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Lei G, Rao Z, Hu Y. The efficacy of different nimodipine administration route for treating subarachnoid hemorrhage: A network meta-analysis. Medicine (Baltimore) 2023; 102:e34789. [PMID: 37773855 PMCID: PMC10545353 DOI: 10.1097/md.0000000000034789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND A systematic review and network meta-analysis (NMA) were conducted to explore the optimal administration route of nimodipine for treatment subarachnoid hemorrhage. METHODS Electronic databases (Pubmed, Embase, Web of Science and Cochrane databases) were systematically searched to identify randomized controlled trials evaluating different administration route of nimodipine (intravenous and enteral) versus placebo for treatment subarachnoid hemorrhage. Outcomes included case fatality at 3 months, poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), incidence of delayed cerebral ischemia (DCI), delayed ischemic neurological deficit. A random-effect Bayesian NMA was conducted for outcomes of interest, and results were presented as odds ratios (ORs) and 95% credible intervals. The NMA was performed using R Software with a GeMTC package. A Bayesian NMA was performed and relative ranking of agents was assessed using surface under the cumulative ranking (SUCRA) probabilities. RESULTS Nine randomized controlled trials met criteria for inclusion and finally included in this NMA. There was no statistically significant between intravenous and enteral in terms of case fatality, the occurrence of DCI, delayed ischemic neurologic deficit and poor outcomes (P > .05). Both intravenous and enteral could reduce case fatality, the occurrence of DCI, delayed ischemic neurologic deficit and poor outcomes (P < .05). The SUCRA shows that enteral ranked first, intravenous ranked second and placebo ranked the last for case fatality, the occurrence of DCI and poor outcomes. The SUCRA shows that intravenous ranked first, enteral ranked second and placebo ranked the last for delayed ischemic neurologic deficit. CONCLUSIONS It is possible that both enteral and intravenous nimodipine have comparable effectiveness in preventing poor outcomes, DCI, and delayed ischemic neurological deficits. However, further investigation may be necessary to determine the exact role of intravenous nimodipine in current clinical practice.
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Affiliation(s)
- Gang Lei
- Department of Neurology, Tianyou Hospital Affiliated to Wuhan University of Science and Technolog, Wuhan, China
| | - Zhongxian Rao
- Hospital of Wuhan University of science and technology, Wuhan, China
| | - Yuping Hu
- Hubei University of Chinese Medicine, Wuhan, China
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2
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Chousterman B, Leclère B, Morisson L, Eude Y, Gayat E, Mebazaa A, Cinotti R. A network meta-analysis of therapeutic and prophylactic management of vasospasm on aneurysmal subarachnoid hemorrhage outcomes. Front Neurol 2023; 14:1217719. [PMID: 37662039 PMCID: PMC10469900 DOI: 10.3389/fneur.2023.1217719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Background Vasospasm and cerebral ischemia after aneurysmal subarachnoid hemorrhage are associated with mortality and poor neurological outcomes. We studied the efficacy of all available strategies targeting vasospasm and cerebral ischemia on outcomes in a network meta-analysis. Methods We searched EMBASE and MEDLINE databases from 1 January 1990 and 28 November 2021 according to PRISMA guidelines. Randomized controlled trials and longitudinal studies were included. All curative or preventive strategies targeting vasospasm and/or cerebral ischemia were eligible. A network meta-analysis was performed to compare all interventions with one another in a primary (randomized controlled trials only) and a secondary analysis (both trials and longitudinal studies). Mortality by 3 months was the primary outcome. Secondary outcomes were vasospasm, neurological outcome by 3 months, and dichotomized as "good" or "poor" recovery according to each study definition. Results A total of 2,382 studies were screened which resulted in the selection of 192 clinical trials (92 (47.9%) and 100 cohorts (52.1%) and the inclusion of 41,299 patients. In randomized controlled studies, no strategy decreased mortality by 3 months. Statins (0.79 [0.62-1]), tirilazad (0.82 [0.69-0.97]), CSF drainage (0.47 [0.29-0.77]), and clazosentan (0.51 [0.36-0.71]) significantly decreased the incidence of vasospasm. Cilostazol was the only treatment associated with improved neurological outcomes by 3 months in the primary (OR 1.16, 95% CI [1.05-1.28]) and secondary analyses (OR 2.97, 95% CI [1.39-6.32]). Discussion In the modern era of subarachnoid hemorrhage, all strategies targeting vasospasm failed to decrease mortality. Cilostazol should be confirmed as a treatment to improve neurological outcomes. The link between vasospasm and neurological outcome appears questionable. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=116073, identifier: PROSPERO CRD42018116073.
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Affiliation(s)
- Benjamin Chousterman
- Department of Anesthesia and Critical Care, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, University Hospital of Saint-Louis-Lariboisière, Paris, France
- UMR 942 MASCOT, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Brice Leclère
- Public Health Department, Hôpital Saint-Jacques, University Hospital of Nantes, Nantes, France
- MiHAR, IRS 2, University of Nantes, Nantes, France
| | - Louis Morisson
- Department of Anesthesia and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, Boulevard de l'Assomption, University of Montréal, Montréal, QC, Canada
| | - Yannick Eude
- Public Health Department, Hôpital Saint-Jacques, University Hospital of Nantes, Nantes, France
| | - Etienne Gayat
- Department of Anesthesia and Critical Care, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, University Hospital of Saint-Louis-Lariboisière, Paris, France
- UMR 942 MASCOT, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, University Hospital of Saint-Louis-Lariboisière, Paris, France
- UMR 942 MASCOT, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Raphael Cinotti
- Department of Anesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France
- UMR 1246 SPHERE MethodS in Patients-Centered Outcomes and Health Research, Institut de Recherche en Santé 2, Nantes, France
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3
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Intravenous Nimodipine Versus Enteral Nimodipine: The Meta-analysis Paradox. Neurocrit Care 2022; 37:813-814. [PMID: 36050536 DOI: 10.1007/s12028-022-01589-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 10/14/2022]
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4
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A Comparison Between Enteral and Intravenous Nimodipine in Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis. Neurocrit Care 2022; 36:1071-1079. [PMID: 35419702 DOI: 10.1007/s12028-022-01493-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/14/2022] [Indexed: 12/13/2022]
Abstract
Our objective was to compare the effectiveness of intravenous and enteral nimodipine in preventing poor outcome from delayed cerebral ischemia in patients with subarachnoid hemorrhage. We performed a systematic search and a network meta-analysis using the following databases: PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar. Risk of Bias 2 tool was used to assess risk of bias of included studies. A ranking among methods was performed on the basis of the frequentist analog of the surface under the cumulative ranking curve. Published studies that met the following population, intervention, comparison, outcomes and study (PICOS) criteria were included: patients with subarachnoid hemorrhage aged 15 years or older (P); nimodipine, intravenous and oral formulation (I); placebo or no intervention (C); poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), case fatality at 3 months, delayed cerebral ischemia, delayed ischaemic neurologic deficit, and vasospasm measured with transcranial Doppler or digital subtraction angiography (O); and randomized controlled trials (S). No language or publication date restrictions were applied. Ten studies were finally included, with a total of 1527 randomly assigned patients. Oral and intravenous nimodipine were both effective in preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. Neither treatment was effective in improving case fatality. Evolving clinical protocols over a 30-year period and the risk of bias of the included studies may limit the strength of our results. Enteral and intravenous nimodipine may have a similar effectiveness in terms of preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. More research may be needed to fully establish the role of intravenous nimodipine in current clinical practice.
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5
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Dayyani M, Sadeghirad B, Grotta JC, Zabihyan S, Ahmadvand S, Wang Y, Guyatt GH, Amin-Hanjani S. Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials. Stroke 2022; 53:1993-2005. [PMID: 35354302 DOI: 10.1161/strokeaha.121.035699] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials. METHODS We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence. RESULTS We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia. CONCLUSIONS Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.
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Affiliation(s)
- Mojtaba Dayyani
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, TX (M.D.).,Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.).,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. (B.S.).,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada. (B.S.)
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center (J.C.G.)
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Saba Ahmadvand
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
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Göttsche J, Schweingruber N, Groth JC, Gerloff C, Westphal M, Czorlich P. Safety and Clinical Effects of Switching From Intravenous to Oral Nimodipine Administration in Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:748413. [PMID: 34867733 PMCID: PMC8636241 DOI: 10.3389/fneur.2021.748413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Several guidelines recommend oral administration of nimodipine as vasospasm prophylaxis after aneurysmal subarachnoid hemorrhage (SAH). However, in clinical practice, the drug is administered orally and intravenously (i.v.), depending on clinical conditions and local treatment regimens. We have therefore investigated the safety and clinical effects of switching from i.v. to oral nimodipine therapy. Methods: Patients with aneurysmal SAH between January 2014 and April 2018 and initial i.v. nimodipine therapy, which was subsequently switched to oral administration, were included in this retrospective study. Transcranial Doppler sonography (TCD) of the vessels of the anterior circulation was performed daily. The occurrence of vasospasm and infarction during the overall course of the treatment was recorded. Statistical level of significance was set to p < 0.05. Results: A total of 133 patients (mean age 55.8 years, 65% female) initially received nimodipine i.v. after aneurysmal SAH, which was subsequently switched to oral administration after a mean of 12 days. There were no significant increases in mean flow velocities on TCD after the switch from i.v. to oral nimodipine administration regarding the anterior cerebral artery. For the middle cerebral artery, an increase from 62.36 to 71.78 cm/sec could only be detected in the subgroup of patients with infarction. There was no clustering of complicating events such as new-onset vasospasm or infarction during or after the switch. Conclusions: Our results do not point to any safety concerns when switching nimodipine from initial i.v. to oral administration. Switching was neither associated with clinically relevant increases in TCD velocities nor other relevant adverse events.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, Hamburg University Medical Center, Hamburg, Germany
| | | | - Christian Gerloff
- Department of Neurology, Hamburg University Medical Center, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
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7
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Abstract
Nimodipine has been shown to improve outcomes following aneurysmal subarachnoid hemorrhage. Guidelines recommend that all patients receive a fixed dose of oral nimodipine for 21 days. However, pharmacokinetic studies have suggested variability of nimodipine pharmacokinetics in subarachnoid hemorrhage and in other patient populations. The clinical relevance of such variability is unknown. Therefore, the objective of the present review is, first, to conduct a literature review and summarize nimodipine pharmacokinetic data and sources of variability in various patient groups. Second, to determine if there is any evidence reporting an association between nimodipine exposure and clinical outcomes in patients with subarachnoid hemorrhage. A systematic literature search was performed in MEDLINE and EMBASE. The following keywords were used: ("nimodipine" OR "nymalize" OR "nimotop") AND ("pharmacokinetic*", OR "PK"). The search results were limited to English language and human studies. A large interpatient variability in nimodipine pharmacokinetics has been reported. Patient-specific factors that had an influence on pharmacokinetic parameters are age, comorbidities, variabilities in metabolism due to genetic polymorphism and co-administered medications, as well as nimodipine administration technique. The association between nimodipine exposure and clinical outcomes remains unclear and data available are too scarce to reach a firm conclusion. Here, we present a narrative review with a systematic literature search discussing nimodipine pharmacokinetic variability in various patient populations. It is not clear if minimal or lack of systemic exposure to nimodipine denies its benefit and contributes to worsening outcomes in patients with subarachnoid hemorrhage. Further studies are needed to determine if such an association exists.
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8
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Cerebrospinal Fluid Concentrations of Nimodipine Correlate With Long-term Outcome in Aneurysmal Subarachnoid Hemorrhage: Pilot Study. Clin Neuropharmacol 2020; 42:157-162. [PMID: 31306217 DOI: 10.1097/wnf.0000000000000356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim was to evaluate plasma and cerebrospinal fluid (CSF) nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage and their correlation with clinical outcome. METHODS Nimodipine infusion was started at 1 mg/h and increased up to 2 mg/h and continued up to 21 days in surviving patients. Arterial and CSF samples were collected at least after 24 hours of stable nimodipine dosing. Delayed cerebral ischemia and vasospasm were documented by new neurological deficits and neuroimaging. The clinical outcome was assessed at 9 months by the modified Rankin scale. RESULTS Twenty-three patients were enrolled. Nimodipine dose was 13 to 38 μg/kg per hour. Nimodipine arterial and CSF concentrations were 24.9 to 71.8 ng/mL and 37 to 530 pg/mL, respectively. Dose did not correlate with arterial or CSF concentrations. Arterial concentrations did not correlate with corresponding CSF concentrations. Doses and arterial concentrations did not correlate with the clinical outcome and were not associated with the occurrence of delayed cerebral ischemia. However, patients with no significant disability after 9 months of hemorrhage showed significantly higher CSF nimodipine concentrations (P = 0.015) and CSF-to-plasma ratios (P = 0.011) compared with patients who showed some degree of disability or who died. CONCLUSIONS Cerebrospinal fluid nimodipine concentrations measured during hospital drug infusion showed a correlation with long-term clinical outcome in patients with aneurysmal subarachnoid hemorrhage. These very preliminary data suggest that CSF concentrations monitoring may have some value in managing these patients.
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9
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The role of nimodipine and magnesium sulfate in the prevention and treatment of vascular spasm in patients in the acute rupture of cerebral aneurysms. ACTA ACUST UNITED AC 2020. [DOI: 10.17816/clinpract19137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vascular spasm in patients with hemorrhage from rupture of cerebral aneurysms is the main cause of adverse outcomes of the disease. One way to treat persistent contraction of cerebral arteries is to use nimodipine and magnesium sulfate. This literature review presents studies on the use of nimodipine and magnesium sulfate in the treatment of vascular spasm, and highlights the main links of pathogenesis and drug action mechanisms.
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10
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Carlson AP, Hänggi D, Macdonald RL, Shuttleworth CW. Nimodipine Reappraised: An Old Drug With a Future. Curr Neuropharmacol 2020; 18:65-82. [PMID: 31560289 PMCID: PMC7327937 DOI: 10.2174/1570159x17666190927113021] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/02/2019] [Accepted: 09/25/2019] [Indexed: 12/21/2022] Open
Abstract
Nimodipine is a dihydropyridine calcium channel antagonist that blocks the flux of extracellular calcium through L-type, voltage-gated calcium channels. While nimodipine is FDAapproved for the prevention and treatment of neurological deficits in patients with aneurysmal subarachnoid hemorrhage (aSAH), it affects myriad cell types throughout the body, and thus, likely has more complex mechanisms of action than simple inhibition of cerebral vasoconstriction. Newer understanding of the pathophysiology of delayed ischemic injury after a variety of acute neurologic injuries including aSAH, traumatic brain injury (TBI) and ischemic stroke, coupled with advances in the drug delivery method for nimodipine, have reignited interest in refining its potential therapeutic use. In this context, this review seeks to establish a firm understanding of current data on nimodipine's role in the mechanisms of delayed injury in aSAH, TBI, and ischemic stroke, and assess the extensive clinical data evaluating its use in these conditions. In addition, we will review pivotal trials using locally administered, sustained release nimodipine and discuss why such an approach has evaded demonstration of efficacy, while seemingly having the potential to significantly improve clinical care.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Daniel Hänggi
- Department of Neurosurgery, University of Dusseldorf Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Robert L. Macdonald
- University of California San Francisco Fresno Department of Neurosurgery and University Neurosciences Institute and Division of Neurosurgery, Department of Surgery, University of Toronto, Canada
| | - Claude W. Shuttleworth
- Department of Neuroscience University of New Mexico School of Medicine, Albuquerque, NM, USA
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Kaneko J, Tagami T, Unemoto K, Tanaka C, Kuwamoto K, Sato S, Tani S, Shibata A, Kudo S, Kitahashi A, Yokota H. Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage. J NIPPON MED SCH 2019; 86:81-90. [PMID: 31130569 DOI: 10.1272/jnms.jnms.2019_86-203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus. METHODS We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes. RESULTS A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8). CONCLUSIONS Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.
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Affiliation(s)
- Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital.,Health Services and Systems Research, Duke-NUS Medical School.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Chie Tanaka
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | | | - Shin Sato
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Shosei Tani
- Department of Neurosurgery, Tominaga Hospital
| | - Ami Shibata
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Saori Kudo
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Akiko Kitahashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School
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12
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Griffiths S, Clark J, Adamides AA, Ziogas J. The role of haptoglobin and hemopexin in the prevention of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a review of current literature. Neurosurg Rev 2019; 43:1273-1288. [PMID: 31493061 DOI: 10.1007/s10143-019-01169-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 01/01/2023]
Abstract
Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major cause of mortality and morbidity. The pathophysiology of DCI after aSAH is thought to involve toxic mediators released from lysis of red blood cells within the subarachnoid space, including free haemoglobin and haem. Haptoglobin and hemopexin are endogenously produced acute phase proteins that are involved in the clearance of these toxic mediators. The aim of this review is to investigate the pathophysiological mechanisms involved in DCI and the role of both endogenous as well as exogenously administered haptoglobin and hemopexin in the prevention of DCI.
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Affiliation(s)
- Sean Griffiths
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia. .,Western Hospital, 160 Gordon St, Footscray, 3011, Australia.
| | - Jeremy Clark
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - Alexios A Adamides
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - James Ziogas
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, 3010, Australia
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13
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Ren C, Gao J, Xu GJ, Xu H, Liu G, Liu L, Zhang L, Cao JL, Zhang Z. The Nimodipine-Sparing Effect of Perioperative Dexmedetomidine Infusion During Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Controlled Trial. Front Pharmacol 2019; 10:858. [PMID: 31427968 PMCID: PMC6688624 DOI: 10.3389/fphar.2019.00858] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/05/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Nimodipine can block the influx of calcium into the vascular smooth muscle cell and prevent secondary ischemia in patients with aneurysmal subarachnoid hemorrhage. However, the reduction of blood pressure after long-term intravenous administration of nimodipine has been associated with neurological deterioration. Yet, no effective solutions have been suggested to address this phenomenon. The use of neuroprotective drug combinations may reduce the risk of sudden blood pressure loss. This prospective, randomized, controlled trial was performed to evaluate the nimodipine-sparing effect of perioperative dexmedetomidine infusion during aneurysmal subarachnoid hemorrhage. Methods: One hundred nine patients who underwent aneurysm embolization were divided into three groups: group C (n = 35, infused with 0.9% sodium chloride at the same rate as other two groups), group D1 (n = 38, dexmedetomidine infusion at 0.5 µg·kg–1 for 10 min, then adjusted to 0.2 µg·kg–1·h–1), and group D2 (n = 36, dexmedetomidine infusion at 0.5 µg·kg–1 for 10 min, then adjusted to 0.4 µg·kg–1·h–1). Patient-controlled analgesia was given for 48 h after surgery. The primary outcome measure was the total consumption of nimodipine during the first 48 h after surgery. The secondary outcome measures were recovery time at post-anesthesia care unit (PACU), postoperative pain intensity scores, dexmedetomidine and sufentanil consumption, hemodynamic, satisfaction of patients and neurosurgeon, neurologic examination (Glasgow Coma Scale, GCS), Bruggemann comfort scale, and adverse effects. Intraoperative hemodynamics were recorded at the following time-points: arrival at the operating room (T1); before intubation (T2); intubation (T3); 5 min (T4), 10 min (T5), and 15 min (T6) after intubation; suturing of femoral artery (T7); end of surgery (T8); extubation (T9); and 5 min (T10), 10 min (T11), and 15 min (T12) after arrival at the PACU. The level of sedation was recorded at 15 min, 30 min, 1 h, and 2 h after extubation. We also recorded the incidence of symptomatic cerebral vasospasm during 7 days after surgery, Glasgow Outcome Score (GOS) at 3 months, and incidence of cerebral infarction 30 days after surgery. Results: The consumption of nimodipine during the first 48 h after surgery was significantly lower in group D2 (P < 0.05). Compared with group C, HR and MAP were significantly decreased from T2 to T12 in group D1 and D2 (P < 0.05). Patients in group D2 showed a significantly decreased MAP from T5 to T9 compared with group D1 (P < 0.05). The consumption of sevoflurane, remifentanil, dexmedetomidine, and nimodipine were all significantly reduced in groups D1 and D2 during surgery (P < 0.05). Compared with group C, MAP was significantly decreased in groups D1 and D2 during the first 48 h after surgery (P < 0.05). Compared with group C, consumption of sufentanil and dexmedetomidine at 1 h, pain intensity at 1 h, and 8 h after surgery were significantly decreased in groups D1 and D2 (P < 0.05). FAS was significantly higher in group D2 at 8 h, 16 h, and 24 h after surgery. LOS was significantly lower only in group D2 at 0.5 h after surgery (P < 0.05). Compared with group C, BCS was significantly higher group D2 at 4 h and 8 h after surgery (P < 0.05). There were no significant differences among the three groups in consumption of propofol, cisatracurium, fentanyl, and vasoactive drugs during operation, recovery time at PACU, satisfaction of patients and neurosurgeon, and number of applied urapidil and GCS during the first 48 h after surgery. The incidence of symptomatic cerebral vasospasm during 7 days after surgery, GOS of 3 months, and cerebral infarction after 30 days were also comparable among the three groups. Conclusions: Dexmedetomidine (infusion at 0.5 µg·kg–1 for 10 min, then adjusted to 0.4 µg·kg–1·h–1 during the surgery) significantly reduced the total consumption of nimodipine during the first 48 h after surgery and promoted early rehabilitation of patients although the incidences of symptomatic cerebral vasospasm, GOS, and cerebral infarction were not reduced.
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Affiliation(s)
- Chunguang Ren
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Jian Gao
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Guang Jun Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Huiying Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Guoying Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Lei Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Jun-Li Cao
- Department of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Zongwang Zhang
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
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14
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Blackburn SL, Swisher CB, Grande AW, Rubi A, Verbick LZ, McCabe A, Lad SP. Novel Dual Lumen Catheter and Filtration Device for Removal of Subarachnoid hemorrhage: First Case Report. Oper Neurosurg (Hagerstown) 2018; 16:E148-E153. [DOI: 10.1093/ons/opy151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/16/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
The amount of subarachnoid blood and the presence of toxic blood breakdown products in the cerebrospinal fluid (CSF) have long been associated with poor outcomes in aneurysmal subarachnoid hemorrhage. The Neurapheresis™ system (Minnetronix Inc, St. Paul, Minnesota) has been developed to filter CSF and remove blood products, and is being investigated for safety and feasibility in the ExtracorPoreal FILtration of subarachnoid hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device.
CLINICAL PRESENTATION
A 65-yr-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 h of filtration during 31 h of catheter indwelling resulted in 309.47 mL of processed CSF without complication. Computed tomography images demonstrated an interval reduction of subarachnoid hemorrhage immediately after filtration. The patient was discharged home on postbleed day 11 and at 30 d showed good recovery.
CONCLUSION
Safety of the Neurapheresis procedure was confirmed in this first case, and we will continue to evaluate safety of the Neurapheresis system through the PILLAR trial.
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Affiliation(s)
- Spiros L Blackburn
- Department of Neurosurgery, University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Christa B Swisher
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Alba Rubi
- Department of Neurosurgery, University of Texas Health Sciences Center at Houston, Houston, Texas
| | | | | | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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15
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Samseethong T, Suansanae T, Veerasarn K, Liengudom A, Suthisisang C. Impact of Early Versus Late Intravenous Followed by Oral Nimodipine Treatment on the Occurrence of Delayed Cerebral Ischemia Among Patients With Aneurysm Subarachnoid Hemorrhage. Ann Pharmacother 2018; 52:1061-1069. [PMID: 29783859 DOI: 10.1177/1060028018778751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Guidelines for aneurysm subarachnoid hemorrhage (aSAH) management recommend treatment with nimodipine to all patients to reduce delayed cerebral ischemia (DCI) and poor clinical outcome. However, it did not give the most beneficial time to start therapy and route of administration. OBJECTIVES To compare the DCI occurrence and clinical outcome among aSAH patients who received nimodipine treatment at different times. METHODS A retrospective cohort study was conducted by collecting data from medical chart reviews between August 30, 2010, and October 31, 2015, at Prasart Neurological Institute, Thailand. Patients were classified into 2 groups by time to receive nimodipine: early group and late group (<96 and >96 hours, respectively). All patients received intravenous (IV) followed by oral nimodipine to complete treatment course. Clinical outcome was graded using the Glasgow Outcome Scale at 21 days. The factors related to DCI were analyzed using multivariate logistic regression. RESULTS A total of 149 patients were recruited: early (n = 97) and late (n = 52). No difference in baseline characteristics between groups was observed. The occurrence of DCI was not statistically significantly different between groups (early group, 18.60%, vs late group, 20.80%; P = 0.74). The World Federation of Neurosurgical Societies IV to V was associated with DCI occurrence. The proportion of patients with good outcome, poor outcome, or death did not show any difference between groups. CONCLUSIONS AND RELEVANCE Receiving IV nimodipine 3 to 7 days following oral therapy after bleeding can be the alternative regimen in patients who did not start nimodipine within 96 hours.
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Affiliation(s)
- Tipada Samseethong
- 1 Mahidol University, Bangkok, Thailand.,2 Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | | | | | - Anusak Liengudom
- 3 Prasat Neurological Institute, Bangkok, Thailand.,4 Vichaiyut Hospital, Bangkok, Thailand
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16
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Zhang Q, Li Y, Bao Y, Yin C, Xin X, Guo Y, Gao F, Huo S, Wang X, Wang Q. Pretreatment with nimodipine reduces incidence of POCD by decreasing calcineurin mediated hippocampal neuroapoptosis in aged rats. BMC Anesthesiol 2018; 18:42. [PMID: 29661144 PMCID: PMC5902967 DOI: 10.1186/s12871-018-0501-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/29/2018] [Indexed: 12/31/2022] Open
Abstract
Background Calcineurin (CaN) having a high expression in hippocampal neurons is closely related to apoptosis. Pretreatment with nimodipine can lower the apoptosis rate of hippocampal neuron to reduce the incidence of postoperative cognitive dysfunction (POCD). However, the relationship between cerebral protective effect of pretreatment with nimodipine and CaN is controversial in the literature. The aim of this study is to evaluate the relationship between neuroprotective effect of nimodipine and CaN on POCD in aged rats. Methods Ninety-six 18-month-old male Sprague-Dawley rats were randomly assigned into 4 groups (n = 24 each): control group (Group C), nimodipine group (Group N), surgery group (Group S) and nimodipine + surgery group (Group N + S). In Group N and Group N + S, nimodipine 1 mg/kg was intraperitoneally injected, while the equal volume of normal saline was given instead in Group S. 30 min later, Group N and Group C inhaled pure oxygen for 2 h, and Group S and N + S inhaled 3% sevoflurane for 2 h when exploratory laparotomy was performed. Morris water maze test was performed on 1 day before operation and 1, 3 and 7 days after operation. After the end of Morris water maze test at 1 day before operation and 1 and 7 days after operation, 8 rats were sacrificed, brains were removed and hippocampal tissues were obtained for detection of apoptosis in hippocampal neurons, cytoplasmic calcium ([Ca2+]i), and hippocampal CaN and caspase-3 expression. Results Compared with the 1st day before operation, the escape latency, apoptosis rate, [Ca2+]i, expression of CaN and caspase-3 increased significantly, but the frequency of crossing the original platform decreased dramatically in Group S and N + S(P<0.05). In addition, the escape latency, apoptosis rate, [Ca2+]i, and expression of CaN and caspase-3 decreased markedly, but the frequency of crossing the original platform increased significantly in Group N + S as compared with Group S (P<0.05). Conclusions Pretreatment with nimodipine reduces the incidence of POCD by decreasing CaN mediated hippocampal neuroapoptosis in aged rats.
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Affiliation(s)
- Qi Zhang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Yanan Li
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Yongjuan Bao
- Editorial Department of Chinese Journal of Anesthesiology, Hebei Provincial Institute of Medical Science Information, No. 050071, Western Heping Road, Shijiazhuang City, 050071, Hebei, China
| | - Chunping Yin
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Xi Xin
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Yangyang Guo
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Fang Gao
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Shuping Huo
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Xiuli Wang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China
| | - Qiujun Wang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang City, 050051, Hebei, China.
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17
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Tallarico RT, Pizzi MA, Freeman WD. Investigational drugs for vasospasm after subarachnoid hemorrhage. Expert Opin Investig Drugs 2018; 27:313-324. [DOI: 10.1080/13543784.2018.1460353] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Yu S, Zeng Y, Sun X. Neuroprotective effects of p53/microRNA‑22 regulate inflammation and apoptosis in subarachnoid hemorrhage. Int J Mol Med 2018; 41:2406-2412. [PMID: 29336471 DOI: 10.3892/ijmm.2018.3392] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/22/2017] [Indexed: 11/06/2022] Open
Affiliation(s)
- Shui Yu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Yi‑Jun Zeng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Xiao‑Chuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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19
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Stehouwer BL, van der Kleij LA, Hendrikse J, Rinkel GJ, De Vis JB. Magnetic resonance imaging and brain injury in the chronic phase after aneurysmal subarachnoid hemorrhage: A systematic review. Int J Stroke 2017; 13:24-34. [PMID: 28920537 DOI: 10.1177/1747493017730781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Case-fatality rates after aneurysmal subarachnoid hemorrhage have decreased over the past decades. However, many patients who survive an aneurysmal subarachnoid hemorrhage have long-term functional and cognitive impairments. Aims We sought to review all data on conventional brain MRI obtained in the chronic phase after aneurysmal subarachnoid hemorrhage to (1) analyze the proportion of patients with cerebral infarction or brain volume changes; (2) investigate baseline determinants predictive of MRI-detected damage; and (3) assess if brain damage is predictive of patient outcome. Summary of review All original data published between 1 January 2000 and 4 October 2017 was searched using the PUBMED, EMBASE, and Web of Science databases. Based on preset inclusion criteria, 15 from 5200 articles were included with a total of 996 aneurysmal subarachnoid hemorrhage patients. Quality assessment, risk of bias assessment, and level of evidence assessment were performed. The results according to aim, with levels of evidence, were: (1) 25 to 81% of aneurysmal subarachnoid hemorrhage patients show infarcts (strong); there is a higher ratio of cerebrospinal fluid-to-intracranial volume in patients compared to controls (strong); (2) there is a negative relation between age (moderate), DCI (low) and brain volume measurement outcomes; (3) lower brain parenchymal volume (strong) and the presence of infarcts or infarct volumes (moderate) are associated with a worse outcome. Conclusion Patients after aneurysmal subarachnoid hemorrhage may demonstrate brain infarcts and decreased brain parenchyma, which is related to worse outcome. Thereby, both brain infarcts and brain volume measurements could be used as outcome markers in pharmaceutical trials. Systematic Review Registration PROSPERO CRD42016040095.
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Affiliation(s)
- Bertine L Stehouwer
- 1 Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lisa A van der Kleij
- 1 Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen Hendrikse
- 1 Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gabriel Je Rinkel
- 2 Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jill B De Vis
- 1 Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.,3 Division of Magnetic Resonance Research, Russell H. Morgan Department of Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Rustemi O. Letter by Rustemi Regarding Article, “Randomized, Open-Label, Phase 1/2a Study to Determine the Maximum Tolerated Dose of Intraventricular Sustained Release Nimodipine for Subarachnoid Hemorrhage (NEWTON [Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage])”. Stroke 2017; 48:e113. [DOI: 10.1161/strokeaha.116.016512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Oriela Rustemi
- Department of Neuroscience and Neurosurgery, San Bortolo Hospital, Vicenza, Italy
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21
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Albanna W, Weiss M, Conzen C, Clusmann H, Schneider T, Reinsch M, Müller M, Wiesmann M, Höllig A, Schubert GA. Systemic and Cerebral Concentration of Nimodipine During Established and Experimental Vasospasm Treatment. World Neurosurg 2017; 102:459-465. [PMID: 28344178 DOI: 10.1016/j.wneu.2017.03.062] [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: 01/04/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Oral nimodipine is an established prophylactic agent for cerebral vasospasm after subarachnoid hemorrhage (SAH). In highly selected cases, intra-arterial (IA) or intravenous (IV) application of nimodipine may be considered; however, the optimum dosage and modality of application remain a matter of debate. The purpose of this investigation is analysis of nimodipine concentration in serum, cerebrospinal fluid, and cerebral microdialysate in the context of currently effective dose and route of application (oral, IA, IV). METHODS We prospectively collected 156 samples from 37 patients treated for aneurysmal SAH from May 2014 to July 2015. Treatment groups were stratified according to modality of application and low-dose or high-dose treatment. At time of sampling, current dose and modality of application effectively sustained cerebral perfusion as documented by common diagnostics. Samples were analyzed for nimodipine concentration via high-performance liquid chromatography and tandem mass spectrometry. RESULTS In most cases (94.3%), nimodipine remained below the limit of quantification (0.5 ng/mL) within the brain (microdialysis, cerebrospinal fluid), even during targeted, local application (IA nimodipine). The median serum concentration for all treatment groups was 17.3 ng/mL. Modality of application (oral, IA, IV) was not associated with significant differences in serum concentrations (P = 0.712), even after stratification for dosage (P = 0.371), implying a comparable systemic distribution, if not efficacy. CONCLUSIONS Nimodipine does not accumulate sufficiently within the target organ for treatment monitoring. Comparable systemic concentrations can be observed irrespective of application modality and dosing. Future studies will clarify the role of efficacy-driven treatment algorithms, in which lowest dose and least invasive mode of application still effective should be identified.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Toni Schneider
- Department of Neurophysiology, University of Cologne, Cologne, Germany
| | | | - Marguerite Müller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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22
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Veldeman M, Höllig A, Clusmann H, Stevanovic A, Rossaint R, Coburn M. Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review. Br J Anaesth 2016; 117:17-40. [PMID: 27160932 DOI: 10.1093/bja/aew095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED : The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials. CLINICAL TRIAL REGISTRATION This systematic review was registered in the international prospective register of systematic reviews. PROSPERO CRD42015019817.
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Affiliation(s)
- M Veldeman
- Department of Neurosurgery Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | | | | | - A Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - M Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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Pharmacological agents in aneurysmal subarachnoid hemorrhage: successes and failures. Clin Neuropharmacol 2016; 38:104-8. [PMID: 25970278 DOI: 10.1097/wnf.0000000000000085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition with high mortality. Proper management of this complex disease requires early surgical intervention followed by medical therapy. Pharmacological agents that unequivocally improve outcomes in aSAH are scarce. METHODS The authors performed an exhaustive query of several databases including MEDLINE, the CENTRAL Register of Controlled Trials, and the Cochrane Database of Systematic Reviews for specific evidence on key medications that have been used in the treatment of aSAH. RESULTS The bulk of the data available pertained to the following medications: calcium channel blockers, magnesium, statins, antifibrinolytics, aspirin, glucocorticoids, clazosentan, and tirilazad. Except for calcium channel blockers, the authors could not find any hard evidence that any of these agents affected outcome to a tangible degree. Aspirin may have some promise in prevention of aneurysm rupture and incidence of aSAH, but more substantive data are needed to conclusively corroborate this. CONCLUSIONS Investigational efforts to attain outcome-modifying agents have had dubious results, but the inquest for discovery should not discontinue.
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A dilemma regarding the optimal administration of nimodipine in the subarachnoid hemorrhage. Acta Neurochir (Wien) 2015; 157:1131-2. [PMID: 25948077 PMCID: PMC4471394 DOI: 10.1007/s00701-015-2429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/14/2015] [Indexed: 11/29/2022]
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25
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Abboud T, Regelsberger J. Serum Levels of Nimodipine in Enteral and Parenteral Administration in Patients with Aneurysmal Subarachnoid Hemorrhage. Acta Neurochir (Wien) 2015; 157:1133-4. [PMID: 25976341 DOI: 10.1007/s00701-015-2447-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 05/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Tammam Abboud
- Department of Neurosurgery, University Medical Center Hamburg Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany,
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Huttunen J, Kurki MI, von und zu Fraunberg M, Koivisto T, Ronkainen A, Rinne J, Jaaskelainen JE, Kalviainen R, Immonen A. Epilepsy after aneurysmal subarachnoid hemorrhage: A population-based, long-term follow-up study. Neurology 2015; 84:2229-37. [DOI: 10.1212/wnl.0000000000001643] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/20/2015] [Indexed: 11/15/2022] Open
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Serum levels of nimodipine in enteral and parenteral administration in patients with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2015; 157:763-7. [PMID: 25701099 DOI: 10.1007/s00701-015-2369-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/02/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate serum nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage (SAH) after parenteral therapy and a following course of enteral administration. METHODS SAH patients were treated with intravenous nimodipine (2 mg/h) during the 1st week after hemorrhage, and on day 8, we switched over to enteral administration (60 mg/4 h), either orally or by gavage. Serum nimodipine concentrations were measured on days 3, 5, 8, 9 and 12. Area under the curve (AUC) was calculated during parenteral and enteral therapy. The data of 15 patients were analyzed retrospectively. RESULTS In this study, 157 blood samples were obtained. In seven samples, during the administration by gavage to two patients with high-grade SAH, the serum nimodipine concentrations were negligible. The AUC values during parenteral administration (median 149.3 ng-h/ml) were significantly higher than during oral administration on days 9 (median 92.1 ng-h/ml) and 12 (median 44.1 ng-h/ml) in seven patients (p = 0.030 and p = 0.016, respectively). The AUC values during parenteral administration were significantly higher than during administration by gavage on day 9 in eight patients (median 87.9 and 34 ng-h/ml, respectively, p = 0.001). The AUC values during enteral administration were higher in patients who received nimodine orally than in those who received it by gavage (median 52.3 and 23.1 ng-h/ml, respectively, p = 0.006). CONCLUSIONS Enteral administration of nimodipine showed lower bioavailability during the 2nd week after SAH compared to parenteral application during the 1st week. Negligible serum concentrations were even expected when nimodipine was given by gavage in patients with high-grade SAH, thus suggesting that parenteral administration may be the better route in these patients.
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Rawal S, Barnett C, John-Baptiste A, Thein HH, Krings T, Rinkel GJ. Effectiveness of Diagnostic Strategies in Suspected Delayed Cerebral Ischemia. Stroke 2015; 46:77-83. [DOI: 10.1161/strokeaha.114.005916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Purpose—
Delayed cerebral ischemia (DCI) is a serious complication after aneurysmal subarachnoid hemorrhage. If DCI is suspected clinically, imaging methods designed to detect angiographic vasospasm or regional hypoperfusion are often used before instituting therapy. Uncertainty in the strength of the relationship between imaged vasospasm or perfusion deficits and DCI-related outcomes raises the question of whether imaging to select patients for therapy improves outcomes in clinical DCI.
Methods—
Decision analysis was performed using Markov models. Strategies were either to treat all patients immediately or to first undergo diagnostic testing by digital subtraction angiography or computed tomography angiography to assess for angiographic vasospasm, or computed tomography perfusion to assess for perfusion deficits. According to current practice guidelines, treatment consisted of induced hypertension. Outcomes were survival in terms of life-years and quality-adjusted life-years.
Results—
When treatment was assumed to be ineffective in nonvasospasm patients, Treat All and digital subtraction angiography were equivalent strategies; when a moderate treatment effect was assumed in nonvasospasm patients, Treat All became the superior strategy. Treating all patients was also superior to selecting patients for treatment via computed tomography perfusion. One-way sensitivity analyses demonstrated that the models were robust; 2- and 3-way sensitivity analyses with variation of disease and treatment parameters reinforced dominance of the Treat All strategy.
Conclusions—
Imaging studies to test for the presence of angiographic vasospasm or perfusion deficits in patients with clinical DCI do not seem helpful in selecting which patients should undergo treatment and may not improve outcomes. Future directions include validating these results in prospective cohort studies.
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Affiliation(s)
- Sapna Rawal
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada (S.R., T.K.); Division of Neurology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada (C.B.); Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada (A.J.-B.); Women’s College Research Institute, Women’s College Hospital,
| | - Carolina Barnett
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada (S.R., T.K.); Division of Neurology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada (C.B.); Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada (A.J.-B.); Women’s College Research Institute, Women’s College Hospital,
| | - Ava John-Baptiste
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada (S.R., T.K.); Division of Neurology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada (C.B.); Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada (A.J.-B.); Women’s College Research Institute, Women’s College Hospital,
| | - Hla-Hla Thein
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada (S.R., T.K.); Division of Neurology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada (C.B.); Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada (A.J.-B.); Women’s College Research Institute, Women’s College Hospital,
| | - Timo Krings
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada (S.R., T.K.); Division of Neurology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada (C.B.); Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada (A.J.-B.); Women’s College Research Institute, Women’s College Hospital,
| | - Gabriel J.E. Rinkel
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada (S.R., T.K.); Division of Neurology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada (C.B.); Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada (A.J.-B.); Women’s College Research Institute, Women’s College Hospital,
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Baltsavias G, Yella S, Al Shameri RA, Luft A, Valavanis A. Intra-arterial administration of papaverine during mechanical thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2014; 24:41-7. [PMID: 25440359 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 07/13/2014] [Accepted: 07/27/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The use of stent retrievers for mechanical thrombectomy in acute ischemic stroke may induce significant vasospasm, which at the early phases of reperfusion may be crucial for rethrombosis of the recanalized vessel. We aimed to study whether the use of intra-arterial papaverine in selected cases of vasospasm was associated with improved cerebral perfusion, arterial reocclusion, or increased hemorrhagic complications. METHODS We retrospectively studied 9 consecutive patients with large artery acute occlusion, treated with stent retriever and intra-arterial papaverine. Onset to administration of intravenous recombinant tissue-plasminogen activator time, baseline National Institute of Health Stroke Scale, time to reperfusion, number of passes of the stent retriever, modified Rankin Scale score at discharge, postprocedural hemorrhage, onset to reperfusion time, papaverine dose, and thrombolysis in cerebral infarction grade were recorded in all patients. RESULTS After papaverine administration, the caliber of the infused arteries and their flow was increased in all cases. In none of the treated cases a reocclusion occurred after papaverine infusion. In one of the studied patients (11%), a parenchymal bleeding occurred 36 hours postoperatively. CONCLUSIONS This small study suggests that intra-arterial infusion of papaverine for the treatment of cerebral vasospasm after mechanical thrombectomy in acute ischemic stroke is effective and safe.
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Affiliation(s)
| | - Susmitha Yella
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Anton Valavanis
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
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Wan H, AlHarbi BM, Macdonald RL. Mechanisms, treatment and prevention of cellular injury and death from delayed events after aneurysmal subarachnoid hemorrhage. Expert Opin Pharmacother 2013; 15:231-43. [PMID: 24283706 DOI: 10.1517/14656566.2014.865724] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Subarachnoid hemorrhage (SAH) patients often develop brain injury as a result of a number of delayed complications, resulting in significant morbidity and mortality. Many of these complications arise due to delayed cerebral ischemia, which occurs secondary to the hemorrhage. AREAS COVERED The mechanisms of the delayed injury are reviewed, including angiographic vasospasm, cortical spreading ischemia, small arteriolar constriction, microthromboemboli, free radical injury and inflammation. Some current and prospective therapies for SAH are discussed, in the context of these complications. Statins have been particularly promising in experimental studies. EXPERT OPINION Multiple mechanisms are involved in the pathogenesis of the delayed insult after SAH. New drugs may need to target multiple pathways to injury. Trials aiming to treat complications after SAH could benefit from taking into account the multifactorial pathogenesis of delayed insults.
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Affiliation(s)
- Hoyee Wan
- University of Toronto, 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, Division of Neurosurgery, Department of Surgery , Toronto, Ontario, M5B 1W8 , Canada
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Wolf S, Wartenberg KE. [Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: prevention, diagnostics and therapy]. DER NERVENARZT 2013. [PMID: 23180054 DOI: 10.1007/s00115-012-3528-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Delayed cerebral ischemia (DCI) is the second most important impacting factor for functional outcome after aneurysmal subarachnoid hemorrhage (SAH) following the initial severity of the bleeding. In contrast to the initial SAH severity the presence and consequences of DCI can be managed with prophylactic and therapeutic interventions. The previous notion of treatment of angiographically observed vasospasm has not been shown to be successful.This article covers prevention, monitoring and therapeutic concepts for patients with SAH with emphasis on the efficacy for DCI and current and ongoing research projects.
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Affiliation(s)
- S Wolf
- Klinik für Neurochirurgie, Charité-Universitätsmedizin Berlin, Campus Virchow, Berlin, Deutschland
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Clinical trials in cardiac arrest and subarachnoid hemorrhage: lessons from the past and ideas for the future. Stroke Res Treat 2013; 2013:263974. [PMID: 23533956 PMCID: PMC3606808 DOI: 10.1155/2013/263974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 01/29/2013] [Indexed: 11/17/2022] Open
Abstract
Introduction. Elevated intracranial pressure that occurs at the time of cerebral aneurysm rupture can lead to inadequate cerebral blood flow, which may mimic the brain injury cascade that occurs after cardiac arrest. Insights from clinical trials in cardiac arrest may provide direction for future early brain injury research after subarachnoid hemorrhage (SAH). Methods. A search of PubMed from 1980 to 2012 and clinicaltrials.gov was conducted to identify published and ongoing randomized clinical trials in aneurysmal SAH and cardiac arrest patients. Only English, adult, human studies with primary or secondary mortality or neurological outcomes were included. Results. A total of 142 trials (82 SAH, 60 cardiac arrest) met the review criteria (103 published, 39 ongoing). The majority of both published and ongoing SAH trials focus on delayed secondary insults after SAH (70%), while 100% of cardiac arrest trials tested interventions within the first few hours of ictus. No SAH trials addressing treatment of early brain injury were identified. Twenty-nine percent of SAH and 13% of cardiac arrest trials showed outcome benefit, though there is no overlap mechanistically. Conclusions. Clinical trials in SAH assessing acute brain injury are warranted and successful interventions identified by the cardiac arrest literature may be reasonable targets of the study.
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