion group, even after adjusting for sex, age, and admission grades. Thus, while IA vasodilator therapy was effective in reversing the vasospasm-mediated deterioration in blood flow, clinical outcomes in the treated group were worse than the untreated group. There is need for a prospective randomized controlled trial to avoid potential confounding effect of selection bias.
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Affiliation(s)
- Laleh Daftari Besheli
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Can Ozan Tan
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Cerebrovascular Research Laboratory, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States of America
- * E-mail:
| | - Donnie L. Bell
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Joshua A. Hirsch
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Rajiv Gupta
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
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121
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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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122
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van Lieshout JH, Dibué-Adjei M, Cornelius JF, Slotty PJ, Schneider T, Restin T, Boogaarts HD, Steiger HJ, Petridis AK, Kamp MA. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2017; 41:917-930. [PMID: 28215029 DOI: 10.1007/s10143-017-0827-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
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Affiliation(s)
- Jasper H van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Toni Schneider
- Institute for Neurophysiology, Medical Faculty, University of Cologne, Robert-Koch-Str. 39, 50931, Köln, Germany
| | - Tanja Restin
- Zurich Centre for Integrative Human Physiology, Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Institute of Anesthesiology, Medical Faculty, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios K Petridis
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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123
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Abstract
Subarachnoid hemorrhage (SAH) affects 30,000 people in the Unites States alone each year. Delayed cerebral ischemia occurs days after subarachnoid hemorrhage and represents a potentially treatable cause of morbidity for approximately one-third of those who survive the initial hemorrhage. While vasospasm has been traditionally linked to the development of cerebral ischemia several days after subarachnoid hemorrhage, emerging evidence reveals that delayed cerebral ischemia is part of a much more complicated post-subarachnoid hemorrhage syndrome. The development of delayed cerebral ischemia involves early arteriolar vasospasm with microthrombosis, perfusion mismatch and neurovascular uncoupling, spreading depolarizations, and inflammatory responses that begin at the time of the hemorrhage and evolve over time, culminating in cortical infarction. Large-vessel vasospasm is likely a late contributor to ongoing injury, and effective treatment for delayed cerebral ischemia will require improved detection of critical early pathophysiologic changes as well as therapeutic options that target multiple related pathways.
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124
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Clinical Development and Implementation of an Institutional Guideline for Prospective EEG Monitoring and Reporting of Delayed Cerebral Ischemia. J Clin Neurophysiol 2017; 33:217-26. [PMID: 27258445 DOI: 10.1097/wnp.0000000000000281] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Delayed cerebral ischemia (DCI) is the most common and disabling complication among patients admitted to the hospital for subarachnoid hemorrhage (SAH). Clinical and radiographic methods often fail to detect DCI early enough to avert irreversible injury. We assessed the clinical feasibility of implementing a continuous EEG (cEEG) ischemia monitoring service for early DCI detection as part of an institutional guideline. An institutional neuromonitoring guideline was designed by an interdisciplinary team of neurocritical care, clinical neurophysiology, and neurosurgery physicians and nursing staff and cEEG technologists. The interdisciplinary team focused on (1) selection criteria of high-risk patients, (2) minimization of safety concerns related to prolonged monitoring, (3) technical selection of quantitative and qualitative neurophysiologic parameters based on expert consensus and review of the literature, (4) a structured interpretation and reporting methodology, prompting direct patient evaluation and iterative neurocritical care, and (5) a two-layered quality assurance process including structured clinician interviews assessing events of neurologic worsening and an adjudicated consensus review of neuroimaging and medical records. The resulting guideline's clinical feasibility was then prospectively evaluated. The institutional SAH monitoring guideline used transcranial Doppler ultrasound and cEEG monitoring for vasospasm and ischemia monitoring in patients with either Fisher group 3 or Hunt-Hess grade IV or V SAH. Safety criteria focused on prevention of skin breakdown and agitation. Technical components included monitoring of transcranial Doppler ultrasound velocities and cEEG features, including quantitative alpha:delta ratio and percent alpha variability, qualitative evidence of new focal slowing, late-onset epileptiform activity, or overall worsening of background. Structured cEEG reports were introduced including verbal communication for findings concerning neurologic decline. The guideline was successfully implemented over 27 months, during which neurocritical care physicians referred 71 SAH patients for combined transcranial Doppler ultrasound and cEEG monitoring. The quality assurance process determined a DCI rate of 48% among the monitored population, more than 90% of which occurred during the duration of cEEG monitoring (mean 6.9 days) beginning 2.7 days after symptom onset. An institutional guideline implementing cEEG for SAH ischemia monitoring and reporting is feasible to implement and efficiently identify patients at high baseline risk of DCI during the period of monitoring.
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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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Bruder M, Won SY, Kashefiolasl S, Wagner M, Brawanski N, Dinc N, Seifert V, Konczalla J. Effect of heparin on secondary brain injury in patients with subarachnoid hemorrhage: an additional ‘H’ therapy in vasospasm treatment. J Neurointerv Surg 2017; 9:659-663. [DOI: 10.1136/neurintsurg-2016-012925] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveSecondary brain injury leads to high morbidity and mortality rates in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, evidence-based treatment strategies are sparse. Since heparin has various effects on neuroinflammation, microthromboembolism and vasomotor function, our objective was to determine whether heparin can be used as a multitarget prophylactic agent to ameliorate morbidity in SAH.MethodsBetween June 1999 and December 2014, 718 patients received endovascular treatment after rupture of an intracranial aneurysm at our institution; 197 of them were treated with continuous unfractionated heparin in therapeutic dosages after the endovascular procedure. We performed a matched pair analysis to evaluate the effect of heparin on cerebral vasospasm (CVS), cerebral infarction (CI), and outcome.ResultsThe rate of severe CVS was significantly reduced in the heparin group compared with the control group (14.2% vs 25.4%; p=0.005). CI and multiple ischemic lesions were less often present in patients with heparin treatment. These effects were enhanced if patients were treated with heparin for >48 hours, but the difference was not significant. Favorable outcome at 6-month follow-up was achieved in 69% in the heparin group and in 65% in the control group.ConclusionsPatients receiving unfractionated continuous heparin after endovascular aneurysm occlusion have a significant reduction in the rate of severe CVS, have CI less often, and tend to have a favorable outcome more often. Our findings support the potential beneficial effects of heparin as a multitarget therapy in patients with SAH, resulting in an additional ‘H’ therapy in vasospasm treatment.
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Kumar M, Cao W, McDaniel JK, Pham HP, Raju D, Nawalinski K, Frangos S, Kung D, Zager E, Kasner SE, Levine JM, Zheng XL. Plasma ADAMTS13 activity and von Willebrand factor antigen and activity in patients with subarachnoid haemorrhage. Thromb Haemost 2017; 117:691-699. [PMID: 28102428 DOI: 10.1160/th16-11-0834] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/15/2016] [Indexed: 11/05/2022]
Abstract
Increased von Willebrand factor (VWF) and reduced ADAMTS13 activity are associated with arterial thrombosis. This may also be the culprit mechanism implicated in delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage (SAH). It was our objective to determine plasma VWF and ADAMTS13 in patients with SAH and healthy subjects; and to explore the levels of those markers and outcome after SAH. Forty consecutive patients were enrolled between September 2007 and April 2014 in a pilot study. Plasma samples were collected from SAH patients on post-bleed day (PBD) 0, 1, 3, 5, 7 and 10 and healthy controls. VWF antigen (VWFAg) and VWF activity (VWFAc) were determined by enzyme-linked immunoassay and collagen binding assay, respectively. ADAMTS13 activity was determined by the cleavage of a fluorescent substrate. Univariate descriptive statistics and cluster analyses were performed based on outcomes in the group with SAH only. Mean age of SAH patients was 52.4 years (26-84 years) and 30 (75 %) were women. 12/40 (30 %) had a high Hunt and Hess grade (IV-V) and 25 (62.5 %) were treated with coil embolisation. Plasma VWFAg and VWFAc were significantly higher in SAH patients than those in healthy subjects on each PBD (p<0.0001). Concurrently, plasma ADAMTS13 activity in SAH patients was significantly lower than that in healthy subjects (p<0.0001). Among those with SAH, cluster analysis demonstrated that patients with higher VWFAg and VWFAc and/or lower ADAMTS13 activity might be at risk of increased mortality. In conclusion, the relative deficiency of plasma ADAMTS13 activity in SAH patients may associate with worse outcome.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - X Long Zheng
- X. Long Zheng, MD, PhD, Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL 35249, USA, E-mail:
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Biomarkers of Glycocalyx Injury are Associated with Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage: A Case Series Supporting a New Hypothesis. Neurocrit Care 2016; 26:339-347. [DOI: 10.1007/s12028-016-0357-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Foreman PM, Chua M, Harrigan MR, Fisher WS, Vyas NA, Lipsky RH, Walters BC, Tubbs RS, Shoja MM, Griessenauer CJ. Association of nosocomial infections with delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neurosurg 2016; 125:1383-1389. [DOI: 10.3171/2015.10.jns151959] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE
Delayed cerebral ischemia (DCI) is a recognized complication of aneurysmal subarachnoid hemorrhage (aSAH) that contributes to poor outcome. This study seeks to determine the effect of nosocomial infection on the incidence of DCI and patient outcome.
METHODS
An exploratory analysis was performed on 156 patients with aSAH enrolled in the Cerebral Aneurysm Renin Angiotensin System study. Clinical and radiographic data were analyzed with univariate analysis to detect risk factors for the development of DCI and poor outcome. Multivariate logistic regression was performed to identify independent predictors of DCI.
RESULTS
One hundred fifty-three patients with aSAH were included. DCI was identified in 32 patients (20.9%). Nosocomial infection (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.09–11.2, p = 0.04), ventriculitis (OR 25.3, 95% CI 1.39–458.7, p = 0.03), aneurysm re-rupture (OR 7.55, 95% CI 1.02–55.7, p = 0.05), and clinical vasospasm (OR 43.4, 95% CI 13.1–143.4, p < 0.01) were independently associated with the development of DCI. Diagnosis of nosocomial infection preceded the diagnosis of DCI in 15 (71.4%) of 21 patients. Patients diagnosed with nosocomial infection experienced significantly worse outcomes as measured by the modified Rankin Scale score at discharge and 1 year (p < 0.01 and p = 0.03, respectively).
CONCLUSIONS
Nosocomial infection is independently associated with DCI. This association is hypothesized to be partly causative through the exacerbation of systemic inflammation leading to thrombosis and subsequent ischemia.
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Affiliation(s)
- Paul M. Foreman
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Michelle Chua
- 2Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mark R. Harrigan
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Winfield S. Fisher
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Nilesh A. Vyas
- 3Department of Neurosciences, INOVA Health System, Fairfax, Virginia
| | - Robert H. Lipsky
- 3Department of Neurosciences, INOVA Health System, Fairfax, Virginia
| | - Beverly C. Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 3Department of Neurosciences, INOVA Health System, Fairfax, Virginia
| | | | | | - Christoph J. Griessenauer
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 5Beth Israel Deaconess Medical Center, Division of Neurosurgery, Harvard University, Boston, Massachusetts
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Wang X, Friis TE, Masci PP, Crawford RW, Liao W, Xiao Y. Alteration of blood clot structures by interleukin-1 beta in association with bone defects healing. Sci Rep 2016; 6:35645. [PMID: 27767056 PMCID: PMC5073366 DOI: 10.1038/srep35645] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/30/2016] [Indexed: 12/18/2022] Open
Abstract
The quality of hematomas are crucial for successful early bone defect healing, as the structure of fibrin clots can significantly influence the infiltration of cells, necessary for bone regeneration, from adjacent tissues into the fibrin network. This study investigated if there were structural differences between hematomas from normal and delayed healing bone defects and whether such differences were linked to changes in the expression of IL-1β. Using a bone defect model in rats, we found that the hematomas in the delayed healing model had thinner fibers and denser clot structures. Moreover, IL-1β protein levels were significantly higher in the delayed healing hematomas. The effects of IL-1β on the structural properties of human whole blood clots were evaluated by thrombelastograph (TEG), scanning electronic microscopy (SEM), compressive study, and thrombolytic assays. S-nitrosoglutathione (GSNO) was applied to modulate de novo hematoma structure and the impact on bone healing was evaluated in the delayed healing model. We found that GSNO produced more porous hematomas with thicker fibers and resulted in significantly enhanced bone healing. This study demonstrated that IL-1β and GSNO had opposing effects on clot architecture, the structure of which plays a pivotal role in early bone healing.
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Affiliation(s)
- Xin Wang
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000 Guizhou, China
- Australia-China Centre for Tissue Engineering and Regenerative Medicine, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
- Translational Research Institute, School of Medicine, The University of Queensland, Brisbane, 4102 Queensland, Australia
| | - Thor E. Friis
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
- Australia-China Centre for Tissue Engineering and Regenerative Medicine, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
| | - Paul P. Masci
- Translational Research Institute, School of Medicine, The University of Queensland, Brisbane, 4102 Queensland, Australia
| | - Ross W. Crawford
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
- Australia-China Centre for Tissue Engineering and Regenerative Medicine, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
| | - Wenbo Liao
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000 Guizhou, China
| | - Yin Xiao
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
- Australia-China Centre for Tissue Engineering and Regenerative Medicine, Queensland University of Technology, Brisbane, 4059 Queensland, Australia
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Abstract
For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.
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Affiliation(s)
- Charles L Francoeur
- Critical Care Division, Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Québec, Canada
| | - Stephan A Mayer
- Department of Neurology (Neurocritical Care), Mount Sinai, New York, NY, USA.
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1522, New York, NY, 10029-6574, USA.
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Red Blood Cell Distribution Width is Associated with Poor Clinical Outcome After Subarachnoid Hemorrhage: A Pilot Study. Neurocrit Care 2016; 23:217-24. [PMID: 25672971 DOI: 10.1007/s12028-015-0117-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The red cell distribution width (RDW) is a biomarker strongly associated with poor outcome in inflammatory and thrombotic diseases. Subarachnoid hemorrhage (SAH) is both an inflammatory and thrombotic state in which many biomarkers have been studied. In this exploratory pilot study, we sought to determine whether RDW predicts poor outcome in patients with SAH. METHODS Patients with moderate-to-severe SAH were prospectively enrolled in an observational study of biomarkers and outcome. CBC, ESR, high sensitivity CRP, D-dimer, and fibrinogen were obtained on post-bleed days (PBD) 1, 3, 5, 7, and 10. Poor outcome was defined as a modified Rankin score of 3-6 at 90-days. RESULTS Of 40 patients, 5 (12.5%) died and 19 (47.5%) had a poor outcome. RDW (p = 0.046) when measured serially over the study period, was significantly higher among patients with poor outcome. Maximum RDW (OR 2.3 95% CI 1.2-3.6; p = 0.014) and maximum WBC count (OR 1.29 95% CI 1.04-1.60; p = 0.018) were associated with poor outcome. Stepwise addition of maximum ESR, CRP, D-dimer, and fibrinogen yielded a model with RDW (OR 2.54 95% CI 1.21-5.35; p = 0.014) and fibrinogen (OR 1.01 95% CI 1.002-1.01; p = 0.004) predicting outcome. With addition of age and Hunt and Hess grade, RDW, fibrinogen, and high-grade status remained significantly associated with poor outcome. Use of PBD1 RDW in lieu of maximum RDW, resulted in a similar model. CONCLUSIONS An elevated RDW is associated with poor outcome in SAH patients. RDW may be a useful predictor of outcomes after SAH.
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Importance of Early Postoperative Body Temperature Management for Treatment of Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2016; 25:1482-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/10/2016] [Accepted: 01/31/2016] [Indexed: 11/19/2022] Open
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Ramchand P, Nyirjesy S, Frangos S, Doerfler S, Nawalinski K, Quattrone F, Ju C, Patel H, Driscoll N, Maloney-Wilensky E, Stein SC, Levine JM, Kasner SE, Kumar MA. Thromboelastography Parameter Predicts Outcome After Subarachnoid Hemorrhage: An Exploratory Analysis. World Neurosurg 2016; 96:215-221. [PMID: 27072337 DOI: 10.1016/j.wneu.2016.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Hypercoagulability after subarachnoid hemorrhage (SAH) is well described and may be platelet mediated. Thromboelastography (TEG) provides a global assessment of coagulation. We sought to determine whether the maximum amplitude (MA) parameter of TEG, a measure of platelet strength and function, is associated with outcome after SAH. METHODS One hundred ten TEG analyses were performed for patients with moderate-to-severe SAH and compared with 6 healthy age- and sex-matched controls. TEG indices included MA, G value (G), alpha angle, and thrombus generation and were correlated to functional outcomes and laboratory tests including complete blood count, erythrocyte sedimentation rate, high sensitivity C-reactive protein, fibrinogen, and d-dimer, obtained on post-bleed days (PBDs) 1, 3, 5, 7, and 10. RESULTS MA was significantly elevated compared with controls on PBD 3 (70.0 mm ± 4.5 mm vs. 64.1 mm ± 6.5 mm; P = 0.02), PBD 5 (72.6 mm ± 5.3 mm vs. 64.1 mm ± 6.5 mm; P = 0.003), PBD 7 (73.0 mm ± 5.4 mm vs. 64.1 mm ± 6.5 mm; P = 0.003), and PBD 10 (73.4 mm ± 6.0 mm vs. 64.1 mm ± 6.5 mm; P = 0.005). G was significantly elevated compared with controls on PBD 3 (P = 0.03), PBD 5 (P = 0.01), PBD 7 (P = 0.01), and PBD 10 (P = 0.02). The only biomarker associated with poor outcome was CRP. Multivariate logistic regression demonstrated an association between elevated MA and outcome (odds ratio 39.1, P = 0.006) independent of CRP, age, Hunt Hess grade, and transfusion. CONCLUSIONS TEG indices are associated with poor outcome after SAH and may identify a platelet-mediated hypercoagulable state. The association between MA and outcome was stronger than that between traditional biomarkers and was independent of age and Hunt Hess grade.
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Affiliation(s)
- Preethi Ramchand
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah Nyirjesy
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Suzanne Frangos
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelsey Nawalinski
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis Quattrone
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Connie Ju
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hiren Patel
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicki Driscoll
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Levine
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Monisha A Kumar
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Glial cell response after aneurysmal subarachnoid hemorrhage — Functional consequences and clinical implications. Biochim Biophys Acta Mol Basis Dis 2016; 1862:492-505. [DOI: 10.1016/j.bbadis.2015.10.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/12/2015] [Accepted: 10/15/2015] [Indexed: 12/17/2022]
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Zhu G, Yao Y, Pan L, Zhu W, Yan S. Reduction of Leukocyte Counts by Hydroxyurea Improves Cardiac Function in Rats with Acute Myocardial Infarction. Med Sci Monit 2015; 21:3941-7. [PMID: 26675565 PMCID: PMC4687945 DOI: 10.12659/msm.893744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND This study aimed to decrease leukocytes counts by hydroxyurea (Hu) in an acute myocardial infarction (AMI) rat model and examine its effect on the inflammatory response of myocardial infarction and cardiac functions. MATERIAL AND METHODS AMI was successfully caused in 36 rats, and 12 control rats received sham operation. Rats in the AMI group were then randomly divided into Hu and vehicle group with 18 rats each. Rats in the Hu AMI group received Hu (200 mg/kg) intragastrically while vehicle AMI group received saline. Leukocytes counts, cardiac functions, myocardial tissue morphology, and levels of soluble intercellular adhesion molecule-1 (sICAM), P-selectin and platelet activating factor (PAF) were measured and compared among the three groups four weeks after AMI induction. RESULTS Leukocytes, neutrophils, and leukomonocyte counts in vehicle AMI rats were significantly higher than that of the normal control group (p<0.05). However, Hu treatment decreased their counts significantly (p<0.05). sICAM, P-selectin, and PAF level in vehicle AMI group were significantly higher than those of the normal group, and their level was also decreased by Hu treatment (p<0.05). Echocardiography analysis showed that Hu treatment increased left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) compared to that of vehicle AMI group (p<0.05). Histopathological examination showed that Hu significantly reduced the swelling of the heart muscle fiber in necrotic foci and the number of inflammatory cells infiltrated into myocardial interstitium compared to vehicle AMI group. CONCLUSIONS Decrease leukocytes counts by Hu significantly reduced inflammatory reaction and improved cardiac functions in AMI rats.
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Affiliation(s)
- Guiyue Zhu
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, Shandong, China (mainland)
| | - Yucai Yao
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Ji'nan, Shandong, China (mainland)
| | - Lingyun Pan
- Department of Emergency Medicine, Second People's Hospital of Liaocheng, Linqing, Shandong, China (mainland)
| | - Wei Zhu
- Institute of Radiation Medicine, Shandong Academy of Medical Sciences, Ji'nan, Shandong, China (mainland)
| | - Suhua Yan
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Ji'nan, Shandong, China (mainland)
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Kato Y, Hayashi T, Tanahashi N, Kobayashi S. Influence of Antiplatelet Drugs on the Outcome of Subarachnoid Hemorrhage Differs with Age. J Stroke Cerebrovasc Dis 2015. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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139
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Yamamoto T, Mori K, Esaki T, Nakao Y, Tokugawa J, Watanabe M. Preventive effect of continuous cisternal irrigation with magnesium sulfate solution on angiographic cerebral vasospasms associated with aneurysmal subarachnoid hemorrhages: a randomized controlled trial. J Neurosurg 2015; 124:18-26. [PMID: 26230471 DOI: 10.3171/2015.1.jns142757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECT Although cerebral vasospasm (CV) is one of the most important predictors for the outcome in patients with subarachnoid hemorrhage (SAH), no treatment has yet been established for this condition. This study investigated the efficacy of continuous direct infusion of magnesium sulfate (MgSO4) solution into the intrathecal cistern in patients with an aneurysmal SAH. METHODS An SAH caused by a ruptured aneurysm was identified on CT scans within 72 hours after SAH onset. All patients were treated by surgical clipping and randomized into 2 groups: a control group of patients undergoing a standard treatment and a magnesium (Mg) group of patients additionally undergoing continuous infusion of 5 mmol/L MgSO4 solution for 14 days. The Mg(2+) concentrations in serum and CSF were recorded daily. Neurological examinations were performed by intensive care clinicians. Delayed cerebral ischemia was monitored by CT or MRI. To assess the effect of the Mg treatment on CV, the CVs were graded on the basis of the relative degree of constriction visible on cerebral angiograms taken on Day 10 after the SAH, and transcranial Doppler ultrasonography was performed daily to measure blood flow velocity in the middle cerebral artery (MCA). Neurological outcomes and mortality rates were evaluated with the Glasgow Outcome Scale and modified Rankin Scale at 3 months after SAH onset. RESULTS Seventy-three patients admitted during the period of April 2008 to March 2013 were eligible and enrolled in this study. Three patients were excluded because of violation of protocol requirements. The 2 groups did not significantly differ in age, sex, World Federation of Neurosurgical Societies grade, or Fisher grade. In the Mg group, the Mg(2+) concentration in CSF gradually increased from Day 4 after initiation of the continuous MgSO4 intrathecal administration. No such increase was observed in the control group. No significant changes in the serum Mg(2+) levels were observed for 14 days, and no cardiovascular complications such as bradycardia or hypotension were observed in any of the patients. However, bradypnea was noted among patients in the Mg group. The Mg group had a significantly better CV grade than the control group (p < 0.05). Compared with the patients in the Mg group, those in the control group had a significantly elevated blood flow velocity in the MCA. Both groups were similar in the incidences of cerebral infarction, and the 2 groups also did not significantly differ in clinical outcomes. CONCLUSIONS Continuous cisternal irrigation with MgSO4 solution starting on Day 4 and continuing to Day 14 significantly inhibited CV in patients with aneurysmal SAH without severe cardiovascular complications. However, this improvement in CV neither reduced the incidence of delayed cerebral ischemia nor improved the functional outcomes in patients with SAH.
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Affiliation(s)
- Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama; and
| | - Takanori Esaki
- Department of Rehabilitation, Gifu Central Hospital, Gifu, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
| | - Mitsuya Watanabe
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
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140
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Guvenc Tuna B, Lachkar N, de Vos J, Bakker EN, VanBavel E. Cerebral Artery Remodeling in Rodent Models of Subarachnoid Hemorrhage. J Vasc Res 2015; 52:103-15. [DOI: 10.1159/000431366] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 05/13/2015] [Indexed: 11/19/2022] Open
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141
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Ehlert A, Schmidt C, Wölfer J, Manthei G, Jacobs AH, Brüning R, Heindel W, Ringelstein EB, Stummer W, Pluta RM, Hesselmann V. Molsidomine for the prevention of vasospasm-related delayed ischemic neurological deficits and delayed brain infarction and the improvement of clinical outcome after subarachnoid hemorrhage: a single-center clinical observational study. J Neurosurg 2015; 124:51-8. [PMID: 26162034 DOI: 10.3171/2014.12.jns13846] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Delayed ischemic neurological deficits (DINDs) and cerebral vasospasm (CVS) are responsible fora poor outcome in patients with aneurysmal subarachnoid hemorrhage (SAH), most likely because of a decreased availability of nitric oxide (NO) in the cerebral microcirculation. In this study, the authors examined the effects of treatment with the NO donor molsidomine with regard to decreasing the incidence of spasm-related delayed brain infarctions and improving clinical outcome in patients with SAH. METHODS Seventy-four patients with spontaneous aneurysmal SAH were included in this post hoc analysis. Twenty-nine patients with SAH and proven CVS received molsidomine in addition to oral or intravenous nimodipine. Control groups consisted of 25 SAH patients with proven vasospasm and 20 SAH patients without. These patients received nimodipine therapy alone. Cranial computed tomography (CCT) before and after treatment was analyzed for CVS-related infarcts. A modified National Institutes of Health Stroke Scale (mNIHSS) and the modified Rankin Scale (mRS) were used to assess outcomes at a 3-month clinical follow-up. RESULTS Four of the 29 (13.8%) patients receiving molsidomine plus nimodipine and 22 of the 45 (48%) patients receiving nimodipine therapy alone developed vasospasm-associated brain infarcts (p < 0.01). Follow-up revealed a median mNIHSS score of 3.0 and a median mRS score of 2.5 in the molsidomine group compared with scores of 11.5 and 5.0, respectively, in the nimodipine group with CVS (p < 0.001). One patient in the molsidomine treatment group died, and 12 patients in the standard care group died (p < 0.01). CONCLUSIONS In this post hoc analysis, patients with CVS who were treated with intravenous molsidomine had a significant improvement in clinical outcome and less cerebral infarction. Molsidomine offers a promising therapeutic option in patients with severe SAH and CVS and should be assessed in a prospective study.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St. Georg, Hamburg;
| | | | | | - Gerd Manthei
- Department of Neurosurgery, Asklepios Hospital St. Georg, Hamburg;
| | | | - Roland Brüning
- Department of Radiology, Asklepios Hospital Barmbek, Hamburg
| | | | | | | | - Ryszard M Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Volker Hesselmann
- Radiology, and.,Asklepios Hospital Hamburg North, Hamburg, Germany; and
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142
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Chen JX, Lai LF, Zheng K, Li GX, He XY, Li LP, Duan CZ. Influencing factors of immediate angiographic results in intracranial aneurysms patients after endovascular treatment. J Neurol 2015; 262:2115-23. [PMID: 26100332 DOI: 10.1007/s00415-015-7824-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to analyze influencing factors associated with immediate angiographic results in intracranial aneurysms patients after endovascular treatment (EVT), providing theoretical evidence and guidance for clinical treatment of intracranial aneurysms. Totally 529 patients met the inclusive criteria, consisting of 338 males and 191 females. Gender; age; history of hypertension, diabetes, and smoking; intracranial atherosclerosis; rupture status, size and location, features of aneurysmal neck, shapes; vasospasm; treatment modality; and degree of aneurysm occlusion were all carefully and completely recorded. All data were investigated in univariate and multivariate logistic regression model to determine whether they were correlated with the degree of aneurysm occlusion. According to aneurysm size, aneurysms were classified as micro-miniature, miniature, and large aneurysms. There were 451 narrow-neck aneurysms and 78 wide-neck aneurysms. Totally 417 were regular and 112 were irregular. And 125 were un-ruptured aneurysms; 404 were ruptured aneurysms. The modalities of treatment were as follows: embolization with coil (n = 415), stent-assisted coil embolization (n = 89), and balloon-assisted coil embolization (n = 25). Univariate analysis showed that aneurysm size, feature of aneurysm neck, shape, and rupture status might affect the immediate occlusion after EVT. Multivariate logistic regression analysis indicated that ruptured aneurysm, tiny aneurysm, and wide-neck aneurysm were independent influencing factors of complete occlusion of intracranial aneurysm. Aneurysm rupture status, size, feature of aneurysmal neck, and shape might be the independent influencing factors of immediate angiographic results in intracranial aneurysm patients after EVT. Un-ruptured, micro-miniature, narrow-neck, and regular-shaped aneurysms were more probable to be occluded completely.
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Affiliation(s)
- Jia-Xiang Chen
- Department of Neurosurgery, Guangzhou Red Cross Hospital, The Fourth Affiliated Hospital of Jinan University, Guangzhou, People's Republic of China
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China
| | - Ling-Feng Lai
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China
| | - Kuang Zheng
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China
| | - Guo-Xiong Li
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China
| | - Xu-Ying He
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China
| | - Liang-Ping Li
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China
| | - Chuan-Zhi Duan
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, No. 253, Industrial Avenue, Haizhu District, Guangzhou, 510282, People's Republic of China.
- Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Institute of Neurosurgery, Southern Medical University, Guangzhou, 510200, Guangdong, People's Republic of China.
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143
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Boettinger S, Lackner P. Cellular Microparticles in Subarachnoid Hemorrhage. Transl Stroke Res 2015; 6:342-4. [PMID: 26099349 DOI: 10.1007/s12975-015-0413-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Susanne Boettinger
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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144
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Baradaran H, Fodera V, Mir D, Kesavabhotla K, Kesavobhotla K, Ivanidze J, Ozbek U, Gupta A, Claassen J, Sanelli PC. Evaluating CT Perfusion Deficits in Global Cerebral Edema after Aneurysmal Subarachnoid Hemorrhage. AJNR Am J Neuroradiol 2015; 36:1431-5. [PMID: 25977478 DOI: 10.3174/ajnr.a4328] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/18/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Global cerebral edema is an independent predictor of mortality and poor outcomes after aneurysmal SAH. Global cerebral edema, a complex disease process, is thought to be associated with an altered cerebral autoregulatory response. We studied the association between cerebral hemodynamics and early global cerebral edema by using CTP. MATERIALS AND METHODS We retrospectively studied consecutive patients with aneurysmal SAH with admission CTP performed at days 0-3. Two neuroradiologists classified global cerebral edema and hydrocephalus on NCCT performed concurrently with CTP. Global cerebral edema was defined as diffuse effacement of the sulci and/or basal cisterns or diffuse disruption of the cerebral gray-white matter junction. CTP was postprocessed into CBF and MTT maps by using a standardized method. Quantitative analysis of CTP was performed by using standard protocol with ROI sampling of the cerebral cortex. The Fisher exact test, Mann-Whitney test, and independent-samples t test were used to determine statistical associations. RESULTS Of the 45 patients included, 42% (19/45) had global cerebral edema and 58% (26/45) did not. Patient groups with and without global cerebral edema were well-matched for demographic and clinical data. Patients with global cerebral edema were more likely to have qualitative global CTP deficits than those without global cerebral edema (P = .001) with an OR = 13.3 (95% CI, 2.09-138.63). Patients with global cerebral edema also had a very strong trend toward statistical significance, with reduced quantitative CBF compared with patients without global cerebral edema (P = .064). CONCLUSIONS Global perfusion deficits are significantly associated with global cerebral edema in the early phase after aneurysmal SAH, supporting the theory that hemodynamic disturbances occur in global cerebral edema.
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Affiliation(s)
- H Baradaran
- From the Departments of Radiology (H.B., V.F., D.M., K.K., J.I., A.G.)
| | - V Fodera
- From the Departments of Radiology (H.B., V.F., D.M., K.K., J.I., A.G.)
| | - D Mir
- From the Departments of Radiology (H.B., V.F., D.M., K.K., J.I., A.G.)
| | | | - K Kesavobhotla
- From the Departments of Radiology (H.B., V.F., D.M., K.K., J.I., A.G.)
| | - J Ivanidze
- From the Departments of Radiology (H.B., V.F., D.M., K.K., J.I., A.G.)
| | - U Ozbek
- Public Health (U.O.), NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - A Gupta
- From the Departments of Radiology (H.B., V.F., D.M., K.K., J.I., A.G.)
| | - J Claassen
- Department of Neurology (J.C.), NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - P C Sanelli
- Department of Radiology (P.C.S.), North-Shore-Long Island Jewish Health System, Great Neck, New York
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145
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Caspers J, Rubbert C, Turowski B, Martens D, Reichelt DC, May R, Aissa J, Hänggi D, Etminan N, Mathys C. Timing of Mean Transit Time Maximization is Associated with Neurological Outcome After Subarachnoid Hemorrhage. Clin Neuroradiol 2015; 27:15-22. [PMID: 25939528 DOI: 10.1007/s00062-015-0399-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/15/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Computed tomography perfusion (CTP) has gained significant relevance for the radiological screening of patients at risk of developing delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Particularly, the impact of MTTPEAK, i.e., the maximal mean transit time value in a series of CTP measurements, for the prediction of long-term outcome has recently been demonstrated by our group. Complementing this recent work, the present study investigated how the timing of MTTPEAK affected the long-term outcome after aneurysmal subarachnoid hemorrhage. METHODS CTP examinations from 103 patients with clinical deterioration attributed to DCI after aSAH were retrospectively analyzed for time interval between SAH ictus and onset of MTTPEAK in association with modified Rankin Scale (mRS) 23.1 months after SAH. RESULTS Patients with unfavorable outcome (mRS > = 2) suffered significant earlier MTTPEAK onsets than patients with favorable outcome (mRS = 0 and 1). MTTPEAK within the first week was associated with significantly higher mRS scores compared to later MTTPEAK. Timing of MTTPEAK together with the value of MTTPEAK and initial World Federation of Neurosurgical Societies (WFNS) grade was a significant predictor for an unfavorable outcome (mRS > = 2). CONCLUSIONS The current findings suggest a presumably higher vulnerability of the brain to early microcirculatory impairments after aSAH and highlight that timing of MTT elevations could be considered for the identification of patients at increased risk for poor neurological outcome due to DCI.
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Affiliation(s)
- J Caspers
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, 52425, Jülich, Germany
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany.
| | - B Turowski
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Martens
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D C Reichelt
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - R May
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - J Aissa
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - N Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - C Mathys
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
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146
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Boluijt J, Meijers JCM, Rinkel GJE, Vergouwen MDI. Hemostasis and fibrinolysis in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review. J Cereb Blood Flow Metab 2015; 35:724-33. [PMID: 25690473 PMCID: PMC4420861 DOI: 10.1038/jcbfm.2015.13] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/09/2015] [Accepted: 01/12/2015] [Indexed: 11/09/2022]
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with microthrombosis, which can result from activated hemostasis, inhibited fibrinolysis, or both. We systematically searched the PUBMED and EMBASE databases to identify hemostatic or fibrinolytic parameters that can be used for the prediction or diagnosis of DCI, or that inform on the pathogenesis of DCI and may serve as treatment targets. We included 24 studies that fulfilled predefined criteria and described 39 biomarkers. Only one study fulfilled predefined criteria for high quality. Since no parameter on admission was associated with DCI and in none of the included studies blood was drawn at the time of clinical deterioration, none of the studied parameters can presently be used for the prediction or diagnosis of DCI. Regarding the pathogenesis of DCI, it was shown that compared with patients without DCI those with DCI had higher levels of von Willebrand factor and platelet activating factor in plasma 5 to 9 days after aSAH, membrane tissue factor in cerebrospinal fluid 5 to 9 days after aSAH, and D-dimer in plasma 11 to 14 days after aSAH. Confirmation in high-quality studies is needed to investigate whether these parameters can serve as targets for new intervention studies.
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Affiliation(s)
- Jacoline Boluijt
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost C M Meijers
- 1] Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands [2] Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- 1] Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands [2] Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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147
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Aneurysmal Subarachnoid Hemorrhage—Status Quo and Perspective. Transl Stroke Res 2015; 6:167-70. [DOI: 10.1007/s12975-015-0398-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 03/31/2015] [Indexed: 11/26/2022]
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148
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Abstract
Cerebral vasospasm causes delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage. This is a well-established clinical entity with significant associated morbidity and mortality. The underlying patholphysiology is highly complex and poorly understood. Large-vessel vasospasm, autoregulatory dysfunction, inflammation, genetic predispositions, microcirculatory failure, and spreading cortical depolarization are aspects of delayed neurologic deterioration that have been described in the literature. This article presents a perspective on cerebral vasospasm, as guided by the literature to date, specifically examining the mechanism, diagnosis, and treatment of cerebral vasospasm.
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149
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Young AMH, Karri SK, Helmy A, Budohoski KP, Kirollos RW, Bulters DO, Kirkpatrick PJ, Ogilvy CS, Trivedi RA. Pharmacologic Management of Subarachnoid Hemorrhage. World Neurosurg 2015; 84:28-35. [PMID: 25701766 DOI: 10.1016/j.wneu.2015.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 01/31/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
Abstract
Subarachnoid hemorrhage (SAH) remains a condition with suboptimal functional outcomes, especially in the young population. Pharmacotherapy has an accepted role in several aspects of the disease and an emerging role in several others. No preventive pharmacologic interventions for SAH currently exist. Antiplatelet medications as well as anticoagulation have been used to prevent thromboembolic events after endovascular coiling. However, the main focus of pharmacologic treatment of SAH is the prevention of delayed cerebral ischemia (DCI). Currently the only evidence-based medical intervention is nimodipine. Other calcium channel blockers have been evaluated without convincing efficacy. Anti-inflammatory drugs such as statins have demonstrated early potential; however, they failed to provide significant evidence for the use in preventing DCI. Similar findings have been reported for magnesium, which showed potential in experimental studies and a phase 2 trial. Clazosentane, a potent endothelin receptor antagonist, did not translate to improve functional outcomes. Various other neuroprotective agents have been used to prevent DCI; however, the results have been, at best inconclusive. The prevention of DCI and improvement in functional outcome remain the goals of pharmacotherapy after the culprit lesion has been treated in aneurysmal SAH. Therefore, further research to elucidate the exact mechanisms by which DCI is propagated is clearly needed. In this article, we review the current pharmacologic approaches that have been evaluated in SAH and highlight the areas in which further research is needed.
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Affiliation(s)
- Adam M H Young
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Surya K Karri
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ramez W Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Diederik O Bulters
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Christopher S Ogilvy
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rikin A Trivedi
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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150
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van Ierssel SH, Conraads VM, Van Craenenbroeck EM, Liu Y, Maas AIR, Parizel PM, Hoymans VY, Vrints CJ, Jorens PG. Endothelial dysfunction in acute brain injury and the development of cerebral ischemia. J Neurosci Res 2015; 93:866-72. [PMID: 25677574 DOI: 10.1002/jnr.23566] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 11/22/2014] [Accepted: 01/05/2015] [Indexed: 01/13/2023]
Abstract
Cerebral ischemia (CeI) is a major complicating event after acute brain injury (ABI) in which endothelial dysfunction is a key player. This study evaluates cellular markers of endothelial function and in vivo reactive hyperemia in patients with ABI and their relationship to the development of cerebral ischemia. We studied cellular markers of endothelial dysfunction and the peripheral reactive hyperemia index (RHI) in 26 patients with ABI at admission and after 6 and 12 days, and compared these with those of healthy volunteers (n = 15). CeI was determined clinically or by computer tomography. In patients with ABI, RHI at admission was significantly reduced compared with healthy subjects (P = 0.003), coinciding with a decrease in circulating endothelial progenitor cells (EPC; P = 0.002). The RHI recovered in eight patients without development of CeI, but failed to fully recover by day 12 in three of four patients who developed CeI. Despite recovery of the RHI within 12 days in these patients (P = 0.003), EPC count remained significantly lower after 12 days in patients with ABI (P = 0.022). CD31(+) T cells and endothelial microparticles were not different between controls and patients. No differences were noted in cellular markers of endothelial dysfunction in patients developing CeI and those not. In conclusion, patients with ABI exhibit impaired microvascular endothelial function measured as RHI and a decreased circulating level of EPC.
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Affiliation(s)
- Sabrina H van Ierssel
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium; Department of Internal Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
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