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Lind ANR, Krabbenhøft MG, Valentin JB, Haldrup M, Dyrskog S, Rasmussen M, Simonsen CZ, Korshoej AR. Cisternal and intraventricular irrigation in subarachnoid and intraventricular haemorrhage. Stroke Vasc Neurol 2024:svn-2023-003062. [PMID: 38782496 DOI: 10.1136/svn-2023-003062] [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: 12/22/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Subarachnoid haemorrhage (SAH) and intraventricular haemorrhage (IVH) are associated with poor patient outcomes. Intraventricular fibrinolysis is effective in clearing IVH and improving patient survival and neurological outcome. By similar rationale, cisternal irrigation has been proposed as a potential method to accelerate haematoma clearance in SAH. We aimed to provide a comprehensive review and meta-analysis evaluating the effect of intraventricular and cisternal irrigation on clinical outcomes in patients with SAH and IVH. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed preparing this systematic review and study selection was performed by multiple investigators. We extracted ORs from the individual studies and aggregated these using a random effects model. The quality of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations assessment and ROBINS-I or RoB-2. RESULTS 24 articles were included. In SAH, we found that cisternal irrigation with fibrinolytic agents was associated with reduced mortality (OR: 0.68, 95% CI 0.46 to 1.00), higher probability of favourable functional outcome (OR: 1.80, 95% CI 1.30 to 2.51), and reduced risks of DCI (OR: 0.28, 95% CI 0.18 to 0.42) and cerebral vasospasm (OR: 0.28, 95% CI 0.18 to 0.42), compared with conventional therapy. Cisternal irrigation with vasodilatory agents was associated with lower mortality (OR: 0.32, 95% CI 0.13 to 0.79) and reduced risk of cerebral vasospasm (OR: 0.37, 95% CI 0.17 to 0.79). The evidence for irrigation therapy of IVH was sparse and insufficient to show any significant effect. CONCLUSION In this study, we found that cisternal irrigation could improve the prognosis in patients with SAH compared with conventional therapy. There is no evidence to support cisternal irrigation treatment of IVH.
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Affiliation(s)
- Allice Nyborg Rosenkrans Lind
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Mette Haldrup
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Stig Dyrskog
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Rasmussen
- Department of Anesthesiology, Gødstrup Regional Hospital, Herning, Denmark
| | - Claus Ziegler Simonsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Rosendal Korshoej
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Vandenbulcke A, Messerer M, Daniel RT, Cossu G. The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review. Brain Sci 2023; 13:1580. [PMID: 38002540 PMCID: PMC10670052 DOI: 10.3390/brainsci13111580] [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: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, 1015 Lausanne, Switzerland
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Nishikawa Y, Yamada S, Uchida M, Yamanaka T, Hayashi Y, Katano H, Tanikawa M, Iwama T, Iihara K, Morioka M, Mase M. Japanese nationwide questionnaire survey on delayed cerebral infarction due to vasospasm after subarachnoid hemorrhage. Front Neurol 2023; 14:1296995. [PMID: 38020653 PMCID: PMC10654625 DOI: 10.3389/fneur.2023.1296995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background and purpose Various prophylactic drugs for cerebral vasospasm and delayed cerebral infarction (DCI) after subarachnoid hemorrhage (SAH) have been used in Japan. To investigate the treatment trends for cerebral vasospasm and frequency of DCI after SAH throughout Japan in 2021. Methods In 2021 we conducted an anonymous questionnaire survey on management for preventing cerebral vasospasm after aneurysmal SAH, and the frequency of DCI. The questionnaire was emailed to 955 certified neurosurgeons at 553 hospitals in Japan. Of them, 162 hospitals (29% response rate) responded to the questionnaire. Of these, 158 were included in this study, while four hospitals that responded insufficiently were excluded. The efficacy of treatments for reducing DCI were examined through a logistic regression analysis. Results Among 3,093 patients treated with aneurysmal SAH, 281 patients (9.1%) were diagnosed with DCI related to cerebral vasospasm. Coil embolization had significantly lower DCI frequency (6.9%), compared to microsurgical clipping (11.8%, odds ratio, 0.90; 95% confidential intervals, 0.84-0.96; P, 0.007). In addition, cilostazol administration was associated with significantly lower DCI frequency (0.48; 0.27-0.82; 0.026). The efficacy of cilostazol in reducing DCI remained unchanged after adjustment for covariates. The most effective combination of multiple prophylactic drugs in reducing DCI related to cerebral vasospasm was cilostazol, fasudil, and statin (0.38; 0.22-0.67; 0.005). Conclusions This study elucidated the trends in prophylactic drugs to prevent cerebral vasospasm and frequency of DCI after aneurysmal SAH in Japan. Coil embolization and cilostazol administration showed effectiveness in reducing DCI related to cerebral vasospasm in 2021.
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Affiliation(s)
- Yusuke Nishikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Shigeki Yamada
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
- Interfaculty Initiative in Information Studies, Institute of Industrial Science, The University of Tokyo, Tokyo, Japan
| | - Mitsuru Uchida
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Tomoyasu Yamanaka
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Yuki Hayashi
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Hiroyuki Katano
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Motoki Tanikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Iihara
- National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | | | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
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Continuous lumbar drainage after aneurysmal subarachnoid hemorrhage decreased malondialdehyde in cerebrospinal fluid and improved outcome. J Formos Med Assoc 2023; 122:164-171. [PMID: 36117035 DOI: 10.1016/j.jfma.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/31/2022] [Accepted: 09/01/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The use of a continuous lumbar drain (LD) for the treatment of aneurysmal subarachnoid hemorrhage (aSAH), and malondialdehyde (MDA), a marker of oxidative stress, is correlated with clinical outcome. This study aimed to investigate the relationship between LD placement and MDA level after aSAH. METHODS Patients with modified Fisher's grade III and IV aSAH who underwent early aneurysm obliteration were enrolled. Cerebrospinal fluid (CSF) was obtained on day 7 after aSAH in non-LD group. In LD group, the LD was inserted on day 3 after aSAH for continuous CSF drainage. The levels of intrathecal hemoglobin, total bilirubin, ferritin, and MDA were measured. RESULTS There were 41 patients in non-LD group (age: 58.7 ± 13.7 years; female: 61.0%) and 48 patients in LD group (age: 58.3 ± 10.4 years; female: 79.2%). There were more favorable outcomes (Glasgow Outcome Scale ≥4) at 3 months after aSAH in LD group (p = 0.0042). The intrathecal hemoglobin, total bilirubin, ferritin, and MDA levels at day 7 after aSAH were all significantly lower in LD group. An older age (>60 years) (p = 0.0293), higher MDA level in the CSF (p = 0.0208), and delayed ischemic neurological deficit (p = 0.0451) were independent factors associated with unfavorable outcomes. LD placement was associated with a decreased intrathecal MDA level on day 7 after aSAH (p < 0.001). CONCLUSION The intrathecal MDA level at day 7 after aSAH can be an effective outcome indicator in modified Fisher's grade III/IV aSAH. Continuous CSF drainage via a LD can decrease the intrathecal MDA level and improve the functional outcome.
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Ota N, Noda K, Chida D, Kiko K, Miyoshi N, Kondo T, Haraguchi K, Kamiyama H, Tokuda S, Tanikawa R. Emergent Subarachnoid Clot Removal with Aneurysm Repair for Subarachnoid Hemorrhage Might Improves Clinical Outcome. World Neurosurg 2022; 167:e100-e109. [PMID: 35953044 DOI: 10.1016/j.wneu.2022.07.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH. METHODS Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed. RESULTS Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04-01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01-01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01-01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63-02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52-0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0-2 and 3-6. CONCLUSIONS Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.
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Affiliation(s)
- Nakao Ota
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan.
| | - Kosumo Noda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Daiki Chida
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Katsunari Kiko
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Norio Miyoshi
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tomomasa Kondo
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kenichi Haraguchi
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Sadahisa Tokuda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Rokuya Tanikawa
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
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Cisternal irrigation and clot removal to prevent vasospasm and poor outcome in aneurysmal subarachnoid hemorrhage: Systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Helbok R, Rass V, Kofler M, Talasz H, Schiefecker A, Gaasch M, Scherfler C, Pfausler B, Thomé C, Beer R, Lindner HH, Schmutzhard E. Intracerebral Iron Accumulation may be Associated with Secondary Brain Injury in Patients with Poor Grade Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:171-179. [PMID: 34374002 PMCID: PMC8813702 DOI: 10.1007/s12028-021-01278-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The amount of intracranial blood is a strong predictor of poor outcome after subarachnoid hemorrhage (SAH). Here, we aimed to measure iron concentrations in the cerebral white matter, using the cerebral microdialysis (CMD) technique, and to associate iron levels with the local metabolic profile, complications, and functional outcome. METHODS For the observational cohort study, 36 patients with consecutive poor grade SAH (Hunt & Hess grade of 4 or 5, Glasgow Coma Scale Score ≤ 8) undergoing multimodal neuromonitoring were analyzed for brain metabolic changes, including CMD iron levels quantified by graphite furnace atomic absorption spectrometry. The study time encompassed 14 days after admission. Statistical analysis was performed using generalized estimating equations. RESULTS Patients were admitted in a poor clinical grade (n = 26, 72%) or deteriorated within 24 h (n = 10, 28%). The median blood volume in the subarachnoid space was high (SAH sum score = 26, interquartile range 20-28). Initial CMD iron was 44 µg/L (25-65 µg/L), which significantly decreased to a level of 25 µg/L (14-30 µg/L) at day 4 and then constantly increased over the remaining neuromonitoring days (p < 0.01). A higher intraventricular hemorrhage sum score (≥ 5) was associated with higher CMD iron levels (Wald-statistic = 4.1, df = 1, p = 0.04) but not with the hemorrhage load in the subarachnoid space (p = 0.8). In patients developing vasospasm, the CMD iron load was higher, compared with patients without vasospasm (Wald-statistic = 4.1, degree of freedom = 1, p = 0.04), which was not true for delayed cerebral infarction (p = 0.4). Higher iron concentrations in the brain extracellular fluid (34 µg/L, 36-56 µg/L vs. 23 µg/L, 15-37 µg/L) were associated with mitochondrial dysfunction (CMD lactate to pyruvate ratio > 30 and CMD-pyruvate > 70 µM/L, p < 0.001). Brain extracellular iron load was not associated with functional outcome after 3 months (p > 0.5). CONCLUSIONS This study suggests that iron accumulates in the cerebral white matter in patients with poor grade SAH. These findings may support trials aiming to scavenger brain extracellular iron based on the hypothesis that iron-mediated neurotoxicity may contribute to acute and secondary brain injury following SAH.
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Affiliation(s)
- Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Heribert Talasz
- Division of Clinical Biochemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Alois Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Scherfler
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Herbert H Lindner
- Division of Clinical Biochemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Erich Schmutzhard
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
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Yoshikane T, Miyazaki T, Yasuda S, Uchimura M, Fujiwara Y, Nakagawa F, Kambara M, Nagai H, Akiyama Y. Aggressive Intraoperative Cisternal Clot Removal After Clipping Aneurismal Subarachnoid Hemorrhage in Elderly Patients. World Neurosurg 2020; 147:e482-e490. [PMID: 33383198 DOI: 10.1016/j.wneu.2020.12.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) in the elderly often has a poor prognosis even after surgical treatment in the acute phase. Additionally, subarachnoid clots are the strongest predictors of cerebral vasospasm and tend to be thicker and heavier due to cerebral atrophy. We aimed to compare the conventional surgical treatment in such patients and identify the independent predictors of a favorable outcome after aggressive surgical clot removal. METHODS We included 40 patients with aSAH aged 70 or older. Each patient underwent aneurysmal clipping. We used the modified Rankin Scale to assess the primary outcome of neurologic status at discharge. We performed univariate analysis using the following factors: sex, age, neurologic, and general medical condition, radiographic data, aneurysm location, treatment approach, and timing of the aneurysm surgery. We divided the patients into irrigation and nonirrigation groups. We focused mainly on subarachnoid clots and analyzed them semiquantitatively using computed tomography. RESULTS Clot removal was significantly greater in the irrigation group (n = 21) than in the nonirrigation group (n = 19). The period of intrathecal drainage was significantly shorter in the irrigation group (P = 0.002). The rate of occurrence of new low-density areas on CT scans was higher in the nonirrigation group. Outcomes were better in the irrigation group (P = 0.010). CONCLUSIONS In elderly patients with aSAH in the acute phase, aggressive surgical clot removal after clipping showed favorable outcomes by facilitating early out-of-bed mobilization.
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Affiliation(s)
- Tsutomu Yoshikane
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan.
| | - Takeshi Miyazaki
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Shinichi Yasuda
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Masahiro Uchimura
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yuta Fujiwara
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Fumio Nakagawa
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Mizuki Kambara
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Hidemasa Nagai
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yasuhiko Akiyama
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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Tamura T, Ota N, Okada Y, Valenzuela J, Noda K, Kamiyama H, Tanikawa R. Sylvian Hematoma Removal after the Stent-Retriever Thrombectomy Accompanied by Arteriole Avulsion: Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:94-99. [PMID: 37502806 PMCID: PMC10370804 DOI: 10.5797/jnet.cr.2020-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/28/2020] [Indexed: 07/29/2023]
Abstract
Objective We describe an instructive case of post-thrombectomy subarachnoid hemorrhage (PTSAH) by sylvian hematoma removal. Case Presentations An 83-year-old female presented with an acute cardiogenic right M1 occlusion. After the thrombectomy with combined stent retriever and aspiration technique with total five passes, TICI 2b reperfusion was achieved; however, CT imaging displayed subarachnoid hematoma (SAH) along the right sylvian fissure. Throughout the approach, contrast extravasation was not confirmed. The SAH grew up to become the sylvian hematoma; therefore, removal of the sylvian hematoma was conducted. An abrupt arteriole tear around the distal M2 of parietal artery was confirmed as bleeding point and those teared arteriole's stumps were electrically coagulated not to re-bleed. Conclusion We suggest that the PTSAH is possible even in invisible-extravasation cases and the sylvian hematoma removal is effective to elucidate the etiology of the PTSAH, and is a reliable method to prevent the re-bleeding and is anticipated to improve the prognosis. Craniotomy is required for medically resistant PTSAH after thrombectomy, and avulsion of the pial artery can be the cause.
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Affiliation(s)
- Takamitsu Tamura
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Yasuaki Okada
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | | | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
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Abstract
PURPOSE OF REVIEW Over the last years, the focus of clinical and animal research in subarachnoid hemorrhage (SAH) shifted towards the early phase after the bleeding based on the association of the early injury pattern (first 72 h) with secondary complications and poor outcome. This phase is commonly referenced as early brain injury (EBI). In this clinical review, we intended to overview commonly used definitions of EBI, underlying mechanisms, and potential treatment implications. RECENT FINDINGS We found a large heterogeneity in the definition used for EBI comprising clinical symptoms, neuroimaging parameters, and advanced neuromonitoring techniques. Although specific treatments are currently not available, therapeutic interventions are aimed at ameliorating EBI by improving the energy/supply mismatch in the early phase after SAH. Future research integrating brain-derived biomarkers is warranted to improve our pathophysiologic understanding of EBI in order to ameliorate early injury patterns and improve patients' outcomes.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Ota N, Noda K, Hatano Y, Hashimoto A, Miyazaki T, Kondo T, Kinoshita Y, Kamiyama H, Tokuda S, Kamada K, Tanikawa R. Preoperative Predictors and Prognosticators After Microsurgical Clipping of Poor-Grade Subarachnoid Hemorrhage: A Retrospective Study. World Neurosurg 2019; 125:e582-e592. [DOI: 10.1016/j.wneu.2019.01.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/28/2022]
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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: 80] [Impact Index Per Article: 16.0] [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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13
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Matsukawa H, Miyazaki T, Kiko K, Kamiyama H, Ota N, Noda K, Takahashi O, Shonai T, Fujisawa T, Tokuda S, Tanikawa R. Thick Clot in the Inferior Limiting Sulcus on Computed Tomography Image as an Indicator of Sylvian Subpial Hematoma in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 125:e612-e619. [PMID: 30716497 DOI: 10.1016/j.wneu.2019.01.138] [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: 10/18/2018] [Revised: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Sylvian subpial hematoma (SSH) is occasionally observed in aneurysm subarachnoid hemorrhage (aSAH) when accompanied with the thick clot in the inferior limiting sulcus (ILS). We aimed to determine whether the thickness of the clot in the ILS (TCILS) was an indicator of SSH. METHODS Data from 150 consecutive patients with aSAH were retrospectively analyzed. The relationship between TCILS on axial computed tomography (CT) image and intraoperatively confirmed SSH was reviewed. In patients without SSH, the average of the clot thickness in the bilateral ILS was used. The primary outcome was SSH. RESULTS The median TCILS of the SSH group (n = 18, 12%) was larger than that of the non-SSH group (n = 132, 88%) (21 vs. 2.1 mm, respectively; P < 0.001). The intraclass correlation coefficients for clot thickness in the right and left ILS between 2 observers were 0.97 (P < 0.001) and 0.85 (P < 0.001). The TCILS threshold of ≥6.0 mm was associated with SSH, with a sensitivity of 89% and specificity of 99%. The unadjusted and adjusted odds ratios of the SSH of clot thickness in the affected ILS ≥6 mm relative to clot thickness in the affected ILS <6 mm were 263 (95% confidence interval [CI], 46-5063) and 137 (95% CI, 19-3029), respectively. CONCLUSIONS The clot thickness in the ILS on CT image was easily measured and could be a marker of SSH. SSH assessment could be useful in helping us predict the clinical course in patients with aSAH.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Takanori Miyazaki
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Katsunari Kiko
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Osamu Takahashi
- St.Luke's International University Graduate School of Public Health, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Takaharu Shonai
- Department of Radiology, Teishinkai Hospital, Sapporo, Japan
| | | | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan.
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14
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Pilipenko YV, Varyukhina MD, Eliava SS, Belousova OB, Savin IA, Okishev DN, Mikeladze KG, Shekhtman OD, Kheyreddin AS, Konovalov AN, Gorozhanin VA, Spiru AM, Kurdyumova NV, Tabasaransky TF, Baranich AI, Vinogradov EV. [Intracisternal administration of verapamil for the prevention and treatment of vasospasm in patients after microsurgical treatment of cerebral aneurysms in the acute period of hemorrhage]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2019; 83:18-33. [PMID: 31577267 DOI: 10.17116/neiro20198304118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
UNLABELLED The first results of intracisternal administration of verapamil for the prevention and treatment of cerebral vasospasm (CVS) in patients in the acute period of subarachnoid hemorrhage (SAH) after microsurgical clipping of cerebral aneurysms are presented. OBJECTIVE Safety assessment of the method of prolonged intracisternal infusion (PII) of verapamil. MATERIAL AND METHODS Over the period from May 2017 to December 2018, 42 patients were included in the study, who underwent clipping of aneurysm of the anterior segments of the Willis circle. Most patients (78.6%) were operated during the first 6 days after SAH. For each patient, a thin silicone catheter was installed, through which verapamil was infused. A prerequisite was the installation of external ventricular drainage and opening of the lamina terminalis. The daily dosage of verapamil varied from 25 to 50 mg of the drug diluted in 200-400 ml of isotonic sodium chloride solution. The indication for the use of the PII method was the presence of one of the following factors: a score on the Hunt-Hess scale from III to V, 3 or 4 points on the Fisher scale, confirmed angiographically by the CVS before the operation. RESULTS The PII procedure was performed from 2 to 5 days. The average dose of verapamil was 143.5±41.2 mg additionally, in the presence of an angiographically confirmed CVS accompanied by clinical manifestations, 14 (33.4%) patients received intra-arterial injection of verapamil in several stages, with individual selection of the drug dose. The formation of new cerebral ischemic foci of vasospastic genesis was observed in only 1 (2.4%) patient. No infectious intracranial complications were noted. The average follow-up period was 297.6±156.1 days. Long-term treatment outcomes, assessed by a modified Rankin scale from 0 to 2 points, were observed in 83.3% of patients. There were no outcomes such as vegetative status and no deaths. The frequency of liquorodynamic disorders, as well as epileptic syndrome did not exceed that among patients with SAH according to the literature. CONCLUSION The study has confirmed the safety of prolonged PII. The efficacy of the method, compared with other methods for CVS treatment requires further investigation. The first results look quite promising: the observation shows a low percentage of new foci of cerebral ischemia and the absence of deaths associated with it. In patients with severe CVS, the efficacy of the PII method is increased when combined with intra-arterial administration of verapamil.
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Affiliation(s)
| | | | | | | | - I A Savin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | | | | | - A M Spiru
- Burdenko Neurosurgical Center, Moscow, Russia
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15
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Matsukawa H, Kamiyama H, Miyazaki T, Kinoshita Y, Ota N, Noda K, Shonai T, Takahashi O, Tokuda S, Tanikawa R. Surgical Treatment of Middle Cerebral Artery Aneurysms: Aneurysm Location and Size Ratio as Risk Factors for Neurologic Worsening and Ischemic Complications. World Neurosurg 2018; 117:e563-e570. [PMID: 29929026 DOI: 10.1016/j.wneu.2018.06.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/09/2018] [Accepted: 06/11/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Regardless of acceptable surgical results of middle cerebral artery aneurysms (MCAs), MCA territory infarction (MCATI) remains a major obstacle to achieving a good outcome. We investigated the MCATI in patients with surgically treated MCA aneurysms. METHODS The data of 286 consecutive patients with 322 MCA aneurysms were evaluated retrospectively. The aneurysm location was classified as early frontal cortical branch (EFCB), early temporal cortical branch (ETCB), bifurcation or trifurcation (M1-2), and distal aneurysms on the insular, opercular, or cortical segments of the MCA (distal MCA). Neurologic worsening was defined as an increase in 1 or more modified Rankin Scale (mRS) scores. RESULTS Multivariate analysis identified EFCB location as the sole risk factor for MCATI (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.2-12; P = 0.021) and MCATI (OR, 18; 95% CI, 2.8-117; P = 0.002) and a larger size ratio (OR, 1.4; 95% CI, 1.1-1.8; P = 0.019) were related to 12-month neurologic worsening (n = 6; 1.9%). During follow-up (median, 885 days; interquartile range, 485-1229 days), posttreatment rupture and aneurysm recurrence were not observed. CONCLUSIONS In the present study, compared with M1-2 aneurysms, MCATIs were observed more frequently in EFCB aneurysms, and the presence of MCATI and a larger size ratio were related to 12-month neurologic worsening in patients with surgically treated MCA aneurysms.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Takanori Miyazaki
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Yu Kinoshita
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Takaharu Shonai
- Department of Radiology, Teishinkai Hospital, Sapporo, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan.
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