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Krenzlin H, Wesp DMA, Korinek AAE, Ubbens H, Volland J, Masomi-Bornwasser J, Weber KJ, Mole D, Sommer C, Ringel F, Alessandri B, Keric N. Effects of Argon in the Acute Phase of Subarachnoid Hemorrhage in an Endovascular Perforation Model in Rats. Neurocrit Care 2024:10.1007/s12028-024-02090-3. [PMID: 39174846 DOI: 10.1007/s12028-024-02090-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/31/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is a devastating disease with high morbidity and mortality. Neuroprotective effects of the noble gas argon have been shown in animal models of ischemia. The aim of this study was to investigate the effects of argon in the immediate early phase of SAH in a rat model. METHODS A total of 19 male Wistar rats were randomly assigned to three treatment groups. SAH was induced using a endovascular filament perforation model. Cerebral blood flow, mean arterial blood pressure (MAP), and body temperature were measured continuously. Group A received 2 h of ventilation by 50% argon/50% O2 (n = 7) immediately following SAH. Group B underwent a sham operation and was also ventilated by 50% argon/50% O2 (n = 6). Group C underwent SAH and 50% O2/50% N2 ventilation (n = 6). Preoperative and postoperative neurological and behavioral testing were performed. Histology and immunohistochemistry were used to evaluate the extent of brain injury and vasospasm. RESULTS The cerebral blood flow dropped in both treatment groups after SAH induction (SAH, 63.0 ± 11.6% of baseline; SAH + argon, 80.2 ± 8.2% of baseline). During SAH, MAP increased (135.2 ± 10.5%) compared with baseline values (85.8 ± 26.0 mm Hg) and normalized thereafter. MAP in both groups showed no significant differences (p = 0.3123). Immunohistochemical staining for neuronal nuclear antigen demonstrated a decrease of hippocampal immunoreactivity after SAH in the cornu ammonis region (CA) 1-3 compared with baseline hippocampal immunoreactivity (p = 0.0127). Animals in the argon-ventilated group showed less neuronal loss compared with untreated SAH animals (p < 0.0001). Ionized calcium-binding adaptor molecule 1 staining showed a decreased accumulation after SAH + argon (CA1, 2.57 ± 2.35%; CA2, 1.89 ± 1.89%; CA3, 2.19 ± 1.99%; DG, 2.6 ± 2.24%) compared with untreated SAH animals (CA1, 5.48 ± 2.39%; CA2, 4.85 ± 4.06%; CA3, 4.22 ± 3.01%; dentate gyrus (DG), 3.82 ± 3.23%; p = 0.0007). The neuroscore assessment revealed no treatment benefit after SAH compared with baseline (p = 0.385). CONCLUSION In the present study, neuroprotective effects of argon occurred early after SAH. Because neurological deterioration was similar in the preadministration and absence of argon, it remains uncertain if neuroprotective effects translate in improved outcome over time.
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Affiliation(s)
- Harald Krenzlin
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Dominik M A Wesp
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Anika A E Korinek
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Henning Ubbens
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Jakob Volland
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Julia Masomi-Bornwasser
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Katharina J Weber
- Institute of Neuropathology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Dominik Mole
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Clemens Sommer
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Beat Alessandri
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
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Bellapart J, Laupland KB, Malacova E, Roberts JA, Paratz J. Nimodipine prophylaxis in aneurysmal subarachnoid hemorrhage, a question of tradition or evidence: A scoping review. J Clin Neurosci 2024; 123:91-99. [PMID: 38564967 DOI: 10.1016/j.jocn.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/14/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The prophylactic use of nimodipine following subarachnoid hemorrhage is a practice established four decades ago when clinical management differed from current and the concept of Delayed Cerebral Ischemia (DCI) was not established. The applicability of the original studies is limited by the fact of not reflecting current practice; by utilising a dichotomised outcome measure such as good neurological outcome versus death and vegetative state; by applying variable dosing regimens and including all causes of poor neurological outcome different than DCI. This study aims to review the available evidence to discuss the ongoing role of nimodipine in contemporaneous clinical practice. METHODS PRISMA guidelines based review, evaluated the evidence on the prophylactic use of nimodipine. The following search engines: Medline, Embase, Cochrane, Web of Science and PubMed, identified Randomized Control Trials (RCTs) with neurological benefit as outcome measure and the impact of fixed versus weight-based nimodipine dosing regimens. RESULTS Eight RCT were selected. Three of those trials with a total of 349 patients, showed a reduction on death and vegetative state (pooled RR: 0.62; 95 % confidence interval-CI: 0.45, 0.86) related to DCI. Amongst all studies, all cause death (pooled RR = 0.73, [95 % CI: 0.56, 0.97]) favoured a fixed-dose regimen (pooled RR: 0.60; [95 % CI: 0.43, 0.85]). CONCLUSION Available evidence demonstrates that nimodipine only reduces the risk for DCI-related death or vegetative state and that fixed-dose regimens favour all cause infarct and death independent of DCI. Contemporaneous studies assessing the benefit of nimodipine beyond death or vegetative states and applying individualized dosing are warranted.
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Affiliation(s)
- Judith Bellapart
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Burns Trauma and Critical Care Research Centre, the University of Queensland, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029, Brisbane, Australia.
| | - Kevin B Laupland
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Queensland University of Technology (QUT), Brisbane, Australia.
| | - Eva Malacova
- QIMR Berghofer Medical Research Institute, Herston, Brisbane, QLD, 4006, Australia.
| | - Jason A Roberts
- University of Queensland Centre of Clinical Research (UQCCR), the University of Queensland, Herston, Brisbane, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Jennifer Paratz
- School of Allied Health Sciences, Griffith University, Brisbane, Australia; Department of Physiotherapy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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3
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Stetter C, Weidner F, Lilla N, Weiland J, Kunze E, Ernestus RI, Muellenbach RM, Westermaier T. Therapeutic hypercapnia for prevention of secondary ischemia after severe subarachnoid hemorrhage: physiological responses to continuous hypercapnia. Sci Rep 2021; 11:11715. [PMID: 34083595 PMCID: PMC8175721 DOI: 10.1038/s41598-021-91007-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
Temporary hypercapnia has been shown to increase cerebral blood flow (CBF) and might be used as a therapeutical tool in patients with severe subarachnoid hemorrhage (SAH). It was the aim of this study was to investigate the optimum duration of hypercapnia. This point is assumed to be the time at which buffer systems become active, cause an adaptation to changes of the arterial partial pressure of carbon dioxide (PaCO2) and annihilate a possible therapeutic effect. In this prospective interventional study in a neurosurgical ICU the arterial partial pressure of carbon dioxide (PaCO2) was increased to a target range of 55 mmHg for 120 min by modification of the respiratory minute volume (RMV) one time a day between day 4 and 14 in 12 mechanically ventilated poor-grade SAH-patients. Arterial blood gases were measured every 15 min. CBF and brain tissue oxygen saturation (StiO2) were the primary and secondary end points. Intracranial pressure (ICP) was controlled by an external ventricular drainage. Under continuous hypercapnia (PaCO2 of 53.17 ± 5.07), CBF was significantly elevated between 15 and 120 min after the start of hypercapnia. During the course of the trial intervention, cardiac output also increased significantly. To assess the direct effect of hypercapnia on brain perfusion, the increase of CBF was corrected by the parallel increase of cardiac output. The maximum direct CBF enhancing effect of hypercapnia of 32% was noted at 45 min after the start of hypercapnia. Thereafter, the CBF enhancing slowly declined. No relevant adverse effects were observed. CBF and StiO2 reproducibly increased by controlled hypercapnia in all patients. After 45 min, the curve of CBF enhancement showed an inflection point when corrected by cardiac output. It is concluded that 45 min might be the optimum duration for a therapeutic use and may provide an optimal balance between the benefits of hypercapnia and risks of a negative rebound effect after return to normal ventilation parameters. Trial registration: The study was approved by the institutional ethics committee (AZ 230/14) and registered at ClinicalTrials.gov (Trial-ID: NCT01799525). Registered 01/01/2015.
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Affiliation(s)
- Christian Stetter
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany.
| | - Franziska Weidner
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany.,Department of Neuroradiology, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
| | - Ralf Michael Muellenbach
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany.,Department of Anesthesiology, Klinikum Kassel, Moenchebergstrasse 41-43, 34125, Kassel, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany
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4
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Rosenthal ES, Biswal S, Zafar SF, O'Connor KL, Bechek S, Shenoy AV, Boyle EJ, Shafi MM, Gilmore EJ, Foreman BP, Gaspard N, Leslie-Mazwi TM, Rosand J, Hoch DB, Ayata C, Cash SS, Cole AJ, Patel AB, Westover MB. Continuous electroencephalography predicts delayed cerebral ischemia after subarachnoid hemorrhage: A prospective study of diagnostic accuracy. Ann Neurol 2018; 83:958-969. [PMID: 29659050 DOI: 10.1002/ana.25232] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a common, disabling complication of subarachnoid hemorrhage (SAH). Preventing DCI is a key focus of neurocritical care, but interventions carry risk and cannot be applied indiscriminately. Although retrospective studies have identified continuous electroencephalographic (cEEG) measures associated with DCI, no study has characterized the accuracy of cEEG with sufficient rigor to justify using it to triage patients to interventions or clinical trials. We therefore prospectively assessed the accuracy of cEEG for predicting DCI, following the Standards for Reporting Diagnostic Accuracy Studies. METHODS We prospectively performed cEEG in nontraumatic, high-grade SAH patients at a single institution. The index test consisted of clinical neurophysiologists prospectively reporting prespecified EEG alarms: (1) decreasing relative alpha variability, (2) decreasing alpha-delta ratio, (3) worsening focal slowing, or (4) late appearing epileptiform abnormalities. The diagnostic reference standard was DCI determined by blinded, adjudicated review. Primary outcome measures were sensitivity and specificity of cEEG for subsequent DCI, determined by multistate survival analysis, adjusted for baseline risk. RESULTS One hundred three of 227 consecutive patients were eligible and underwent cEEG monitoring (7.7-day mean duration). EEG alarms occurred in 96.2% of patients with and 19.6% without subsequent DCI (1.9-day median latency, interquartile range = 0.9-4.1). Among alarm subtypes, late onset epileptiform abnormalities had the highest predictive value. Prespecified EEG findings predicted DCI among patients with low (91% sensitivity, 83% specificity) and high (95% sensitivity, 77% specificity) baseline risk. INTERPRETATION cEEG accurately predicts DCI following SAH and may help target therapies to patients at highest risk of secondary brain injury. Ann Neurol 2018;83:958-969.
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Affiliation(s)
- Eric S Rosenthal
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA.,Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Siddharth Biswal
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA.,Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Sahar F Zafar
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA.,Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Kathryn L O'Connor
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA
| | - Sophia Bechek
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA
| | - Apeksha V Shenoy
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA
| | - Emily J Boyle
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA.,Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Mouhsin M Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Yale-New Haven Hospital, New Haven, CT
| | - Brandon P Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Nicolas Gaspard
- Department of Neurology, Comprehensive Epilepsy Center, Free University of Brussels, Erasmus Hospital, Brussels, Belgium.,Department of Neurology and Comprehensive Epilepsy Center, Yale University, New Haven, CT
| | - Thabele M Leslie-Mazwi
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA
| | - Daniel B Hoch
- Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Cenk Ayata
- Division of Vascular Neurology, Massachusetts General Hospital, Boston, MA
| | - Sydney S Cash
- Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Andrew J Cole
- Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
| | - M Brandon Westover
- Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, MA
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Abstract
Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.
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Abstract
OPINION STATEMENT Erythropoietin (EPO) is an approved drug that is used in the treatment of chronic anemia associated with chronic renal failure. In the Neuro ICU, there are 2 potential uses for treatment with EPO. Anemia is common in patients with acute neurological disorders and may be a cause of secondary insults. Studies of EPO to treat anemia associated with critical illness have not conclusively shown a beneficial risk/benefit ratio. The relatively small reduction in transfusion requirement with EPO in critically ill patients is likely due to the 7-10 days required to see an effect of EPO on hematocrit. For these reasons, EPO is not recommended to treat anemia of critical illness. Neuroprotection is the other potential use for EPO in the Neuro ICU. Many experimental studies demonstrate neuroprotective effects with EPO in a variety of acute neurological disorders. To date, no clinical studies have confirmed beneficial effects of EPO on neurological outcome although some studies have suggested a reduction in mortality rate in trauma patients treated with EPO. Additional clinical studies are needed before EPO administration can be recommended for cytoprotection in neurological disorders.
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Affiliation(s)
- Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA,
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7
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Suarez JI, Martin RH, Calvillo E, Dillon C, Bershad EM, Macdonald RL, Wong J, Harbaugh R. The Albumin in Subarachnoid Hemorrhage (ALISAH) multicenter pilot clinical trial: safety and neurologic outcomes. Stroke 2012; 43:683-90. [PMID: 22267829 PMCID: PMC3288646 DOI: 10.1161/strokeaha.111.633958] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Human albumin has been shown to exert neuroprotective effects in animal models of cerebral ischemia and humans with various intracranial pathologies. We investigated the safety and tolerability of 25% human albumin in patients with subarachnoid hemorrhage. METHODS The Albumin in Subarachnoid Hemorrhage (ALISAH) Pilot Clinical Trial was an open-label, dose-escalation study. We intended to study 4 different dosages of albumin of increasing magnitude (0.625 g/kg: Tier 1; 1.25 g/kg: Tier 2; 1.875 g/kg: Tier 3; and 2.5 g/kg: Tier 4). Each dosage was to be given to 20 adult patients. Treatment was administered daily for 7 days. We investigated the maximum tolerated dose of albumin based on the rate of severe-to-life-threatening heart failure and anaphylactic reaction and functional outcome at 3 months. RESULTS We treated 47 adult subjects: 20 in Tier 1; 20 in Tier 2; and 7 in Tier 3. We found that doses ranging up to 1.25 g/kg/day×7 days were tolerated by patients without major dose-limiting complications. We also found that outcomes trended toward better responses in those subjects enrolled in Tier 2 compared with Tier 1 (OR, 3.0513; CI, 0.6586-14.1367) and with the International Intraoperative Hypothermia for Aneurysm Surgery Trial cohort (OR, 3.1462; CI, 0.9158-10.8089). CONCLUSIONS Albumin in doses ranging up to 1.25 g/kg/day×7 days was tolerated by patients with subarachnoid hemorrhage without major complications and may be neuroprotective. Based on these results, planning of the ALISAH II, a Phase III, randomized, placebo-controlled trial to test the efficacy of albumin, is underway. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00283400.
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Affiliation(s)
- Jose I Suarez
- Department of Neurology, Baylor College of Medicine, 6501 Fannin Street, NB 302, Houston, TX 77030, USA.
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8
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Evidence-Based Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage English Edition. Neurol Med Chir (Tokyo) 2012; 52:355-429. [DOI: 10.2176/nmc.52.355] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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9
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Suarez JI, Martin RH. Treatment of subarachnoid hemorrhage with human albumin: ALISAH study. Rationale and design. Neurocrit Care 2011; 13:263-77. [PMID: 20535587 DOI: 10.1007/s12028-010-9392-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The primary objective of this prospective dose-finding pilot study is to demonstrate the tolerability and safety of four dosages of 25% human albumin in patients with subarachnoid hemorrhage (SAH). For each dosage group, the study will enroll 20 patients who meet the eligibility criteria. The enrolled patients will undergo follow-up for 90 days post-treatment. The primary tolerability hypothesis is that intravenous 25% human albumin can be given without precipitating treatment related serious adverse events beyond expectations. The study will determine the maximum tolerated dosage of 25% human albumin therapy based on the rate of treatment related serious adverse events during treatment: severe or life-threatening heart failure. The secondary objectives are to obtain preliminary estimates of the albumin treatment effect using the incidence of neurological deterioration within 15 days after symptom onset. In addition, the incidence of rebleeding, hydrocephalus, seizures, delayed cerebral ischemia and the incidence of vasospasm (both symptomatic and by transcranial Doppler ultrasound criteria) within 15 days after symptom onset will be evaluated. Furthermore, the serum osmolality and serum albumin concentrations, serum magnesium concentration, blood pressure and heart rate within 15 days of symptom onset will also be observed. The Glasgow Outcome Scale, Barthel Index, modified Rankin Scale, NIH Stroke Scale, and Stroke Impact Scale will be performed 3 months after the onset of symptoms to assess residual neurological deficits.
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Affiliation(s)
- Jose I Suarez
- Department of Neurology, Divisions Vascular Neurology and Neurocritical Care, Baylor College of Medicine, 6501 Fannin St, MS: NB320, Houston, TX 77030, USA.
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Grande A, Nichols C, Khan U, Pyne-Geithman G, Abruzzo T, Ringer A, Zuccarello M. Treatment of Post-hemorrhagic Cerebral Vasospasm: Role of Endovascular Therapy. ACTA NEUROCHIRURGICA SUPPLEMENTS 2011; 110:127-32. [DOI: 10.1007/978-3-7091-0356-2_23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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11
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Pharmacologic Modification of Acute Cerebral Ischemia. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50061-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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12
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Clinical trials for cytoprotection in stroke. Neurotherapeutics 2004. [DOI: 10.1007/bf03206567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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13
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Abstract
To date, many cytoprotective drugs have reached the stage of pivotal phase 3 efficacy trials in acute stroke patients. (Table 1) Unfortunately, throughout the neuroprotective literature, the phrase "failure to demonstrate efficacy" prevails as a common thread among the many neutral or negative trials, despite the largely encouraging results encountered in preclinical studies. The reasons for this discrepancy are multiple, and have been discussed by Dr. Zivin in his review. Many of the recent trials have addressed deficiencies of the previous ones with more rigorous trial design, including more specific patient selection criteria (ensure homogeneity of stroke location and severity), stratified randomization algorithms (time-to-treat), narrowed therapeutic time-window and pharmacokinetic monitoring. Current trials have also incorporated biologic surrogate markers of toxicity and outcome such as drug levels and neuroimaging. Lastly, multi-modal therapies and coupled cytoprotection/reperfusion strategies are being investigated to optimize tissue salvage. This review will focus on individual therapeutic strategies and we will emphasize what we have learned from these trials both in terms of trial design and the biologic effect (or lack thereof) of these agents.
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Affiliation(s)
- Lise A Labiche
- Stroke Program, University of Texas at Houston Medical School, 6431 Fannin Street, Houston, Texas 77030, USA
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14
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Adams HP, Davis PH. Aneurysmal Subarachnoid Hemorrhage. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Georgiadis D, Schwab S, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50060-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Topcuoglu MA, Pryor JC, Ogilvy CS, Kistler JP. Cerebral Vasospasm Following Subarachnoid Hemorrhage. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2002; 4:373-384. [PMID: 12194810 DOI: 10.1007/s11936-002-0017-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Cerebral vasospasm and related ischemic stroke continue to be significant complicating factors in the course of many patients with subarachnoid hemorrhage from berry aneurysm rupture. The risk of this well-recognized but poorly understood complication can be estimated on the basis of patient medical history, neurologic examination, and head CT findings. Every patient with possible risk needs specialized neurologic intensive care unit care after aneurysm obliteration. Surgical and pharmacologic wash-out of subarachnoid blood around the basal arteries, proper management of intracranial pressure and fluid status, hyponatremia, hypomagnesemia, and fever, as well as use of calcium channel blockers, have been considered helpful in patient management prior to and with the symptomatic vasospasm development. Transcranial Doppler (TCD) ultrasound is important in detecting vasospasm before the patient suffers ischemic neurologic deficit or infarct. Elevated TCD velocities often initiate the use of triple-H (HHH: hypertension, hemodilution, and hypervolemia) therapy and subsequently guide it. Up to the end of the first 3 weeks after subarachnoid hemorrhage and aneurysm obliteration, development of any focal neurologic deficit or mental deterioration, unless convincingly proven otherwise, is assumed to be from cerebral vasospasm. When a hemodynamically significant vasospasm in the arterial segments of clinical concern is suggested, emergency cerebral angiography with balloon dilatation angioplasty or intra-arterial infusion of vasodilating agents may be helpful in relieving ischemic symptoms.
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Affiliation(s)
- M. Akif Topcuoglu
- Neurovascular Surgery, Massachusetts General Hospital, 55 Fruit Street, VBK 802, Boston, MA 02114, USA.
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17
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Abstract
The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.
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Affiliation(s)
- J van Gijn
- Department of Neurology, University Medical Centre, Utrecht, The Netherlands.
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