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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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2
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Faropoulos K, Tsolaki V, Georgakopoulou VE, Trakas I, Tarantinos K, Papalexis P, Spandidos DA, Aravantinou-Fatorou A, Mathioudakis N, Trakas N, Fotakopoulos G. Efficacy of combined intravenous plus intrathecal nimodipine administration in patients with severe cerebral vasospasm post‑aneurysmal subarachnoid hemorrhage: A retrospective cohort study. MEDICINE INTERNATIONAL 2022; 3:3. [PMID: 36699659 PMCID: PMC9829231 DOI: 10.3892/mi.2022.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) and the ensuing cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) comprise the main reasons for morbidity and mortality in affected patients. The present study aimed to evaluate the efficacy of the use of combined intravenous (IV) and intrathecal (IT) nimodipine therapy for preventing permanent neurological deterioration and DCI in patients suffering from CV post-hemorrhage. The evaluation was performed using computed tomography perfusion and transcranial doppler ultrasound. The present retrospective cohort study analyzed 14 out of 146 patients diagnosed with vasospasm due to spontaneous or aSAH. These patients were divided into two groups as follows: i) The IV group, which included patients treated with only IV nimodipine; and ii) the IV + IT group, which included patients who received IV nimodipine in combination with IT nimodipine. Of the 14 patients, 7 patients were males (50%), and the mean age was 50.9 years (SD ±19 years). In total, 6 patients [42.8%; 5 (35.7%) from group A and 1 (7.1%) from group B], who experienced clinical symptoms with severe CV, were administered intra-arterial calcium channel therapy or/and IT nimodipine following the early identification of symptomatic vasospasm. The rate of adverse ischemic events was lower with IT nimodipine management during the 1 month of follow-up (6 vs. 2 events; odds ratio, 15.00; 95% confidence interval, 1.03-218.31; P=0.031). On the whole, the findings of the present study suggest that the combined use of IT nimodipine with IV admission for patients post-aSAH who developed severe CV is a safe procedure that may prevent permanent neurological deterioration and delay unfavorable ischemic incidents.
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Affiliation(s)
| | - Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larisa, 41221 Larisa, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases-COVID-19 Unit, Laiko General Hospital, 11527 Athens, Greece,Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases-COVID-19 Unit, Laiko General Hospital, 17 Agiou Thoma Street, 11527 Athens, Greece NULL
| | - Ilias Trakas
- Department of Infectious Diseases-COVID-19 Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece,Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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NAGAI A, SUZUKI Y, ISHIDA T, SATO Y, INOUE T, TOMINAGA T. Marked Reduction of Cerebral Vasospasm with Intrathecal Urokinase Infusion Therapy after Endovascular Coil Embolization of the Aneurysmal Subarachnoid Hemorrhage: A Case Series. Neurol Med Chir (Tokyo) 2022; 62:566-574. [PMID: 36223948 PMCID: PMC9831621 DOI: 10.2176/jns-nmc.2022-0155] [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] [Indexed: 11/07/2022] Open
Abstract
Delayed cerebral vasospasms after subarachnoid hemorrhage (SAH) are a risk factor for poor prognosis after successful treatment of ruptured intracranial aneurysms. Different strategies to remove clots from the subarachnoid space and prevent vasospasms have different outcomes. Intrathecal urokinase infusion therapy combined with endovascular treatment (EVT) can reduce the incidence of symptomatic vasospasms. To analyze the relationship between symptomatic vasospasms and residual SAHs after urokinase infusion therapy, we retrospectively reviewed the records of 348 consecutive patients managed with EVT and intrathecal urokinase infusion therapy for aneurysmal SAH at our institution between 2010 and 2021. Among them, 163 patients met the study criteria and were classified into two groups according to the presence of residual SAH in the cisterns, Sylvian fissures, and frontal interhemispheric fissure. The incidence of symptomatic vasospasms and the clinical outcomes were assessed. In total, eight (5.0%) patients developed symptomatic vasospasms. Patients with symptomatic vasospasms had a significantly higher incidence of residual SAH in the Sylvian or frontal interhemispheric fissures than those without (P <.0001). No patient with SAHs resolved by urokinase infusion therapy developed symptomatic vasospasms. However, the two groups did not differ significantly in terms of modified Rankin scale scores at discharge. Treatment with intrathecal urokinase infusion after EVT for aneurysmal SAH can substantially reduce the risk of clinically evident vasospasms.
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Affiliation(s)
- Arata NAGAI
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Yasuhiro SUZUKI
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Tomohisa ISHIDA
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Yoshimichi SATO
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tomoo INOUE
- Department of Neurosurgery, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Roelz R, Scheiwe C, Grauvogel J, Csok I, Coenen VA, Beck J, Reinacher PC. Early cisternal fibrinolysis is more effective than rescue spasmolysis for the prevention of delayed infarction after subarachnoid haemorrhage. Stroke Vasc Neurol 2022; 7:108-113. [PMID: 34750281 PMCID: PMC9067274 DOI: 10.1136/svn-2021-001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/03/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND To compare the efficacy of two different concepts of cisternal therapy-PREVENTIVE fibrinolysis plus on-demand spasmolysis versus RESCUE spasmolysis-for the prevention of cerebral vasospasm (CVS) and delayed cerebral infarction (DCI) in patients with aneurysmal subarachnoid haemorrhage (aSAH). METHODS Retrospective analysis of 84 aSAH patients selected for cisternal therapy for DCI prevention. 66 high-risk patients received PREVENTIVE cisternal therapy to enhance blood clearance. Either stereotactic catheter ventriculocisternostomy (STX-VCS) or intraoperative placement of a cisterno-ventriculostomy catheter (CVC), followed by fibrinolytic cisternal lavage using urokinase was performed. In case of vasospasm, nimodipine was applied intrathecally. 22 low-risk patients who developed CVS against expectations were selected for STX-VCS as RESCUE intervention for cisternal spasmolysis with nimodipine. Rates of DCI and mean flow velocities of daily transcranial Doppler (TCD) ultrasonographies were evaluated. RESULTS Despite a higher prespecified DCI risk, patients selected for PREVENTIVE intervention primarily aiming at blood clearance had a lower DCI rate compared with patients selected for intrathecal spasmolysis as a RESCUE therapy (11.3% vs 18.2%). After intrathecal treatment onset, CVS (TCD>160 cm/s) occurred in 45% of patients with PREVENTIVE and 77% of patients with RESCUE therapy (p=0.013). A stronger response of CVS to intrathecal nimodipine was observed in patients with PREVENTIVE intervention as the mean CVS duration after start of intrathecal nimodipine was 3.2 days compared with 5.8 days in patients with RESCUE therapy (p=0.026). CONCLUSIONS PREVENTIVE cisternal therapy directed at blood clearance is more effective for the prevention of CVS and delayed infarction compared with cisternal RESCUE spasmolysis. TRIAL REGISTRATION NUMBER DRKS00016532.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Istvan Csok
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Volker Arnd Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
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Fistouris P, Scheiwe C, Grauvogel J, Csók I, Beck J, Reinacher PC, Roelz R. Mitigation of Blood Load Impact in Patients with Subarachnoid Hemorrhage by Cisternal Lavage. Cerebrovasc Dis 2022; 51:499-505. [PMID: 35021173 DOI: 10.1159/000521203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/19/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECT The initial amount of subarachnoid and ventricular blood is an important prognostic factor for outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this comparative study of an unselected aSAH-population, we assess the modifiability of these factors by implementation of blood clearance by cisternal lavage. METHODS All patients with aSAH treated in our department between October 2011 and October 2019 (8 years, n = 458) were included in our study. In the first 4-year period (BEFORE, n = 237), patients were treated according to international guidelines. In the second 4-year period (AFTER, n = 221), cisternal lavage methods were available and applied in 72 high-risk patients (32.5%). The cisternal and ventricular blood load was recorded by the Hijdra score. Multivariable regression models were used to assess the prognostic significance of risk factors, including blood load, in relation to common aSAH characteristics in both study groups. RESULTS Worse neurological outcomes (mRS > 3) occurred in the BEFORE population with 41.45% versus 30.77% in the AFTER cohort, 6 months after aSAH (HR: 1.59, 95% CI 1.08-2.34, p = 0.01). Admission WFNS grade, comorbidities (Charlson Comorbidity Index), herniation signs, concomitant intracerebral hemorrhage, and the development of delayed cerebral infarction were strongly associated with poor outcome in both study groups. Intraventricular and cisternal blood load and, particularly, a cast fourth ventricle (Cast 4) represented strong prognosticators of poor neurological outcome in the BEFORE cohort. This effect was lost after implementation of cisternal lavage (AFTER cohort). CONCLUSION Cisternal and ventricular blood load - in particular: a Cast 4 - represent important prognosticators in patients with aSAH. They are, however, amenable to modification by blood clearing therapies.
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Affiliation(s)
- Panagiotis Fistouris
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Juergen Grauvogel
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - István Csók
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Juergen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Roelz R, Schubach F, Coenen VA, Jenkner C, Scheiwe C, Grauvogel J, Niesen WD, Urbach H, Taschner C, Seufert J, Kätzler J, Beck J, Reinacher PC. Stereotactic cisternal lavage in patients with aneurysmal subarachnoid hemorrhage with urokinase and nimodipine for the prevention of secondary brain injury (SPLASH): study protocol for a randomized controlled trial. Trials 2021; 22:285. [PMID: 33858493 PMCID: PMC8048077 DOI: 10.1186/s13063-021-05208-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed cerebral infarction (DCI) is a major cause of death and poor neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Direct intrathecal therapies with fibrinolytic and spasmolytic drugs have appeared promising in clinical trials. However, access to the subarachnoid space for intrathecal drug administration is an unsolved problem so far, especially in patients with endovascular aneurysm securing. We investigate a therapy protocol based on stereotactic catheter ventriculocisternostomy (STX-VCS), a new approach to overcome this problem. The primary objective of this study is to assess whether cisternal lavage with urokinase, nimodipine, and Ringer's solution administered via a stereotactically implanted catheter into the basal cisterns (= investigational treatment (IT)) is safe and improves neurological outcome in patients with aSAH. METHODS This is a randomized, controlled, parallel-group, open-label phase II trial. Fifty-four patients with severe aSAH (WFNS grade ≥ 3) will be enrolled at one academic tertiary care center in Southern Germany. Patients will be randomized at a ratio of 1:1 to receive either standard of care only or standard of care plus the IT. The primary endpoint is the proportion of subjects with a favorable outcome on the Modified Rankin Scale (defined as mRS 0-3) at 6 months after aSAH. Further clinical and surrogate outcome parameters are defined as secondary endpoints. DISCUSSION New approaches for the prevention and therapy of secondary brain injury in patients with aSAH are urgently needed. We propose this RCT to assess the clinical safety and efficacy of a novel therapy protocol for intrathecal administration of urokinase, nimodipine, and Ringer's solution. TRIAL REGISTRATION Deutsches Register Klinischer Studien (German Clinical Trials Register), DRKS00015645 . Registered on 8 May 2019.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Fabian Schubach
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carolin Jenkner
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Taschner
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jochen Seufert
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Kätzler
- Department of Internal Medicine III, Clinical Trials Office, University Medical Center Ulm, Ulm, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
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Su YS, Ali MS, Pukenas BA, Favilla CG, Zanaty M, Hasan DM, Kung DK. Novel Treatment of Cerebral Vasospasm Using Solitaire Stent Retriever-Assisted Angioplasty: Case Series. World Neurosurg 2019; 135:e657-e663. [PMID: 31881345 DOI: 10.1016/j.wneu.2019.12.097] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Endovascular procedures such as intraarterial (IA) vasodilator injection and balloon angioplasty are used to treat medically refractory cerebral vasospasm. The effects of IA therapy may be short lived and thus require multiple treatments. Balloon angioplasty also has limitations including transient occlusion of the spastic blood vessel, possible endothelial injury, and limited access to proximal vessels. We aim to demonstrate a novel technique using a stent retriever for the management of medically refractory vasospasm, especially in distal vessels. Compared with balloon angioplasty, stent retrievers provide a passive, self-limiting expansion of blood vessels. Other benefits over balloon angioplasty include 1) ability to simultaneously inject IA vasodilators, 2) limited contact and damage to vessel wall, 3) nonocclusive expansion, and 4) technical ease. METHODS Fourteen blood vessels from 6 patients with symptomatic vasospasm after subarachnoid hemorrhage were identified. We injected 5 mg of IA vasodilator medication into the vasospastic segments without radiographic improvement in vessel diameter and blood flow. The stent retriever was deployed for 2-5 minutes in each vasospastic segment. RESULTS Distal anterior and posterior circulation segments were easily accessible with the stent retriever system. It resulted in improved vessel diameter and blood flow with subsequent improvement in neurologic examination. All patients demonstrated radiographic resolution of vasospasm. No procedural-related complications were noted. CONCLUSIONS We demonstrate the safety and efficacy of a novel technique for the treatment of medically refractory cerebral vasospasm using stent retriever angioplasty in distal vessels. Stent angioplasty can be used as an additional tool in the management of subarachnoid hemorrhage-induced cerebral vasospasm.
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Affiliation(s)
- YouRong S Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Muhammad S Ali
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Bryan A Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher G Favilla
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David K Kung
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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8
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Roelz R, Scheiwe C, Urbach H, Coenen VA, Reinacher P. Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms. Oper Neurosurg (Hagerstown) 2019; 14:231-235. [PMID: 28582545 DOI: 10.1093/ons/opx129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 05/01/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradio-logy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Peter Reinacher
- Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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9
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Neuro Intensive Care Unit. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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10
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Roelz R, Grauvogel J, Scheiwe C, Shah M, Beck J, Reinacher PC, Hubbe U. Cisternal lavage via third ventriculostomy through the fenestrated lamina terminalis after aneurysm clipping: Technical note. J Clin Neurosci 2019; 64:283-286. [PMID: 30922533 DOI: 10.1016/j.jocn.2019.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
Delayed cerebral infarction (DCI) contributes to the burden of morbidity and mortality acquired by patients with aneurysmal subarachnoid hemorrhage (SAH). Cisternal lavage may prevent DCI. Delivery of lavage therapy to the basal cisterns, however, is challenging. Here, we report a novel method for the delivery of cisternal lavage using a cisterno-ventricular catheter (CVC) inserted via the fenestrated lamina terminalis during aneurysm clipping. In two high-risk aSAH patients a CVC was inserted into the third ventricle through the fenestrated lamina terminalis during aneurysm clipping. Post-operatively, continuous cisternal lavage using Urokinase or Nimodipine was applied using an external ventricular drain (EVD) as inflow tract and the CVC as outflow tract. Neurological outcome at 6 months was assessed by modified Rankin scale. Catheter placement into the third ventricle through the fenestrated lamina terminalis was performed without complications. Application of a free-running electrolyte solution containing Urokinase or Nimodipine via the EVD and drainage via the CVC was feasible. Cisternal Nimodipine application normalized sonographic vasospasm in both cases. DCI did not occur. CVC placement for ventriculo-cisternal lavage may represent a useful method for DCI prevention. It can be considered in aSAH patients at risk for DCI if the chiasmatic region is accessed during aneurysm clipping.
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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.
| | - Jürgen Grauvogel
- 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
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg Germany
| | - Jürgen Beck
- Department of 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
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg Germany
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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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12
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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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Reinacher PC, Coenen VA, Kraeutle R, Scheiwe C, Jabbarli R, Roelz R. Feasibility of stereotactic catheter ventriculocisternostomy for cisternal lavage therapy in patients with subarachnoid hemorrhage. Clin Neurol Neurosurg 2017; 163:94-102. [PMID: 29096139 DOI: 10.1016/j.clineuro.2017.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/11/2017] [Accepted: 10/15/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Delayed cerebral infarction (DCI) confers considerable morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Available prevention strategies are insufficient. Cisternal blood clearance by stereotactic catheter ventriculocisternostomy (STX-VCS) and cisternal lavage therapy is a novel concept for DCI prevention. Here, we assess the general feasibility, pitfalls and imaging requirements of STX-VCS after aSAH. PATIENTS AND METHODS 73 aSAH patients admitted between 2008 and 2015 with appropriate imaging for simulation of stereotactic procedures were included. Surgical feasibility of a transventricular trajectory to the basal cisterns was assessed. RESULTS Transventricular catheter access to the basal cisterns was feasible in 94% of cases. In 6% vascular obstacles precluded a transventricular approach and access to the basal cisterns could be simulated via a transparenchymal trajectory. CT-artifacts that interfered with stereotactic planning were observed in 58% after coiling and 5% after clipping. In these cases stereotactic planning was enabled by MRI. Logistic regression of aneurysm size and distance-to-target allowed for precise prediction whether MRI was required for stereotactic planning of STX-VCS after coiling. CONCLUSIONS Stereotactic catheter access to the basal cisterns after aSAH appears to be generally feasible. Coil artifacts compromising CT-based planning can be precisely anticipated and planning enabled by MRI.
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Affiliation(s)
- 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
| | - 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
| | - Rainer Kraeutle
- Department of Nursing-IT, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 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
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, Hufelandstr. 55, 45147, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany.
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Zhou X, Alambyan V, Ostergard T, Pace J, Kohen M, Manjila S, Ramos-Estebanez C. Prolonged Intracisternal Papaverine Toxicity: Index Case Description and Proposed Mechanism of Action. World Neurosurg 2017; 109:251-257. [PMID: 29017981 DOI: 10.1016/j.wneu.2017.09.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intracisternal papaverine (iPPV) is a vasodilator used for prophylaxis of intraoperative vasospasm during aneurysmal clipping. Postoperative side effects of iPPV include transient cranial nerve palsies, most commonly mydriasis owing to oculomotor nerve involvement, with rapid resolution. METHODS We critically reviewed current literature on the adverse effects of iPPV in aneurysmal surgery with a focus on oculomotor nerve involvement. We also present the index case of prolonged bilateral mydriasis secondary to iPPV irrigation toxicity and its putative underlying mechanism. RESULTS Papaverine toxicity occurs in the setting of its antimuscarinic action and blood-cerebrospinal fluid and blood-brain barrier compromise owing to acute subarachnoid hemorrhage and direct effect of papaverine. Our patient also experienced severe vasospasm and a minor stroke, both contributing to further blood-brain barrier disruption, and relatively acidic pH of the subarachnoid hemorrhage milieu. CONCLUSIONS We propose that these factors perpetuate phase dynamics of papaverine crystals and facilitate a sustained slow release of papaverine within the cisternal system. Were it indicated, 0.3% iPPV would reasonably diminish the risk for neurotoxicity.
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Affiliation(s)
- Xiaofei Zhou
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Vilakshan Alambyan
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas Ostergard
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Maryo Kohen
- Department of Ophthalmology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sunil Manjila
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ciro Ramos-Estebanez
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
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15
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Roelz R, Coenen VA, Scheiwe C, Niesen WD, Egger K, Csok I, Kraeutle R, Jabbarli R, Urbach H, Reinacher PC. Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage: A Matched Cohort Study. Stroke 2017; 48:2704-2709. [PMID: 28904239 DOI: 10.1161/strokeaha.117.018397] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/29/2017] [Accepted: 08/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral infarction (DCI) is a major source of morbidity and mortality after aneurysmal subarachnoid hemorrhage. We report a novel intervention-stereotactic catheter ventriculocisternostomy (STX-VCS) and fibrinolytic/spasmolytic lavage therapy-for DCI prevention. Outcomes of 20 consecutive patients are compared with 60 matched controls. METHODS On the basis of individual treatment decisions, STX-VCS was performed in 20 high-risk aneurysmal subarachnoid hemorrhage patients admitted to our department between September 2015 and October 2016. Three controls matched for age, sex, aneurysm treatment method, and admission Hunt and Hess grade were assigned to each case treated by STX-VCS. DCI was the primary outcome. Mortality and mRS at rehabilitation discharge were secondary outcome parameters. The association between STX-VCS and DCI, mortality, and mRS was assessed by conditional logistic regression. RESULTS Stereotactic procedures were performed without surgical complications. Continuous cisternal lavage was feasible in 17 of 20 patients (85%). One adverse event because of cisternal lavage was without sequelae. DCI occurred in 25 of 60 (42%) controls and 3 of 20 (15%) patients with STX-VCS (odds ratio, 0.15; 95% confidence interval, 0.04-0.64). Mortality occurred in 20 of 60 (33%) controls and 1 of 20 (5%) patients with STX-VCS, respectively (odds ratio, 0.08; 95% confidence interval, 0.01 - 0.66). Favorable outcome (mRS≤3) at rehabilitation discharge was observed in 12 of 20 patients with STX-VCS (60%) versus 21 of 60 (35%) matched controls (odds ratio, 0.26; 95% confidence interval, 0.8-0.86). CONCLUSIONS STX-VCS was feasible and safe in patients with severe aneurysmal subarachnoid hemorrhage. Initial results indicate that DCI and mortality can be reduced, and neurological outcome may be improved with this method.
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Affiliation(s)
- Roland Roelz
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.).
| | - Volker A Coenen
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Christian Scheiwe
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Wolf-Dirk Niesen
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Karl Egger
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Istvan Csok
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Rainer Kraeutle
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Ramazan Jabbarli
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Horst Urbach
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
| | - Peter C Reinacher
- From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.)
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16
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[Intensive care treatment after aneurysmal subarachnoid hemorrhage]. Anaesthesist 2017; 65:951-970. [PMID: 27900416 DOI: 10.1007/s00101-016-0242-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease and nearly one third of patients die in the acute phase. Due to the bleeding event, a hyperactive sympathetic nervous system and an uncontrolled inflammatory response have a profound local and systemic impact on other organ functions. Neuroendocrinological disorders and cardiopulmonary morbidity are dominant. Despite a decrease in hospital mortality for high volume centers, a high proportion of survivors suffer from neurological deficits. Knowledge of the pathophysiology of vasospasms in the later stages of the disease has increased. Anti-inflammatory treatment does not improve the outcome. Nimodipine prophylaxis in the first 96 h after SAH seems to be the only intervention which has been proven to be advantageous in studies; however, nearly every second survivor of SAH suffers from some neurological deficits and more than one third of survivors report depressive episodes or symptoms of posttraumatic stress disorder.
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17
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Trends in Ventriculostomy-Associated Infections and Mortality in Aneurysmal Subarachnoid Hemorrhage: Data From the Nationwide Inpatient Sample. World Neurosurg 2017; 99:599-604. [DOI: 10.1016/j.wneu.2016.12.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/15/2016] [Accepted: 12/17/2016] [Indexed: 10/20/2022]
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Continuous intra-arterial nimodipine infusion in patients with severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a feasibility study and outcome results. Acta Neurochir (Wien) 2015; 157:2041-50. [PMID: 26439105 DOI: 10.1007/s00701-015-2597-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Severe cerebral vasospasm is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. No causative treatment is yet available and hypertensive hypervolemic therapy (HHT) is often insufficient to avoid delayed cerebral ischemia and neurological deficits. We compared patients receiving continuous intra-arterial infusion of the calcium-antagonist nimodipine with a historical group treated with HHT and oral nimodipine alone. METHODS Between 0.5 and 1.2 mg/h of nimodipine were continuously administered by intra-arterial infusion via microcatheters either into the internal carotid or vertebral artery or both, depending on the areas of vasospasm. The effect was controlled via multimodal neuromonitoring and transcranial Doppler sonography. Outcome was determined by means of the Glasgow Outcome Scale at discharge and 6 months after the hemorrhage and compared to a historical control group. RESULTS Twenty-one patients received 28 intra-arterial nimodipine infusions. Six months after discharge, the occurrence of cerebral infarctions was significantly lower (42.6 %) in the nimodipine group than in the control group (75.0 %). This result was reflected by a significantly higher proportion (76.0 %) of patients with good outcome in the nimodipine-treated group, when compared to 10.0 % good outcome in the control group. Median GOS was 4 in the nimodipine group and 2 in the control group (p = 0.001). CONCLUSIONS Continuous intra-arterial nimodipine infusion is an effective treatment for patients with severe cerebral vasospasm who fail to respond to HHT and oral nimodipine alone. Key to the effective administration of continuous intra-arterial nimodipine is multimodal neuromonitoring and the individual adaptation of dosage and time of infusion for each patient.
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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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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Intracranial biodegradable silica-based nimodipine drug release implant for treating vasospasm in subarachnoid hemorrhage in an experimental healthy pig and dog model. BIOMED RESEARCH INTERNATIONAL 2015; 2015:715752. [PMID: 25685803 PMCID: PMC4317635 DOI: 10.1155/2015/715752] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/10/2014] [Indexed: 11/30/2022]
Abstract
Nimodipine is a widely used medication for treating delayed cerebral ischemia (DCI) after subarachnoid hemorrhage. When administrated orally or intravenously, systemic hypotension is an undesirable side effect. Intracranial subarachnoid delivery of nimodipine during aneurysm clipping may be more efficient way of preventing vasospasm and DCI due to higher concentration of nimodipine in cerebrospinal fluid (CSF). The risk of systemic hypotension may also be decreased with intracranial delivery. We used animal models to evaluate the feasibility of surgically implanting a silica-based nimodipine releasing implant into the subarachnoid space through a frontotemporal craniotomy. Concentrations of released nimodipine were measured from plasma samples and CSF samples. Implant degradation was followed using CT imaging. After completing the recovery period, full histological examination was performed on the brain and meninges. The in vitro characteristics of the implant were determined. Our results show that the biodegradable silica-based implant can be used for an intracranial drug delivery system and no major histopathological foreign body reactions were observed. CT imaging is a feasible method for determining the degradation of silica implants in vivo. The sustained release profiles of nimodipine in CSF were achieved. Compared to a traditional treatment, higher nimodipine CSF/plasma ratios can be obtained with the implant.
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Etminan N, Macdonald RL, Davis C, Burton K, Steiger HJ, Hänggi D. Intrathecal application of the nimodipine slow-release microparticle system eg-1962 for prevention of delayed cerebral ischemia and improvement of outcome after aneurysmal subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:281-6. [PMID: 25366637 DOI: 10.1007/978-3-319-04981-6_47] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The effective reduction of delayed cerebral ischemia (DCI), a main contributor for poor outcome following aneurysmal subarachnoid hemorrhage (SAH), remains challenging. Previous clinical trials on systemic pharmaceutical treatment of SAH mostly failed to improve outcome, probably because of insensitive pharmaceutical targets and outcome measures, small sample size, insufficient subarachnoid drug concentrations and also detrimental, systemic effects of the experimental treatment per se. Interestingly, in studies that are more recent, intrathecal administration of nicardipine pellets following surgical aneurysm repair was suggested to have a beneficial effect on DCI and neurological outcome. However, this positive effect remained restricted to patients who were treated surgically for a ruptured aneurysm. Because of the favorable results of the preclinical data on DCI and neurological outcome in the absence of neurotoxicity or systemic side effects, we are initiating clinical trials. The PROMISE (Prolonged Release nimOdipine MIcro particles after Subarachnoid hemorrhage) trial is designed as an unblinded, nonrandomized, single-center, single-dose, dose-escalation safety and tolerability phase 1 study in patients surgically treated for aSAH and will investigate the effect of intracisternal EG-1962 administration. The NEWTON (Nimodipine microparticles to Enhance recovery While reducing TOxicity after subarachNoid hemorrhage) trial is a phase 1/2a multicenter, controlled, randomized, open-label, dose-escalation, safety, tolerability, and pharmacokinetic study comparing EG-1962 and nimodipine in patients with aneurysmal SAH.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstr.5, 40225, Düsseldorf, Germany,
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Abstract
PURPOSE OF REVIEW This article reviews recent advances in the postoperative ICU management of patients after subarachnoid hemorrhage (SAH), especially with regards to hemodynamic management, methods of improving neurological outcomes, and management of cardiac and pulmonary complications. RECENT FINDINGS Several hemodynamic monitors and parameters may be useful for guiding volume therapy, including cardiac output, stroke volume variation monitoring, and global end-diastolic volume index. Early goal-directed hemodynamic therapy after SAH has recently been shown to improve clinical outcomes in patients with a poor clinical grade or coexisting cardiopulmonary complications. Recent laboratory and imaging modalities are being developed to identify patients at risk for developing vasospasm after SAH. Evidence for the use of various prophylactic adjuvant therapies to prevent vasospasm, including magnesium, phosphodiesterase 3 inhibitors, and therapeutic hypothermia, is emerging. Intrathecal administration of vasodilators or fibrinolytics may have offered advantages over systemic drug administration in the treatment of vasospasm. Pulmonary and cardiac complications are common after SAH, and are associated with an increased risk of mortality. SUMMARY The postoperative ICU period after SAH is associated with a significant morbidity and mortality risk, and recent studies have greatly contributed to our understanding of how to optimally manage these patients.
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Affiliation(s)
- Shaun E. Gruenbaum
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Fedrico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, ‘Sapienza’ University of Rome, Rome, Italy
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