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Hofmann BB, Donaldson DM, Fischer I, Karadag C, Neyazi M, Piedade GS, Abusabha Y, Muhammad S, Rubbert C, Hänggi D, Beseoglu K. Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation. Neurocrit Care 2023; 39:125-134. [PMID: 36802010 PMCID: PMC10499698 DOI: 10.1007/s12028-023-01683-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. METHODS We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients. RESULTS Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. CONCLUSIONS The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Guilherme S Piedade
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Hofmann BB, Fischer I, Donaldson DM, Abusabha Y, Karadag C, Muhammad S, Beseoglu K, Hänggi D, Turowski B, Rubbert C, Cornelius JF, Kamp MA. Evaluation of MTT Heterogeneity of Perfusion CT Imaging in the Early Brain Injury Phase: An Insight into aSAH Pathopysiology. Brain Sci 2023; 13:brainsci13050824. [PMID: 37239296 DOI: 10.3390/brainsci13050824] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The concept of early brain injury (EBI) is based on the assumption of a global reduction in brain perfusion following aneurysmal subarachnoid hemorrhage (aSAH). However, the heterogeneity of computed tomography perfusion (CTP) imaging in EBI has not yet been investigated. In contrast, increased mean transit time (MTT) heterogeneity, a possible marker of microvascular perfusion heterogeneity, in the delayed cerebral ischemia (DCI) phase has recently been associated with a poor neurological outcome after aSAH. Therefore, in this study, we investigated whether the heterogeneity of early CTP imaging in the EBI phase is an independent predictor of the neurological outcome after aSAH. We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation (cvMTT) in early CTP scans (within 24 h after ictus) of 124 aSAH patients. Both linear and logistic regression were used to model the mRS outcome, which were treated as numerical and dichotomized values, respectively. Linear regression was used to investigate the linear dependency between the variables. No significant difference in cvMTT between the patients with and those without EVD could be observed (p = 0.69). We found no correlation between cvMTT in early CTP imaging and initial modified Fisher (p = 0.07) and WFNS grades (p = 0.23). The cvMTT in early perfusion imaging did not correlate significantly with the 6-month mRS for the entire study population (p = 0.15) or for any of the subgroups (without EVD: p = 0.21; with EVD: p = 0.3). In conclusion, microvascular perfusion heterogeneity, assessed by the heterogeneity of MTT in early CTP imaging, does not appear to be an independent predictor of the neurological outcome 6 months after aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
- Department of Neurosurgery, International Neuroscience Institute, 30625 Hannover, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcel A Kamp
- Centre for Palliative and Neuro-Palliative Care, Brandenburg Medical School Theodor Fontane, Campus Rüdersdorf, 15562 Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
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Hemorrhagic Cerebral Insults and Secondary Takotsubo Syndrome: Findings in a Novel In Vitro Model Using Human Blood Samples. Int J Mol Sci 2022; 23:ijms231911557. [PMID: 36232860 PMCID: PMC9569517 DOI: 10.3390/ijms231911557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Intracranial hemorrhage results in devastating forms of cerebral damage. Frequently, these results also present with cardiac dysfunction ranging from ECG changes to Takotsubo syndrome (TTS). This suggests that intracranial bleeding due to subarachnoid hemorrhage (SAH) disrupts the neuro-cardiac axis leading to neurogenic stress cardiomyopathy (NSC) of different degrees. Following this notion, SAH and secondary TTS could be directly linked, thus contributing to poor outcomes. We set out to test if blood circulation is the driver of the brain-heart axis by investigating serum samples of TTS patients. We present a novel in vitro model combining SAH and secondary TTS to mimic the effects of blood or serum, respectively, on blood-brain barrier (BBB) integrity using in vitro monolayers of an established murine model. We consistently demonstrated decreased monolayer integrity and confirmed reduced Claudin-5 and Occludin levels by RT-qPCR and Western blot and morphological reorganization of actin filaments in endothelial cells. Both tight junction proteins show a time-dependent reduction. Our findings highlight a faster and more prominent disintegration of BBB in the presence of TTS and support the importance of the bloodstream as a causal link between intracerebral bleeding and cardiac dysfunction. This may represent potential targets for future therapeutic inventions in SAH and TTS.
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Wen L, Zhou L, Wu Q, Zhou X, Zhang X. Feasibility of FDCT Early Brain Parenchymal Blood Volume Maps in Predicting Short-Term Prognosis in Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 13:888369. [PMID: 35911895 PMCID: PMC9329812 DOI: 10.3389/fneur.2022.888369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Aneurysmal subarachnoid hemorrhage (SAH) is accompanied by cerebral perfusion changes. We aimed to measure the parenchymal blood volume (PBV) maps acquired by C-arm flat-panel detector CT (FDCT) to assess the cerebral blood volume at an early stage in aneurysmal SAH and to explore the correlation with the outcomes at discharge. Methods Data of 66 patients with aneurysmal SAH who underwent FDCT PBV examination were retrospectively analyzed. The PBV of regions of interest, including the cortices of the bilateral frontal lobe, the parietal lobe, the occipital lobe, and the cerebral hemisphere, as well as the basal ganglia, were measured and quantitatively analyzed. The clinical and imaging data of the patients were also collected, and logistic regression analysis was performed to explore the correlation between the perfusion parameters and outcomes at discharge. Results The favorable and poor outcomes at discharge were found in 37 (56.06%) and 29 (43.94%) patients, respectively. The whole-brain PBV was significantly correlated with the Hunt-Hess grades (p < 0.005) and the WFNSS grades (p < 0.005). The whole-brain PBV of the poor prognosis was significantly higher than that of the favorable prognosis (35.17 ± 7.66 vs. 29.78 ± 5.54, p < 0.005). The logistic regression analysis showed that the PBV of the parietal lobe at the bleeding side (OR = 1.10, 95%CI: 1.00-1.20, p = 0.04) was an independent risk factor predicting the short-term prognosis. Conclusions Parenchymal blood volume (PBV) maps could reflect the cerebral blood volume throughout the brain to characterize its perfusion status at an early stage in aneurysmal SAH. It enables a one-stop imaging evaluation and treatment in the same angio-suite and may serve as a reliable technique in clinical assessment of aneurysmal SAH.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Medical Imaging Center, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Hofmann BB, Fischer I, Engel A, Jannusch K, Donaldson DM, Karadag C, van Lieshout JH, Beseoglu K, Muhammad S, Turowski B, Hänggi D, Kamp MA, Rubbert C. MTT Heterogeneity in Perfusion CT Imaging as a Predictor of Outcome after Aneurysmal SAH. AJNR Am J Neuroradiol 2021; 42:1387-1395. [PMID: 34083263 DOI: 10.3174/ajnr.a7169] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/09/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Impairment of tissue oxygenation caused by inhomogeneous microscopic blood flow distribution, the so-called capillary transit time heterogeneity, is thought to contribute to delayed cerebral ischemia after aneurysmal SAH but has so far not been systematically evaluated in patients. We hypothesized that heterogeneity of the MTT, derived from CTP parameters, would give insight into the clinical course of patients with aneurysmal SAH and may identify patients at risk of poor outcome. MATERIALS AND METHODS We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation in CTP scans from 132 patients. A multivariable logistic regression model was used to model the dichotomized mRS outcome. Linear regression was used to eliminate variables with high linear dependence. T tests were used to compare the means of 2 groups. Furthermore, the time of the maximum coefficient of variation for MTT after bleeding was evaluated for correlation with the mRS after 6 months. RESULTS On average, each patient underwent 5.3 CTP scans during his or her stay. Patients with high coefficient of variation for MTT presented more often with higher modified Fisher (P = .011) and World Federation of Neurosurgical Societies grades (P = .014). A high coefficient of variation for MTT at days 3-21 after aneurysmal SAH correlated significantly with a worse mRS score after 6 months (P = .016). We found no correlation between the time of the maximum coefficient of variation for MTT after bleeding and the patients' outcomes after 6 months (P = .203). CONCLUSIONS Heterogeneity of MTT in CTP after aneurysmal SAH correlates with the patients' outcomes. Because the findings are in line with the pathophysiologic concept of the capillary transit time heterogeneity, future studies should seek to verify the coefficient of variation for MTT as a potential imaging biomarker for outcome.
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Affiliation(s)
- B B Hofmann
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - I Fischer
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - A Engel
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - K Jannusch
- Department of Diagnostic and Interventional Radiology (K.J., B.T., C.R.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - D M Donaldson
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - C Karadag
- Medical Faculty (C.K.), University Düsseldorf, Düsseldorf, Germany
| | - J H van Lieshout
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - K Beseoglu
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - S Muhammad
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - B Turowski
- Department of Diagnostic and Interventional Radiology (K.J., B.T., C.R.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - D Hänggi
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - M A Kamp
- From the Department of Neurosurgery (B.B.H., I.F., A.E., D.M.D., C.K., J.H.v.L., K.B., S.M., D.H., M.A.K.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology (K.J., B.T., C.R.), Medical Faculty, University Düsseldorf, Düsseldorf, Germany
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Shi D, Jin D, Cai W, Zhu Q, Dou X, Fan G, Shen J, Xu L. Serial low-dose quantitative CT perfusion for the evaluation of delayed cerebral ischaemia following aneurysmal subarachnoid haemorrhage. Clin Radiol 2020; 75:131-139. [DOI: 10.1016/j.crad.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
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Starnoni D, Maduri R, Hajdu SD, Pierzchala K, Giammattei L, Rocca A, Grosfilley SB, Saliou G, Messerer M, Daniel RT. Early Perfusion Computed Tomography Scan for Prediction of Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e743-e752. [PMID: 31284055 DOI: 10.1016/j.wneu.2019.06.213] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We investigated the ability of early alteration of cerebral perfusion-computed tomography (PCT) parameters to predict the risk of vasospasm, delayed cerebral ischemia (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective cohort study of 38 aSAH patients investigated with PCT within 48 hours after hemorrhage. Cerebral blood flow (CBF), cerebral blood volume, and mean transit time (MTT) values were recorded. Mean values were compared with clinical data. Vasospasm and DCI were determined by imaging and clinical criteria. Neurologic outcome was assessed by the modified Rankin Scale at discharge and 1-year follow-up visit. RESULTS More than a third (39.5%) of patients developed DCI, of whom 86.7% presented moderate-severe vasospasm. There was a significant correlation between perfusion parameters in the early phase and occurrence of DCI and vasospasm. The occurrence of DCI and vasospasm correlated significantly with lower mean early PCT values. DCI was correlated with lower mean early CBF values (P = 0.049) and vasospasm with lower mean CBF (P = 0.01) and MTT (P < 0.00001) values. MTT values of 5.5s were shown to have 94% specificity and 100% sensitivity for predicting the risk of developing vasospasm. The severity of the SAH according to the Barrow Neurological Institute scale correlated significantly with the risk of developing DCI and vasospasm, both significantly associated with unfavorable neurologic outcome (modified Rankin Scale score 3-6) (P = 0.0002 and P = 0.02, respectively). CONCLUSIONS Early alterations in PCT parameters and high Barrow Neurological Institute grade may identify a subgroup of patients at high risk of developing DCI and vasospasm after aSAH, thus prompting more robust preventative measures and treatment in this subgroup.
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Affiliation(s)
- Daniele Starnoni
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - Steven David Hajdu
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Lorenzo Giammattei
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alda Rocca
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Sarah Beatrice Grosfilley
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
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Neutrophils mediate early cerebral cortical hypoperfusion in a murine model of subarachnoid haemorrhage. Sci Rep 2019; 9:8460. [PMID: 31186479 PMCID: PMC6560094 DOI: 10.1038/s41598-019-44906-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023] Open
Abstract
Cerebral hypoperfusion in the first hours after subarachnoid haemorrhage (SAH) is a major determinant of poor neurological outcome. However, the underlying pathophysiology is only partly understood. Here we induced neutropenia in C57BL/6N mice by anti-Ly6G antibody injection, induced SAH by endovascular filament perforation, and analysed cerebral cortical perfusion with laser SPECKLE contrast imaging to investigate the role of neutrophils in mediating cerebral hypoperfusion during the first 24 h post-SAH. SAH induction significantly increased the intracranial pressure (ICP), and significantly reduced the cerebral perfusion pressure (CPP). At 3 h after SAH, ICP had returned to baseline and CPP was similar between SAH and sham mice. However, in SAH mice with normal neutrophil counts cortical hypoperfusion persisted. Conversely, despite similar CPP, cortical perfusion was significantly higher at 3 h after SAH in mice with neutropenia. The levels of 8-iso-prostaglandin-F2α in the subarachnoid haematoma increased significantly at 3 h after SAH in animals with normal neutrophil counts indicating oxidative stress, which was not the case in neutropenic SAH animals. These results suggest that neutrophils are important mediators of cortical hypoperfusion and oxidative stress early after SAH. Targeting neutrophil function and neutrophil-induced oxidative stress could be a promising new approach to mitigate cerebral hypoperfusion early after SAH.
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Petridis AK, Kamp MA, Cornelius JF, Beez T, Beseoglu K, Turowski B, Steiger HJ. Aneurysmal Subarachnoid Hemorrhage. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:226-236. [PMID: 28434443 DOI: 10.3238/arztebl.2017.0226] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 08/29/2016] [Accepted: 11/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living. METHODS This article is based on a selective review of pertinent literature retrieved by a PubMed search. RESULTS Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping). CONCLUSION SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.
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Affiliation(s)
- Athanasios K Petridis
- Department of Neurosurgery, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital
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Neulen A, Meyer S, Kramer A, Pantel T, Kosterhon M, Kunzelmann S, Goetz H, Thal SC. Large Vessel Vasospasm Is Not Associated with Cerebral Cortical Hypoperfusion in a Murine Model of Subarachnoid Hemorrhage. Transl Stroke Res 2018; 10:10.1007/s12975-018-0647-6. [PMID: 30003500 PMCID: PMC6526146 DOI: 10.1007/s12975-018-0647-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 01/01/2023]
Abstract
Clinical studies on subarachnoid hemorrhage (SAH) have shown discrepancies between large vessel vasospasm, cerebral perfusion, and clinical outcome. We set out to analyze the contribution of large vessel vasospasm to impaired cerebral perfusion and neurological impairment in a murine model of SAH. SAH was induced in C57BL/6 mice by endovascular filament perforation. Vasospasm was analyzed with microcomputed tomography, cortical perfusion by laser SPECKLE contrast imaging, and functional impairment with a quantitative neuroscore. SAH animals developed large vessel vasospasm, as shown by significantly lower vessel volumes of a 2.5-mm segment of the left middle cerebral artery (MCA) (SAH 5.6 ± 0.6 nL, sham 8.3 ± 0.5 nL, p < 0.01). Induction of SAH significantly reduced cerebral perfusion of the corresponding left MCA territory compared to values before SAH, which only recovered partly (SAH vs. sham, 15 min 35.7 ± 3.1 vs. 101.4 ± 10.2%, p < 0.01; 3 h, 85.0 ± 8.6 vs. 121.9 ± 13.4, p < 0.05; 24 h, 75.3 ± 4.6 vs. 110.6 ± 11.4%, p < 0.01; 72 h, 81.8 ± 4.8 vs. 108.5 ± 14.5%, n.s.). MCA vessel volume did not correlate significantly with MCA perfusion after 72 h (r = 0.34, p = 0.25). Perfusion correlated moderately with neuroscore (24 h: r = - 0.58, p < 0.05; 72 h: r = - 0.44, p = 0.14). There was no significant correlation between vessel volume and neuroscore after 72 h (r = - 0.21, p = 0.50). In the murine SAH model, cerebral hypoperfusion occurs independently of large vessel vasospasm. Neurological outcome is associated with cortical hypoperfusion rather than large vessel vasospasm.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Andreas Kramer
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Svenja Kunzelmann
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Hermann Goetz
- Platform for Biomaterial Research, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
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CT Perfusion to Guide Placement of Invasive Cerebral Perfusion Monitor in Subarachnoid Hemorrhage Induced Vasospasm. Case Rep Neurol Med 2018; 2018:5162629. [PMID: 29805825 PMCID: PMC5904811 DOI: 10.1155/2018/5162629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/08/2018] [Accepted: 03/06/2018] [Indexed: 11/30/2022] Open
Abstract
Background Vasospasm is a challenging component of the subarachnoid hemorrhage “syndrome” that is unpredictable and very difficult to monitor using noninvasive or invasive monitoring technologies in neurocritical units. Methods We describe the novel use of computerized tomography perfusion (CTP) imaging to choose proper targets for invasive cerebral blood flow monitors. Results A total of 3 patients are included in this report. CTP parameters were used to generate points of interest to target using invasive cerebral monitoring of the cerebral blood flow and initiate vasodilator therapy and subsequently guide its weaning. Conclusions CTP can be useful in localizing a specific anatomical target for invasive monitoring in subarachnoid hemorrhage patients suffering from vasospasm.
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12
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Kamp MA, Sarikaya-Seiwert S, Petridis AK, Beez T, Cornelius JF, Steiger HJ, Turowski B, Slotty PJ. Intraoperative Indocyanine Green–Based Cortical Perfusion Assessment in Patients Suffering from Severe Traumatic Brain Injury. World Neurosurg 2017; 101:431-443. [DOI: 10.1016/j.wneu.2017.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 01/04/2023]
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13
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van Lieshout JH, Dibué-Adjei M, Cornelius JF, Slotty PJ, Schneider T, Restin T, Boogaarts HD, Steiger HJ, Petridis AK, Kamp MA. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2017; 41:917-930. [PMID: 28215029 DOI: 10.1007/s10143-017-0827-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
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Affiliation(s)
- Jasper H van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Toni Schneider
- Institute for Neurophysiology, Medical Faculty, University of Cologne, Robert-Koch-Str. 39, 50931, Köln, Germany
| | - Tanja Restin
- Zurich Centre for Integrative Human Physiology, Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Institute of Anesthesiology, Medical Faculty, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios K Petridis
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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14
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van Lieshout JH, Bruland I, Fischer I, Cornelius JF, Kamp MA, Turowski B, Tortora A, Steiger HJ, Petridis AK. Increased mortality of patients with aneurysmatic subarachnoid hemorrhage caused by prolonged transport time to a high-volume neurosurgical unit. Am J Emerg Med 2017; 35:45-50. [DOI: 10.1016/j.ajem.2016.09.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/07/2016] [Accepted: 09/29/2016] [Indexed: 01/03/2023] Open
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Prognostic Assessment of Aneurysmal Subarachnoid Patients with WFNS Grade V by CT Perfusion on Arrival. World Neurosurg 2016; 92:1-6. [PMID: 27155385 DOI: 10.1016/j.wneu.2016.04.097] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/25/2016] [Accepted: 04/25/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) depends on their condition on arrival at the hospital. However, a small number of patients recover from an initially poor condition. We investigated the correlation between quantitative measures of computed tomography (CT) perfusion (CTP) on arrival and the outcomes of patients with World Federation of Neurosurgical Society (WFNS) grade V aSAH. METHODS We performed plain CT, CTP, and CT angiography (CTA) in all patients with aSAH on arrival. Aneurysms were surgically obliterated in patients with stable vital signs and the presence of a brain stem response. We measured the average mean transit time (aMTT) and compared it with the modified Rankin Scale (mRS) score at 1 month. Regions of interest were identified as 24 areas in the bilateral anterior, middle, and posterior cerebral artery territories and 2 areas in the basal ganglia. RESULTS A total of 57 patients were treated between 2007 and 2014. None of the 21 patients with aMTT >6.385 seconds achieved a favorable outcome, whereas 8 of the 36 patients with aMTT <6.385 seconds did achieve a favorable outcome (P = 0.015). Furthermore, comparing the number of areas showing a mean transit time (MTT) >7.0 seconds among the aforementioned 8 areas and mRS, favorable outcomes were not seen in 24 patients with more than 2 such areas (P = 0.009). CONCLUSION We cannot expect a favorable outcome for patients with WFNS grade V aSAH with aMTT >6.385 seconds or more than 2 of 8 areas with MTT >7.0 seconds.
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Malinova V, Dolatowski K, Schramm P, Moerer O, Rohde V, Mielke D. Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg 2015; 125:128-36. [PMID: 26684786 DOI: 10.3171/2015.6.jns15720] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This prospective study investigated the role of whole-brain CT perfusion (CTP) studies in the identification of patients at risk for delayed ischemic neurological deficits (DIND) and of tissue at risk for delayed cerebral infarction (DCI). METHODS Forty-three patients with aneurysmal subarachnoid hemorrhage (aSAH) were included in this study. A CTP study was routinely performed in the early phase (Day 3). The CTP study was repeated in cases of transcranial Doppler sonography (TCD)-measured blood flow velocity (BFV) increase of > 50 cm/sec within 24 hours and/or on Day 7 in patients who were intubated/sedated. RESULTS Early CTP studies revealed perfusion deficits in 14 patients, of whom 10 patients (72%) developed DIND, and 6 of these 10 patients (60%) had DCI. Three of the 14 patients (21%) with early perfusion deficits developed DCI without having had DIND, and the remaining patient (7%) had neither DIND nor DCI. There was a statistically significant correlation between early perfusion deficits and occurrence of DIND and DCI (p < 0.0001). A repeated CTP was performed in 8 patients with a TCD-measured BFV increase > 50 cm/sec within 24 hours, revealing a perfusion deficit in 3 of them (38%). Two of the 3 patients (67%) developed DCI without preceding DIND and 1 patient (33%) had DIND without DCI. In 4 of the 7 patients (57%) who were sedated and/or comatose, additional CTP studies on Day 7 showed perfusion deficits. All 4 patients developed DCI. CONCLUSIONS Whole-brain CTP on Day 3 after aSAH allows early and reliable identification of patients at risk for DIND and tissue at risk for DCI. Additional CTP investigations, guided by TCD-measured BFV increase or persisting coma, do not contribute to information gain.
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Affiliation(s)
| | | | - Peter Schramm
- Neuroradiology, and.,Department of Neuroradiology, University of Lübeck, Germany
| | - Onnen Moerer
- Anaesthesiology, Georg-August-University, Göttingen; and
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17
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Effect of APOE Gene Polymorphism on Early Cerebral Perfusion After Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res 2015; 6:446-50. [DOI: 10.1007/s12975-015-0426-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
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18
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Relationship Between Cardiac Dysfunction and Cerebral Perfusion in Patients with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2015; 24:202-6. [DOI: 10.1007/s12028-015-0188-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Early CT perfusion changes and blood-brain barrier permeability after aneurysmal subarachnoid hemorrhage. Neuroradiology 2015; 57:767-73. [PMID: 25868518 DOI: 10.1007/s00234-015-1529-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 04/01/2015] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Early brain injury (EBI) can occur within 72 h of aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to determine if there are differences in early CTP parameters (<72 h) with respect to delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome. METHODS We performed a prospective cohort study of aSAH patients admitted to a single tertiary care center. MTT, CBF and blood-brain barrier permeability (PS) were quantified with CTP within 72 h of aneurysm rupture. Primary outcomes were functional outcome by the Modified Rankin Scale (mRS) at 3 months and cerebral infarction. Secondary outcome was the development of DCI. Differences between early CTP parameters were determined with respect to primary and secondary outcomes. RESULTS Fifty aSAH patients were included in the final analysis. MTT was significantly higher in patients who developed DCI (6.7 ± 1.2 vs 5.9 ± 1.0; p = 0.03) and cerebral infarction (7.0 ± 1.2 vs 5.9 ± 0.9; p = 0.007); however, no difference in MTT was found between patients with and without a poor outcome (mRS > 2). Early CBF and PS did not differ with respect to functional outcome, DCI, and cerebral infarction. CONCLUSIONS Elevated MTT within 72 h of aneurysm rupture is associated with DCI and cerebral infarction but not with long-term functional outcome. Blood-brain barrier permeability, as assessed by CT perfusion, was not associated with DCI or worse outcome in this cohort.
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Moore SA, Rabinstein AA, Stewart MW, David Freeman W. Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage. Expert Rev Neurother 2015; 14:757-68. [PMID: 24949896 DOI: 10.1586/14737175.2014.922414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.
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Affiliation(s)
- S Arthur Moore
- Department of Neurology, Critical Care, Mayo Clinic, Rochester, MN 55902, USA
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Etminan N, Beseoglu K, Heiroth HJ, Turowski B, Steiger HJ, Hänggi D. Early Perfusion Computerized Tomography Imaging as a Radiographic Surrogate for Delayed Cerebral Ischemia and Functional Outcome After Subarachnoid Hemorrhage. Stroke 2013; 44:1260-6. [DOI: 10.1161/strokeaha.111.675975] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nima Etminan
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hi-Jae Heiroth
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Bernd Turowski
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hans Jakob Steiger
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniel Hänggi
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
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Ma J, Huang S, Ma L, Liu Y, Li H, You C. Endothelin-receptor antagonists for aneurysmal subarachnoid hemorrhage: an updated meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R198. [PMID: 23078672 PMCID: PMC3682300 DOI: 10.1186/cc11686] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 10/09/2012] [Indexed: 11/10/2022]
Abstract
Introduction The previous meta-analysis on the use of endothelin-receptor antagonists (ETRAs) to treat aneurysmal subarachnoid hemorrhage (SAH) has become outdated due to recently published phase 3 clinical trials. An up-to-date meta-analysis is needed to provide the best available evidence for the efficacy of ETRAs for aneurysmal SAH. Methods We performed a systematic review and meta-analysis of published randomized controlled trials that investigate efficacy of ETRAs in patients with aneurysmal SAH. Mortality, unfavorable outcome, delayed ischemic neurological deficit (DIND), delayed cerebral infarction (DCI), angiographic vasospasm and adverse events were analyzed. Meta-analysis was performed in terms of the risk ratio (RR) and 95% confidence interval (CI). Results Five eligible studies were reviewed and analyzed, involving 2,595 patients. The pooled RRs of mortality and unfavorable outcome after SAH were 1.03 (95% CI = 0.77 to 1.36) and 1.07 (95% CI = 0.93 to 1.22), respectively. The pooled RRs were 0.87 (95% CI = 0.74 to 1.03) for DCI, 0.77 (95% CI = 0.66 to 0.90) for DIND, and 0.66 (95% CI = 0.57 to 0.77) for angiographic vasospasm. There were significant increases in lung complications (RR = 1.80, 95% CI = 1.55 to 2.09), hypotension (RR = 2.42, 95% CI = 1.78 to 3.29) and anemia (RR = 1.47, 95% CI = 1.19 to 1.83) in patients administered ETRAs. Conclusion There is no evidence that ETRAs could benefit clinical outcome in patients with SAH. Owing to the increased adverse events, further clinical trials of ETRAs in SAH patients should be more carefully formulated and designed. The present results also suggest that DCI may be a better outcome measure than vasospasm and DIND in SAH clinical trials and observational studies.
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