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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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Faropoulos K, Tsolaki V, Georgakopoulou VE, Trakas I, Tarantinos K, Papalexis P, Spandidos DA, Aravantinou-Fatorou A, Mathioudakis N, Trakas N, Fotakopoulos G. Efficacy of combined intravenous plus intrathecal nimodipine administration in patients with severe cerebral vasospasm post‑aneurysmal subarachnoid hemorrhage: A retrospective cohort study. MEDICINE INTERNATIONAL 2022; 3:3. [PMID: 36699659 PMCID: PMC9829231 DOI: 10.3892/mi.2022.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) and the ensuing cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) comprise the main reasons for morbidity and mortality in affected patients. The present study aimed to evaluate the efficacy of the use of combined intravenous (IV) and intrathecal (IT) nimodipine therapy for preventing permanent neurological deterioration and DCI in patients suffering from CV post-hemorrhage. The evaluation was performed using computed tomography perfusion and transcranial doppler ultrasound. The present retrospective cohort study analyzed 14 out of 146 patients diagnosed with vasospasm due to spontaneous or aSAH. These patients were divided into two groups as follows: i) The IV group, which included patients treated with only IV nimodipine; and ii) the IV + IT group, which included patients who received IV nimodipine in combination with IT nimodipine. Of the 14 patients, 7 patients were males (50%), and the mean age was 50.9 years (SD ±19 years). In total, 6 patients [42.8%; 5 (35.7%) from group A and 1 (7.1%) from group B], who experienced clinical symptoms with severe CV, were administered intra-arterial calcium channel therapy or/and IT nimodipine following the early identification of symptomatic vasospasm. The rate of adverse ischemic events was lower with IT nimodipine management during the 1 month of follow-up (6 vs. 2 events; odds ratio, 15.00; 95% confidence interval, 1.03-218.31; P=0.031). On the whole, the findings of the present study suggest that the combined use of IT nimodipine with IV admission for patients post-aSAH who developed severe CV is a safe procedure that may prevent permanent neurological deterioration and delay unfavorable ischemic incidents.
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Affiliation(s)
| | - Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larisa, 41221 Larisa, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases-COVID-19 Unit, Laiko General Hospital, 11527 Athens, Greece,Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases-COVID-19 Unit, Laiko General Hospital, 17 Agiou Thoma Street, 11527 Athens, Greece NULL
| | - Ilias Trakas
- Department of Infectious Diseases-COVID-19 Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece,Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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Schlaeppi JA, Affentranger L, Bervini D, Z’Graggen WJ, Raabe A, Pollo C. Electrical Stimulation for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review. Neuromodulation 2022; 25:1227-1239. [DOI: 10.1016/j.neurom.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/13/2021] [Accepted: 01/04/2022] [Indexed: 10/18/2022]
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Coulibaly AP, Provencio JJ. Aneurysmal Subarachnoid Hemorrhage: an Overview of Inflammation-Induced Cellular Changes. Neurotherapeutics 2020; 17:436-445. [PMID: 31907877 PMCID: PMC7283430 DOI: 10.1007/s13311-019-00829-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease that leads to poor neurological outcomes and is characterized by both vascular and neural pathologies. Recent evidence demonstrates that inflammation mediates many of the vascular and neural changes observed after SAH. Although most studies focus on inflammatory mediators such as cytokines, the ultimate effectors of inflammation in SAH are parenchymal brain and peripheral immune cells. As such, the present review will summarize our current understanding of the cellular changes of both CNS parenchymal and peripheral immune cells after SAH.
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Affiliation(s)
- A P Coulibaly
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - J J Provencio
- Department of Neurology, University of Virginia, Charlottesville, VA, USA.
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA.
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Side Effects of Long-Term Continuous Intra-arterial Nimodipine Infusion in Patients with Severe Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage. Neurocrit Care 2019; 28:65-76. [PMID: 28685393 DOI: 10.1007/s12028-017-0428-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Long-term continuous intra-arterial nimodipine infusion (CIAN) is a rescue therapy option in cases of severe refractory cerebral vasospasm (CV) following acute non-traumatic subarachnoid hemorrhage (SAH). However, CIAN therapy can be associated with relevant side effects. Available studies focus on intracerebral complications, whereas extracerebral side effects are rarely examined. Aim of the present study was to generate descriptive data on the clinical course during CIAN therapy and expectable extracerebral side effects. METHODS All patients treated with CIAN therapy for at least 5 days between May 2011 and December 2015 were included. We retrospectively extracted data from the patient data management system regarding the period between 2 days before the beginning and 5 days after the termination of CIAN therapy to analyze the course of ventilation parameters and pulmonary gas exchange, hemodynamic support, renal and liver function, integrity of the gastrointestinal tract, and the occurrence of infectious complications. In addition, we recorded the mean daily values of intracranial pressure (ICP) and intracerebral problems associated with CIAN therapy. RESULTS Data from 28 patients meeting inclusion criteria were analyzed. The mean duration of long-term CIAN therapy was 10.5 ± 4.5 days. Seventeen patients (60.7%) reached a good outcome level (Glasgow Outcome Scale [GOS] 4-5) 6 months after SAH. An impairment of the pulmonary gas exchange occurred only at the very beginning of CIAN therapy. The required vasopressor support with norepinephrine was significantly higher on all days during and the first day after CIAN therapy compared to the situation before starting CIAN therapy. Two patients required short-time resuscitation due to cardiac arrest during CIAN therapy. Acute kidney injury was observed in four patients, and one of them required renal replacement therapy with sustained low-efficiency daily dialysis. During CIAN therapy, 23 patients (82.1%) needed the escalation of a previous antiinfective therapy or the onset of antibiotics which was in line with a significant increase of C-reactive protein and white blood cell count. Obstipation was observed in 22 patients (78.6%). Ten patients (35.7%) even showed insufficient defecation on at least seven consecutive days. Compared to the situation before, ICP was significantly higher during the whole period of CIAN therapy. CONCLUSIONS Long-term CIAN therapy is associated with diverse side effects. The leading problems are an impairment of the hemodynamic situation and cardiac problems, an increase in infectious complications, a worsening of the motility of the gastrointestinal tract, and rising ICP values. Teams on neurointensive care units must be aware of these side effects to avoid that the beneficial effects of CIAN therapy on CV reported elsewhere are foiled by the problems this technique can be associated with.
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Bruder M, Kashefiolasl S, Keil F, Brawanski N, Won SY, Seifert V, Konczalla J. Pain medication at ictus of subarachnoid hemorrhage—the influence of one-time acetylsalicylic acid usage on bleeding pattern, treatment course, and outcome: a matched pair analysis. Neurosurg Rev 2018; 42:531-537. [DOI: 10.1007/s10143-018-1000-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
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Venkatraman A, Khawaja AM, Gupta S, Hardas S, Deveikis JP, Harrigan MR, Kumar G. Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis. J Neurointerv Surg 2017; 10:380-387. [DOI: 10.1136/neurintsurg-2017-013128] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveThe efficacy of intra-arterial vasodilators (IADs) for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) remains debatable. The objective of this meta-analysis was to pool estimates of angiographic and neurological response, clinical outcome, and mortality following treatment of vasospasm with IADs.MethodsWe searched PubMed, Embase, Scopus, Clinicaltrials.gov, Cochrane database, and CINAHL in December 2015 and August 2016. Studies reporting angiographic and neurological response, clinical outcome, and mortality following IAD treatment of vasospasm in 10 or more adults with aSAH were included. All established IADs were allowed. Two authors independently selected studies and abstracted the data. Mean weighted probabilities (MWP) were calculated using random effects model.ResultsInclusion criteria were met by 55 studies (n=1571). MWP for immediate angiographic response to IAD treatment was 89% (95% CI 83% to 94%), post-IAD neurological improvement 57% (95% CI 49% to 65%), good outcome 66% (95% CI 60% to 71%), and mortality was 9% (95% CI 7% to 12%). After adjusting for publication bias, MWP for mortality was 5% (95% CI 4% to 7%). When transcranial Doppler (TCD) was used along with clinical deterioration for patient selection, rates of neurological response (64%) and good outcome (72%) were better. IADs were not superior to controls (balloon angioplasty or medical management).ConclusionIAD treatment leads to a robust angiographic response and fair (but lower) rates of neurological response and good clinical outcome. Mortality was lower than the average reported in the literature. Rates of neurological response and good outcome were better when TCD was used for patient selection. Carefully designed studies are needed to compare IADs against medical management and balloon angioplasty.
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Maria DN, Abd-Elgawad AEH, Soliman OAE, El-Dahan MS, Jablonski MM. Nimodipine Ophthalmic Formulations for Management of Glaucoma. Pharm Res 2017; 34:809-824. [PMID: 28155073 DOI: 10.1007/s11095-017-2110-x] [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] [Received: 11/23/2016] [Accepted: 01/18/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Preparation and evaluation of topical ophthalmic formulations containing nimodipine-CD complexes prepared using HP-β-CD, SBE-β-CD and M-β-CD for the management of glaucoma. METHODS Nimodipine-CD complexes were prepared using a freeze-drying method. Two different molar ratios (NMD:CD) were used for each cyclodextrin. The inclusion complexes were characterized using DSC, FTIR, yield (%), drug content and in vitro release characteristics. NMD-CD complexes incorporated into chitosan eye drops and a temperature-triggered in situ gelling system were evaluated for their pH, viscosity and in vitro release characteristics. We determined the intraocular pressure (IOP) lowering effect of NMD-hydroxypropylmethylcellulose (HPMC) eye drops through a single dose response design using C57BL/6J mice. The minimum effective concentration (MEC) of nimodipine was further applied to mice that vary in the parental allele of Cacna1s, the drug target of nimodipine. Cytotoxicity was also evaluated. RESULTS Our ophthalmic formulations possessed pH and viscosity values that are compatible with the eye. In vitro release of nimodipine was significantly increased from chitosan eye drops containing NMD-CD complexes compared to uncomplexed drug. Administration of nimodipine can lower IOP significantly after a single drop of drug HPMC suspension. The IOP-lowering response of the MEC (0.6%) was significantly influenced by the parental allele of Cacna1s. CONCLUSIONS Nimodipine can be used as a promising topical drug for management of glaucoma through ocular delivery.
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Affiliation(s)
- Doaa Nabih Maria
- Department of Ophthalmology, Hamilton Eye Institute, The University of Tennessee Health Science Center, 930 Madison Avenue, Suite 731, Memphis, Tennessee, 38163, USA.,Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Pharmaceutics, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
| | | | | | - Marwa Salah El-Dahan
- Department of Pharmaceutics, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
| | - Monica M Jablonski
- Department of Ophthalmology, Hamilton Eye Institute, The University of Tennessee Health Science Center, 930 Madison Avenue, Suite 731, Memphis, Tennessee, 38163, USA. .,Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, 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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Avdagic SS, Brkic H, Avdagic H, Smajic J, Hodzic S. Impact of Comorbidity on Early Outcome of Patients with Subarachnoid Hemorrhage Caused by Cerebral Aneurysm Rupture. Med Arch 2015; 69:280-3. [PMID: 26622076 PMCID: PMC4639362 DOI: 10.5455/medarh.2015.69.280-283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/05/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND One of the complications aneurysms subarachnoid hemorrhage is the development of vasospasm, which is the leading cause of disability and death from ruptured cerebral aneurysm. AIM To evaluate the significance of previous comorbidities on early outcome of patients with subarachnoid hemorrhage caused by rupture of a cerebral aneurysm in the prevention of vasospasm. PATIENTS AND METHODS The study had prospective character in which included 50 patients, whose diagnosed with SAH caused by the rupture of a brain aneurysm in the period from 2011to 2013. Two groups of patients were formed. Group I: patients in addition to the standard initial treatment and "3H therapy" administered nimodipine at a dose of 15-30 mg / kg bw / h (3-10 ml) for the duration of the initial treatment. Group II: patients in addition to the standard initial treatment and "3H therapy" administered with MgSO4 at a dose of 12 grams in 500 ml of 0.9% NaCl / 24 h during the initial treatment. RESULTS Two-thirds of the patients (68%) from both groups had a good outcome measured with values according to GOS scales, GOS IV and V. The poorer outcome, GOS III had 20% patients, the GOS II was at 2% and GOS I within 10% of patients. If we analyze the impact of comorbidity on the outcome, it shows that there is a significant relationship between the presence of comorbidity and outcomes. The patients without comorbidity (83.30%) had a good outcome (GOS IV and V), the same outcome was observed (59.4%) with comorbidities, which has a statistically significant difference (p = 0.04). Patients without diabetes (32%) had a good outcome (GOS IV and V), while the percentage of patients with diabetes less frequent (2%) with a good outcome, a statistically significant difference (p = 0.009). CONCLUSION The outcome of treatment 30 days after the subarachnoid hemorrhage analyzed values WFNS and GOS, is not dependent on the method of prevention and treatment of vasospasm. Most concomitant diseases in patients with SAH which, requiring additional treatment measures are arterial hypertension and diabetes mellitus. The best predictors in the initial treatment of patients with subarachnoid hemorrhage caused by rupture of a cerebral aneurysm has the presence of comorbidity, which has statistical significance.
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Affiliation(s)
- Selma Sijercic Avdagic
- Clinic for Anesthesiology and Reanimatology, University Clinical Center Tuzla, Tuzla, Bosna i Hercegovina
| | - Harun Brkic
- Clinic for Anesthesiology and Reanimatology, University Clinical Center Tuzla, Tuzla, Bosna i Hercegovina
| | - Harun Avdagic
- Clinic for Neurosurgery, University Clinical Center Tuzla, Tuzla, Bosna i Hercegovina
| | - Jasmina Smajic
- Clinic for Neurosurgery, University Clinical Center Tuzla, Tuzla, Bosna i Hercegovina
| | - Samir Hodzic
- Clinic for Cardiovascular Desease, University Clinical Center Tuzla, Tuzla, Bosna i Hercegovina
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Continuous intra-arterial nimodipine infusion in patients with severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a feasibility study and outcome results. Acta Neurochir (Wien) 2015; 157:2041-50. [PMID: 26439105 DOI: 10.1007/s00701-015-2597-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Severe cerebral vasospasm is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. No causative treatment is yet available and hypertensive hypervolemic therapy (HHT) is often insufficient to avoid delayed cerebral ischemia and neurological deficits. We compared patients receiving continuous intra-arterial infusion of the calcium-antagonist nimodipine with a historical group treated with HHT and oral nimodipine alone. METHODS Between 0.5 and 1.2 mg/h of nimodipine were continuously administered by intra-arterial infusion via microcatheters either into the internal carotid or vertebral artery or both, depending on the areas of vasospasm. The effect was controlled via multimodal neuromonitoring and transcranial Doppler sonography. Outcome was determined by means of the Glasgow Outcome Scale at discharge and 6 months after the hemorrhage and compared to a historical control group. RESULTS Twenty-one patients received 28 intra-arterial nimodipine infusions. Six months after discharge, the occurrence of cerebral infarctions was significantly lower (42.6 %) in the nimodipine group than in the control group (75.0 %). This result was reflected by a significantly higher proportion (76.0 %) of patients with good outcome in the nimodipine-treated group, when compared to 10.0 % good outcome in the control group. Median GOS was 4 in the nimodipine group and 2 in the control group (p = 0.001). CONCLUSIONS Continuous intra-arterial nimodipine infusion is an effective treatment for patients with severe cerebral vasospasm who fail to respond to HHT and oral nimodipine alone. Key to the effective administration of continuous intra-arterial nimodipine is multimodal neuromonitoring and the individual adaptation of dosage and time of infusion for each patient.
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12
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Serum levels of nimodipine in enteral and parenteral administration in patients with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2015; 157:763-7. [PMID: 25701099 DOI: 10.1007/s00701-015-2369-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/02/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate serum nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage (SAH) after parenteral therapy and a following course of enteral administration. METHODS SAH patients were treated with intravenous nimodipine (2 mg/h) during the 1st week after hemorrhage, and on day 8, we switched over to enteral administration (60 mg/4 h), either orally or by gavage. Serum nimodipine concentrations were measured on days 3, 5, 8, 9 and 12. Area under the curve (AUC) was calculated during parenteral and enteral therapy. The data of 15 patients were analyzed retrospectively. RESULTS In this study, 157 blood samples were obtained. In seven samples, during the administration by gavage to two patients with high-grade SAH, the serum nimodipine concentrations were negligible. The AUC values during parenteral administration (median 149.3 ng-h/ml) were significantly higher than during oral administration on days 9 (median 92.1 ng-h/ml) and 12 (median 44.1 ng-h/ml) in seven patients (p = 0.030 and p = 0.016, respectively). The AUC values during parenteral administration were significantly higher than during administration by gavage on day 9 in eight patients (median 87.9 and 34 ng-h/ml, respectively, p = 0.001). The AUC values during enteral administration were higher in patients who received nimodine orally than in those who received it by gavage (median 52.3 and 23.1 ng-h/ml, respectively, p = 0.006). CONCLUSIONS Enteral administration of nimodipine showed lower bioavailability during the 2nd week after SAH compared to parenteral application during the 1st week. Negligible serum concentrations were even expected when nimodipine was given by gavage in patients with high-grade SAH, thus suggesting that parenteral administration may be the better route in these patients.
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Joerk A, Seidel RA, Walter SG, Wiegand A, Kahnes M, Klopfleisch M, Kirmse K, Pohnert G, Westerhausen M, Witte OW, Holthoff K. Impact of heme and heme degradation products on vascular diameter in mouse visual cortex. J Am Heart Assoc 2014; 3:jah3660. [PMID: 25169792 PMCID: PMC4310418 DOI: 10.1161/jaha.114.001220] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Delayed cerebral vasospasm is the most common cause of mortality and severe neurological impairment in patients who survive subarachnoid hemorrhage. Despite improvements in the field of diagnostic imaging, options for prevention and medical treatment-primarily with the calcium channel antagonist nimodipine or hemodynamic manipulations-are insufficient. Previous studies have suggested that heme and bilirubin oxidation end products, originating from degraded hemoglobin around ruptured blood vessels, are involved in the development of vasospasm by inhibiting large conductance BKC a potassium channels in vascular smooth muscle cells. In this study, we identify individual heme degradation products regulating arteriolar diameter in dependence of BKC a channel activity. METHODS AND RESULTS Using differential interference contrast video microscopy in acute brain slices, we determined diameter changes of intracerebral arterioles in mouse visual cortex. In preconstricted vessels, the specific BKC a channel blockers paxilline and iberiotoxin as well as iron-containing hemin caused vasoconstriction. In addition, the bilirubin oxidation end product Z-BOX A showed a stronger vasoconstrictive potency than its regio-isomer Z-BOX B. Importantly, Z-BOX A had the same vasoconstrictive effect, independent of its origin from oxidative degradation or chemical synthesis. Finally, in slices of Slo1-deficient knockout mice, paxilline and Z-BOX A remained ineffective in changing arteriole diameter. CONCLUSIONS We identified individual components of the oxidative bilirubin degradation that led to vasoconstriction of cerebral arterioles. The vasoconstrictive effect of Z-BOX A and Z-BOX B was mediated by BKC a channel activity that might represent a signaling pathway in the occurrence of delayed cerebral vasospasm in subarachnoid hemorrhage patients.
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Affiliation(s)
- Alexander Joerk
- Hans‐Berger Department of Neurology, University Hospital Jena, Germany (A.J., S.G.W., A.W., K.K., O.W.W., K.H.)
| | - Raphael Andreas Seidel
- Institute of Inorganic and Analytical Chemistry, Friedrich‐Schiller University, Jena, Germany (R.A.S., M.K., M.K., G.P., M.W.)
- Department of Anesthesiology and Intensive Care Medicine/Center for Sepsis Control and Care, University Hospital, Friedrich Schiller University, Jena, Germany (R.A.S.)
| | - Sebastian Gottfried Walter
- Hans‐Berger Department of Neurology, University Hospital Jena, Germany (A.J., S.G.W., A.W., K.K., O.W.W., K.H.)
| | - Anne Wiegand
- Hans‐Berger Department of Neurology, University Hospital Jena, Germany (A.J., S.G.W., A.W., K.K., O.W.W., K.H.)
| | - Marcel Kahnes
- Institute of Inorganic and Analytical Chemistry, Friedrich‐Schiller University, Jena, Germany (R.A.S., M.K., M.K., G.P., M.W.)
| | - Maurice Klopfleisch
- Institute of Inorganic and Analytical Chemistry, Friedrich‐Schiller University, Jena, Germany (R.A.S., M.K., M.K., G.P., M.W.)
| | - Knut Kirmse
- Hans‐Berger Department of Neurology, University Hospital Jena, Germany (A.J., S.G.W., A.W., K.K., O.W.W., K.H.)
| | - Georg Pohnert
- Institute of Inorganic and Analytical Chemistry, Friedrich‐Schiller University, Jena, Germany (R.A.S., M.K., M.K., G.P., M.W.)
| | - Matthias Westerhausen
- Institute of Inorganic and Analytical Chemistry, Friedrich‐Schiller University, Jena, Germany (R.A.S., M.K., M.K., G.P., M.W.)
| | - Otto Wilhelm Witte
- Hans‐Berger Department of Neurology, University Hospital Jena, Germany (A.J., S.G.W., A.W., K.K., O.W.W., K.H.)
| | - Knut Holthoff
- Hans‐Berger Department of Neurology, University Hospital Jena, Germany (A.J., S.G.W., A.W., K.K., O.W.W., K.H.)
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Pandey AS, Elias AE, Chaudhary N, Thompson BG, Gemmete JJ. Endovascular Treatment of Cerebral Vasospasm. Neuroimaging Clin N Am 2013; 23:593-604. [DOI: 10.1016/j.nic.2013.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.
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NGP1-01, a multi-targeted polycyclic cage amine, attenuates brain endothelial cell death in iron overload conditions. Brain Res 2012; 1489:133-9. [DOI: 10.1016/j.brainres.2012.10.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 10/12/2012] [Accepted: 10/14/2012] [Indexed: 11/23/2022]
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Zhu Y, Zhao H, Zhu X. Prognostic factors for cerebral infraction and outcome in patients with intracranial aneurysm. SURGICAL PRACTICE 2012. [DOI: 10.1111/j.1744-1633.2012.00599.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Yuan Zhu
- Department of Neurosurgery; Union Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan; China
| | - Hongyang Zhao
- Department of Neurosurgery; Union Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan; China
| | - Xianli Zhu
- Department of Neurosurgery; Union Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan; China
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Velat GJ, Kimball MM, Mocco JD, Hoh BL. Vasospasm after aneurysmal subarachnoid hemorrhage: review of randomized controlled trials and meta-analyses in the literature. World Neurosurg 2012; 76:446-54. [PMID: 22152574 DOI: 10.1016/j.wneu.2011.02.030] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 02/08/2011] [Accepted: 02/12/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Cerebral vasospasm is a major source of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). A variety of therapies have been utilized to prevent or treat vasospasm. Despite the large number of clinical trials, few randomized controlled trials (RCTs) of sufficient quality have been published. We review the RCTs and meta-analyses in the literature regarding the treatment and prevention of cerebral vasospasm following aneurysmal SAH. METHODS A literature search of MEDLINE, the Cochrane Controlled Trials Registry, and the National Institutes of Health/National Library of Medicine clinical trials registry was performed in January 2010 using predefined search terms. These trials were critically reviewed and categorized based on therapeutic modality. RESULTS Forty-four RCTs and 9 meta-analyses met the search criteria. Significant findings from these trials were analyzed. The results of this study were as follows: nimodipine demonstrated benefit following aneurysmal SAH; other calcium channel blockers, including nicardipine, do not provide unequivocal benefit; triple-H therapy, fasudil, transluminal balloon angioplasty, thrombolytics, endothelin receptor antagonists, magnesium, statins, and miscellaneous therapies such as free radical scavengers and antifibrinolytics require additional study. Tirilazad is ineffective. CONCLUSIONS There are many possible successful treatment options for preventing vasospasm, delayed ischemic neurologic deficits, and poor neurologic outcome following aneurysmal subarachnoid hemorrhage; however, further multicenter RCTs need to be performed to determine if there is a significant benefit from their use. Nimodipine is the only treatment that provided a significant benefit across multiple studies.
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Affiliation(s)
- Gregory J Velat
- Department of Neurological Surgery, University of Florida, McKnight Brain Institute, Gainesville, Florida, USA
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Tulamo R, Niemelä M, Hernesniemi J. Delayed Vasospasm in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2012; 77:39-41. [DOI: 10.1016/j.wneu.2010.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Indexed: 11/30/2022]
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Pisapia JM, Xu X, Kelly J, Yeung J, Carrion G, Tong H, Meghan S, El-Falaky OM, Grady MS, Smith DH, Zaitsev S, Muzykantov VR, Stiefel MF, Stein SC. Microthrombosis after experimental subarachnoid hemorrhage: time course and effect of red blood cell-bound thrombin-activated pro-urokinase and clazosentan. Exp Neurol 2011; 233:357-63. [PMID: 22079156 DOI: 10.1016/j.expneurol.2011.10.029] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/24/2011] [Accepted: 10/28/2011] [Indexed: 10/15/2022]
Abstract
Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality for patients surviving the rupture of an intracranial aneurysm. Despite an association between vasospasm and DCI, thrombosis and thromboembolism may also contribute to DCI. In this study we investigate the time course of intravascular microclot formation after experimental subarachnoid hemorrhage (SAH) and assess the effects of the following two drugs on microclot burden: mutant thrombin-activated urokinase-type plasminogen activator (scFv/uPA-T), which is bound to red blood cells for use as a thromboprophylactic agent, and clazosentan, an endothelin antagonist. In the first study, adult male C57BL/6 mice were sacrificed at 24 (n=5), 48 (n=6), 72 (n=8), and 96 (n=3) hours after SAH induced by filament perforation of the anterior cerebral artery. Sham animals (n=5) underwent filament insertion without puncture. In the second study, animals received scFv/uPA-T (n=5) 3 hours after hemorrhage, clazosentan (n=5) by bolus and subcutaneous pump after SAH just prior to skin closure, or a combination of scFv/uPA-T and clazosentan (n=4). Control (n=6) and sham (n=5) animals received saline alone. All animals were sacrificed at 48 hours and underwent intra-cardiac perfusion with 4% paraformaldehyde. The brains were then extracted and sliced coronally on a cryostat and processed for immunohistochemistry. An antibody recognizing thrombin-anti-thrombin complexes was used to detect microclots on coronal slices. Microclot burden was calculated for each animal and compared among groups. Following SAH, positive anti-thrombin staining was detected bilaterally in the following brain regions, in order of decreasing frequency: cortex; hippocampus; hypothalamus; basal ganglia. Few microclots were found in the shams. Microclot burden peaked at 48 hours and then decreased gradually. Animals receiving scFv/uPA-T and scFv/uPA-T+clazosentan had a lower microclot burden than controls, whereas animals receiving clazosentan alone had a higher microclot burden (p<0.005). The overall mortality rate in the time course study was 40%; mortality was highest among control animals in the second study. Intravascular microclots form in a delayed fashion after experimental SAH. Microclots may be safely reduced using a novel form of thromboprophylaxis provided by RBC-targeted scFv/uPA-T and represent a potential target for therapeutic intervention in the treatment of DCI.
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Affiliation(s)
- Jared M Pisapia
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Tzeng YC, Chan GSH, Willie CK, Ainslie PN. Determinants of human cerebral pressure-flow velocity relationships: new insights from vascular modelling and Ca²⁺ channel blockade. J Physiol 2011; 589:3263-74. [PMID: 21540346 DOI: 10.1113/jphysiol.2011.206953] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The fundamental determinants of human dynamic cerebral autoregulation are poorly understood, particularly the role of vascular compliance and the myogenic response. We sought to 1) determine whether capacitive blood flow associated with vascular compliance and driven by the rate of change in mean arterial blood pressure (dMAP/dt) is an important determinant of middle cerebral artery velocity (MCAv) dynamics and 2) characterise the impact of myogenic blockade on these cerebral pressure-flow velocity relations in humans. We measured MCAv and mean arterial pressure (MAP) during oscillatory lower body negative pressure (n =8) at 0.10 and 0.05 Hz before and after cerebral Ca²⁺ channel blockade (nimodipine). Pressure-flow velocity relationships were characterised using transfer function analysis and a regression-based Windkessel analysis that incorporates MAP and dMAP/dt as predictors of MCAv dynamics. Results show that incorporation of dMAP/dt accounted for more MCAv variance (R² 0.80-0.99) than if only MAP was considered (R2 0.05-0.90). The capacitive gain relating dMAP/dt and MCAv was strongly correlated to transfer function gain (0.05 Hz, r =0.93, P<0.01; 0.10 Hz, r =0.91, P<0.01), but not to phase or coherence. Ca²⁺ channel blockade increased the conductive gain relation between MAP and MCAv (P<0.05), and reduced phase at 0.05 Hz (P<0.01). Capacitive and transfer function gain were unaltered. The findings suggest capacitive blood flow is an important determinant of cerebral haemodynamics that bears strong relations to some metrics of dynamic cerebral autoregulation derived from transfer function analysis, and that Ca²⁺ channel blockade enhances pressure-driven resistive blood flow but does not alter capacitive blood flow. the causes and effects of cerebrovascular diseases such as stroke and dementia.
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Affiliation(s)
- Yu-Chieh Tzeng
- Cardiovascular Systems Laboratory, Department of Surgery and Anaesthesia, University of Otago, Wellington, 23A Mein Street, PO Box 7343, Wellington South, New Zealand.
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Intravenous magnesium sulfate after aneurysmal subarachnoid hemorrhage: current status. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011. [PMID: 21125466 DOI: 10.1007/978-3-7091-0356-2_31] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Delayed ischemic neurological deficit or clinical vasospasm remained a major cause for delayed neurological morbidity and mortality for patients with aneurysmal subarachnoid hemorrhage (SAH). Magnesium is a cerebral vasodilator. In experimental model of drug or SAH-induced vasospasm, magnesium blocks voltage-dependent calcium channels and reverses cerebral vasoconstriction. Furthermore, its antagonistic action on N-methyl-D-aspartate receptor in the brain prevents glutamate stimulation and decreases calcium influx during ischemic injury. Clinically, the protective effect of magnesium has also been found useful in women with preeclampsia, a condition thought to be due to cerebral vasospasm. Initial experimental result in human was found to safe and effective as compared to historical data. In our pilot study, 60 patients were randomly allocated to receive either magnesium sulfate infusion 80 mmol/day or saline infusion for 14 days. The incidence of symptomatic vasospasm decreased from 13/30(43%) in the saline group to 7/30(23%) in the patients receiving magnesium sulfate infusion, p = 0.10, odds ratio 0.398, 95% CI 0.131-1.211. Favorable outcome (Good recovery and moderate disability, as defined by Glasgow Outcome Scale) was achieved in 20 of 30 (67%) patients receiving magnesium sulfate infusion and 16 of 30 (53%) patients receiving placebo treatment, p = 0.292, odds ratio 1.750, 95% CI 0.616-4.974.From literature review, a total of 441 patients from four studies (including ours) were grouped for analysis. Using random effects model (Mantel-Haenszel, Robins-Breslow-Greenland), the pooled odds ratio for symptomatic vasospasm or delayed cerebral ischemia is, 0.620, 95% CI 0.389-0.987, statistically significant. Similarly, the pooled odds ratio for favorable outcome is 1.598, 95% CI 1.074-2.377, statistically significant. There are two multi-center phase III studies (IMASH and MASH2) being carried out to assess the clinical effects, in which IMASH has finished data collection on 30th June 2009.
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The influence of cisternal and ventricular lavage on cerebral vasospasm in patients suffering from subarachnoid hemorrhage: analysis of effectiveness. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011. [PMID: 21125452 DOI: 10.1007/978-3-7091-0356-2_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
OBJECTIVE within the last decades several clinical trials were performed to analyze the effectiveness of cisternal and ventricular lavage on cerebral vasospasm in patients suffering from subarachnoid hemorrhage. Aim of the present analysis was to review and summarize all documented clinical studies using cisternal or ventricular lavage to prevent vasospasm. METHODS the MEDLINE Web site ( www.pub.med.com ) was searched using the clinical query function optimized for clinical therapy. Search terms were subarachnoid hemorrhage, vasospasm, cisternal and ventricular lavage. Results were divided into cisternal and ventricular lavage therapies alone and its combination with additional treatment modalities. RESULTS so far the literature search revealed a total of nine clinical trials using cisternal or ventricular lavage alone in patients suffering from subarachnoid hemorrhage. The patients were treated using urokinase or recombinant tissue plasminogen activator. A metaanalysis, investigating a total of 652 included patients revealed a significant reduction of delayed neurological deficits, a significant increase of outcome and a significant decrease of mortality in the treatment group. Additional there was no difference of effectiveness or side effects using urokinase or recombinant tissue plasminogen activator. Hence, only one of these studies was based on a prospective, randomized study design. A combination of cisternal or ventricular lavage with some sort of kinetic treatment was documented in a total of three studies. All of them were designed prospectively. The combined application demonstrated reduced delayed neurological deficits, reduced vasospasm and better outcome in two studies for the treatment group. One study was stopped early due to unexpected complication. CONCLUSIONS In conclusion, there is strong evidence that cisternal or ventricular lavage alone and in combination with kinetic therapy lead to a reduction of cerebral vasospasm and better outcome in patients suffering from subarachnoid hemorrhage. As a consequence a prospective randomized study would be of great interest.
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Leng LZ, Fink ME, Iadecola C. Spreading depolarization: a possible new culprit in the delayed cerebral ischemia of subarachnoid hemorrhage. ARCHIVES OF NEUROLOGY 2011; 68:31-6. [PMID: 20837823 PMCID: PMC3998646 DOI: 10.1001/archneurol.2010.226] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease with a high mortality and morbidity rate. Gradual improvements have been made in the reduction of mortality rates associated with the disease during the last 30 years. However, delayed cerebral ischemia (DCI), the major delayed complication of SAH, remains a significant contributor to mortality and morbidity despite substantial research and clinical efforts. During the last several years, the predominant role of cerebral vasospasm, the long-accepted etiologic factor behind DCI, has been questioned. It is now becoming increasingly clear that the pathophysiology underlying DCI is multifactorial. Cortical spreading depression is emerging as a likely factor in this complex web of pathologic changes after SAH. Understanding its role after SAH and its relationship with the other pathologic processes such as vasospasm, microcirculatory dysfunction, and microemboli will be vital to the development of new therapeutic approaches to reduce DCI and improve the clinical outcome of the disease.
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Affiliation(s)
- Lewis Z Leng
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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Al-Tamimi YZ, Orsi NM, Quinn AC, Homer-Vanniasinkam S, Ross SA. A review of delayed ischemic neurologic deficit following aneurysmal subarachnoid hemorrhage: historical overview, current treatment, and pathophysiology. World Neurosurg 2010; 73:654-67. [PMID: 20934153 DOI: 10.1016/j.wneu.2010.02.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 01/30/2010] [Indexed: 01/10/2023]
Abstract
Delayed ischemic neurologic deficit (DIND) is a serious and poorly understood complication of aneurysmal subarachnoid hemorrhage. Although advances in treatment have improved prognosis for these patients, long-term clinical outcomes remain disappointing. Historically, angiographic vasospasm was thought to result in a DIND, although an increasing body of evidence suggests that this is an oversimplification, because interventions that have effectively targeted angiographic vasospasm have not improved outcome. Consequently, the relationship between angiographic vasospasm and neurologic outcome may be associative rather than causative. Although our understanding of the underlying molecular processes and pathophysiology is improving, responsible mediators or pathways have yet to be identified. The aim of this review is to summarize the key historical events that have helped shape our understanding of the pathophysiology of this phenomenon (microcirculation, autoregulation, microthrombosis, inflammation, apoptosis, spreading depolarization, oxidative stress) and to present the evidence underlying current treatment strategies (hemodynamic therapy, oral nimodipine, endovascular therapy, statins, cerebrospinal fluid drainage, thrombolysis, magnesium) and the translational and clinical research investigating DIND.
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Affiliation(s)
- Yahia Z Al-Tamimi
- Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom.
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Risk Factors and Medical Management of Vasospasm After Subarachnoid Hemorrhage. Neurosurg Clin N Am 2010; 21:353-64. [DOI: 10.1016/j.nec.2009.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ruigrok YM, Slooter AJC, Rinkel GJE, Wijmenga C, Rosendaal FR. Genes influencing coagulation and the risk of aneurysmal subarachnoid hemorrhage, and subsequent complications of secondary cerebral ischemia and rebleeding. Acta Neurochir (Wien) 2010; 152:257-62. [PMID: 19826759 PMCID: PMC2815293 DOI: 10.1007/s00701-009-0505-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 11/20/2008] [Indexed: 02/07/2023]
Abstract
Background We investigated whether genes influencing coagulation are associated with the occurrence of aneurysmal subarachnoid hemorrhage (SAH) and with secondary cerebral ischemia and rebleeding in patients with aneurysmal SAH. Method Genotyping for factor V Leiden (G1691A), prothrombin G20210A, methylenetetetrahydrofolate reductase (MTHFR) C677T, factor XIII subunit A Val34Leu, Tyr204Phe and Pro564Leu, and factor XIII subunit B His95Arg was performed in 208 patients with aneurysmal SAH and in 925 controls. Secondary cerebral ischemia occurred in 49 (24%) patients and rebleeding in 28 (14%) during their clinical course of 3 months after the aneurysmal SAH. The risk of aneurysmal SAH was assessed as odds ratio (OR) with 95% confidence interval (95% CI). The risk of secondary cerebral ischemia and rebleeding was assessed as hazard ratio (HR) with 95% CI using Cox regression. Findings Carriers of the subunit B His95Arg factor XIII polymorphism had an increased risk of aneurysmal SAH with 23% of the patients homozygous or heterozygous for the variant allele compared to 17% of control subjects (OR 1.5, 95% CI 1.0–2.2). For the remaining genetic variants no effect on the risk of aneurysmal SAH could be demonstrated. A clear relation with the risk of secondary cerebral ischemia and of rebleeding could not be established for any of the genetic variants. Conclusions We found that aneurysmal SAH patients are more often carriers of the subunit B His95Arg factor XIII polymorphism compared to controls. This suggests that carriers of the subunit B His95Arg factor XIII polymorphism have an increased risk of aneurysmal SAH. Larger studies should confirm our results. As aneurysmal SAH patients who died soon after admission could not be included in the present study, our results only apply to a population of patients who survived the initial hours after the hemorrhage. For the other studied genetic factors involved in coagulation, no association with the occurrence of aneurysmal SAH or with the occurrence of secondary cerebral ischemia or rebleeding after aneurysmal SAH could be demonstrated.
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Critical Care Management of Subarachnoid Hemorrhage. Neurocrit Care 2010. [DOI: 10.1007/978-1-84882-070-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wong GKC, Kwok R, Tang K, Yeung D, Ahuja A, King AD, Poon WS. Effects of magnesium sulfate infusion on cerebral perfusion in patients after aneurysmal SAH. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 106:133-5. [PMID: 19812935 DOI: 10.1007/978-3-211-98811-4_23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND A meta-analysis of current data suggests that magnesium sulfate infusion improves the outcome after aneurysmal subarachnoid hemorrhage through a reduction in delayed ischemic neurological deficit. Two multi-center randomized controlled trials are currently underway to investigate this hypothesis. The possible pharmacological basis of this hypothesis includes neuroprotection and vasodilatation. We aim to investigate the cerebral hemodynamic effects of magnesium sulfate infusion in aneurysmal subarachnoid hemorrhage patients. METHOD A total of 12 patients who had experienced aneurysmal subarachnoid hemorrhage were randomized to magnesium sulfate infusion (n = 6) or placebo infusion (n = 6) for 14 days. Each patient had two perfusion MRIs performed, one in the first week after subarachnoid hemorrhage and one in the second week after subarachnoid hemorrhage. FINDINGS Age, sex, and Fisher CT grade were not different between the two groups. All but one patient were of WFNS Grade I to II on presentation. There was no increase in rCBV, rCBF and MTT between the two perfusion scans within the same group or between the two groups. CONCLUSION Magnesium sulfate infusion, in the dosage of current clinical trials, did not increase cerebral blood volume and cerebral blood flow, as postulated by dilation of small vessels and/or collateral pathways.
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Affiliation(s)
- George Kwok-Chu Wong
- Division of Neurosurgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR.
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Kim JH, Park IS, Park KB, Kang DH, Hwang SH. Intraarterial nimodipine infusion to treat symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2009; 46:239-44. [PMID: 19844625 DOI: 10.3340/jkns.2009.46.3.239] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 08/05/2009] [Accepted: 08/31/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Cerebral vasospasm leading to cerebral ischemic infarction is a major cause of morbidity and mortality in the patients who suffer with aneurysmal subarachnoid hemorrhage. Despite adequate treatment, some patients deteriorate and they develop symptomatic vasospasm. The objective of the present study was to investigate the efficacy and clinical outcome of intraarterial nimodipine infusion on symptomatic vasospasm that is refractory to hemodynamic therapy. METHODS We retrospectively reviewed the procedure reports, the clinical charts and the transcranial doppler, computed tomography and digital subtraction angiography results for the patients who underwent endovascular treatment for symptomatic cerebral vasospasm due to aneurysmal SAH. During the 36 months between Jan. 2005 and Dec. 2007, 19 patients were identified who had undergone a total of 53 procedures. We assessed the difference in the arterial vessel diameter, the blood flow velocity and the clinical outcome before and after these procedures. RESULTS Vascular dilatation was observed in 42 of 53 procedures. The velocities of the affected vessels before and after procedures were available in 33 of 53 procedures. Twenty-nine procedures exhibited a mean decrease of 84.1 cm/s. We observed clinical improvement and an improved level of consciousness with an improved GCS score after 23 procedures. CONCLUSION Based on our results, the use of intraarterial nimodipine is effective and safe in selected cases of vasospasm following aneurysmal SAH. Prospective, randomized studies are needed to confirm these results.
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Affiliation(s)
- Jong Hoon Kim
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
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Intensive care of aneurysmal subarachnoid hemorrhage: an international survey. Intensive Care Med 2009; 35:1556-66. [DOI: 10.1007/s00134-009-1533-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 05/22/2009] [Indexed: 10/20/2022]
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Feasibility and safety of intrathecal nimodipine on posthaemorrhagic cerebral vasospasm refractory to medical and endovascular therapy. Clin Neurol Neurosurg 2008; 110:784-90. [PMID: 18554777 DOI: 10.1016/j.clineuro.2008.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/18/2008] [Accepted: 05/02/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The effectiveness of balloon angioplasty and intra-arterial infusion of vasodilating agents for patients suffering from severe vasospasm following aneurysmal subarachnoid haemorrhage (SAH) is often unsatisfying and there is still demand for further last resort treatment strategies. In the current prospective study, we attempted the intrathecal lavage administration of nimodipine in cases of severe cerebral vasospasm that were refractory to medical and endovascular therapy. METHODS Eight of 146 patients with aneurysmal SAH were included in the prospective study, which had been approved by the local ethics committee. Treatment was instituted by intraventricular nimodipine bolus (0.4 mg), followed by a continuous lumbar intrathecal infusion (0.4 mg/h). Effectiveness was monitored angiographically, with transcranial Doppler (TCD), perfusion CT (pCT), and by neurological examination during treatment course and follow-up. RESULTS The neurological condition improved directly in three patients and remained unchanged in four patients. Seventeen (70.8%) CT perfusion analyses revealed improved perfusion. A reduction of vasospasm was seen angiographically by digital subtraction angiography (DSA) in seven (66.6%) investigations. Additional ischaemic infarction after onset of the intrathecal therapy was documented in two (25%) patients. There were no serious adverse effects observed. CONCLUSION The present study has for the first time demonstrated the feasibility and safety of intrathecal nimodipine lavage in patients with severe vasospasm resistant to the established medical and endovascular treatment strategies. The results of the study are therefore encouraging, and further experimental and clinical trials should be carried out so as to investigate the efficacy of intrathecal nimodipine lavage in vasospasm therapy.
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Hänggi D, Turowski B, Beseoglu K, Yong M, Steiger HJ. Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid hemorrhage: influence on clinical course and cerebral perfusion. AJNR Am J Neuroradiol 2008; 29:1053-60. [PMID: 18372422 PMCID: PMC8118836 DOI: 10.3174/ajnr.a1005] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 01/02/2008] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The efficacy of intra-arterial administration of nimodipine (IAN) in patients with severe vasospasm after aneurysmal subarachnoid hemorrhage (SAH) remains unproved. The goal of the present study was to investigate the clinical effect and cerebral perfusion after IAN in patients with severe vasospasm refractory to hemodynamic treatment. MATERIALS AND METHODS Twenty-six of 214 patients with aneurysmal SAH were included in the prospective study, approved by the local ethics committee. All patients met the criteria of medically refractory cerebral vasospasm. Effectiveness was monitored angiographically by digital subtraction angiography and by transcranial Doppler (TCD), perfusion CT (PCT), and neurologic examination during treatment course and follow-up. RESULTS No angiographic effect was observed in 8 patients. The pooled PCT values revealed a reduction of time to peak (P = .03) and mean transit time (P = .17) 1 day after intervention. This effect did not persist during the following days. The pooled TCD analysis demonstrated a transient increase in flow 1 day after intervention (P = .03). No trend was evident during the next 7 days after intervention. Additional infarction was experienced by 61.1% of patients. CONCLUSIONS IAN in a selective patient group resulted in a positive response with reduction of angiographic vasospasm and increase in cerebral perfusion as detected by PCT after 24 hours. Therefore, IAN appears more effective than intra-arterial papaverine. Nevertheless the efficacy of IAN is temporary. Therefore, the search for more effective treatment strategies to reduce critical vasospasm and to improve cerebral perfusion must be continued.
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Affiliation(s)
- D Hänggi
- Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany.
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Edlow JA, Malek AM, Ogilvy CS. Aneurysmal Subarachnoid Hemorrhage: Update for Emergency Physicians. J Emerg Med 2008; 34:237-51. [DOI: 10.1016/j.jemermed.2007.10.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 08/13/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
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Affiliation(s)
- Michael E Kelly
- Department of Neurosurgery, Stanford University, Stanford, CA 94305-5327, USA
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Suarez JI. Treatment of ruptured cerebral aneurysms and vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am 2007; 17 Suppl 1:57-69. [PMID: 17967693 DOI: 10.1016/s1042-3680(06)80007-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Jose I Suarez
- Departmem of Neurology, Cerebrovascular Center, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA.
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Tavernier B, Decamps F, Vega E, Poidevin P, Verdin M, Riegel B. Traitements systémiques du vasospasme. ACTA ACUST UNITED AC 2007; 26:980-4. [DOI: 10.1016/j.annfar.2007.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Dorhout Mees S, van den Bergh WM, Algra A, Rinkel GJE. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2007; 2007:CD006184. [PMID: 17943892 PMCID: PMC8919458 DOI: 10.1002/14651858.cd006184.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Secondary ischaemia is a frequent cause of poor outcome in patients with aneurysmal subarachnoid haemorrhage (SAH). Besides vasospasm, platelet aggregation seems to play a role in the pathogenesis of secondary ischaemia. Experimental studies have suggested that antiplatelet agents can prevent secondary ischaemia. OBJECTIVES To determine whether antiplatelet agents change outcome in patients with aneurysmal SAH. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched August 2006), MEDLINE (1966 to August 2006) and EMBASE databases (1980 to August 2006). We also searched reference lists of identified trials. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing any antiplatelet agent with control in patients with aneurysmal SAH. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data and assessed trial quality. Relative risks (RR) were calculated with regard to poor outcome, case fatality, secondary ischaemia, haemorrhagic intracranial complications and aneurysmal rebleeding according to the intention-to-treat principle. In case of a statistically significant primary analysis, a worst case analysis was performed. MAIN RESULTS Seven RCTs were included in the review, totalling 1385 patients. Four of these trials met the criteria for good quality studies. For any antiplatelet agent there were reductions of a poor outcome (RR 0.79, 95% confidence interval (CI) 0.62 to 1.01) and secondary brain ischaemia (RR 0.79, 95% CI 0.56 to 1.22) and more intracranial haemorrhagic complications (RR 1.36, 95% CI 0.59 to 3.12), but none of these differences were statistically significant. There was no effect on case fatality (RR 1.01, 95% CI 0.74 to 1.37) or aneurysmal rebleeding (RR 0.98, 95% CI 0.78 to 1.38). For individual antiplatelet agents, only ticlopidine was associated with statistically significant fewer occurrences of a poor outcome (RR 0.37, 95% CI 95% CI 0.14 to 0.98) but this estimate was based on only one small RCT. AUTHORS' CONCLUSIONS This review shows a trend towards better outcome in patients treated with antiplatelet agents, possibly due to a reduction in secondary ischaemia. However, results were not statistically significant, thus no definite conclusions can be drawn. Also, antiplatelet agents could increase the risk of haemorrhagic complications. On the basis of the current evidence treatment with antiplatelet agents in order to prevent secondary ischaemia or poor outcome cannot be recommended.
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Affiliation(s)
- Sanne Dorhout Mees
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Walter M van den Bergh
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Ale Algra
- University Medical Center UtrechtJulius Centre for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
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Khan OH, McPhee LC, Moddemann LN, Del Bigio MR. Calcium antagonism in neonatal rats with kaolin-induced hydrocephalus. J Child Neurol 2007; 22:1161-6. [PMID: 17940241 DOI: 10.1177/0883073807306259] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Juvenile rats with kaolin-induced hydrocephalus have reduced brain injury if treated with nimodipine or magnesium sulfate. Experiments were conducted to determine if the neuroprotective effects could be replicated in neonatal rats with experimental hydrocephalus at an age comparable to prematurely born humans. In a blinded and randomized manner, drugs were administered for 14 days beginning 7 days after induction of hydrocephalus. Nimodipine was given twice daily by subcutaneous injections. Daily doses greater than 38 mg/kg of body weight were fatal. Daily doses of 3.8 to 30 mg/kg were not associated with behavioral, structural, or biochemical improvements. Magnesium chloride was administered via daily subcutaneous minipump infusion (0.87 or 1.74 mM/kg) along with twice daily injections of 0.74 or 1.48 mM/kg. Magnesium sulfate was administered by twice daily subcutaneous doses of 1.54 or 7.72 mM/kg. Sedation occurred, but there was no statistically significant protection in regard to behavior, brain structure, or brain composition in any of the magnesium experiments. Developmental alterations in calcium channels of the neonatal rat brain could account for differences from prior experiments in young hydrocephalic rats.
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Affiliation(s)
- Osaama H Khan
- Department of Pathology, University of Manitoba, 727 McDermot Avenue, Winnipeg, Manitoba, Canada
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Dorhout Mees S, Rinkel GJE, Feigin VL, Algra A, van den Bergh WM, Vermeulen M, van Gijn J. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2007; 2007:CD000277. [PMID: 17636626 PMCID: PMC7044719 DOI: 10.1002/14651858.cd000277.pub3] [Citation(s) in RCA: 212] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Secondary ischaemia is a frequent cause of poor outcome in patients with subarachnoid haemorrhage (SAH). Its pathogenesis has been incompletely elucidated, but vasospasm probably is a contributing factor. Experimental studies have suggested that calcium antagonists can prevent or reverse vasospasm and have neuroprotective properties. OBJECTIVES To determine whether calcium antagonists improve outcome in patients with aneurysmal SAH. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched April 2006), MEDLINE (1966 to March 2006) and EMBASE (1980 to March 2006). We handsearched two Russian journals (1990 to 2003), and contacted trialists and pharmaceutical companies in 1995 and 1996. SELECTION CRITERIA Randomised controlled trials comparing calcium antagonists with control, or a second calcium antagonist (magnesium sulphate) versus control in addition to another calcium antagonist (nimodipine) in both the intervention and control groups. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. MAIN RESULTS Sixteen trials, involving 3361 patients, were included in the review; three of the studies were of magnesium sulphate in addition to nimodipine. Overall, calcium antagonists reduced the risk of poor outcome: the relative risk (RR) was 0.81 (95% confidence interval (CI) 0.72 to 0.92); the corresponding number of patients needed to treat was 19 (95% CI 1 to 51). For oral nimodipine alone the RR was 0.67 (95% CI 0.55 to 0.81), for other calcium antagonists or intravenous administration of nimodipine the results were not statistically significant. Calcium antagonists reduced the occurrence of secondary ischaemia and showed a favourable trend for case fatality. For magnesium in addition to standard treatment with nimodipine, the RR was 0.75 (95% CI 0.57 to 1.00) for a poor outcome and 0.66 (95% CI 0.45 to 0.96) for clinical signs of secondary ischaemia. AUTHORS' CONCLUSIONS Calcium antagonists reduce the risk of poor outcome and secondary ischaemia after aneurysmal SAH. The results for 'poor outcome' depend largely on a single large trial of oral nimodipine; the evidence for other calcium antagonists is inconclusive. The evidence for nimodipine is not beyond all doubt, but given the potential benefits and modest risks of this treatment, oral nimodipine is currently indicated in patients with aneurysmal SAH. Intravenous administration of calcium antagonists cannot be recommended for routine practice on the basis of the present evidence. Magnesium sulphate is a promising agent but more evidence is needed before definite conclusions can be drawn.
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Affiliation(s)
- Sanne Dorhout Mees
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Valery L Feigin
- University of AucklandClinical Trials Research UnitPrivate Bag 92019AucklandNew Zealand
| | - Ale Algra
- University Medical Center UtrechtJulius Centre for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA
| | - Walter M van den Bergh
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Marinus Vermeulen
- Academic Medical CentreDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Jan van Gijn
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
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Gaasch JA, Geldenhuys WJ, Lockman PR, Allen DD, Van der Schyf CJ. Voltage-gated calcium channels provide an alternate route for iron uptake in neuronal cell cultures. Neurochem Res 2007; 32:1686-93. [PMID: 17404834 DOI: 10.1007/s11064-007-9313-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 02/08/2007] [Indexed: 10/23/2022]
Abstract
Recent studies suggest that iron enters cardiomyocytes via the L-type voltage-gated calcium channel (VGCC). The neuronal VGCC may also provide iron entry. As with calcium, extraneous iron is associated with the pathology and progression of neurodegenerative diseases such as Parkinson's and Alzheimer's disease. VGCCs, ubiquitously expressed, may be an important route of excessive entry for both iron and calcium, contributing to cell toxicity or death. We evaluated the uptake of (45)Ca(2+) and (55)Fe(2+) into NGF-treated rat PC12, and murine N-2alpha cells. Iron not only competed with calcium for entry into these cells, but iron uptake (similar to calcium uptake) was inhibited by nimodipine, a specific L-type VGCC blocker, and enhanced by FPL 64176, an L-VGCC activator, in a dose-dependent manner. Taken together, these data suggest that voltage-gated calcium channels are an alternate route for iron entry into neuronal cells under conditions that promote cellular iron overload toxicity.
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Affiliation(s)
- Julie A Gaasch
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas 79106, USA
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42
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Soppi V, Kokki H, Koivisto T, Lehtonen M, Helin-Tanninen M, Lehtola S, Rinne J. Early-phase pharmacokinetics of enteral and parenteral nimodipine in patients with acute subarachnoid haemorrhage - a pilot study. Eur J Clin Pharmacol 2007; 63:355-61. [PMID: 17318527 DOI: 10.1007/s00228-007-0267-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Accepted: 01/16/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The pharmacokinetics of nimodipine following enteral administration in the early phase after subarachnoid haemorrhage (SAH) has not been described. If a sufficient absorption could be achieved with enterally administered nimodipine, this would be more feasible dosage form and result in a significant reduction in pharmaceutical costs given that the parenteral formulation of nimodipine currently used is tenfold more expensive than the enteral formulation. METHODS This was a pilot study in which 17 patients with aneurysmal SAH were randomly assigned to receive nimodipine within 24 h after initial bleeding either as an 60 mg tablet/suspension at 4-h intervals, or as a continuous intravenous infusion of 2 mg/h. Serum nimodipine concentrations were measured during the 4 h following the first dose, and at 24 and 72 h on a validated gas chromatography mass spectrometer (GC-MS). RESULTS Nimodipine AUC values (expressed in mug min/ml) were lower in the eight SAH patients receiving enteral nimodipine [AUC(0-4) range: 0.13-5.4 (median: 0.32); AUC(24-28) range: 0.16-6.1 (0.71); AUC(72-76) range: 0.47-20.6 (1.9)] than in the nine patients receiving a continuous intravenous infusion of nimodipine [AUC(0-4) range: 2.4-4.9 (3.4), p=0.059; AUC(24-28) range: 4.7-10.3 (7.3), p=0.001; AUC(72-76) range: 3.4-8.6 (6.9), p=0.001]. In three of five good-grade SAH patients receiving nimodipine tablets the AUC values were comparable to those of the intravenous administration, but in two good-grade patients with tablets and in all three poor-grade (Hunt&Hess, grade IV) SAH patients receiving the suspension, the rate and extent of nimodipine absorption was negligible. CONCLUSION This pilot study indicates that the rate and extent of nimodipine absorption following enteral administration in some acute SAH patients could be negligible, and this may particularly be the case in patients with a decreased level of consciousness.
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Affiliation(s)
- Ville Soppi
- Department of Neurosurgery, Kuopio University Hospital, P.O. Box 1777, 70211, Kuopio, Finland.
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Vergouwen MDI, Vermeulen M, Roos YBWEM. Effect of nimodipine on outcome in patients with traumatic subarachnoid haemorrhage: a systematic review. Lancet Neurol 2007; 5:1029-32. [PMID: 17110283 DOI: 10.1016/s1474-4422(06)70582-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite several randomised controlled trials, there is still much debate whether nimodipine improves outcome in patients with traumatic subarachnoid haemorrhage. A 2003 Cochrane review reported improved outcome with nimodipine in these patients; however, because the results of Head Injury Trial (HIT) 4 were only partly presented there is still discussion whether patients with traumatic subarachnoid haemorrhage should be treated with this drug. Here, we present data from all head-injury trials, including previously unpublished results from HIT 4. METHODS We systematically searched PubMed and EMBASE databases using the following combinations of variables: "nimodipine" or "calcium antagonist" with "traumatic subarachnoid haemorrhage", "head injury", "head trauma", "brain injury", or "brain trauma". Bayer AG and all principal investigators or corresponding authors of the identified studies were contacted for additional information. FINDINGS Five manuscripts were identified, describing the results of four trials. We obtained additional data from HIT 1, 2, and 4. In total, 1074 patients with traumatic subarachnoid haemorrhage were included. The occurrence of poor outcome was similar in patients treated with nimodipine (39%) and those treated with placebo (40%); odds ratio was 0.88 (95% CI 0.51-1.54). Mortality rates did not differ between nimodipine (26%) and placebo (27%) treated patients (odds ratio 0.95; 95% CI 0.71-1.26). INTERPRETATION Our results do not lend support to the finding of a beneficial effect of nimodipine on outcome in patients with traumatic subarachnoid haemorrhage as reported in an earlier Cochrane review.
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Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology, Academic Medical Centre, Meibergdreef 9, Amsterdam, Netherlands.
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Keyrouz SG, Diringer MN. Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage. Crit Care 2007; 11:220. [PMID: 17705883 PMCID: PMC2206512 DOI: 10.1186/cc5958] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.
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Affiliation(s)
- Salah G Keyrouz
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
| | - Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
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Sen J, Belli A. Nimodipine for subarachnoid haemorrhage: the end of the road or better trials? Lancet Neurol 2006; 5:993-4. [PMID: 17110273 DOI: 10.1016/s1474-4422(06)70583-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Al-Shahi R, Robson M. Prevention of delayed cerebral ischaemia after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2006; 77:1300-1. [PMID: 17110743 PMCID: PMC2077428 DOI: 10.1136/jnnp.2006.100958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Physiological abnormalities are a worthwhile target
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Affiliation(s)
- Rustam Al-Shahi
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU.
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Schmid-Elsaesser R, Kunz M, Zausinger S, Prueckner S, Briegel J, Steiger HJ. Intravenous magnesium versus nimodipine in the treatment of patients with aneurysmal subarachnoid hemorrhage: a randomized study. Neurosurgery 2006; 58:1054-65; discussion 1054-65. [PMID: 16723884 DOI: 10.1227/01.neu.0000215868.40441.d9] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The prophylactic use of nimodipine in patients with aneurysmal subarachnoid hemorrhage reduces the risk of ischemic brain damage. However, its efficacy seems to be rather moderate. The question arises whether other types of calcium antagonists offer better protection. Magnesium, nature's physiological calcium antagonist, is neuroprotective in animal models, promotes dilatation of cerebral arteries, and has an established safety profile. The aim of the current pilot study is to evaluate the efficacy of magnesium versus nimodipine to prevent delayed ischemic deficits after aneurysmal subarachnoid hemorrhage. METHODS One hundred and thirteen patients with aneurysmal subarachnoid hemorrhage were enrolled in the study and were randomized to receive either magnesium sulfate (loading 10 mg/kg followed by 30 mg/kg daily) or nimodipine (48 mg/d) intravenously until at least postoperative Day 7. Primary outcome parameters were incidence of clinical vasospasm and infarction. Secondary outcome measures were the incidence of transcranial Doppler/angiographic vasospasm, the neuronal markers (neuron-specific enolase, S-100), and the patients' Glasgow Outcome Scale scores at discharge and after 1 year. RESULTS One hundred and four patients met the study requirements. In the magnesium group (n = 53), eight patients (15%) experienced clinical vasospasm and 20 (38%) experienced transcranial Doppler/angiographic vasospasm compared with 14 (27%) and 17 (33%) patients in the nimodipine group (n = 51). If clinical vasospasm occurred, 75% of the magnesium-treated versus 50% of the nimodipine-treated patients experienced cerebral infarction resulting in fatal outcome in 37 and 14%, respectively. Overall, the rate of infarction attributable to vasospasm was virtually the same (19 versus 22%). There was no difference in outcome between groups. CONCLUSION The efficacy of magnesium in preventing delayed ischemic neurological deficits in patients with aneurysmal subarachnoid hemorrhage seems to be comparable with that of nimodipine. The difference in their pharmacological properties makes studies on the combined administration of magnesium and nimodipine seem promising.
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Petzold A, Keir G, Kay A, Kerr M, Thompson EJ. Axonal damage and outcome in subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2006; 77:753-9. [PMID: 16705199 PMCID: PMC2077447 DOI: 10.1136/jnnp.2005.085175] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Revised: 01/14/2006] [Accepted: 01/19/2006] [Indexed: 01/22/2023]
Abstract
BACKGROUND On the basis of preliminary evidence from patients with subarachnoid haemorrhage (SAH), axonal degeneration is thought to be an underestimated pathological feature. METHODS A longitudinal study in 17 patients with aneurysmal SAH. Ventricular CSF was collected daily for up to 14 days. The neurofilament heavy chain(SMI35) (NfH(SMI35), a biomarker for axonal damage) was quantified using a standard ELISA (upper limit of normal 0.73 ng/ml). The primary outcome measure was the Glasgow Outcome Score (GOS) at 3 months. RESULTS Of 148 samples from patients with SAH, pathologically high NfH levels in the CSF were found in 78 (52.7%) samples, compared with 20 (5%) of 416 samples from the reference population (p<0.0001). A pathological increase in NfH was observed in all patients with a bad outcome (GOS 1-3) compared with 8% of those with a good outcome (GOS 4-5, p<0.0001). This increase typically became significant 7 days after the haemorrhage (p<0.01). The result was confirmed by analysing the individual mean NfH concentrations in the CSF (3.45 v 0.37 ng/ml, p<0.01), and was reinforced by the inverse correlation of NfH in the CSF with the GOS (r = -0.65, p<0.01). Severity of injury was found to be correlated to NfH(SMI35) levels in the CSF (World Federation of Neurological Surgeons, r = 0.63, p<0.01 and Glasgow Coma Score, r = -0.61, p<0.01). CONCLUSION Patients with SAH thus have secondary axonal degeneration, which may adversely affect their outcome.
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Affiliation(s)
- A Petzold
- Department of Neuroimmunology, Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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50
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Blissitt PA, Mitchell PH, Newell DW, Woods SL, Belza B. Cerebrovascular Dynamics With Head-of-Bed Elevation in Patients With Mild or Moderate Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Am J Crit Care 2006. [DOI: 10.4037/ajcc2006.15.2.206] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background In patients with aneurysmal subarachnoid hemorrhage, elevation of the head of the bed during vasospasm has been limited in an attempt to minimize vasospasm or its sequelae or both. Consequently, some patients have remained on bed rest for weeks.
• Objectives To determine how elevations of the head of the bed of 20° and 45° affect cerebrovascular dynamics in adult patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage and to describe the response of mild or moderate vasospasm to head-of-bed elevations of 20° and 45° with respect to variables such as grade of subarachnoid hemorrhage and degree of vasospasm.
• Methods A within-patient repeated-measures design was used. The head of the bed was positioned in the sequence of 0°-20°-45°-0° in 20 patients with mild or moderate vasospasm between days 3 and 14 after aneurysmal subarachnoid hemorrhage. Continuous transcranial Doppler recordings were obtained for 2 to 5 minutes after allowing approximately 2 minutes for stabilization in each position.
• ResultsNo patterns or trends indicated that having the head of the bed elevated increases vasospasm. As a group, there were no significant differences within patients at the different positions of the head of the bed. Utilizing repeated-measures analysis of variance, P values ranged from .34 to .97, well beyond .05. No neurological deterioration occurred.
• Conclusions In general, elevation of the head of the bed did not cause harmful changes in cerebral blood flow related to vasospasm.
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Affiliation(s)
- Patricia A. Blissitt
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - Pamela H. Mitchell
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - David W. Newell
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - Susan L. Woods
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - Basia Belza
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
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