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Addis A, Baggiani M, Citerio G. Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:59-69. [PMID: 37280411 PMCID: PMC10499755 DOI: 10.1007/s12028-023-01752-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 05/12/2023] [Indexed: 06/08/2023]
Abstract
Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. Although cerebrospinal fluid withdrawal via an external ventricular drain is commonly used, ICP monitoring is not always consistently practiced. Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.
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Affiliation(s)
- Alberto Addis
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Neurological Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Neurological Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy.
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2
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Solár P, Zamani A, Lakatosová K, Joukal M. The blood-brain barrier and the neurovascular unit in subarachnoid hemorrhage: molecular events and potential treatments. Fluids Barriers CNS 2022; 19:29. [PMID: 35410231 PMCID: PMC8996682 DOI: 10.1186/s12987-022-00312-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
The response of the blood-brain barrier (BBB) following a stroke, including subarachnoid hemorrhage (SAH), has been studied extensively. The main components of this reaction are endothelial cells, pericytes, and astrocytes that affect microglia, neurons, and vascular smooth muscle cells. SAH induces alterations in individual BBB cells, leading to brain homeostasis disruption. Recent experiments have uncovered many pathophysiological cascades affecting the BBB following SAH. Targeting some of these pathways is important for restoring brain function following SAH. BBB injury occurs immediately after SAH and has long-lasting consequences, but most changes in the pathophysiological cascades occur in the first few days following SAH. These changes determine the development of early brain injury as well as delayed cerebral ischemia. SAH-induced neuroprotection also plays an important role and weakens the negative impact of SAH. Supporting some of these beneficial cascades while attenuating the major pathophysiological pathways might be decisive in inhibiting the negative impact of bleeding in the subarachnoid space. In this review, we attempt a comprehensive overview of the current knowledge on the molecular and cellular changes in the BBB following SAH and their possible modulation by various drugs and substances.
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Affiliation(s)
- Peter Solár
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Pekařská 53, 656 91, Brno, Czech Republic
| | - Alemeh Zamani
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Klaudia Lakatosová
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Marek Joukal
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic.
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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4
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Veldeman M, Albanna W, Weiss M, Park S, Hoellig A, Clusmann H, Helbok R, Temel Y, Alexander Schubert G. Invasive Multimodal Neuromonitoring in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review. Stroke 2021; 52:3624-3632. [PMID: 34304602 DOI: 10.1161/strokeaha.121.034633] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal subarachnoid hemorrhage is a devastating disease leaving surviving patients often severely disabled. Delayed cerebral ischemia (DCI) has been identified as one of the main contributors to poor clinical outcome after subarachnoid hemorrhage. The objective of this review is to summarize existing clinical evidence assessing the diagnostic value of invasive neuromonitoring (INM) in detecting DCI and provide an update of evidence since the 2014 consensus statement on multimodality monitoring in neurocritical care. METHODS Three invasive monitoring techniques were targeted in the data collection process: brain tissue oxygen tension (ptiO2), cerebral microdialysis, and electrocorticography. Prospective and retrospective studies as well as case series (≥10 patients) were included as long as monitoring was used to detect DCI or guide DCI treatment. RESULTS Forty-seven studies reporting INM in the context of DCI were included (ptiO2: N=21; cerebral microdialysis: N=22; electrocorticography: N=4). Changes in brain oxygen tension are associated with angiographic vasospasm or reduction in regional cerebral blood flow. Metabolic monitoring with trend analysis of the lactate to pyruvate ratio using cerebral microdialysis, identifies patients at risk for DCI. Clusters of cortical spreading depolarizations are associated with clinical neurological worsening and cerebral infarction in selected patients receiving electrocorticography monitoring. CONCLUSIONS Data supports the use of INM for the detection of DCI in selected patients. Generalizability to all subarachnoid hemorrhage patients is limited by design bias of available studies and lack of randomized trials. Continuous data recording with trend analysis and the combination of INM modalities can provide tailored treatment support in patients at high risk for DCI. Future trials should test interventions triggered by INM in relation to cerebral infarctions.
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Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, NY (S.P.)
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Austria (R.H.)
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, the Netherlands (Y.T)
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.).,Department of Neurosurgery, Kantonsspital Aarau, Switzerland (G.A.S.)
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5
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Neuroprotective Strategies in Aneurysmal Subarachnoid Hemorrhage (aSAH). Int J Mol Sci 2021; 22:ijms22115442. [PMID: 34064048 PMCID: PMC8196706 DOI: 10.3390/ijms22115442] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) remains a disease with high mortality and morbidity. Since treating vasospasm has not inevitably led to an improvement in outcome, the actual emphasis is on finding neuroprotective therapies in the early phase following aSAH to prevent secondary brain injury in the later phase of disease. Within the early phase, neuroinflammation, thromboinflammation, disturbances in brain metabolism and early neuroprotective therapies directed against delayed cerebral ischemia (DCI) came into focus. Herein, the role of neuroinflammation, thromboinflammation and metabolism in aSAH is depicted. Potential neuroprotective strategies regarding neuroinflammation target microglia activation, metalloproteases, autophagy and the pathway via Toll-like receptor 4 (TLR4), high mobility group box 1 (HMGB1), NF-κB and finally the release of cytokines like TNFα or IL-1. Following the link to thromboinflammation, potential neuroprotective therapies try to target microthrombus formation, platelets and platelet receptors as well as clot clearance and immune cell infiltration. Potential neuroprotective strategies regarding metabolism try to re-balance the mismatch of energy need and supply following aSAH, for example, in restoring fuel to the TCA cycle or bypassing distinct energy pathways. Overall, this review addresses current neuroprotective strategies in aSAH, hopefully leading to future translational therapy options to prevent secondary brain injury.
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Jeong HG, Cha BG, Kang DW, Kim DY, Ki SK, Kim SI, Han JH, Yang W, Kim CK, Kim J, Lee SH. Ceria Nanoparticles Synthesized With Aminocaproic Acid for the Treatment of Subarachnoid Hemorrhage. Stroke 2019; 49:3030-3038. [PMID: 30571409 DOI: 10.1161/strokeaha.118.022631] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background and Purpose- Despite early aneurysm repair and aggressive management for complications, subarachnoid hemorrhage (SAH) results in at least 25% mortality rate and 50% persistent neurological deficit. We investigated whether ceria nanoparticles which have potent antioxidative activities can protect against subarachnoid hemorrhage via attenuating fatal brain injuries. Methods- Uniform, 3 nm, water-dispersed ceria nanoparticles were prepared from short sol-gel reaction of cerium (III) ions with aminocaproic acid in aqueous phase. SAH was induced by endovascular perforation of middle cerebral artery of rats. A single dose of ceria nanoparticles (0.5 mg Ce/kg) or saline control was randomly administered intravenously at an hour post-SAH. Neuronal death, macrophage infiltration, SAH grade, and brain edema were evaluated at 72 hours. Mortality and neurological function were assessed for 14 days. Results- The obtained ceria nanoparticles with high Ce3+ to Ce4+ ratio demonstrated potent antioxidative, cytoprotective, and anti-inflammatory activities in vitro. In rodent SAH models, the severity of hemorrhage was comparable between the ceria nanoparticles- and saline-treated groups. However, ceria nanoparticles significantly reduced neuronal death, macrophage infiltration, and brain edema after SAH. Ceria nanoparticles successfully improved survival rates (88.2% in the ceria nanoparticles group versus 21.1% in the control group; P<0.001) and neurological outcomes (modified Garcia score: 12.1±0.5 in the ceria nanoparticles group versus 4.4±0.5 in the control group; P<0.001) of the animals with SAH. Conclusions- Ceria nanoparticles, totally synthesized in aqueous phase using aminocaproic acid, demonstrated promising results against SAH via potent antioxidative, neuroprotective and anti-inflammatory activities. Given the obvious limitations of current therapies for SAH, ceria nanoparticles can be a potential therapeutic agent which might result in a paradigm shift in SAH treatment.
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Affiliation(s)
- Han-Gil Jeong
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Bong Geun Cha
- School of Chemical Engineering (B.G.C., J.K.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Dong-Wan Kang
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Do Yeon Kim
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Seul Ki Ki
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Song I Kim
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Ju Hee Han
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Wookjin Yang
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Chi Kyung Kim
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea.,Department of Neurology, Korea University Guro Hospital and Korea University College of Medicine, Seoul (C.K.K.)
| | - Jaeyun Kim
- School of Chemical Engineering (B.G.C., J.K.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea.,Department of Health Sciences and Technology, Samsung Advanced Institute for Health Science & Technology (SAIHST) (J.K.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea.,Biomedical Institute for Convergence (BICS) (J.K.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea
| | - Seung-Hoon Lee
- From the Laboratory of Innovative Nanotechnology, Biomedical Research Institute and Department of Neurology, Seoul National University Hospital, Republic of Korea (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.).,Korean Cerebrovascular Research Institute, Seoul (H.-G.J., D.-W.K., D.Y.K., S.K.K., S.I.K., J.h.H., W.Y., C.K.K., S.-H.L.), Sungkyunkwan University (SKKU), Suwon, Republic of Korea.,Center for Nanoparticle Research, Institute for Basic Science (IBS), Seoul, Republic of Korea (S.-H.L.)
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Yamaki VN, Cavalcanti DD, Figueiredo EG. Delayed Ischemic Neurologic Deficit after Aneurysmal Subarachnoid Hemorrhage. Asian J Neurosurg 2019; 14:641-647. [PMID: 31497080 PMCID: PMC6703066 DOI: 10.4103/ajns.ajns_15_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Delayed ischemic neurologic deficit (DIND) is the main preventable cause of poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Of 50% of survivors from a SAH, approximately 30% of patients will present clinical vasospasm (VS). The cornerstone of the DIND management comprises prevention and early identification. Several diagnostic methods have been proposed differing in efficacy, invasiveness, and costs. Serial neurological examination is the most reliable method to detect a new neurological deficit. On the other hand, comatose patients require advanced monitoring methods which identify changes in the microcirculatory environment, brain autoregulation, and spreading depolarization. Multimodality monitoring with continuous electroencephalography, microdialysis, and intracranial pressure monitoring represents altogether the current state-of-art technology for the intensive care of SAH patients. Moreover, advances in genetic biomarkers to predict clinical VS have shown consistent accuracy which may in the near future allow the early prediction of DIND through a simple blood test. Several clinical trials have tested drugs with theoretical effects on DIND prevention or treatment. Nevertheless, nimodipine remains the Holy Grail in the prevention of clinical VS. Among rescue therapies, the endovascular treatment through intra-arterial vasodilator (verapamil or nicardipine) infusion is the most employed method for DIND reversal; however, there is no good quality evidence comparing results of intra-arterial infusion of vasodilators versus balloon angioplasty. Although we have addressed the most refined technology in the management of SAH and DIND, the clinical experience and strict follow-up in neurointensive care will be determinant for favorable long-term outcomes.
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Affiliation(s)
- Vitor Nagai Yamaki
- Department of Neurosurgery, Universidade De Sao Paulo, São Paulo, SP, Brazil
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8
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Poblete RA, Cen SY, Zheng L, Emanuel BA. Serum Lactic Acid Following Aneurysmal Subarachnoid Hemorrhage Is a Marker of Disease Severity but Is Not Associated With Hospital Outcomes. Front Neurol 2018; 9:593. [PMID: 30083130 PMCID: PMC6064931 DOI: 10.3389/fneur.2018.00593] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
Background: Following aneurysmal subarachnoid hemorrhage, peripherally-drawn lactic acid has been associated with poor outcomes; however, its clinical significance is unknown. We investigated admission factors and patient outcomes associated with serum lactic acid in this population. Methods: This was a retrospective observational study of 105 consecutive patients with serum lactate collected within 24 h of admission. Primary objectives were to determine the incidence of admission lactic acidemia, and factors positively and negatively associated with lactate levels. We also sought to determine if admission lactic acidemia was associated with patient outcomes, including vasospasm, delayed cerebral ischemia, mortality, and discharge disposition. Results: Admission serum lactic acid was elevated in 56 patients (53% of the cohort). Levels were positively associated with Hunt & Hess and modified Fisher grade, glucose, troponin I and white blood cell counts, and negatively associated with GCS and ventilator-free days. Admission lactate was not associated with the development of vasospasm or delayed cerebral ischemia. Patients with elevated lactic acid more often died during hospitalization, and less often were discharged home. After adjusting for other predictors of poor outcome, the adjusted odds of inpatient mortality (OR 0.97, 95% CI 0.79–1.20; p = 0.80) and discharge to home (OR 1.00, 95% CI 0.80–1.26; p = 0.97) was not associated with admission lactic acid. Conclusions: Early serum lactic acid elevation is common following aneurysmal subarachnoid hemorrhage and is associated with the clinical and radiographic grade of hemorrhage. Levels did not independently predict short-term outcomes when adjusted for established predictors of poor outcome. Further study is needed to determine the clinical significance of peripherally-drawn lactic acid in aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Steven Yong Cen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ling Zheng
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Benjamin A Emanuel
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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9
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Rostami E, Engquist H, Howells T, Johnson U, Ronne-Engström E, Nilsson P, Hillered L, Lewén A, Enblad P. Early low cerebral blood flow and high cerebral lactate: prediction of delayed cerebral ischemia in subarachnoid hemorrhage. J Neurosurg 2018; 128:1762-1770. [DOI: 10.3171/2016.11.jns161140] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVEDelayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) is one of the major contributors to poor outcome. It is crucial to be able to detect early signs of DCI to prevent its occurrence. The objective of this study was to determine if low cerebral blood flow (CBF) measurements and pathological microdialysis parameters measured at the bedside can be observed early in patients with SAH who later developed DCI.METHODSThe authors included 30 patients with severe SAH. The CBF measurements were performed at Day 0–3 after disease onset, using bedside xenon-CT. Interstitial glucose, lactate, pyruvate, glycerol, and glutamate were measured using microdialysis.RESULTSNine of 30 patients developed DCI. Patients with DCI showed significantly lower global and regional CBF, and lactate was significantly increased in these patients. A high lactate/pyruvate ratio was also detected in patients with DCI.CONCLUSIONSEarly low CBF measurements and a high lactate and lactate/pyruvate ratio may be early warning signs of the risk of developing DCI. The clinical value of these findings needs to be confirmed in larger studies.
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Affiliation(s)
- Elham Rostami
- 1Section of Neurosurgery, Department of Neuroscience,
| | - Henrik Engquist
- 1Section of Neurosurgery, Department of Neuroscience,
- 2Anesthesiology and Intensive Care, Department of Surgical Sciences, and
| | | | - Ulf Johnson
- 1Section of Neurosurgery, Department of Neuroscience,
- 3Department of Surgical Sciences and Radiology, Uppsala University, Uppsala, Sweden
| | | | - Pelle Nilsson
- 1Section of Neurosurgery, Department of Neuroscience,
| | - Lars Hillered
- 1Section of Neurosurgery, Department of Neuroscience,
| | - Anders Lewén
- 1Section of Neurosurgery, Department of Neuroscience,
| | - Per Enblad
- 1Section of Neurosurgery, Department of Neuroscience,
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Helbok R, Kofler M, Schiefecker AJ, Gaasch M, Rass V, Pfausler B, Beer R, Schmutzhard E. Clinical Use of Cerebral Microdialysis in Patients with Aneurysmal Subarachnoid Hemorrhage-State of the Art. Front Neurol 2017; 8:565. [PMID: 29163332 PMCID: PMC5676489 DOI: 10.3389/fneur.2017.00565] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/09/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To review the published literature on the clinical application of cerebral microdialysis (CMD) in aneurysmal subarachnoid hemorrhage (SAH) patients and to summarize the evidence relating cerebral metabolism to pathophysiology, secondary brain injury, and outcome. Methods Study selection: Two reviewers identified all manuscripts reporting on the clinical use of CMD in aneurysmal SAH patients from MEDLINE. All identified studies were grouped according to their focus on brain metabolic changes during the early and subacute phase after SAH, their association with mechanisms of secondary brain injury and outcome. Results The review demonstrated: (1) limited literature is available in the very early phase before the aneurysm is secured. (2) Brain metabolic changes related to early and delayed secondary injury mechanisms may be used in addition to other neuromonitoring parameters in the critical care management of SAH patients. (3) CMD markers of ischemia may detect delayed cerebral ischemia early (up to 16 h before onset), underlining the importance of trend analysis. (4) Various CMD-derived parameters may be associated with patient outcome at 3–12 months, including CMD-lactate-to-pyruvate-ratio, CMD-glucose, and CMD-glutamate. Conclusion The clinical use of CMD is an emerging area in the literature of aneurysmal SAH patients. Larger prospective multi-center studies on interventions based on CMD findings are needed.
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Affiliation(s)
- Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois Josef Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Hejčl A, Cihlář F, Smolka V, Vachata P, Bartoš R, Procházka J, Cihlář J, Sameš M. Chemical angioplasty with spasmolytics for vasospasm after subarachnoid hemorrhage. Acta Neurochir (Wien) 2017; 159:713-720. [PMID: 28224318 DOI: 10.1007/s00701-017-3104-5] [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: 10/19/2016] [Accepted: 01/26/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clinically symptomatic vasospasm leading to delayed ischemic neurological deficits occurs in up to 30% of patients with subarachnoid hemorrhage (SAH). Vasospasm can result in a serious decline in clinical conditions of patients with SAH, yet the algorithm for vasospasm treatment and prevention remains unclear. Intra-arterial administration of vasodilators is one of the modalities used for vasospasm therapy. METHODS Over the last 7 years, we have treated 27 female and 7 male patients with vasospasm using intra-arterial administration of either nimodipine or milrinone; all had suffered aneurysm rupture. Of these patients, 28 were treated surgically (clip), and 6 patients had their aneurysm coiled. Spasmolytics were applied from day 2 to day 18 after rupture. RESULTS Of the 53 procedures, angiographic improvement was documented in 92% of cases with a mean flow velocity decrease of 65 cm/s. Brain metabolism changes were monitored after the procedure. The highest level of immediate clinical improvement was observed in conscious patients with a focal neurological deficit (aphasia, hemiparesis). Overall clinical outcomes (Glasgow outcome scale, GOS) were as follows: GOS 5 (12 patients), GOS 4 (5 patients), GOS 3 (5 patients), GOS 2 (6 patients), and GOS 1 (6 patients). CONCLUSIONS Intra-arterial administration of spasmolytics is a safe and potent method of vasospasm treatment. It is most effective when applied to conscious patients with a focal deficit. For unconscious patients, its therapeutic benefits are inconclusive. Patients in severe clinical states would further require use of other diagnostic tools such as multimodal brain monitoring to complement vasospasm therapy.
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Abstract
Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
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Glial cell response after aneurysmal subarachnoid hemorrhage — Functional consequences and clinical implications. Biochim Biophys Acta Mol Basis Dis 2016; 1862:492-505. [DOI: 10.1016/j.bbadis.2015.10.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/12/2015] [Accepted: 10/15/2015] [Indexed: 12/17/2022]
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Young B, Kalanuria A, Kumar M, Burke K, Balu R, Amendolia O, McNulty K, Marion B, Beckmann B, Ciocco L, Miller K, Schuele D, Maloney-Wilensky E, Frangos S, Wright D. Cerebral Microdialysis. Crit Care Nurs Clin North Am 2016; 28:109-24. [DOI: 10.1016/j.cnc.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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15
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International multidisciplinary consensus conference on multimodality monitoring: cerebral metabolism. Neurocrit Care 2015; 21 Suppl 2:S148-58. [PMID: 25208673 DOI: 10.1007/s12028-014-0035-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Microdialysis is a powerful technique, which enables the chemistry of the extracellular space to be measured directly. Applying this technique to patients in neurointensive care has increased our understanding of the pathophysiology of traumatic brain injury and spontaneous hemorrhage. In parallel, it is important to determine the place of microdialysis in assisting in the management of patients on an individual intention to treat basis. This is made possible by the availability of analyzers which can measure the concentration of glucose, pyruvate, lactate, and glutamate at the bedside. Samples can then be stored for later analysis of other substrate and metabolites e.g., other amino acids and cytokines. The objective of this paper is to review the fundamental literature pertinent to the clinical application of microdialysis in neurointensive care and to give recommendations on how the technique can be applied to assist in patient management and contribute to outcome. A literature search detected 1,933 publications of which 55 were used for data abstraction and analysis. The role of microdialysis was evaluated in three conditions (traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage) and recommendations focused on three fundamental areas (relationship to outcome, application of microdialysis to guide therapy, and the ability of microdialysis to predict secondary deterioration).
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Sehba FA, Hou J, Pluta RM, Zhang JH. The importance of early brain injury after subarachnoid hemorrhage. Prog Neurobiol 2012; 97:14-37. [PMID: 22414893 PMCID: PMC3327829 DOI: 10.1016/j.pneurobio.2012.02.003] [Citation(s) in RCA: 442] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 02/01/2012] [Accepted: 02/16/2012] [Indexed: 12/11/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency that accounts for 5% of all stroke cases. Individuals affected are typically in the prime of their lives (mean age 50 years). Approximately 12% of patients die before receiving medical attention, 33% within 48 h and 50% within 30 days of aSAH. Of the survivors 50% suffer from permanent disability with an estimated lifetime cost more than double that of an ischemic stroke. Traditionally, spasm that develops in large cerebral arteries 3-7 days after aneurysm rupture is considered the most important determinant of brain injury and outcome after aSAH. However, recent studies show that prevention of delayed vasospasm does not improve outcome in aSAH patients. This finding has finally brought in focus the influence of early brain injury on outcome of aSAH. A substantial amount of evidence indicates that brain injury begins at the aneurysm rupture, evolves with time and plays an important role in patients' outcome. In this manuscript we review early brain injury after aSAH. Due to the early nature, most of the information on this injury comes from animals and few only from autopsy of patients who died within days after aSAH. Consequently, we began with a review of animal models of early brain injury, next we review the mechanisms of brain injury according to the sequence of their temporal appearance and finally we discuss the failure of clinical translation of therapies successful in animal models of aSAH.
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Affiliation(s)
- Fatima A Sehba
- The Departments of Neurosurgery and Neuroscience, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Spiotta AM, Provencio JJ, Rasmussen PA, Manno E. Brain Monitoring After Subarachnoid Hemorrhage: Lessons Learned. Neurosurgery 2011; 69:755-66; discussion 766. [DOI: 10.1227/neu.0b013e31821d2b61] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Tholance Y, Barcelos G, Quadrio I, Renaud B, Dailler F, Perret-Liaudet A. Analytical validation of microdialysis analyzer for monitoring glucose, lactate and pyruvate in cerebral microdialysates. Clin Chim Acta 2010; 412:647-54. [PMID: 21185817 DOI: 10.1016/j.cca.2010.12.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 12/17/2010] [Accepted: 12/18/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral microdialysis is a valuable tool for neurochemical monitoring of acute brain injury. We performed an independent analytical validation of glucose, lactate and pyruvate methods on the new ISCUS(flex) new analyzer developed by CMA Microdialysis. METHODS Evaluation of analytical parameters included limit of detection, limit of quantification, linearity, intra- and inter-assay imprecision expressed as the coefficient of variation (CV), recovery, inter-sample and inter-reagent contamination, drug and bilirubin interferences, sample stability, method comparison. RESULTS Linearity ranges were 0.1-25 mmol/L, 0.2-12 mmol/L and 19-1500 μmol/L for glucose, lactate and pyruvate respectively. For critical threshold, intra- and inter-assay CVs were 3.1/4.5% for glucose (1 mmol/L), 3.5/4% for lactate (4 mmol/L) and 3.3/4.3% for pyruvate (100 μmol/L). Inter-assay CVs for lactate/pyruvate (LPR) and lactate/glucose (LGR) ratios were 5.9% and 6.0% respectively. For glucose, lactate, pyruvate, LPR and LGR, the reference change values (RCV) were 20%, 26%, 20%, 27% and 28% respectively. Practically, variations below 27% between two successive LPR values could not be interpreted as significant. CONCLUSION These data prove that ISCUS(flex) has the qualities required for clinical application in neuro-intensive care. Correct clinical interpretation of data need the implementation of a strict quality control program and strong cooperation between clinicians and biologists.
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Affiliation(s)
- Yannick Tholance
- HCL, Centre de Biologie et de Pathologie Est, Laboratoire de Neurobiologie, Lyon, France.
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Zetterling M, Hallberg L, Hillered L, Karlsson T, Enblad P, Ronne Engström E. Brain energy metabolism in patients with spontaneous subarachnoid hemorrhage and global cerebral edema. Neurosurgery 2010; 66:1102-10. [PMID: 20495425 DOI: 10.1227/01.neu.0000370893.04586.73] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies of spontaneous subarachnoid hemorrhage (SAH) have shown that global cerebral edema on the first computed tomography scan is associated with a more severe initial injury and is an independent predictor of poor outcome. Effects of secondary ischemic events also influence outcome after SAH. OBJECTIVE This study demonstrates that early global edema is related to markers of an increased cerebral energy metabolism as measured with intracerebral microdialysis, which could increase vulnerability to adverse events. METHODS Fifty-two patients with microdialysis monitoring after spontaneous SAH were stratified according to the occurrence of global cerebral edema on the first computed tomography scan taken a median of 2 hours after the initial bleed. Microdialysis levels of glucose, lactate, and pyruvate were compared between the global edema (n = 31) and no global edema (n = 21) groups. Clinical outcome was assessed with the Glasgow Outcome Scale score at >/= 6 months. RESULTS Patients with global edema showed significantly elevated lactate and pyruvate levels 70 to 79 hours after SAH and marginally significantly higher levels of lactate 60 to 69 hours and 80 to 89 hours after SAH. There was a trend toward worse outcome in the edema group. CONCLUSION Patients with global cerebral edema have higher interstitial levels of lactate and pyruvate. The edema group may have developed a cerebral hypermetabolism to meet the increased energy demand in the recovery phase after SAH. This stress would make the brain more vulnerable to secondary insults, increasing the likelihood of energy failure.
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Affiliation(s)
- Maria Zetterling
- Department of Neuroscience, Neurosurgery, Uppsala University Hospital, Uppsala, Sweden.
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