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Masson A, Boulouis G, Janot K, Herbreteau D, Cottier JP, Bibi R, Cohen C, Obry S, Velut S, Amelot A, Ifergan H. Acute hydrocephalus and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:2401-2408. [PMID: 35918615 DOI: 10.1007/s00701-022-05321-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 07/17/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Delayed cerebral infarction (DCIn) following aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of morbi-mortality; yet, the causes for DCIn remain incompletely understood. OBJECTIVE We tested the hypothesis that acute hydrocephalus could be related to the occurrence of DCIn, independently of the occurrence and severity of vasospasm. METHODS Radiological and clinical data of patients treated at a single large volume academic center for aSAH between 2017 and 2019 were retrospectively analyzed. DCIn was defined as imaging stigma of cerebral infarction visible on 6-week imaging follow-up after aSAH. Hydrocephalus was defined on baseline imaging as a relative bicaudate index above 1. Cerebral vasospasm was defined by reduction of artery diameter in comparison with initial diameter. We used uni- and multivariable models to test the associations between these variables, hydrocephalus and DCIn. RESULTS Of 164 included patients, vasospasm occurred in 58 patients (35.4%), and DCIn in 47 (28.7%). Acute hydrocephalus was present in 85 patients (51.8%) on baseline CT. No relation was found between acute hydrocephalus and delayed cerebral infarction in our multivariate analysis (adjusted OR: 1.20 95% CI [0.43-3.37]; p = 0.732). Only vasospasm occurrence was independently associated with DCIn (adjusted OR: 10.97 95% CI [4.60-26.01]). CONCLUSION Our study did not show an association between acute hydrocephalus and DCIn after aSAH, after adjustment for the presence and severity of cerebral vasospasm.
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Affiliation(s)
- Axel Masson
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France.
| | - Grégoire Boulouis
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Kevin Janot
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Denis Herbreteau
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Jean-Phlippe Cottier
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Richard Bibi
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Clara Cohen
- Department of Diagnostic Neuroradiology, Orleans Hospital Center, Orleans, France
| | - Sandra Obry
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Stéphane Velut
- Department of Neurosurgery, Bretonneau Hospital, University of Tours, Tours, France
| | - Aymeric Amelot
- Department of Neurosurgery, Bretonneau Hospital, University of Tours, Tours, France
| | - Héloïse Ifergan
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France.
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Merkel H, Lindner D, Gaber K, Ziganshyna S, Jentzsch J, Mucha S, Gerhards T, Sari S, Stock A, Vothel F, Falter L, Quäschling U, Hoffmann KT, Meixensberger J, Halama D, Richter C. Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography. J Clin Med 2022; 11:jcm11072011. [PMID: 35407619 PMCID: PMC9000178 DOI: 10.3390/jcm11072011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023] Open
Abstract
Background: During the last decade, cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) was a current research focus without a standardized classification in digital subtraction angiography (DSA). This study was performed to investigate a device-independent visual cerebral vasospasm classification for endovascular treatment. Methods: The analyses are DSA based rather than multimodal. Ten defined points of intracranial arteries were measured in 45 patients suffering from cerebral vasospasm after SAH at three time points (hospitalization, before spasmolysis, control after six months). Mathematical clustering of vessel diameters was performed to generate four objective grades for comparison. Six interventional neuroradiologists in two groups scored 237 DSAs after a new visual classification (grade 0–3) developed on a segmental pattern of vessel contraction. For the second group, a threshold-based criterion was amended. Results: The raters had a reproducibility of 68.4% in the first group and 75.2% in the second group. The complementary threshold-based criterion increased the reproducibility by about 6.8%, while the rating deviated more from the mathematical clustering in all grades. Conclusions: The proposed visual classification scheme of cerebral vasospasm is suitable as a standard grading procedure for endovascular treatment. There is no advantage of a threshold-based criterion that compensates for the effort involved. Automated vessel analysis is superior to compare inter-group results in research settings.
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Affiliation(s)
- Helena Merkel
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Dirk Lindner
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Khaled Gaber
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Svitlana Ziganshyna
- Department of Anaesthesiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany;
| | - Jennifer Jentzsch
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Simone Mucha
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Thilo Gerhards
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Sabine Sari
- Department of Neuroradiology, Giessen University Hospital, Klinikstraße 33, 35392 Giessen, Germany;
| | - Annika Stock
- Department of Neuroradiology, Würzburg University Hospital, Josef-Schneider-Straße 2, 97080 Würzburg, Germany;
| | - Felicitas Vothel
- Department of Radiology and Neuroradiology, Sana Hospital Borna, Rudolf-Virchow-Straße 2, 04552 Borna, Germany;
| | - Lea Falter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Ulf Quäschling
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Jürgen Meixensberger
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Dirk Halama
- Department of Oral and Maxillofacial Surgery, Leipzig University Hospital, Liebigstraße 12, 04103 Leipzig, Germany;
| | - Cindy Richter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
- Correspondence: ; Tel.: +49-341-97-20196
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3
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García-Pastor C, Navarro-Garcia de Llano JP, Balcázar-Padrón JC, Tristán-López L, Rios C, Díaz-Ruíz A, Rodríguez-Hernandez LA, Nathal E. Neuroprotective effect of dapsone in patients with aneurysmal subarachnoid hemorrhage: a prospective, randomized, double-blind, placebo-controlled clinical trial. Neurosurg Focus 2022; 52:E12. [PMID: 35231887 DOI: 10.3171/2021.12.focus21663] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study, the authors sought to define the differences in the incidence of delayed cerebral ischemia (DCI) between patients treated with dapsone and those treated with placebo. Secondary objectives were to define the clinical outcome at discharge and 3 months and the incidence of brain infarction. METHODS A prospective, randomized, double-blind, placebo-controlled study was performed and included patients with aneurysmal subarachnoid hemorrhage (SAH) within 5 days from ictus who were candidates for aneurysm occlusion, and who had a Fisher grade of 3 or 4. Patients with sulfa or sulfone drug allergies, hemoglobin < 11 g/dl, known G6PD deficiency, and those refusing informed consent were excluded. A minimal relevant effect decrease of 35% in the incidence of DCI was established. Patients were randomly assigned to receive a regimen of dapsone 2.5 ml (100 mg) daily or a placebo (aluminum hydroxide suspension, 2.5 ml daily). Both groups received validated treatment for aneurysmal SAH. The appearance of DCI on CT was assessed in every patient at discharge and 3 months later. We used the chi-square test to compare the DCI incidence between both groups, and the Student t-test or nonparametric tests to compare quantitative variables. RESULTS Overall, 48 patients (70.8% women and 29.2% men) were included. The mean age was 50 years (SD 14.28 years, range 18-72 years). Prerandomization and postrandomization characteristics were balanced, except for the necessity of intra-arterial nimodipine administration in patients treated with placebo (15.4% vs 45.5%, p = 0.029. The incidence of DCI, the primary endpoint, for the whole cohort was 43.8% and was significantly lower in the dapsone group (26.9% vs 63.6%, p = 0.011). In addition, the irreversible DCI incidence was lower in the dapsone group (11.5% vs 54.5%, p = 0.12). A favorable modified Rankin Scale score was more frequent in the dapsone group at discharge and at 3 months (76.9% vs 36.4%, p = 0.005 and 80% vs 38.9%, p = 0.019, respectively). Also, the brain infarction incidence was lower in the dapsone group (19.2% vs 63.6%, p = 0.001). There was no difference between groups regarding adverse events. CONCLUSIONS Dapsone seems to play a role as a prophylactic agent in patients at high risk of developing DCI after aneurysmal SAH. A multicenter investigation is necessary to increase the study population and confirm the consistency of the results observed in this study.
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Affiliation(s)
| | | | | | - Luis Tristán-López
- 2Neurochemistry Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Camilo Rios
- 2Neurochemistry Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Araceli Díaz-Ruíz
- 2Neurochemistry Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
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4
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Schacht H, Küchler J, Neumann A, Schramm P, Tronnier VM, Ditz C. Analysis of angiographic treatment response to intra-arterial nimodipine bolus injection in patients with medically refractory cerebral vasospasm after spontaneous subarachnoid hemorrhage. World Neurosurg 2022; 162:e457-e467. [DOI: 10.1016/j.wneu.2022.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
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5
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Simonato D, Borchert RJ, Vallee F, Joachim J, Civelli V, Cancian L, Houdart E, Labeyrie MA. Distribution of symptomatic cerebral vasospasm following subarachnoid hemorrhage assessed using cone-beam CT angiography. J Neurointerv Surg 2021; 14:1107-1111. [PMID: 34740985 DOI: 10.1136/neurintsurg-2021-018080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/25/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE Cone-beam CT angiography (CB-CTA) provides a three-dimensional spatial resolution which is, so far, unmatched in clinical practice compared with other conventional techniques such as two-dimensional digital subtracted angiography. We aimed to assess the distribution of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) using CB-CTA. METHODS 30 consecutive patients with aSAH undergoing vasospasm percutaneous balloon angioplasty (PBA) were recruited and underwent CB-CTA in this single-center prospective cohort series. Intracranial arteries were systematically analyzed by two independent observers from the large trunks to the distal cortical branches and perforators using a high-resolution reconstruction protocol. Intermediate and severe cerebral vasospasm was defined as 30-50% and >50% narrowing in the diameter of the vessel, respectively. RESULTS 35 arterial cervical artery territories were analyzed, of which 80% were associated with clinical or radiological signs of delayed cerebral ischemia. The median spatial resolution was 150 µm (range 100-250 µm). Intermediate or severe vasospasm was observed in the proximal (86%, 95% CI 74% to 97%), middle (89%, 95% CI 78% to 99%), and distal (60%, 95% CI 44% to 76%) segments of the large trunks, as well as the cortical branches (11%, 95% CI 1% to 22%). No vasospasm was observed in basal ganglia or cortical perforators, or in arteries smaller than 900 µm. Vasospasm was more severe in middle or distal segments compared with proximal segments in 43% (95% CI 26% to 59%) of cases. CONCLUSIONS Our study demonstrated that symptomatic cerebral vasospasm following aSAH did not involve arteries smaller than 900 µm, and frequently predominated in middle or distal segments. These results offer new insights into the potential management options for vasospasm using PBA.
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Affiliation(s)
- Davide Simonato
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robin Jacob Borchert
- Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Neurology, Lister Hospital, Stevenage, UK
| | - Fabrice Vallee
- INSERM U942, PARIS, France.,Intensive Care Unit Department, Groupe Hospitalier Saint-Louis Lariboisiere et Fernand-Widal, Paris, France
| | - Jona Joachim
- INSERM U942, PARIS, France.,Intensive Care Unit Department, Groupe Hospitalier Saint-Louis Lariboisiere et Fernand-Widal, Paris, France
| | | | - Luca Cancian
- Radiology, Azienda ULSS 6 Euganea, Padova, Italy
| | | | - Marc-Antoine Labeyrie
- INSERM U942, PARIS, France .,Neuroradiology, GH Lariboisiere Fernand-Widal, Paris, France
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6
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Smith NM, Sweeney EM, Gupta A, Patsalides A, Sanelli P, Ivanidze J. Diagnostic accuracy of shuttle CT angiography (CTA) and helical CTA in the diagnosis of vasospasm. Clin Imaging 2021; 81:37-42. [PMID: 34598002 DOI: 10.1016/j.clinimag.2021.09.004] [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: 05/06/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy of computed tomography angiography (CTA) acquired with shuttle technique (CTAs) and helical CTA (CTAh) for vasospasm, using digital subtraction angiography (DSA) obtained within 24 h as reference standard. METHODS Thirty-six patients with suspected vasospasm in the setting of aneurysmal subarachnoid hemorrhage (ASAH, 30/36) or acute inflammatory/infectious conditions (6/36) who underwent CTAs (17/36) or CTAh (19/36) followed by DSA within 24 h were identified retrospectively. Presence of vasospasm in the proximal cerebral arterial segments was assessed qualitatively and semi-quantitatively on CTA and subsequent DSA. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Inter-rater variability was assessed using Cohen's kappa. RESULTS On CTAs, 35% of patients had low and 65% had high vasospasm burden. On CTAh, 37% had low and 63% had high vasospasm burden. ROC analysis demonstrated an AUC of 0.87 for CTAs (95%CI 0.67-1.00, p = 0.015) and 0.88 for CTAh (0.72-1.00, p = 0.028). Cohen's kappa was 0.843 (95%CI 0.548-1.000). Thresholding with Youden's J index, CTAs had a sensitivity of 85.71% (95%CI 48.69 to 99.27) and specificity of 66.67% (35.42 to 87.94). CTAh had sensitivity of 100% (56.55 to 100.00) and specificity of 78.57% (52.41 to 92.43). CONCLUSION CTAs and CTAh yielded similar sensitivity, specificity, and AUC values on ROC analysis for the detection of vasospasm using DSA as reference standard. Our findings suggest that CTAs is a promising alternative to CTAh especially in patients requiring serial imaging, given its potential advantages of decreased radiation exposure, contrast dose, and cost-effectiveness.
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Affiliation(s)
- Natasha M Smith
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| | - Elizabeth M Sweeney
- Division of Biostatistics and Epidemiology, Department of Population Health Sciences, New York Presbyterian, Weill Cornell Medical College, 1300 York Ave., New York, NY 10065, USA.
| | - Ajay Gupta
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
| | - Athos Patsalides
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Pina Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Jana Ivanidze
- Department of Radiology, New York Presbyterian, Weill Cornell Medical College, 525 East 68th Street New York, NY 10065, USA.
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7
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Mishra S, Garg K, Gaonkar VB, Singh PM, Singh M, Suri A, Chandra PS, Kale SS. Effects of Various Therapeutic Agents on Vasospasm and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage-Results of a Network Meta-Analysis. World Neurosurg 2021; 155:41-53. [PMID: 34339892 DOI: 10.1016/j.wneu.2021.07.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH. METHODS A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH. RESULTS Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63-56.71), decreasing mortality (OR, 0.08; 95% CrI, 0-0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057-0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97-6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12-1.15). Fasudil (OR, 0.16; 95% CrI, 0.03-0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057-1.0) in preventing delayed ischemic neurologic deficits. CONCLUSIONS Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.
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Affiliation(s)
- Sandeep Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.
| | - Vishwa Bharathi Gaonkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Preet Mohinder Singh
- Department of Anesthesia, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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8
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Ivanidze J, Sanelli PC. Vasospasm: Role of Imaging in Detection and Monitoring Treatment. Neuroimaging Clin N Am 2021; 31:147-155. [PMID: 33902870 DOI: 10.1016/j.nic.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cerebral vasospasm (VS) and delayed cerebral ischemia (DCI) are important complications of aneurysmal subarachnoid hemorrhage (ASAH). Imaging approaches to VS monitoring include noninvasive bedside assessment with transcranial Doppler ultrasonography, angiographic evaluation with digital subtraction angiography, and computed tomography (CT) angiography. DCI is a clinical diagnosis and is not fully explained by the presence of angiographic VS. CT perfusion has shown clinical utility and implications for future research in the evaluation of DCI in patients with ASAH. This review article discusses the common approaches to diagnosis and monitoring of VS and DCI, current treatment strategies, and future research directions.
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Affiliation(s)
- Jana Ivanidze
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA.
| | - Pina C Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 300 Community Drive, Manhasset, NY 11030, USA
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9
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Interleukin 6 and Aneurysmal Subarachnoid Hemorrhage. A Narrative Review. Int J Mol Sci 2021; 22:ijms22084133. [PMID: 33923626 PMCID: PMC8073154 DOI: 10.3390/ijms22084133] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
Interleukin 6 (IL-6) is a prominent proinflammatory cytokine. Neuroinflammation in general, and IL-6 signaling in particular, appear to play a major role in the pathobiology and pathophysiology of aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Most importantly, elevated IL-6 CSF (rather than serum) levels appear to correlate with delayed cerebral ischemia (DCI, “vasospasm”) and secondary (“vasospastic”) infarctions. IL-6 CSF levels may also reflect other forms of injury to the brain following SAH, i.e., early brain damage and septic complications of SAH and aneurysm treatment. This would explain why many researchers have found an association between IL-6 levels and patient outcomes. These findings clearly suggest CSF IL-6 as a candidate biomarker in SAH patients. However, at this point, discrepant findings in variable study settings, as well as timing and other issues, e.g., defining proper clinical endpoints (i.e., secondary clinical deterioration vs. angiographic vasospasm vs. secondary vasospastic infarct) do not allow for its routine use. It is also tempting to speculate about potential therapeutic measures targeting elevated IL-6 CSF levels and neuroinflammation in SAH patients. Corticosteroids and anti-platelet drugs are indeed used in many SAH cases (not necessarily with the intention to interfere with detrimental inflammatory signaling), however, no convincing benefit has been demonstrated yet. The lack of a robust clinical perspective against the background of a relatively large body of data linking IL-6 and neuroinflammation with the pathophysiology of SAH is somewhat disappointing. One underlying reason might be that most relevant studies only report correlative data. The specific molecular pathways behind elevated IL-6 levels in SAH patients and their various interactions still remain to be delineated. We are optimistic that future research in this field will result in a better understanding of the role of neuroinflammation in the pathophysiology of SAH, which in turn, will translate into the identification of suitable biomarkers and even potential therapeutic targets.
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10
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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11
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Interleukin 6 in cerebrospinal fluid is a biomarker for delayed cerebral ischemia (DCI) related infarctions after aneurysmal subarachnoid hemorrhage. Sci Rep 2021; 11:12. [PMID: 33420113 PMCID: PMC7794326 DOI: 10.1038/s41598-020-79586-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022] Open
Abstract
Interleukin 6 (IL-6) is a prominent proinflammatory cytokine and has been discussed as a potential biomarker for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage. In the present study we have analyzed the time course of serum and cerebrospinal fluid (CSF) IL-6 levels in 82 patients with severe aneurysmal subarachnoid hemorrhage (SAH) requiring external ventricular drains in correlation to angiographic vasospasm, delayed cerebral ischemia, secondary infarctions and other clinical parameters. We observed much higher daily mean IL-6 levels (but also large interindividual variations) in the CSF than the serum of the patients with a peak between days 4 and 14 including a maximum on day 5 after SAH. Individual CSF peak levels correlated significantly with DCI (mean day 4–14 peak, DCI: 26,291 ± 24,159 pg/ml vs. no DCI: 16,184 ± 13,163 pg/ml; P = 0.023). Importantly, CSF IL-6 levels differed significantly between cases with DCI and infarctions and patients with DCI and no infarction (mean day 4–14 peak, DCI with infarction: 37,209 ± 26,951 pg/ml vs. DCI, no infarction: 15,123 ± 11,239 pg/ml; P = 0.003), while findings in the latter patient group were similar to cases with no vasospasm (mean day 4–14 peak, DCI, no infarction: 15,123 ± 11,239 vs. no DCI: 15,840 ± 12,979; P = 0.873). Together, these data support a potential role for elevated CSF IL-6 levels as a biomarker for DCI with infarction rather than for DCI in general. This fits well with a growing body of evidence linking neuroinflammation to ischemia and infarction, but (together with the large interindividual variations observed) limits the diagnostic usefulness of CSF IL-6 levels in SAH patients.
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