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Cho YD, Byoun HS, Park KH, Won YI, Lim J. The Impact of Enteral Nimodipine on Endothelial Cell Apoptosis in an Animal Subarachnoid Hemorrhage Model. Neurocrit Care 2024; 41:608-618. [PMID: 38589694 DOI: 10.1007/s12028-024-01980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Enteral nimodipine is the most evidence-based and widely used drug for the treatment of delayed cerebral ischemia and is known to have various neuroprotective functions. However, the neuroprotective mechanism of nimodipine still remains unclear, and the effects of nimodipine remain ambiguous. Herein, we studied the effect of enteral nimodipine on endothelial apoptosis after subarachnoid hemorrhage (SAH). METHODS SAH was experimentally introduced in white rabbits (n = 42) that were grouped as follows: enteral nimodipine (SAH-nimodipine group, n = 14), a control that received normal saline (SAH-saline group, n = 13), and a control without hemorrhage (control group, n = 15). On the third day after SAH induction, the brain stem, including the vertebrobasilar vascular system, was extracted. The effects of enteral nimodipine were analyzed by group using histopathologic analysis, including immunohistochemical staining of apoptosis-related proteins (Bcl2 [anti-apoptotic] and Bax [pro-apoptotic]). RESULTS Cytoplasmic vacuolation of smooth muscle cells was observed in two SAH hemorrhagic groups and was more prominent in the SAH-saline group. Endothelial desquamation was observed only in the SAH-saline group. For the basilar artery, expression of Bcl2 and Bax in the SAH-nimodipine group was lower than that in the SAH-saline group, but significant differences were not observed (pBcl2 = 0.311 and pBax = 0.720, respectively). In penetrated arterioles, the expression of Bax in the SAH-nimodipine group was significantly lower than that of the SAH-saline group (p < 0.001). The thickness of the tunica media in the basilar artery was thinner in the SAH-nimodipine group than in the SAH-saline group (p < 0.001). CONCLUSIONS This study suggests that enteral nimodipine may have a neuroprotective function by inhibiting endothelial apoptosis in small arterioles and preventing smooth muscle cell proliferation in large arteries.
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Affiliation(s)
- Young Dae Cho
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong, South Korea
- Department of Neurosurgery, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kwang Hyon Park
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong, South Korea
| | - Young Il Won
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong, South Korea
| | - Jeongwook Lim
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong, South Korea.
- Department of Neurosurgery, Chungnam National University School of Medicine, Daejeon, Korea.
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Döring K, Sperling S, Ninkovic M, Lanfermann H, Streit F, Fischer A, Rohde V, Malinova V. Ultrasound-Induced Release Profile of Nimodipine from Drug-Loaded Block Copolymers after Singular vs. Repeated Sonication: In Vitro Analysis in Artificial Cerebrospinal Fluid. Brain Sci 2024; 14:912. [PMID: 39335407 PMCID: PMC11430527 DOI: 10.3390/brainsci14090912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/30/2024] Open
Abstract
OBJECTIVE Nimodipine still represents a unique selling point in the prevention of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH). Its intrathecal effect is limited by a low oral bioavailability, leading to the development of nanocarrier systems to overcome this limitation. This study investigated the ultrasound-induced release profile of nimodipine from drug-loaded copolymers in artificial cerebrospinal fluid (CSF) within 72 h after a singular versus repeated sonication. METHODS Pluronic® F127 copolymers (Sigma-Aldrich, Taufkirchen, Germany)were loaded with nimodipine by direct dissolution. Spontaneous and on-demand drug release by ultrasound (1 MHz at 1.7 W/cm2) was determined in artificial cerebrospinal fluid using the dialysis bag method. Nimodipine concentrations were measured at predefined time points within 72 h of sonication. RESULTS Spontaneous release of nimodipine was enhanced by ultrasound application with significantly increased nimodipine concentrations two hours after a repeated sonication compared to a singular sonication (median 1.62 vs. 17.48 µg/µL, p = 0.04). A further trend was observed after four hours (median 1.82 vs. 22.09 µg/µL, p = 0.06). There was no difference in the overall nimodipine concentrations between the groups with a singular versus repeated sonication (357.2 vs. 540.3 µg/µL, p = 0.60) after 72 h. CONCLUSIONS Repeated sonication resulted in an acceleration of nimodipine release from the drug-loaded copolymer in a CSF medium. These findings confirm the proof of principle of an on-demand guidance of nimodipine release from nimodipine-loaded nanodrugs by means of ultrasound, which suggests that evaluating the concept in an animal model may be appropriate.
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Affiliation(s)
- Katja Döring
- Department of Neurosurgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (K.D.); (S.S.); (M.N.); (V.R.)
- Department of Interventional and Diagnostic Neuroradiology, Hannover Medical School, 30625 Hannover, Germany;
| | - Swetlana Sperling
- Department of Neurosurgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (K.D.); (S.S.); (M.N.); (V.R.)
| | - Milena Ninkovic
- Department of Neurosurgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (K.D.); (S.S.); (M.N.); (V.R.)
| | - Heinrich Lanfermann
- Department of Interventional and Diagnostic Neuroradiology, Hannover Medical School, 30625 Hannover, Germany;
| | - Frank Streit
- Department of Clinical Chemistry, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.S.); (A.F.)
| | - Andreas Fischer
- Department of Clinical Chemistry, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.S.); (A.F.)
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (K.D.); (S.S.); (M.N.); (V.R.)
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (K.D.); (S.S.); (M.N.); (V.R.)
- Department of Neurosurgery, Georg-August-University, Robert-Koch-Straße 40, 37075 Göttingen, Germany
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3
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Luzzi S, Bektaşoğlu PK, Doğruel Y, Güngor A. Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia. Neurosurg Rev 2024; 47:305. [PMID: 38967704 PMCID: PMC11226492 DOI: 10.1007/s10143-024-02543-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/15/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Türkiye
| | - Yücel Doğruel
- Department of Neurosurgery, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Abuzer Güngor
- Faculty of Medicine, Department of Neurosurgery, Istinye University, İstanbul, Türkiye
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4
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Feulner J, Weidinger CS, Dörfler A, Birkholz T, Buchfelder M, Sommer B. Early Intravenous Magnesium Sulfate and Its Impact on Cerebral Vasospasm as well as Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Retrospective Matched Case-Control Analysis. World Neurosurg 2024; 186:e106-e113. [PMID: 38514031 DOI: 10.1016/j.wneu.2024.03.062] [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: 02/16/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Magnesium sulfate (MgSO4) is a potential neuroprotective agent for patients with aneurysmal subarachnoid hemorrhage (SAH). We analyzed the effect of early application of intraoperative intravenous MgSO4 and compared cerebral vasospasm (CV), delayed cerebral ischemia (DCI), and neurological outcome in 2 patient cohorts. METHODS A retrospective matched-pair analysis from patients at a single center in Germany was performed without (group A) and with (group B) MgSO4 application <24 hours after diagnosis. Pairs were matched according to the known risk factors for DCI and CV (age, Fisher grade, smoking, severity of SAH). Incidence of CV and DCI and neurological outcome using the modified Rankin Scale score 3 and 12 months after SAH were recorded. RESULTS The inclusion criteria were met by 196 patients. After risk stratification, 48 patients were included in the final analysis (age 54.2 ± 8.1 years; 30 women and 18 men) and were assigned to group A (n = 24) or group B (n = 24). CV occurred less frequently in group B (33%) than in group A (46%). Likewise, DCI was present in 13% in group B compared with 42% in group A. After 12 months, 22 patients in group B had a favorable functional outcome (modified Rankin Scale score 0-3) compared with 15 patients in group A. CONCLUSIONS In this study, the incidence of CV and DCI was lower in patients receiving intravenous MgSO4 within 24 hours after aneurysmal SAH onset. Favorable functional outcome was more likely in the MgSO4 group after 12 months of follow-up.
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Affiliation(s)
- Julian Feulner
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany; Department of Neurosurgery, Klinikum Fürth, Fürth, Germany
| | | | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Torsten Birkholz
- Department of Anesthesiology, University Hospital Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Björn Sommer
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany; Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany.
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5
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Llompart-Pou JA, Pérez-Bárcena J, Lagares A, Godoy DA. Twelve controversial questions in aneurysmal subarachnoid hemorrhage. Med Intensiva 2024; 48:92-102. [PMID: 37951804 DOI: 10.1016/j.medine.2023.09.003] [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: 07/06/2023] [Accepted: 09/28/2023] [Indexed: 11/14/2023]
Abstract
Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients.
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Affiliation(s)
- Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain.
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Alfonso Lagares
- Servicio de Neurocirugía. Hospital Universitario 12 de Octubre. Madrid. Spain
| | - Daniel Agustín Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina
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Findlay MC, Kundu M, Nelson JR, Cole KL, Winterton C, Tenhoeve S, Lucke-Wold B. Emerging Treatments for Subarachnoid Hemorrhage. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2024; 23:1345-1356. [PMID: 38409689 DOI: 10.2174/0118715273279212240130065713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/19/2023] [Accepted: 01/01/2024] [Indexed: 02/28/2024]
Abstract
The current landscape of therapeutic strategies for subarachnoid hemorrhage (SAH), a significant adverse neurological event commonly resulting from the rupture of intracranial aneurysms, is rapidly evolving. Through an in-depth exploration of the natural history of SAH, historical treatment approaches, and emerging management modalities, the present work aims to provide a broad overview of the shifting paradigms in SAH care. By synthesizing the historical management protocols with contemporary therapeutic advancements, patient-specific treatment plans can be individualized and optimized to deliver outstanding care for the best possible SAH-related outcomes.
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Affiliation(s)
- Matthew C Findlay
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Mrinmoy Kundu
- Institute of Medical Sciences and SUM Hospital, Bhubaneswar, India
| | - Jayson R Nelson
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kyril L Cole
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Candace Winterton
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Samuel Tenhoeve
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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7
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Apostolakis S, Stavrinou P. Pharmacotherapy in SAH: Clinical Trial Lessons. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2024; 23:1308-1319. [PMID: 38243987 DOI: 10.2174/0118715273251761231127095039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 10/13/2023] [Accepted: 10/23/2023] [Indexed: 01/22/2024]
Abstract
Subarachnoid Haemorrhage (SAH) is a medical emergency with potentially devastating outcomes. It is without doubt that over the past decades, there has been a radical change in the approach towards patients with SAH, both in terms of the surgical as well as of the pharmacological treatments offered. The present review aims to outline the principal data regarding the best practice in the pharmacotherapy of SAH, as well as to sum up the emerging evidence from the latest clinical trials. To date, nimodipine is the only evidence-based treatment of vasospasm. However, extensive research is currently underway to identify novel substances with magnesium sulphate, cilostazol, clazosentan and fasudil, demonstrating promising results. Antifibrinolytic therapy could help reduce mortality, and anticoagulants, in spite of their associated hazards, could actually reduce the incidence of delayed cerebral ischemia. The effectiveness of triple-H therapy has been challenged, yet evidence on the optimal regimen is still pending. Statins may benefit some patients by reducing the incidence of vasospasm and delayed ischemic events. As several clinical trials are underway, it is expected that in the years to come, more therapeutic options will be added to the attending physician's armamentarium.
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Affiliation(s)
- Sotirios Apostolakis
- Department of Neurosurgery, KAT General Hospital of Attica, Kifisia, Greece
- Department of Neurosurgery, Metropolitan Hospital, Piraeus, Greece
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8
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Lei G, Rao Z, Hu Y. The efficacy of different nimodipine administration route for treating subarachnoid hemorrhage: A network meta-analysis. Medicine (Baltimore) 2023; 102:e34789. [PMID: 37773855 PMCID: PMC10545353 DOI: 10.1097/md.0000000000034789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND A systematic review and network meta-analysis (NMA) were conducted to explore the optimal administration route of nimodipine for treatment subarachnoid hemorrhage. METHODS Electronic databases (Pubmed, Embase, Web of Science and Cochrane databases) were systematically searched to identify randomized controlled trials evaluating different administration route of nimodipine (intravenous and enteral) versus placebo for treatment subarachnoid hemorrhage. Outcomes included case fatality at 3 months, poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), incidence of delayed cerebral ischemia (DCI), delayed ischemic neurological deficit. A random-effect Bayesian NMA was conducted for outcomes of interest, and results were presented as odds ratios (ORs) and 95% credible intervals. The NMA was performed using R Software with a GeMTC package. A Bayesian NMA was performed and relative ranking of agents was assessed using surface under the cumulative ranking (SUCRA) probabilities. RESULTS Nine randomized controlled trials met criteria for inclusion and finally included in this NMA. There was no statistically significant between intravenous and enteral in terms of case fatality, the occurrence of DCI, delayed ischemic neurologic deficit and poor outcomes (P > .05). Both intravenous and enteral could reduce case fatality, the occurrence of DCI, delayed ischemic neurologic deficit and poor outcomes (P < .05). The SUCRA shows that enteral ranked first, intravenous ranked second and placebo ranked the last for case fatality, the occurrence of DCI and poor outcomes. The SUCRA shows that intravenous ranked first, enteral ranked second and placebo ranked the last for delayed ischemic neurologic deficit. CONCLUSIONS It is possible that both enteral and intravenous nimodipine have comparable effectiveness in preventing poor outcomes, DCI, and delayed ischemic neurological deficits. However, further investigation may be necessary to determine the exact role of intravenous nimodipine in current clinical practice.
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Affiliation(s)
- Gang Lei
- Department of Neurology, Tianyou Hospital Affiliated to Wuhan University of Science and Technolog, Wuhan, China
| | - Zhongxian Rao
- Hospital of Wuhan University of science and technology, Wuhan, China
| | - Yuping Hu
- Hubei University of Chinese Medicine, Wuhan, China
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Kerschbaumer J, Freyschlag CF, Petr O, Adage T, Breitenbach J J, Wessels L, Wolf S, Hecht N, Gempt J, Wostrack M, Gmeiner M, Gollwitzer M, Stefanits H, Bendszus M M, Gruber A, Meyer B, Vajkoczy P, Thomé C. A randomized, single ascending dose safety, tolerability and pharmacokinetics study of NicaPlant® in aneurysmal subarachnoid hemorrhage patients undergoing clipping. BRAIN & SPINE 2023; 3:102673. [PMID: 38021019 PMCID: PMC10668089 DOI: 10.1016/j.bas.2023.102673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Post-hemorrhagic vasospasm with neurological deterioration is a major concern in this context. NicaPlant®, a modified release formulation of the calcium channel blocker nicardipine, has shown vasodilator efficacy preclinically and a similar formulation known as NPRI has shown anti-vasospasm activity in aSAH patients under compassionate use. Research question The study aimed to assess pharmacokinetics and pharmacodynamics of NicaPlant® pellets to prevent vasospasm after clip ligation in aSAH. Material and methods In this multicenter, controlled, randomized, dose escalation trial we assessed the safety and tolerability of NicaPlant®. aSAH patients treated by clipping were randomized to receive up to 13 NicaPlant® implants, similarly to the dose of NPRIs previous used, or standard of care treatment. Results Ten patients across four dose groups were treated with NicaPlant® (3-13 implants) while four patients received standard of care. 45 non-serious and 13 serious adverse events were reported, 4 non-serious adverse events and 5 serious adverse events assessed a probable or possible causal relationship to the investigational medical product. Across the NicaPlant® groups there was 1 case of moderate vasospasm, while in the standard of care group there were 2 cases of severe vasospasm. Discussion and conclusion The placement of NicaPlant® during clip ligation of a ruptured cerebral aneurysm raised no safety concern. The dose of 10 NicaPlant® implants was selected for further clinical studies.
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Affiliation(s)
| | | | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Lars Wessels
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Maria Gollwitzer
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Martin Bendszus M
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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10
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Rass V, Kindl P, Lindner A, Kofler M, Altmann K, Putnina L, Ianosi BA, Schiefecker AJ, Beer R, Pfausler B, Helbok R. Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:104-115. [PMID: 37308727 PMCID: PMC10499738 DOI: 10.1007/s12028-023-01760-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Nimodipine is recommended to prevent delayed cerebral ischemia in patients with spontaneous subarachnoid hemorrhage (SAH). Here, we studied hemodynamic side effects of different nimodipine formulations (per os [PO] and intravenous [IV]) in patients with SAH undergoing continuous blood pressure monitoring. METHODS This observational cohort study includes consecutive patients with SAH (271 included in the IV group, 49 in the PO group) admitted to a tertiary care center between 2010 and 2021. All patients received prophylactic IV or PO nimodipine. Hemodynamic responses were evaluated based on median values within the first hour after continuous IV nimodipine initiation or PO nimodipine application (601 intakes within 15 days). Significant changes were defined as > 10% drop in systolic blood pressure (SBP) or diastolic blood pressure from baseline (median values 30 min before nimodipine application). With the use of multivariable logistic regression, risk factors associated with SBP drops were identified. RESULTS Patients were admitted with a median Hunt & Hess score of 3 (2-5; IV 3 [2-5], PO 1 [1-2], p < 0.001) and were 58 (49-69) years of age. Initiation of IV nimodipine was associated with a > 10% SBP drop in 30% (81/271) of patients, with a maximum effect after 15 min. A start or increase in noradrenaline was necessary in 136/271 (50%) patients, and colloids were administered in 25/271 (9%) patients within 1 h after IV nimodipine initiation. SBP drops > 10% occurred after 53/601 (9%) PO nimodipine intakes, with a maximum effect after 30-45 min in 28/49 (57%) patients. Noradrenaline application was uncommon (3% before and 4% after nimodipine PO intake). Hypotensive episodes to an SBP < 90 mm Hg were not observed after IV or PO nimodipine application. In multivariable analysis, only a higher SBP at baseline was associated with a > 10% drop in SBP after IV (p < 0.001) or PO (p = 0.001) nimodipine application, after adjusting for the Hunt & Hess score on admission, age, sex, mechanical ventilation, days after intensive care unit admission, and delayed cerebral ischemia. CONCLUSIONS Significant drops in SBP occur in one third of patients after the start of IV nimodipine and after every tenth PO intake. Early recognition and counteracting with vasopressors or fluids seems necessary to prevent hypotensive episodes.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Philipp Kindl
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Klaus Altmann
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 160] [Impact Index Per Article: 160.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Rigoard P, Billot M, Moens M, Goudman L, El-Hajj H, Ingrand P, Ounajim A, Roulaud M, Page P, Babin E, Et Talby M, Dany J, Johnson S, Bataille B, David R, Slavin KV. Evaluation of External Trigeminal Nerve Stimulation to Prevent Cerebral Vasospasm after Subarachnoid Hemorrhage Due to Aneurysmal Rupture: A Randomized, Double-Blind Proof-of-Concept Pilot Trial (TRIVASOSTIM Study). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105836. [PMID: 37239562 DOI: 10.3390/ijerph20105836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
Cerebral vasospasm remains the most frequent and devastating complication after subarachnoid aneurysmal hemorrhage because of secondary cerebral ischemia and its sequelae. The underlying pathophysiology involves vasodilator peptide release (such as CGRP) and nitric oxide depletion at the level of the precapillary sphincters of the cerebral (internal carotid artery network) and dural (external carotid artery network) arteries, which are both innervated by craniofacial autonomic afferents and tightly connected to the trigeminal nerve and trigemino-cervical nucleus complex. We hypothesized that trigeminal nerve modulation could influence the cerebral flow of this vascular network through a sympatholytic effect and decrease the occurrence of vasospasm and its consequences. We conducted a prospective double-blind, randomized controlled pilot trial to compare the effect of 10 days of transcutaneous electrical trigeminal nerve stimulation vs. sham stimulation on cerebral infarction occurrence at 3 months. Sixty patients treated for aneurysmal SAH (World Federation of Neurosurgical Societies scale between 1 and 4) were included. We compared the radiological incidence of delayed cerebral ischemia (DCI) on magnetic resonance imaging (MRI) at 3 months in moderate and severe vasospasm patients receiving trigeminal nerve stimulation (TNS group) vs. sham stimulation (sham group). Our primary endpoint (the infarction rate at the 3-month follow-up) did not significantly differ between the two groups (p = 0.99). Vasospasm-related infarctions were present in seven patients (23%) in the TNS group and eight patients (27%) in the sham group. Ultimately, we were not able to show that TNS can decrease the rate of cerebral infarction secondary to vasospasm occurrence. As a result, it would be premature to promote trigeminal system neurostimulation in this context. This concept should be the subject of further research.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
- Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Radiology, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Research Foundation-Flanders (FWO), 1090 Brussels, Belgium
| | - Hassan El-Hajj
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Pierre Ingrand
- CIC 1402, Clinical Investigation Center, Bio-Statistic and Epidemiology, University of Poitiers, 86021 Poitiers, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Philippe Page
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Etienne Babin
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Mohamed Et Talby
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Jonathan Dany
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Simona Johnson
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Benoit Bataille
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, 86021 Poitiers, France
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA
- Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, IL 60612, USA
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Intravenous Nimodipine Versus Enteral Nimodipine: The Meta-analysis Paradox. Neurocrit Care 2022; 37:813-814. [PMID: 36050536 DOI: 10.1007/s12028-022-01589-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 10/14/2022]
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14
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Geraldini F, De Cassai A, Diana P, Boscolo A, Munari M. A Meta-analysis Paradox or Simply Broadening the Perspective? Neurocrit Care 2022; 37:815-816. [PMID: 36050533 DOI: 10.1007/s12028-022-01590-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Federico Geraldini
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy.
| | - Alessandro De Cassai
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Paolo Diana
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Annalisa Boscolo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Marina Munari
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
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