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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Safety and Tolerability of Concentrated Intraventricular Nicardipine for Poor-Grade Aneurysmal Subarachnoid Hemorrhage–Related Vasospasm. J Pers Med 2023; 13:jpm13030428. [PMID: 36983610 PMCID: PMC10058919 DOI: 10.3390/jpm13030428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Objective: To report the preliminary safety, tolerability, and cerebral spinal fluid (CSF) sampling utility of serial injections of concentrated intraventricular nicardipine (IVN) in the treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: We report the clinical, radiographic, and laboratory safety and tolerability data of a retrospective case series from a single academic medical center. All patients with aSAH developed vasospasm despite enteral nimodipine and received serial injections of concentrated IVN (2.5 mg/mL). CSF injection safety, tolerability, and utility are defined and reported. Results: A total of 59 doses of concentrated IVN were administered to three patients with poor-grade SAH. In Case 1, a 33-year-old man with modified Fisher scale (mFS) grade 4 and Hunt-Hess scale (HH) score 4 received 26 doses; in Case 2, a 36-year-old woman with mFS grade 4 and HH score 5 received 13 doses; and in Case 3, a 70-year-old woman with mFS grade 3 and HH score 4 received 20 doses. No major safety or tolerability events occurred. Two patients were discharged to a rehabilitation facility, and one died after discharge from the hospital. Conclusions: A concentrated 4 mg IVN dose (2.5 mg/mL) in a 1.6 mL injection appears relatively safe and tolerable and potentially offers a second-line strategy for treating refractory vasospasm in poor-grade SAH without compromising intracranial pressure or cerebral perfusion pressure.
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Grandhi R, Menacho ST, Ravindra VM, Condie C, Taussky P, Hawryluk GWJ. Correlation of intraventricular nicardipine for refractory vasospasm in aneurysmal subarachnoid hemorrhage with improved neurophysiology on intracranial multimodality monitoring: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 3:CASE22113. [PMID: 35734609 PMCID: PMC9204924 DOI: 10.3171/case22113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cerebral vasospasm after aneurysmal subarachnoid hemorrhage can lead to considerable mortality and morbidity affecting the intracranial vessels, leading to delayed cerebral ischemia and stroke. Therapeutic options for patients with treatment-refractory vasospasm are limited, particularly in the setting of significant cardiopulmonary disease. Administration of nicardipine, a calcium channel blocker, into the intrathecal space may represent a potential treatment option for this population. OBSERVATIONS A 56-year-old woman had treatment-refractory vasospasm, severe acute respiratory distress syndrome, and Takotsubo cardiomyopathy. As an adjunct to vasopressor administration and endovascular intraarterial calcium channel blocker administration, the patient received intraventricular nicardipine. The patient demonstrated improved neurophysiology on invasive multimodality neuromonitoring, with increased cerebral blood flow and oxygenation as a result of intraventricular nicardipine administration. LESSONS Intraventricular nicardipine can be used as rescue therapy for patients with treatment-refractory cerebral vasospasm. This case demonstrates that intrathecal nicardipine may prevent delayed ischemic neurological deficits and improve outcomes.
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Affiliation(s)
| | - Sarah T. Menacho
- Departments of Neurosurgery and
- Neurocritical Care, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | | | - Chad Condie
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah; and
| | | | - Gregory W. J. Hawryluk
- Departments of Neurosurgery and
- Neurocritical Care, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
- Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Grossen AA, Ernst GL, Bauer AM. Update on intrathecal management of cerebral vasospasm: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E10. [PMID: 35231885 DOI: 10.3171/2021.12.focus21629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) accounts for a relatively small portion of strokes but has the potential to cause permanent neurological deficits. Vasospasm with delayed ischemic neurological deficit is thought to be responsible for much of the morbidity associated with aSAH. This has illuminated some treatment options that have the potential to target specific components of the vasospasm cascade. Intrathecal management via lumbar drain (LD) or external ventricular drain (EVD) offers unique advantages in this patient population. The aim of this review was to provide an update on intrathecal vasospasm treatments, emphasizing the need for larger-scale trials and updated protocols using data-driven evidence. METHODS A search of PubMed, Ovid MEDLINE, and Cochrane databases included the search terms (subarachnoid hemorrhage) AND (vasospasm OR delayed cerebral ischemia) AND (intrathecal OR intraventricular OR lumbar drain OR lumbar catheter) for 2010 to the present. Next, a meta-analysis was performed of select therapeutic regimens. The primary endpoints of analysis were vasospasm, delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome. RESULTS Twenty-nine studies were included in the analysis. There were 10 studies in which CSF drainage was the primary experimental group. Calcium channel antagonists were the focus of 7 studies. Fibrinolytics and other vasodilators were each examined in 6 studies. The meta-analysis included studies examining CSF drainage via LD (n = 4), tissue plasminogen activator in addition to EVD (n = 3), intraventricular nimodipine (n = 2), and cisternal magnesium (n = 2). Results showed that intraventricular nimodipine decreased vasospasm (OR 0.59, 95% CI 0.37-0.94; p = 0.03). Therapies that significantly reduced DCI were CSF drainage via LD (OR 0.47, 95% CI 0.25-0.88; p = 0.02) and cisternal magnesium (OR 0.27, 95% CI 0.07-1.02; p = 0.05). CSF drainage via LD was also found to significantly reduce the incidence of cerebral infarction (OR 0.35, 95% 0.24-0.51; p < 0.001). Lastly, functional outcome was significantly better in patients who received CSF drainage via LD (OR 2.42, 95% CI 1.39-4.21; p = 0.002). CONCLUSIONS The authors' results showed that intrathecal therapy is a safe and feasible option following aSAH. It has been shown to attenuate cerebral vasospasm, reduce the incidence of DCI, and improve clinical outcome. The authors support the use of intrathecal management in the prevention and rescue management of cerebral vasospasm. More randomized controlled trials are warranted to determine the best combination of pharmaceutical agents and administration route in order to formulate a standardized treatment approach.
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Parish JM, Ziechmann R, Guley NM, Joy J, Karimian B, Dyer EH, Wait SD, Stetler WR, Bernard JD. Safety and efficacy of intrathecal nicardipine for aneurysmal subarachnoid hemorrhage induced vasospasm. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2021. [DOI: 10.1016/j.inat.2020.101045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Maruhashi T, Higashi Y. An overview of pharmacotherapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage. Expert Opin Pharmacother 2021; 22:1601-1614. [PMID: 33823726 DOI: 10.1080/14656566.2021.1912013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Survival from aneurysmal subarachnoid hemorrhage has increased in the past few decades. However, functional outcome after subarachnoid hemorrhage is still suboptimal. Delayed cerebral ischemia (DCI) is one of the major causes of morbidity.Areas covered: Mechanisms underlying vasospasm and DCI after aneurysmal subarachnoid hemorrhage and pharmacological treatment are summarized in this review.Expert opinion: Oral nimodine, an L-type dihydropyridine calcium channel blocker, is the only FDA-approved drug for the prevention and treatment of neurological deficits after aneurysmal subarachnoid hemorrhage. Fasudil, a potent Rho-kinase inhibitor, has also been shown to improve the clinical outcome and has been approved in some countries for use in patients with aneurysmal subarachnoid hemorrhage. Although other drugs, including nicardipine, cilostazol, statins, clazosentan, magnesium and heparin, have been expected to have beneficial effects on DCI, there has been no convincing evidence supporting the routine use of those drugs in patients with aneurysmal subarachnoid hemorrhage in clinical practice. Further elucidation of the mechanisms underlying DCI and the development of effective therapeutic strategies for DCI, including combination therapy, are necessary to further improve the functional outcome and mortality after subarachnoid hemorrhage.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
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Macdonald RL, Hänggi D, Ko NU, Darsaut TE, Carlson AP, Wong GK, Etminan N, Mayer SA, Aldrich EF, Diringer MN, Ng D, Strange P, Bleck T, Grubb R, Suarez JI. NEWTON-2 Cisternal (Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage): A Phase 2, Multicenter, Randomized, Open-Label Safety Study of Intracisternal EG-1962 in Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 88:E13-E26. [PMID: 32985652 DOI: 10.1093/neuros/nyaa430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A sustained release microparticle formulation of nimodipine (EG-1962) was developed for treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To assess safety, tolerability, and pharmacokinetics of intracisternal EG-1962 in an open-label, randomized, phase 2 study of up to 12 subjects. METHODS Subjects were World Federation of Neurological Surgeons grades 1 to 2, modified Fisher grades 2 to 4, and underwent aneurysm clipping within 48 h of aSAH. EG-1962, containing 600 mg nimodipine, was administered into the basal cisterns. Outcome on the extended Glasgow Outcome Scale (eGOS), pharmacokinetics, delayed cerebral ischemia and infarction, rescue therapy, and safety were evaluated. RESULTS The study was halted when a phase 3 study of intraventricular EG-1962 stopped because that study was unlikely to meet its primary endpoint. Six subjects were randomized (5 EG-1962 and 1 oral nimodipine). After 90-d follow-up, favorable outcome on the eGOS occurred in 1 of 5 EG-1962 and in the single oral nimodipine patient. Four EG-1962 and the oral nimodipine subject had angiographic vasospasm. One EG-1962 subject had delayed cerebral ischemia, and all subjects with angiographic vasospasm received rescue therapy except 1 EG-1962 patient. One subject treated with EG-1962 developed right internal carotid and middle cerebral artery narrowing 5 mo after placement of EG-1962, leading to occlusion and cerebral infarction. Pharmacokinetics showed similar plasma concentrations of nimodipine in both groups. CONCLUSION Angiographic vasospasm and unfavorable clinical outcome still occurred after placement of EG-1962. Internal carotid artery narrowing and occlusion after placement of EG-1962 in the basal cisterns has not been reported.
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Affiliation(s)
- R Loch Macdonald
- Department of Neurological Surgery, University of California, San Francisco, Fresno, California.,Edge Therapeutics, Berkeley Heights, New Jersey
| | - Daniel Hänggi
- Department of Neurosurgery, Düsseldorf University Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nerissa U Ko
- Department of Neurology, University of California, San Francisco, California
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - George K Wong
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Nima Etminan
- University Medical Center Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Stephan A Mayer
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan
| | - E Francois Aldrich
- Neurological Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Michael N Diringer
- Neurological Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | | | - Poul Strange
- Integrated Medical Development LLC, Princeton, New Jersey
| | - Thomas Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Robert Grubb
- Neurological Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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8
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Macdonald RL, Hänggi D, Strange P, Steiger HJ, Mocco J, Miller M, Mayer SA, Hoh BL, Faleck HJ, Etminan N, Diringer MN, Carlson AP, Aldrich F. Nimodipine pharmacokinetics after intraventricular injection of sustained-release nimodipine for subarachnoid hemorrhage. J Neurosurg 2021; 134:95-101. [PMID: 31812149 DOI: 10.3171/2019.9.jns191366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to measure the concentration of nimodipine in CSF and plasma after intraventricular injection of a sustained-release formulation of nimodipine (EG-1962) in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS Patients with SAH repaired by clip placement or coil embolization were randomized to EG-1962 or oral nimodipine. Patients were classified as grade 2-4 on the World Federation of Neurosurgical Societies grading scale for SAH and had an external ventricular drain inserted as part of their standard of care. Cohorts of 12 patients received 100-1200 mg of EG-1962 as a single intraventricular injection (9 per cohort) or they remained on oral nimodipine (3 per cohort). Plasma and CSF were collected from each patient for measurement of nimodipine concentrations and calculation of maximum plasma and CSF concentration, area under the concentration-time curve from day 0 to 14, and steady-state concentration. RESULTS Fifty-four patients in North America were randomized to EG-1962 and 18 to oral nimodipine. Plasma concentrations increased with escalating doses of EG-1962, remained stable for 14 to 21 days, and were detectable at day 30. Plasma concentrations in the oral nimodipine group were more variable than for EG-1962 and were approximately equal to those occurring at the EG-1962 800-mg dose. CSF concentrations of nimodipine in the EG-1962 groups were 2-3 orders of magnitude higher than in the oral nimodipine group, in which nimodipine was only detected at low concentrations in 10% (21/213) of samples. In the EG-1962 groups, CSF nimodipine concentrations were 1000 times higher than plasma concentrations. CONCLUSIONS Plasma concentrations of nimodipine similar to those achieved with oral nimodipine and lasting for 21 days could be achieved after a single intraventricular injection of EG-1962. The CSF concentrations from EG-1962, however, were at least 2 orders of magnitude higher than those with oral nimodipine. These results supported a phase 3 study that demonstrated a favorable safety profile for EG-1962 but yielded inconclusive efficacy results due to notable differences in clinical outcome based on baseline disease severity.Clinical trial registration no.: NCT01893190 (ClinicalTrials.gov).
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Affiliation(s)
- R Loch Macdonald
- 1Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Departments of Surgery and Physiology, University of Toronto, Ontario, Canada
- 2Edge Therapeutics, Berkeley Heights, New Jersey
| | - Daniel Hänggi
- 3Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Poul Strange
- 4Integrated Medical Development, LLC, Princeton, New Jersey
| | - Hans Jakob Steiger
- 5Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - J Mocco
- 6Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York, New York
| | - Michael Miller
- 4Integrated Medical Development, LLC, Princeton, New Jersey
| | - Stephan A Mayer
- 7Department of Neurology, Henry Ford Health System, Detroit, Michigan
| | - Brian L Hoh
- 8Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Nima Etminan
- 3Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael N Diringer
- 9Neurological Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Andrew P Carlson
- 10Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico; and
| | - Francois Aldrich
- 11Neurological Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Abstract
New evidence and increased use of intracranial devices have increased the frequency of intraventricular (IVT) medication administration in the neurologic intensive care unit. Significant benefits and risks are associated with administration of medications directly into the central nervous system. This review summarizes important literature, along with key information for clinicians regarding the administration, dosing, monitoring, and adverse effects related to IVT medication usage. Multiple medications have supporting literature for their use in critically ill patients including amphotericin B, aminoglycosides, colistimethate, daptomycin, quinupristin/dalfopristin, vancomycin, alteplase, and nicardipine. Sterile preparation and delivery, along with different types of devices that support medication administration, are also reviewed. One randomized, placebo-controlled trial of alteplase demonstrated decreased mortality but no change in good functional outcome. Other reports of IVT medication use are mainly limited to case reports and retrospective case series. There is a need for increased research on the topic; however, several practical barriers decrease the likelihood of a large, placebo-controlled, prospective study for most indications. Providers should consider implementing protocols to maximize safety of IVT medication delivery to ensure optimal patient outcomes.
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10
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Hafeez S, Grandhi R. Systematic Review of Intrathecal Nicardipine for the Treatment of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 31:399-405. [PMID: 30607826 DOI: 10.1007/s12028-018-0659-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intrathecal nicardipine has been shown to have some efficacy for the treatment of symptomatic cerebral vasospasm in aneurysmal subarachnoid hemorrhage (aSAH). We performed a PRISMA-based systematic review of intrathecal nicardipine for the treatment of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. A total of 825 articles were reviewed. After duplicates were removed and the search criteria was applied, 9 articles remained that were eligible for inclusion and analysis. 377 patients received a total of 6,596 injections of intrathecal nicardipine for aSAH-related cerebral vasospasm. The cumulative ventriculostomy-associated infection risk was 6%. Intrathecal nicardipine injections for aSAH-related cerebral vasospasm appears efficacious and safe. Administration of 4 mg of nicardipine every 12 hours was the most commonly reported dosing regimen. Intrathecal nicardipine decreases mean flow velocities on transcranial Doppler and reduces angiographic and clinical vasospasm. The infection risk appears to be in-line with studies in which rates of EVD-related infections have been reported.
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Affiliation(s)
- Shaheryar Hafeez
- Neurocritical Care, Department of Neurosurgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
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11
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Pharmacologic Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Crit Care Nurs Q 2020; 43:138-156. [DOI: 10.1097/cnq.0000000000000299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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12
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Biel S, Durrant J. Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU. Curr Treat Options Neurol 2020; 22:12. [PMID: 38624320 PMCID: PMC7223748 DOI: 10.1007/s11940-020-0618-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of review This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing. Recent findings In response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation. Summary Although death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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Neuropharmacology in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Intracranial Administration of Nicardipine After Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature. World Neurosurg 2019; 125:511-518.e1. [DOI: 10.1016/j.wneu.2019.01.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 01/08/2023]
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16
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Roelz R, Scheiwe C, Coenen VA, Reinacher PC. A novel rescue therapy for cerebral vasospasm: Cisternal Nimodipine application via stereotactic catheter ventriculocisternostomy. J Clin Neurosci 2019; 63:244-248. [PMID: 30737093 DOI: 10.1016/j.jocn.2019.01.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 01/28/2019] [Indexed: 01/03/2023]
Abstract
Delayed Cerebral Infarction (DCI) due to Cerebral Vasospasm (CVS) is an important contributor to poor outcome after aneurysmal subarachnoid haemorrhage (aSAH). Despite established risk factors CVS and DCI are unpredictable at the individual patient level. Efficient treatments are lacking. We report a novel rescue therapy for DCI: Access to the basal cisterns by stereotactic catheter ventriculocisternostomy (STX-VCS) and direct cisternal application of the spasmolytic agent Nimodipine. On the basis of individual treatment decisions three aSAH patients who developed CVS underwent STX-VCS. Continuous lavage with Nimodipine was performed. CVS was assessed by daily transcranial doppler ultrasonography. Neurological outcome at 3 months was assessed by modified Rankin scale. STX-VCS was performed without complications in all patients. CVS rapidly resolved upon cisternal application of Nimodipine. CVS recurred in two patients upon interruption of Nimodpine application and resolved upon restart of Nimodipine. DCI did not occur in all three cases. STX-VCS and cisternal Nimodipine application is a novel rescue therapy for CVS treatment and DCI-prevention in patients with aSAH.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany.
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
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Pilipenko YV, Varyukhina MD, Eliava SS, Belousova OB, Savin IA, Okishev DN, Mikeladze KG, Shekhtman OD, Kheyreddin AS, Konovalov AN, Gorozhanin VA, Spiru AM, Kurdyumova NV, Tabasaransky TF, Baranich AI, Vinogradov EV. [Intracisternal administration of verapamil for the prevention and treatment of vasospasm in patients after microsurgical treatment of cerebral aneurysms in the acute period of hemorrhage]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2019; 83:18-33. [PMID: 31577267 DOI: 10.17116/neiro20198304118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
UNLABELLED The first results of intracisternal administration of verapamil for the prevention and treatment of cerebral vasospasm (CVS) in patients in the acute period of subarachnoid hemorrhage (SAH) after microsurgical clipping of cerebral aneurysms are presented. OBJECTIVE Safety assessment of the method of prolonged intracisternal infusion (PII) of verapamil. MATERIAL AND METHODS Over the period from May 2017 to December 2018, 42 patients were included in the study, who underwent clipping of aneurysm of the anterior segments of the Willis circle. Most patients (78.6%) were operated during the first 6 days after SAH. For each patient, a thin silicone catheter was installed, through which verapamil was infused. A prerequisite was the installation of external ventricular drainage and opening of the lamina terminalis. The daily dosage of verapamil varied from 25 to 50 mg of the drug diluted in 200-400 ml of isotonic sodium chloride solution. The indication for the use of the PII method was the presence of one of the following factors: a score on the Hunt-Hess scale from III to V, 3 or 4 points on the Fisher scale, confirmed angiographically by the CVS before the operation. RESULTS The PII procedure was performed from 2 to 5 days. The average dose of verapamil was 143.5±41.2 mg additionally, in the presence of an angiographically confirmed CVS accompanied by clinical manifestations, 14 (33.4%) patients received intra-arterial injection of verapamil in several stages, with individual selection of the drug dose. The formation of new cerebral ischemic foci of vasospastic genesis was observed in only 1 (2.4%) patient. No infectious intracranial complications were noted. The average follow-up period was 297.6±156.1 days. Long-term treatment outcomes, assessed by a modified Rankin scale from 0 to 2 points, were observed in 83.3% of patients. There were no outcomes such as vegetative status and no deaths. The frequency of liquorodynamic disorders, as well as epileptic syndrome did not exceed that among patients with SAH according to the literature. CONCLUSION The study has confirmed the safety of prolonged PII. The efficacy of the method, compared with other methods for CVS treatment requires further investigation. The first results look quite promising: the observation shows a low percentage of new foci of cerebral ischemia and the absence of deaths associated with it. In patients with severe CVS, the efficacy of the PII method is increased when combined with intra-arterial administration of verapamil.
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Affiliation(s)
| | | | | | | | - I A Savin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | | | | | - A M Spiru
- Burdenko Neurosurgical Center, Moscow, Russia
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18
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Raghavan A, Xu J, Wright JM, Wright CH, Miller B, Hu Y. Protective effect of unilateral vasospasm in the setting of HHH-associated posterior reversible encephalopathy syndrome: case report, review of the literature, and treatment considerations. Chin Neurosurg J 2018; 4:34. [PMID: 32922894 PMCID: PMC7398370 DOI: 10.1186/s41016-018-0141-8] [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: 07/30/2018] [Accepted: 10/01/2018] [Indexed: 11/10/2022] Open
Abstract
Background Hyperdynamic therapy, also called triple-H therapy, is the standard treatment and prophylaxis for aneurysmal-associated vasospasm. In patients who are able to tolerate cardiopulmonary stressors induced by this therapy, it is of benefit as a modality for prevention and treatment of delayed ischemic neurologic deficit. However, it can be a cause of significant cardiopulmonary or neurologic sequelae. In rare cases, it can be associated with posterior reversible encephalopathy syndrome (PRES), secondary to prolonged vasopressor and hypertensive therapies. Case presentation We present the case of a patient with right-sided aneurysmal-associated vasospasm who, after 10 days of triple-H therapy, experienced a seizure and was found to have left-sided PRES. Right-sided vasospasm served as a protective mechanism from triple-H therapy-associated PRES. It presented a treatment conundrum due to contradictory perfusion requirements. Hypertensive therapy was curtailed and in efforts to preserve local cerebral perfusion and vasodilation, local therapy with intrathecal nicardipine was initiated. We present our case, a review of the literature, and management considerations. Conclusions Therapies that have conventionally functioned as second line treatments for aneurysmal subarachnoid hemorrhage (intra-arterial vasodilators and intrathecal vasodilators) may be beneficial as earlier treatments in the setting of vasospasm given the systemic difficulties and complications associated with HHH therapy in patients with PRES.
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Affiliation(s)
- Alankrita Raghavan
- School of Medicine, Case Western Reserve University, 2109 Adelbert Road, Cleveland, OH 44106 USA
| | - Jordan Xu
- Department of Neurological Surgery, University of California Irvine SOM, 1001 Health Sciences Rd, Irvine, CA 92617 USA
| | - James M Wright
- School of Medicine, Case Western Reserve University, 2109 Adelbert Road, Cleveland, OH 44106 USA.,Department of Neurological Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Christina Huang Wright
- School of Medicine, Case Western Reserve University, 2109 Adelbert Road, Cleveland, OH 44106 USA.,Department of Neurological Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Benjamin Miller
- Department of Neurology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 USA
| | - Yin Hu
- School of Medicine, Case Western Reserve University, 2109 Adelbert Road, Cleveland, OH 44106 USA.,Department of Neurological Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106 USA
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Burns SK, Brewer KJ, Jenkins C, Miller S. Aneurysmal Subarachnoid Hemorrhage and Vasospasm. AACN Adv Crit Care 2018; 29:163-174. [DOI: 10.4037/aacnacc2018491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Aneurysmal subarachnoid hemorrhage is potentially fatal and is associated with poor outcomes in many patients. Advances in neurosurgical and medical management of ruptured aneurysms have improved mortality rates in patients with aneurysmal subarachnoid hemorrhage. Surgical and endovascular interventions, such as external ventricular drain placement, aneurysm clipping, and endovascular coiling, have been developed over the past few decades. Patients with aneurysmal subarachnoid hemorrhage are also at risk for cerebral vasospasm and delayed cerebral ischemia. This article describes the diagnosis and treatment of aneurysmal subarachnoid hemorrhage, vasospasm, and cerebral ischemia. Concurrent medical considerations and ideas for future neuroinflammatory vasospasm research are also discussed.
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Affiliation(s)
- Shannon K. Burns
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
| | - Kacie J. Brewer
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
| | - Courtney Jenkins
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
| | - Sally Miller
- Shannon K. Burns is Neurocritical Care Nurse Practitioner, Neurocritical Care, University of Florida Health Jacksonville, Jacksonville, FL, 32209 . Kacie J. Brewer is Neurosurgical Physician Assistant, University of Florida Health Jacksonville. Courtney Jenkins is Neurosurgical Nurse Practitioner, University of Florida Health Jacksonville. Sally Miller is Neurocritical Care Nurse Practitioner, University of Florida Health Jacksonville
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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21
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Burrell C, Avalon NE, Siegel J, Pizzi M, Dutta T, Charlesworth MC, Freeman WD. Precision medicine of aneurysmal subarachnoid hemorrhage, vasospasm and delayed cerebral ischemia. Expert Rev Neurother 2016; 16:1251-1262. [PMID: 27314601 DOI: 10.1080/14737175.2016.1203257] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Precision medicine provides individualized treatment of diseases through leveraging patient-to-patient variation. Aneurysmal subarachnoid hemorrhage carries tremendous morbidity and mortality with cerebral vasospasm and delayed cerebral ischemia proving devastating and unpredictable. Lack of treatment measures for these conditions could be improved through precision medicine. Areas covered: Discussed are the pathophysiology of CV and DCI, treatment guidelines, and evidence for precision medicine used for prediction and prevention of poor outcomes following aSAH. A PubMed search was performed using keywords cerebral vasospasm or delayed cerebral ischemia and either biomarkers, precision medicine, metabolomics, proteomics, or genomics. Over 200 peer-reviewed articles were evaluated. The studies presented cover biomarkers identified as predictive markers or therapeutic targets following aSAH. Expert commentary: The biomarkers reviewed here correlate with CV, DCI, and neurologic outcomes after aSAH. Though practical use in clinical management of aSAH is not well established, using these biomarkers as predictive tools or therapeutic targets demonstrates the potential of precision medicine.
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Affiliation(s)
| | - Nicole E Avalon
- a Department of Neurology , Mayo Clinic , Jacksonville , FL , USA
| | - Jason Siegel
- a Department of Neurology , Mayo Clinic , Jacksonville , FL , USA
| | - Michael Pizzi
- a Department of Neurology , Mayo Clinic , Jacksonville , FL , USA
| | - Tumpa Dutta
- b Endocrine Research Unit , Mayo Clinic , Rochester , MN , USA
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Hänggi D, Etminan N, Macdonald RL, Steiger HJ, Mayer SA, Aldrich F, Diringer MN, Hoh BL, Mocco J, Strange P, Faleck HJ, Miller M. NEWTON: Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage. Neurocrit Care 2016; 23:274-84. [PMID: 25678453 DOI: 10.1007/s12028-015-0112-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. EG-1962 is a sustained-release microparticle formulation of nimodipine that has shown preclinical efficacy when administered intraventricularly or intracisternally to dogs with SAH, without evidence of toxicity at doses in the anticipated therapeutic range. Thus, we propose to administer EG-1962 to humans in order to assess safety and tolerability and determine a dose to investigate efficacy in subsequent clinical studies. METHODS We describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the maximum tolerated dose (MTD) and assess the safety and tolerability of EG-1962 in patients with aSAH. The study will comprise two parts: a dose escalation period (Part 1) to determine the MTD of EG-1962 and a treatment period (Part 2) to assess the safety and tolerability of the selected dose of EG-1962. Patients with a ruptured saccular aneurysm treated by neurosurgical clipping or endovascular coiling will be considered for enrollment. Patients will be randomized to receive either EG-1962 (study drug: nimodipine microparticles) or oral nimodipine in the approved dose regimen (active control) within 60 h of aSAH. RESULTS Primary objectives are to determine the MTD and the safety and tolerability of the selected dose of intraventricular EG-1962 as compared to enteral nimodipine. The secondary objective is to determine release and distribution by measuring plasma and CSF concentrations of nimodipine. Exploratory objectives are to determine the incidence of delayed cerebral infarction on computed tomography, clinical features of delayed cerebral ischemia, angiographic vasospasm, and incidence of rescue therapy and clinical outcome. Clinical outcome will be determined at 90 days after aSAH using the extended Glasgow outcome scale, modified Rankin scale, Montreal cognitive assessment, telephone interview of cognitive status, and Barthel index. CONCLUSION Here, we describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the MTD and assess the safety and tolerability of EG-1962 in patients with aSAH.
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Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany,
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23
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Pharmacological agents in aneurysmal subarachnoid hemorrhage: successes and failures. Clin Neuropharmacol 2016; 38:104-8. [PMID: 25970278 DOI: 10.1097/wnf.0000000000000085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition with high mortality. Proper management of this complex disease requires early surgical intervention followed by medical therapy. Pharmacological agents that unequivocally improve outcomes in aSAH are scarce. METHODS The authors performed an exhaustive query of several databases including MEDLINE, the CENTRAL Register of Controlled Trials, and the Cochrane Database of Systematic Reviews for specific evidence on key medications that have been used in the treatment of aSAH. RESULTS The bulk of the data available pertained to the following medications: calcium channel blockers, magnesium, statins, antifibrinolytics, aspirin, glucocorticoids, clazosentan, and tirilazad. Except for calcium channel blockers, the authors could not find any hard evidence that any of these agents affected outcome to a tangible degree. Aspirin may have some promise in prevention of aneurysm rupture and incidence of aSAH, but more substantive data are needed to conclusively corroborate this. CONCLUSIONS Investigational efforts to attain outcome-modifying agents have had dubious results, but the inquest for discovery should not discontinue.
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Ko SB, Choi HA, Helbok R, Kurtz P, Schmidt JM, Badjatia N, Claassen J, Connolly ES, Mayer SA, Lee K. Acute effects of intraventricular nicardipine on cerebral hemodynamics: A preliminary finding. Clin Neurol Neurosurg 2016; 144:48-52. [PMID: 26971295 DOI: 10.1016/j.clineuro.2016.02.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 02/26/2016] [Accepted: 02/27/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Intraventricular nicardipine (IVTN) is a treatment option for severe vasospasm in patients with subarachnoid hemorrhage (SAH). However, its acute effects on cerebral hemodynamics have not been studied in detail. METHODS Between June 2008 and December 2010, IVTN was administered (mainly 4mg every 8h) to 11 SAH patients (54 doses) with multimodality monitoring for refractory vasospasm. Retrospective analyses on physiological parameters were made from baseline and up to 6h after IVTN injection. Statistical analysis was performed with a mixed-effects model. RESULTS Mean intracranial pressure (ICP) increased slightly, reaching its peak at 20min after IVTN injection (2.5±0.9mmHg (mean±standard error), P<0.01), and decreased gradually thereafter over the next hour. Mean cerebral perfusion pressure transiently decreased 20-30min after injection (3.7±1.8mmHg, P<0.05). Mean arterial pressure, partial pressure of brain oxygen tension (PbtO2), cerebral blood flow (CBF), autoregulation indices did not change significantly. Lactate/pyruvate ratio and glucose remained stable. One patient underwent transcranial Doppler ultrasonography monitoring while on IVTN, which showed a transient increase in mean flow velocity with concomitant decrease in Pulsatility index, suggesting vasodilation in the distal resistance vessels. CONCLUSIONS The vasodilatory effect of IVTN transiently increased ICP, but did not significantly affect PbtO2, CBF or oxidative glucose metabolism in the immediate phase after injection.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - H Alex Choi
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA
| | - Raimund Helbok
- Clinical Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Pedro Kurtz
- Neuro Intensive Care Unit, Brain Institute Paulo Niemeyer, Rio de Janeiro, RJ, Brazil
| | - J Michael Schmidt
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neeraj Badjatia
- Section of Neurocritical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA.
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Flynn L, Andrews P. Advances in the understanding of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage. F1000Res 2015; 4:F1000 Faculty Rev-1200. [PMID: 26937276 PMCID: PMC4752028 DOI: 10.12688/f1000research.6635.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2015] [Indexed: 12/23/2022] Open
Abstract
Delayed cerebral ischaemia has been described as the single most important cause of morbidity and mortality in patients who survive the initial aneurysmal subarachnoid haemorrhage. Our understanding of the pathophysiology of delayed cerebral ischaemia is meagre at best and the calcium channel blocker nimodipine remains the only intervention to consistently improve functional outcome after aneurysmal subarachnoid haemorrhage. There is substantial evidence to support cerebral vessel narrowing as a causative factor in delayed cerebral ischaemia, but contemporary research demonstrating improvements in vessel narrowing has failed to show improved functional outcomes. This has encouraged researchers to investigate other potential causes of delayed cerebral ischaemia, such as early brain injury, microthrombosis, and cortical spreading depolarisation. Adherence to a common definition of delayed cerebral ischaemia is needed in order to allow easier assessment of studies using multiple different terms. Furthermore, improved recognition of delayed cerebral ischaemia would not only allow for faster treatment but also better assessment of interventions. Finally, understanding nimodipine's mechanism of action may allow us to develop similar agents with improved efficacy.
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Affiliation(s)
- Liam Flynn
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Durrant JC, Hinson HE. Rescue therapy for refractory vasospasm after subarachnoid hemorrhage. Curr Neurol Neurosci Rep 2015; 15:521. [PMID: 25501582 DOI: 10.1007/s11910-014-0521-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia.
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Affiliation(s)
- Julia C Durrant
- Department of Neurology and Neurocritical Care, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, CR-127, Portland, OR, 97239, USA,
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Kiser TH. Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions? Hosp Pharm 2014; 49:923-41. [PMID: 25477565 DOI: 10.1310/hpj4910-923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.
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Affiliation(s)
- Tyree H Kiser
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital, University of Colorado Anschutz Medical Campus , 12850 E. Montview Boulevard, C238, Aurora, CO 80045 ; phone: 303-724-2883 ; fax: 303-724-0979 ; e-mail:
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Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. INTERVENTIONAL NEUROLOGY 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
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Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
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Zhang YP, Shields LB, Yao TL, Dashti SR, Shields CB. Intrathecal Treatment of Cerebral Vasospasm. J Stroke Cerebrovasc Dis 2013; 22:1201-11. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 04/11/2012] [Indexed: 11/24/2022] Open
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30
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Kiser TH. Pharmacologic Options for Prevention and Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Hosp Pharm 2013; 48:S2-S9. [PMID: 35694374 PMCID: PMC7210716 DOI: 10.1310/hpj48s5-s2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2024]
Abstract
Background Cerebral vasospasm and delayed cerebral ischemia continue to be major contributors to morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Purpose The purpose of this review was to evaluate the pharmacotherapy interventions for the prevention and management of cerebral vasospasm in patients with SAH. Methods A search of MEDLINE (January 1966-April 2012) and EMBASE (January 1974-April 2012) was conducted to retrieve relevant studies of pharmacotherapy options for prevention or treatment of cerebral vasospasm in SAH. Results Triple-H therapy (hypervolemia, hemodilution, hypertension) has been a widely accepted option by many clinicians for the management of cerebral vasospasm and delayed cerebral ischemia. However, implementation of Triple-H therapy varies considerably at individual institutions. Nimodipine and nicardipine have demonstrated the most dependable improvements in patient outcomes to date. High doses of intravenous magnesium have failed to show consistent benefits. Magnesium supplementation to prevent hypomagnesaemia should be employed. Statin therapy should be continued in patients who are taking statins prior to hospital admission. Use of statins in naive patients may be recommended when the results of an ongoing prospective study are available. Of the available locally administered pharmacologic therapies, nicardipine and thrombolytics appear to provide the most intriguing benefit-to-risk ratio. However, the data supporting the use of locally administered therapy are modest at best and require careful consideration prior to application. Conclusions Clinical studies have tested a variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm. Of available therapies, nimodipine has demonstrated consistent benefits and should be employed routinely. Demonstration of reduced cerebral vasospasm and improved neurological outcomes in larger prospective studies are needed for most pharmacologic therapy options prior to recommending their routine use.
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Affiliation(s)
- Tyree H. Kiser
- *Department of Clinical Pharmacy, University of Colorado
School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy
Specialist, University of Colorado Hospital
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Intraventricular nicardipine for aneurysmal subarachnoid hemorrhage related vasospasm: assessment of 90 days outcome. Neurocrit Care 2012; 16:368-75. [PMID: 22160865 DOI: 10.1007/s12028-011-9659-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Delayed cerebral arterial vasospasm is one of the leading causes of death and disability after aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the safety of intraventricular nicardipine (IVN) for vasospasm (VSP) in aSAH patients, and outcomes compared with a control population. METHODS A retrospective case-control study was conducted for aSAH patients treated with IVN at Mayo Clinic, Jacksonville, FL, from March 2009 to January 2011. Controls were matched by age, gender, and Fisher grade. Safety was evaluated by the incidence of intracranial bleeding and infection. Outcome was measured by Glasgow Outcome Scale at 30 and 90 days. IVN effects on VSP were evaluated by transcranial Doppler (TCD). RESULTS Thirteen aSAH patients and one arteriovenous malformation (AVM)-related SAH patient received IVN for VSP and were matched with 14 aSAH patients without IVN therapy for a total of 28 cases. Median dose was 4 mg (range 3-7), and median number of doses was seven (range 1-17). Mean flow velocity decreased after IVN (120.2 and 101.6 cm/s-82.0 and 72.8 cm/s, right and left middle cerebral arteries, respectively). No significant difference was seen in clinical outcomes between controls and cases at 30 days (P = 0.443) and 90 days (P = 0.153). There were no incidences of bleeding or infection with 111 nicardipine injections. CONCLUSIONS IVN appears relatively safe and effective in treating VSP by TCD, but there was no difference in clinical outcomes between nicardipine and control patients at 30 and 90 days. In the future, larger studies are needed to evaluate the clinical outcome with IVN.
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Pandey P, Steinberg GK, Dodd R, Do HM, Marks MP. A Simplified Method for Administration of Intra-Arterial Nicardipine for Vasospasm With Cervical Catheter Infusion. Oper Neurosurg (Hagerstown) 2011; 71:77-85. [DOI: 10.1227/neu.0b013e3182426257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Nicardipine has previously been used to treat vasospasm through superselective intracranial microcatheter injections.
OBJECTIVE:
To evaluate a simple method of treatment of vasospasm with slow infusion of nicardipine from a cervical catheter.
METHODS:
Twenty-seven patients with symptomatic vasospasm were treated over 4 years with cervical catheter infusions. Nicardipine was infused at 20 mg/h for 30 to 60 minutes. Angioplasty was used in severe cases at the operator's discretion. Outcome at discharge and follow-up was evaluated with Glasgow Outcome Scale.
RESULTS:
Twenty-seven patients (17 women, 12 men) received intra-arterial therapy for vasospasm. Vasospasm treatment was done at a mean post-hemorrhage date of 7.2 days (range, 4-15 days). They underwent 48 sessions of treatment (mean, 1.8 per patient) in 72 separate arterial territories. Twelve patients underwent multiple treatments. The mean dose used per session was 19.2 mg (range, 5-50 mg). Four patients underwent angioplasty for severe vasospasm. Twenty-two patients (81.5%) had clinical improvement after the infusion. Angiographic improvement was seen in 86.1% of the vessels analyzed, which had moderate or severe spasm before infusion. Overall, 17 patients (62.9%) had good outcome (Glasgow Outcome Scale score, 4 and 5) at discharge, 11 had poor outcome, and 1 patient died. Follow-up was available in 19 patients, and 18 were doing well (Glasgow Outcome Scale score, 4 and 5).
CONCLUSION:
Intra-arterial nicardipine is an effective and safe treatment for cerebral vasospasm. In most patients, infusion can be performed from the cervical catheter, with microcatheter infusion and angioplasty reserved for the more severe and resistant cases.
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Affiliation(s)
| | | | - Robert Dodd
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Huy M. Do
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael P. Marks
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
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Refractory caffeine and ergot-induced cervico-cerebral vasospasm and stroke treated with combined medical and endovascular approach. Neuroradiology 2011; 54:77-9. [PMID: 21468675 DOI: 10.1007/s00234-011-0859-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 03/07/2011] [Indexed: 10/18/2022]
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Diedler J, Sykora M, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hansen-Schwartz J. Advances in treatment of cerebral vasospasm: an update. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 110:23-26. [PMID: 21116909 DOI: 10.1007/978-3-7091-0353-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
An update of published clinical advances in the treatment of cerebral vasospasm after subarachnoid haemorrhage was provided. Searching MEDLINE using the search terms "cerebral vasospasm" and "clinical trials" 46 papers were identified that had been published since the International Conference on Cerebral Vasospasm in Istanbul, Turkey in 2006. Of these 26 were either safety studies or case reports leaving 20 papers for consideration. The major topics covered were calcium antagonists, magnesium sulphate, statins, and fasudil hydrochloride. The studies published did not reach an impact justified recommended routine use, but certainly as options. Results of the CONSCIOUS trials on endothelin receptor antagonists are awaited.
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Affiliation(s)
- Jacob Hansen-Schwartz
- Department of Neurosurgery, Glostrup University Hospital, DK-2600, Glostrup, Denmark.
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Rhoney DH, McAllen K, Liu-DeRyke X. Current and future treatment considerations in the management of aneurysmal subarachnoid hemorrhage. J Pharm Pract 2010; 23:408-24. [PMID: 21507846 DOI: 10.1177/0897190010372334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a type of hemorrhagic stroke that can cause significant morbidity and mortality. Although guidelines have been published to help direct the care of these patients, there is insufficient quality literature regarding the medical and pharmacological management of patients with aSAH. Treatment is divided into 3 categories: supportive therapy, prevention of complications, and treatment of complications. There are numerous pharmacological therapies that are targeted at prevention and treatment of the neurological and medical complications that may arise. Rebleeding, hydrocephalus, cerebral vasospasm, and seizures are the most common neurological complications while the most common medical complications include hyponatremia, pulmonary edema, cardiac arrhythmias, neurogenic stunned myocardium, fever, anemia, infection, hyperglycemia, and venous thromboembolism. Risk factors, clinical presentation, diagnosis, pathophysiology, as well as initial management, prevention, and treatment of complications will be the focus of this discussion.
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Affiliation(s)
- Denise H Rhoney
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI 48201, USA.
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Abstract
Subarachnoid hemorrhage (SAH) is a catastrophic event that carries a mortality rate of 25% to 50%, with 10% to 15% of patients dying before reaching a hospital. Approximately 30,000 aneurysms rupture each year in the United States. Aneurysmal SAH accounts for 2% to 5% of all new strokes each year. Unlike other types of strokes, the incidence of SAH has not declined over time. As many as 46% of SAH survivors have long-term cognitive impairment, with impact on functional status and quality of life. Modern therapy offers the opportunity to reduce the morbidity of SAH by reducing secondary injury, preventing complications, and reducing the risk of future bleeding events. For most people, an aneurysmal rupture is a life-changing event.
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The Effect of Intraventricular Administration of Nicardipine on Mean Cerebral Blood Flow Velocity Measured by Transcranial Doppler in the Treatment of Vasospasm Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2009; 12:159-64. [DOI: 10.1007/s12028-009-9307-8] [Citation(s) in RCA: 34] [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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Pluta RM, Butman JA, Schatlo B, Johnson DL, Oldfield EH. Subarachnoid hemorrhage and the distribution of drugs delivered into the cerebrospinal fluid. Laboratory investigation. J Neurosurg 2009; 111:1001-7, 1-4. [PMID: 19374502 DOI: 10.3171/2009.2.jns081256] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Investigators in experimental and clinical studies have used the intrathecal route to deliver drugs to prevent or treat vasospasm. However, a clot near an artery or arteries after subarachnoid hemorrhage (SAH) may hamper distribution and limit the effects of intrathecally delivered compounds. In a primate model of right middle cerebral artery (MCA) SAH, the authors examined the distribution of Isovue-M 300 and 3% Evans blue after infusion into the cisterna magna CSF. METHODS Ten cynomolgus monkeys were assigned to SAH and sham SAH surgery groups (5 in each group). Monkeys received CSF injections as long as 28 days after SAH and were killed 3 hours after the contrast/Evans blue injection. The authors assessed the distribution of contrast material on serial CT within 2 hours after contrast injection and during autopsy within 3 hours after Evans blue staining. RESULTS Computed tomography cisternographies showed no contrast in the vicinity of the right MCA (p < 0.05 compared with left); the distribution of contrast surrounding the entire right cerebral hemisphere was substantially reduced. Postmortem analysis demonstrated much less Evans blue staining of the right hemisphere surface compared with the left. Furthermore, the Evans blue dye did not penetrate into the right sylvian fissure, which occurred surrounding the left MCA. The authors observed the same pattern of changes and differences in contrast distribution between SAH and sham SAH animals and between the right and the left hemispheres on Days 1, 3, 7, 14, 21, and 28 after SAH. CONCLUSIONS Intrathecal drug distribution is substantially limited by SAH. Thus, when using intrathecal drug delivery after SAH, vasoactive drugs are unlikely to reach the arteries that are at the highest risk of delayed cerebral vasospasm.
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Affiliation(s)
- Ryszard M Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
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