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Routine use of perfusion computed tomography for the detection of delayed cerebral ischemia in unconscious patients after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2021; 163:151-160. [PMID: 32910294 DOI: 10.1007/s00701-020-04571-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/03/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) is difficult to diagnose in unconscious patients, but it is essential for the prognosis. We analyzed the diagnostic value of routinely performed perfusion computed tomography (rPCT) to detect DCI-related hypoperfusion in this subgroup of patients. METHODS Retrospective analysis of unconscious aSAH patients who underwent rPCT according to a predefined protocol. We exclusively analyzed PCT examinations in patients who were clinically and functionally asymptomatic with regard to transcranial Doppler ultrasound (TCD) and invasive neuromonitoring at the time of the PCT examination. The perfusion maps were quantitatively evaluated to detect DCI-related hypoperfusion. Possible clinical risk factors for the occurrence of DCI-related hypoperfusion in rPCT imaging were analyzed by multivariate analyses. RESULTS One hundred thirty-six rPCTs were performed in 55 patients. New onset of DCI-related hypoperfusion was observed in 18% of rPCTs. The positive predictive value of rPCT to detect angiographic CVS was 0.80. Between examination days 6 and 10, the rate of DCI-related hypoperfusion was increased significantly (p < 0.05). After rPCT imaging with proof of DCI-related hypoperfusion, short-term follow-up showed secondary cerebral infarction (SCI) in 38%, compared with 5% for patients with normal perfusion on rPCT. The parameters "high risk phase (examination days 6-10)" and "new onset of DCI-related SCI" were significantly associated with the occurrence of DCI-related hypoperfusion in rPCT. CONCLUSIONS In unconscious and asymptomatic aSAH patients, rPCT identifies DCI-related hypoperfusion in a relevant number of examinations. However, despite timely endovascular rescue therapy, a significant proportion of secondary infarction still occurs in this subgroup.
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Li K, Barras CD, Chandra RV, Kok HK, Maingard JT, Carter NS, Russell JH, Lai L, Brooks M, Asadi H. A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 126:513-527. [PMID: 30898740 DOI: 10.1016/j.wneu.2019.03.083] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage. OBJECTIVE To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era. METHODS A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage. RESULTS Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy. CONCLUSIONS Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.
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Affiliation(s)
- Kenny Li
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
| | - Christen D Barras
- University of Adelaide, North Terrace Campus, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Service, Monash Health, Clayton, Victoria, Australia
| | - Hong K Kok
- Interventional Radiology Service, Northern Health, Epping, Victoria, Australia
| | - Julian T Maingard
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Nicole S Carter
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Leon Lai
- Department of Neurosurgery, Monash Health, Clayton, Victoria, Australia
| | - Mark Brooks
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Hamed Asadi
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Donaldson C, O'Neill AH, Slater LA, Chong W, Lai LT, Chandra RV. Feasibility of Real-Time Angiographic Perfusion Imaging in the Treatment of Cerebral Vasospasm. INTERVENTIONAL NEUROLOGY 2017; 6:163-169. [PMID: 29118793 DOI: 10.1159/000468157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Objective assessment and quantification of the severity of cerebral vasospasm following aneurysmal subarachnoid hemorrhage is not routinely utilized. We investigated the feasibility of angiographic perfusion imaging derived from digital subtraction angiography (DSA) following endovascular vasospasm treatment procedures. Methodology Real-time blood flow analysis was performed using parametric color coding on pre- and postintervention DSA. Semiquantitative parenchymal perfusion parameters (arrival time [AT] of contrast, time to peak [TTP] opacification, and mean transit time [MTT] of contrast) were calculated across 3 vascular territories (anterior cerebral artery [ACA], middle cerebral artery [MCA], and lenticulostriate arteries) using standard 2-D angiographic perfusion software. The pre- and postintervention arterial vessel diameters were compared. Results Twelve endovascular vasospasm treatments in 6 patients were performed. All patients received intra-arterial vasodilator therapy with either nimodipine, milrinone, or both. Following intra-arterial intervention, parenchymal flow analysis showed improvement in TTP and MTT across all vascular territories (p < 0.002) and improvement in AT in the ACA and MCA territories (p < 0.03). Improvement in parenchymal perfusion parameters was associated with improvement in vessel diameters in all territories following treatment (p < 0.05). Conclusion Real-time parenchymal perfusion imaging during endovascular vasospasm treatment procedures is feasible and provides reliable semiquantitative measurement of angiographic treatment response.
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Affiliation(s)
- Christopher Donaldson
- Department of Neurosurgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Anthea H O'Neill
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lee-Anne Slater
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Winston Chong
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ronil V Chandra
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, Victoria, Australia
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Goel R, Aggarwal A, Salunke P, Kumar A, Chhabra R. Is intra arterial nimodipine really beneficial in vasospasm following aneurysmal subarachnoid haemorrhage? Br J Neurosurg 2016; 30:407-10. [PMID: 26999260 DOI: 10.3109/02688697.2016.1161172] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Object/Background: Vasospasm is a common cause of mortality and morbidity following rupture of intracranial aneurysm. Hemodynamic therapy instituted in these patients in the past has been replaced by direct manipulation of the spastic vessels by angioplasty and intra-arterial infusion of vasodilators. However, no case control studies exist proving its superiority. The purpose of our study was to compare the efficacy of intra-arterial nimodipine (IAN) to that of hemodynamic therapy in patients with vasospasm following aSAH. MATERIAL AND METHODS Fifty-three patients who developed vasospasm following aSAH were included in the study. IAN was instilled in addition to hemodynamic therapy in 39 patients and 14 patients (who refused to give consent for IAN) were continued on hemodynamic therapy alone and served as controls. The response to IAN was studied on angiogram. The clinical response was assessed in both the groups at regular intervals. IAN was repeated if necessary. The outcome (GOS) at discharge and at 3 months after discharge was compared. RESULTS Thirty-six (92.3%) out of 39 patients showed immediate angiographic reversal of vasospasm.28 of them showed clinical response, of which only 11 had lasting response. 11(28.2%) of 39 patients who received IAN had a good outcome at discharge and 23(58.9%) had a favourable outcome at 3 months follow up. In those who received hemodynamic therapy alone, 4 out of 14(28.6%) patients had a good outcome at discharge and 8 (57.1%) a favourable outcome at 3 months. CONCLUSIONS Angiographic reversal of vasospasm is seen in majority of the patients following IAN. However, this does not necessarily translate into a long lasting clinical response. The final outcome in patients who received hemodynamic therapy is comparable to those who received additional IAN. IAN does not appear to provide a major added advantage over the conventional hemodynamic therapy.
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Affiliation(s)
- Rajeev Goel
- a Department of Neurosurgery , PGIMER , Chandigarh , India
| | | | - Pravin Salunke
- a Department of Neurosurgery , PGIMER , Chandigarh , India
| | - Ajay Kumar
- b Department of Radiodiagnosis , PGIMER , Chandigarh , India
| | - Rajesh Chhabra
- a Department of Neurosurgery , PGIMER , Chandigarh , India
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Lin CF, Hsu SPC, Lin CJ, Guo WY, Liao CH, Chu WF, Hung SC, Shih YS, Lin YT. Prolonged Cerebral Circulation Time Is the Best Parameter for Predicting Vasospasm during Initial CT Perfusion in Subarachnoid Hemorrhagic Patients. PLoS One 2016; 11:e0151772. [PMID: 26986626 PMCID: PMC4795708 DOI: 10.1371/journal.pone.0151772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 03/03/2016] [Indexed: 12/03/2022] Open
Abstract
Purpose We sought to imitate angiographic cerebral circulation time (CCT) and create a similar index from baseline CT perfusion (CTP) to better predict vasospasm in patients with subarachnoid hemorrhage (SAH). Methods Forty-one SAH patients with available DSA and CTP were retrospectively included. The vasospasm group was comprised of patients with deterioration in conscious functioning and newly developed luminal narrowing; remaining cases were classified as the control group. The angiography CCT (XA-CCT) was defined as the difference in TTP (time to peak) between the selected arterial ROIs and the superior sagittal sinus (SSS). Four arterial ROIs were selected to generate four corresponding XA-CCTs: the right and left anterior cerebral arteries (XA-CCTRA2 and XA-CCTLA2) and right- and left-middle cerebral arteries (XA-CCTRM2 and XA-CCTLM2). The CCTs from CTP (CT-CCT) were defined as the differences in TTP from the corresponding arterial ROIs and the SSS. Correlations of the different CCTs were calculated and diagnostic accuracy in predicting vasospasm was evaluated. Results Intra-class correlations ranged from 0.96 to 0.98. The correlations of XA-CCTRA2, XA-CCTRM2, XA-CCTLA2, and XA-CCTLM2 with the corresponding CT-CCTs were 0.64, 0.65, 0.53, and 0.68, respectively. All CCTs were significantly prolonged in the vasospasm group (5.8–6.4 s) except for XA-CCTLA2. CT-CCTA2 of 5.62 was the optimal cut-off value for detecting vasospasm with a sensitivity of 84.2% and specificity 82.4% Conclusion CT-CCTs can be used to interpret cerebral flow without deconvolution algorithms, and outperform both MTT and TTP in predicting vasospasm risk. This finding may help facilitate management of patients with SAH.
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Affiliation(s)
- Chun Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sanford P. C. Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wan Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
| | - Chih Hsiang Liao
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei Fa Chu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng Che Hung
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yang Shin Shih
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen Tzu Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Bacigaluppi S, Zona G, Secci F, Spena G, Mavilio N, Brusa G, Agid R, Krings T, Ottonello G, Fontanella M. Diagnosis of cerebral vasospasm and risk of delayed cerebral ischemia related to aneurysmal subarachnoid haemorrhage: an overview of available tools. Neurosurg Rev 2015; 38:603-18. [DOI: 10.1007/s10143-015-0617-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 11/16/2014] [Indexed: 01/01/2023]
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Goel G, Gupta V, Chinchure S, Gupta A, Kaur G, Jha AN. A decade after International Subarachnoid Aneurysm Trial: Coiling as a first choice treatment in the management of intracranial aneurysms - Technical feasibility and early management outcomes. Asian J Neurosurg 2015; 9:137-43. [PMID: 25685204 PMCID: PMC4323897 DOI: 10.4103/1793-5482.142733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Purpose: The technique of coiling has evolved in the last decade with evolution in both equipment and material. The preferable treatment of intracranial aneurysms at our center is endovascular coiling. We discuss the technical and management outcomes of consecutive patients treated with this approach and compare our results with a decade old International Subarachnoid Aneurysm Trial. Materials and Methods: Between January 2006 and November 2011, a total of 324 aneurysms in 304 consecutive patients were treated. Endovascular treatment was done in 308 aneurysms (95.0%) in 288 patients while 16 patients (5%) underwent surgical clipping. Of the 308 aneurysms treated endovascularly, 269 (87.3%) were ruptured, and 39 (12.7%) were unruptured aneurysms. Results: The endovascular coiling was feasible in all (99.6%) but 1 case. The immediate postoperative occlusion status was complete occlusion in 240 aneurysms (77.9%), neck remnant in 57 aneurysms (18.5%), and aneurysm remnant in 11 aneurysms (3.6%). Technical issues – with or without clinical effect–were encountered in 20 patients (6.9%). They included 18 thromboembolic events (6.2%) and intraprocedural aneurysmal rupture in 2 cases (0.7%). In “good grade” patients, H and H grade 1-3, a good outcome (modified Rankin score [mRS] 0-2) was in 87.6% patients while the bad outcome (mRS 3-5) was in 10.2% patients and mortality of 2.2%. In “bad grade” patients, H and H grade 3-5, a good outcome was in 29.2%, and bad outcome was in 41.7% patients with mortality was 29.1%. In the unruptured aneurysm group, the good outcome was seen in 97.7% and bad outcome in 2.3% with no mortality. Conclusions: In the current era, the favorable results of coiling demonstrated in previous studies may be applicable to the larger proportion of patients. In our series of consecutively treated patients using latest advances, such as three-dimensional imaging and the interventional material, endovascular management as first choice was feasible in 95% of patients with good technical and management outcomes.
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Affiliation(s)
- Gaurav Goel
- Department of Neurointervention surgery and Neurosurgery, Institute of Neurosciences, Medanta Hospital, Gurgaon, Haryana, India
| | - Vipul Gupta
- Department of Neurointervention surgery and Neurosurgery, Institute of Neurosciences, Medanta Hospital, Gurgaon, Haryana, India
| | - Swati Chinchure
- Department of Neurointervention surgery and Neurosurgery, Institute of Neurosciences, Medanta Hospital, Gurgaon, Haryana, India
| | - Aditya Gupta
- Department of Neurointervention surgery and Neurosurgery, Institute of Neurosciences, Medanta Hospital, Gurgaon, Haryana, India
| | - Gurmeen Kaur
- Department of Neurointervention surgery and Neurosurgery, Institute of Neurosciences, Medanta Hospital, Gurgaon, Haryana, India
| | - Ajaya N Jha
- Department of Neurointervention surgery and Neurosurgery, Institute of Neurosciences, Medanta Hospital, Gurgaon, Haryana, India
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8
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Tekle WG, Chaudry SA, Hassan AE, Qaiser H, Grigoryan M, Rodriguez GJ, Qureshi AI. High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm. Neurocrit Care 2015; 20:399-405. [PMID: 23463421 DOI: 10.1007/s12028-013-9825-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.
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Affiliation(s)
- Wondwossen G Tekle
- Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, 420 Delaware St. SE. MMC 295, Minneapolis, MN, 55455, USA,
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9
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Zhang YP, Shields LB, Yao TL, Dashti SR, Shields CB. Intrathecal Treatment of Cerebral Vasospasm. J Stroke Cerebrovasc Dis 2013; 22:1201-11. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 04/11/2012] [Indexed: 11/24/2022] Open
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Hagel JM, Facchini PJ. Benzylisoquinoline alkaloid metabolism: a century of discovery and a brave new world. PLANT & CELL PHYSIOLOGY 2013; 54:647-72. [PMID: 23385146 DOI: 10.1093/pcp/pct020] [Citation(s) in RCA: 239] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Benzylisoquinoline alkaloids (BIAs) are a structurally diverse group of plant specialized metabolites with a long history of investigation. Although the ecophysiological functions of most BIAs are unknown, the medicinal properties of many compounds have been exploited for centuries. These include the narcotic analgesics codeine and morphine, the antimicrobial agents sanguinarine and berberine, and the antitussive and anticancer drug noscapine. BIA biosynthesis involves a restricted number of enzyme types that catalyze landmark coupling reactions and subsequent functional group modifications. A pathogenesis-related (PR)10/Bet v1 'Pictet-Spenglerase', several O-methyl-, N-methyl- and O-acetyltransferases, cytochromes P450, FAD-dependent oxidases, non-heme dioxygenases and NADPH-dependent reductases have been implicated in the multistep pathways leading to structurally diverse alkaloids. A small number of plant species, including opium poppy (Papaver somniferum) and other members of the Ranunculales, have emerged as model systems to study BIA metabolism. The expansion of resources to include a wider range of plant species is creating an opportunity to investigate previously uncharacterized BIA pathways. Contemporary knowledge of BIA metabolism reflects over a century of research coupled with the development of key innovations such as radioactive tracing, enzyme isolation and molecular cloning, and functional genomics approaches such as virus-induced gene silencing. Recently, the emergence of transcriptomics, proteomics and metabolomics has expedited the discovery of new BIA biosynthetic genes. The growing repository of BIA biosynthetic genes is providing the parts required to apply emerging synthetic biology platforms to the development of production systems in microbes as an alternative to plants as a commecial source of valuable BIAs.
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Affiliation(s)
- Jillian M Hagel
- Department of Biological Sciences, University of Calgary, Calgary, Alberta T2N 1N4, Canada
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11
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Intra-arterial dantrolene for refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2013; 17:245-9. [PMID: 22815125 DOI: 10.1007/s12028-012-9737-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Intravenous dantrolene has been used to prevent and treat cerebral vasospasm. We report a case of refractory cerebral vasospasm treated with intra-arterial dantrolene after aneurysmal subarachnoid hemorrhage. METHODS A 56-year-old woman suffered a diffuse subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm which was successfully treated with coil embolization. She subsequently developed bilateral severe angiographic vasospasm which was treated with intra-arterial vasodilators. However, owing to the recurrence of vasospasm, intra-arterial dantrolene followed by balloon angioplasty was used. RESULTS There was moderate improvement of the severe vasospasm in bilateral A1 segments of the anterior cerebral arteries after microcatheter-based intra-arterial infusion of 30 ml (1 mg/ml) dantrolene. Patient's hemodynamic parameters were monitored during and after the procedure and no significant changes were seen after dantrolene infusion. A follow up cerebral angiogram after 1 day demonstrated the persistence of therapeutic effect. CONCLUSION Intra-arterial dantrolene induced a sustained improvement in cerebral vasospasm secondary to ruptured aneurysm. No significant side effects were observed during or after the infusion of the drug.
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13
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Green DM, Burns JD, DeFusco CM. ICU management of aneurysmal subarachnoid hemorrhage. J Intensive Care Med 2012; 28:341-54. [PMID: 22328599 DOI: 10.1177/0885066611434100] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (SAH) has very high morbidity and mortality rates. Optimal intensive care unit (ICU) management requires knowledge of the potential complications that occur in this patient population. METHODS Review of the ICU management of SAH. Level of evidence for specific recommendations is provided. RESULTS Grading scales utilizing clinical factors and brain imaging studies can help in determining prognosis and are reviewed. Misdiagnosis of SAH is fairly common so the clinical symptoms and signs of SAH are summarized. The ICU management of SAH is discussed beginning with a focus on avoiding aneurysm re-rupture and securing the aneurysm, followed by a review of the neurologic and medical complications that may occur after the aneurysm is secured. Detailed treatment strategies and areas of current and future research are reviewed. CONCLUSIONS The ICU management of the patient with SAH can be particularly challenging and requires an awareness of all potential neurologic and medical complications and their urgent treatments.
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Affiliation(s)
- Deborah M Green
- Neurology and Neurosurgery, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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Qahwash OM, Alaraj A, Aletich V, Charbel FT, Amin-Hanjani S. Safety of early endovascular catheterization and intervention through extracranial-intracranial bypass grafts. J Neurosurg 2012; 116:201-7. [DOI: 10.3171/2011.8.jns11747] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goal of this study was to demonstrate feasibility and evaluate technical aspects of early endovascular access through extracranial-intracranial (EC-IC) bypass grafts.
Methods
Patients undergoing endovascular interventions through the graft in the acute postoperative period following EC-IC bypass are presented. Results, complications, and technical nuances are reviewed.
Results
Fourteen endovascular procedures were performed in 5 patients after EC-IC bypass for ruptured aneurysms in 4 patients and posterior circulation ischemia in 1 patient. In 2 patients, a saphenous vein graft (SVG) was used to bypass the common carotid artery (CCA) to the middle cerebral artery (MCA). One patient underwent a superficial temporal artery (STA)–MCA bypass, and in 2 other patients the STA stump was connected to the intracranial circulation via an interposition SVG. The interval from surgery to endovascular intervention spanned 2–18 days; the indication was intracranial vasospasm in all patients. One case involved angioplasty of the proximal anastomosis on postoperative Day 14. All other interventions entailed proximal access through the bypass conduit for intraarterial infusion of vasodilators. Significant vasospasm of the STA itself was encountered in 2 patients during endovascular manipulation, and it was treated with intraarterial nitroglycerin. There were no cases of anastomotic disruption.
Conclusions
Endovascular catheterization and intervention involving a recent EC-IC bypass is feasible. The main limitation in this series was catheter-induced vasospasm involving the STA. A vein graft may be the more appropriate option in patients with subarachnoid hemorrhage who may require subsequent endovascular intervention for vasospasm.
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Pandey P, Steinberg GK, Dodd R, Do HM, Marks MP. A Simplified Method for Administration of Intra-Arterial Nicardipine for Vasospasm With Cervical Catheter Infusion. Oper Neurosurg (Hagerstown) 2011; 71:77-85. [DOI: 10.1227/neu.0b013e3182426257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Nicardipine has previously been used to treat vasospasm through superselective intracranial microcatheter injections.
OBJECTIVE:
To evaluate a simple method of treatment of vasospasm with slow infusion of nicardipine from a cervical catheter.
METHODS:
Twenty-seven patients with symptomatic vasospasm were treated over 4 years with cervical catheter infusions. Nicardipine was infused at 20 mg/h for 30 to 60 minutes. Angioplasty was used in severe cases at the operator's discretion. Outcome at discharge and follow-up was evaluated with Glasgow Outcome Scale.
RESULTS:
Twenty-seven patients (17 women, 12 men) received intra-arterial therapy for vasospasm. Vasospasm treatment was done at a mean post-hemorrhage date of 7.2 days (range, 4-15 days). They underwent 48 sessions of treatment (mean, 1.8 per patient) in 72 separate arterial territories. Twelve patients underwent multiple treatments. The mean dose used per session was 19.2 mg (range, 5-50 mg). Four patients underwent angioplasty for severe vasospasm. Twenty-two patients (81.5%) had clinical improvement after the infusion. Angiographic improvement was seen in 86.1% of the vessels analyzed, which had moderate or severe spasm before infusion. Overall, 17 patients (62.9%) had good outcome (Glasgow Outcome Scale score, 4 and 5) at discharge, 11 had poor outcome, and 1 patient died. Follow-up was available in 19 patients, and 18 were doing well (Glasgow Outcome Scale score, 4 and 5).
CONCLUSION:
Intra-arterial nicardipine is an effective and safe treatment for cerebral vasospasm. In most patients, infusion can be performed from the cervical catheter, with microcatheter infusion and angioplasty reserved for the more severe and resistant cases.
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Affiliation(s)
| | | | - Robert Dodd
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Huy M. Do
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael P. Marks
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
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Predicting symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage: are we there yet? World Neurosurg 2011; 80:e161-3. [PMID: 22079275 DOI: 10.1016/j.wneu.2010.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 10/29/2010] [Indexed: 11/21/2022]
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