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Kanamaru H, Suzuki H. Therapeutic potential of stem cells in subarachnoid hemorrhage. Neural Regen Res 2025; 20:936-945. [PMID: 38989928 DOI: 10.4103/nrr.nrr-d-24-00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/27/2024] [Indexed: 07/12/2024] Open
Abstract
Aneurysm rupture can result in subarachnoid hemorrhage, a condition with potentially severe consequences, such as disability and death. In the acute stage, early brain injury manifests as intracranial pressure elevation, global cerebral ischemia, acute hydrocephalus, and direct blood-brain contact due to aneurysm rupture. This may subsequently cause delayed cerebral infarction, often with cerebral vasospasm, significantly affecting patient outcomes. Chronic complications such as brain volume loss and chronic hydrocephalus can further impact outcomes. Investigating the mechanisms of subarachnoid hemorrhage-induced brain injury is paramount for identifying effective treatments. Stem cell therapy, with its multipotent differentiation capacity and anti-inflammatory effects, has emerged as a promising approach for treating previously deemed incurable conditions. This review focuses on the potential application of stem cells in subarachnoid hemorrhage pathology and explores their role in neurogenesis and as a therapeutic intervention in preclinical and clinical subarachnoid hemorrhage studies.
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Affiliation(s)
- Hideki Kanamaru
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
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2
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Burns JD, Lerner DP. Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage: Still More Questions Than Answers. Neurology 2024; 103:e209690. [PMID: 38950290 DOI: 10.1212/wnl.0000000000209690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Affiliation(s)
- Joseph D Burns
- From the Department of Neurology (J.D.B.), Lahey Hospital and Medical Center, Burlington, and UMass Chan Medical School, Worcester, MA; and Department of Neurology (D.P.L.), Brookdale Hospital and Medical Center and SUNY Downstate, Brooklyn, NY
| | - David P Lerner
- From the Department of Neurology (J.D.B.), Lahey Hospital and Medical Center, Burlington, and UMass Chan Medical School, Worcester, MA; and Department of Neurology (D.P.L.), Brookdale Hospital and Medical Center and SUNY Downstate, Brooklyn, NY
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Al-Salihi MM, Saha R, Abd Elazim A, Helal A, Sabah Al-Jebur M, Al-Salihi Y, Ayyad A. The effectiveness and safety of clazosentan in treating aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. J Clin Neurosci 2024; 126:173-181. [PMID: 38924824 DOI: 10.1016/j.jocn.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a severe event often complicated by cerebral vasospasm (CV). This study aimed to assess the efficacy and safety of clazosentan, an endothelin receptor antagonist, in reducing CV, delayed cerebral ischemia (DCI), and the need for rescue therapy in aSAH patients, while evaluating its impact on functional outcomes and mortality. METHODS We conducted a literature search across multiple databases to identify relevant studies evaluating the effects of clazosentan in aSAH patients. Both cohort studies and randomized controlled trials (RCTs) were included. The primary outcomes were vasospasm incidence, moderate to severe vasospasm, DCI, and the need for rescue therapy. Secondary outcomes included functional outcomes, mortality, and adverse events. The data were pooled as Risk ratios (R/R) with 95 % confidence intervals (CI) using RevMan 5.4 software. RESULTS A total of 11 studies, including 10 published and one unpublished, comprising 8,469 patients were included in the meta-analysis. Clazosentan significantly reduced the incidence of vasospasm (R/R = 0.49: 0.34-0.70), moderate to severe vasospasm (R/R = 0.53: 0.46-0.61), DCI (R/R = 0.70: 0.59-0.82), and the need for rescue therapy (R/R = 0.65: 0.52-0.83) compared to placebo. However, no significant improvement in functional outcomes or mortality rates was observed. Clazosentan was associated with increased rates of pulmonary adverse events (R/R = 1.89: 1.64-2.18), hypotension (R/R = 2.47: 1.79-3.42), and anemia (R/R = 1.49: 1.23-1.79) but no increased risk of hepatobiliary adverse events or cerebral hemorrhage. CONCLUSIONS Clazosentan demonstrates efficacy in reducing vasospasm, moderate to severe vasospasm, DCI, and the need for rescue therapy in aSAH patients, but does not significantly improve functional outcomes or mortality rates. While associated with specific adverse events, clazosentan may be a valuable adjunctive therapy in the management of aSAH, particularly in a high-risk population for vasospasm.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Ram Saha
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Amer Helal
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Saxony Anhalt, Germany
| | | | | | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar; Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
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4
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Sagues E, Gudino A, Dier C, Aamot C, Samaniego EA. Outcomes Measures in Subarachnoid Hemorrhage Research. Transl Stroke Res 2024:10.1007/s12975-024-01284-3. [PMID: 39073651 DOI: 10.1007/s12975-024-01284-3] [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: 04/12/2024] [Revised: 06/18/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
Despite advancements in acute management, morbidity rates for subarachnoid hemorrhage (SAH) remain high. Therefore, it is imperative to utilize standardized outcome scales in SAH research for evaluating new therapies effectively. This review offers a comprehensive overview of prevalent scales and clinical outcomes used in SAH assessment, accompanied by recommendations for their application and prognostic accuracy. Standardized terminology and diagnostic criteria should be employed when reporting pathophysiological outcomes such as symptomatic vasospasm and delayed cerebral ischemia. Furthermore, integrating clinical severity scales like the World Federation of Neurosurgical Societies scale and modified Fisher score into clinical trials is advised to evaluate their prognostic significance, despite their limited correlation with outcomes. The modified Rankin score is widely used for assessing functional outcomes, while the Glasgow outcome scale-extended version is suitable for broader social and behavioral evaluations. Avoiding score dichotomization is crucial to retain valuable information. Cognitive and behavioral outcomes, though frequently affected in patients with favorable neurological outcomes, are often overlooked during follow-up outpatient visits, despite their significant impact on quality of life. Comprehensive neuropsychological evaluations conducted by trained professionals are recommended for characterizing cognitive function, with the Montreal Cognitive Assessment serving as a viable screening tool. Additionally, integrating psychological inventories like the Beck Depression and Anxiety Inventory, along with quality-of-life scales such as the Stroke-Specific Quality of Life Scale, can effectively assess behavioral and quality of life outcomes in SAH studies.
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Affiliation(s)
- Elena Sagues
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Andres Gudino
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Carlos Dier
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Connor Aamot
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA.
- Department of Radiology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA.
- Department of Neurosurgery, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA.
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5
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Luzzi S, Bektaşoğlu PK, Doğruel Y, Güngor A. Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia. Neurosurg Rev 2024; 47:305. [PMID: 38967704 PMCID: PMC11226492 DOI: 10.1007/s10143-024-02543-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/15/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Türkiye
| | - Yücel Doğruel
- Department of Neurosurgery, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Abuzer Güngor
- Faculty of Medicine, Department of Neurosurgery, Istinye University, İstanbul, Türkiye
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6
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Becerril-Gaitan A, Nguyen T, Liu C, Mokua C, Gusdon AM, Brown RJ, Cochran J, Blackburn S, Chen PR, Dannenbaum M, Choi HA, Chen CJ. The Effect of Age on Cerebral Vasospasm and Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2024; 187:e1017-e1024. [PMID: 38750887 DOI: 10.1016/j.wneu.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND The association between patient age and cerebral arterial vasospasm (CVS) and delayed cerebral ischemia (DCI) risk following aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. This study aims to assess the role of age on aSAH-related complications. METHODS Single-center retrospective study comprising aSAH patients treated between January 2009 and March 2023. Age was analyzed as continuous and categorical variables (<60 yrs vs. ≥60 yrs and by decade). Outcomes of interest included radiographic CVS, DCI, cerebral infarction, in-hospital mortality, length-of-stay (LOS), ventriculoperitoneal shunt placement, and modified Rankin Scale (mRS) scores at discharge and 3-month follow-up. RESULTS Nine hundred and twenty-five aSAH patients were included. Most (n = 598; 64.6%) were <60 yrs old (46 ± 9.1 yrs). CVS likelihood was lower in the older cohort (aOR = 0.56 [0.38-0.82]). Patients ≥60 yrs had higher mortality rates (aOR = 2.24 [1.12-4.47]) and worse mRS scores at discharge (aOR = 2.66 [1.91-3.72]) and 3-month follow-up (aOR = 2.19 [1.44-3.32]). Advanced age did not have a significant effect on DCI or cerebral infarction risk. Higher in-hospital mortality was documented with increasing age (P < 0.001). A significant interaction between CVS and age for the outcome of DCI was documented, with a stronger positive effect on poor outcomes (i.e., higher odds of DCI) among patients aged <60 years compared to those aged ≥60. CONCLUSIONS There is an inverse relationship between patient age and CVS incidence following aSAH. Nonetheless, patients ≥60 yrs had comparable DCI rates, higher in-hospital mortality, and worse functional outcomes than their younger counterparts. Routine screening and reliance on radiographic CVS as primary marker for aSAH-related complications should be reconsidered, particularly in older patients.
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Affiliation(s)
- Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Tien Nguyen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Collin Liu
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Collins Mokua
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Aaron M Gusdon
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Robert J Brown
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Joseph Cochran
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Spiros Blackburn
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peng Roc Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mark Dannenbaum
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Huimahn A Choi
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Bömers JP, Holm A, Kazantzi S, Edvinsson L, Mathiesen TI, Haanes KA. Protein kinase C-inhibition reduces critical weight loss and improves functional outcome after experimental subarachnoid haemorrhage. J Stroke Cerebrovasc Dis 2024; 33:107728. [PMID: 38643942 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/23/2024] Open
Abstract
OBJECTIVES Subarachnoid haemorrhage (SAH) carries a high burden of morbidity and mortality. One in three patients develop vasospasm, which is associated with Delayed Cerebral Ischemia. The pathophysiology includes vasoconstrictor receptor upregulation in cerebral arteries. The protein kinase C - inhibitor RO-31-7549 reduces the expression of several vasoconstrictor receptors and normalizes cerebral blood flow in experimental SAH but functional and behavioural effects are unknown. This study was undertaken to analyse functional outcomes up to 14 days after experimental SAH. MATERIALS AND METHODS 54 male rats were randomised to experimental SAH or sham, using the pre-chiasmatic, single injection model, and subsequent treatment or vehicle. 42 remained for final analysis. The animals were euthanized on day 14 or when reaching a humane endpoint. The primary endpoint was overall survival, defined as either spontaneous mortality or when reaching a predefined humane endpoint. The secondary outcomes were differences in the rotating pole test, weight, open field test, novel object recognition and qPCR of selected inflammatory markers. RESULTS In the vehicle group 6/15 rats reached the humane endpoint of >20 % weight loss compared to 1/14 in the treatment group. This resulted in a significant reduced risk of early euthanasia due to >20 % weight loss of HR 0.15 (0.03-0.66, p = 0.04). Furthermore, the treatment group did significantly better on the rotating pole test, RR 0.64 (0.47-0.91, p = 0.02). CONCLUSION RO-31-7549 improved outcomes in terms >20 % weight loss and rotating pole performance after experimental SAH and could be investigated.
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Affiliation(s)
- Jesper P Bömers
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.
| | - Anja Holm
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Center for RNA Medicine, Aalborg University, Copenhagen, Denmark
| | - Spyridoula Kazantzi
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Lars Edvinsson
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Tiit I Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kristian A Haanes
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Biology, University of Copenhagen, Copenhagen, Denmark
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8
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Macias-Gómez A, Jiménez-Balado J, Fernández-Pérez I, Suárez-Pérez A, Vallverdú-Prats M, Guimaraens L, Vivas E, Saldaña J, Giralt-Steinhauer E, Guisado-Alonso D, Villalba G, Gracia MP, Esteller M, Rodriguez-Campello A, Jiménez-Conde J, Ois A, Cuadrado-Godia E. The influence of epigenetic biological age on key complications and outcomes in aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2024; 95:675-681. [PMID: 38302433 DOI: 10.1136/jnnp-2023-332889] [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: 10/27/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND We aimed to investigate the association between DNA-methylation biological age (B-age) calculated as age acceleration (ageAcc) and key aneurysmal subarachnoid haemorrhage (aSAH) complications such as vasospasm, delayed cerebral ischaemia (DCI), poor outcome, and mortality. METHODS We conducted a prospective study involving 277 patients with aSAH. B-age was determined in whole blood samples using five epigenetic clocks: Hannum's, Horvath's, Levine's and both versions of Zhang's clocks. Age acceleration was calculated as the residual obtained from regressing out the effect of C-age on the mismatch between C-age and B-age. We then tested the association between ageAcc and vasospasm, DCI and 12-month poor outcome (mRS 3-5) and mortality using linear regression models adjusted for confounders. RESULTS Average C-age was 55.0 years, with 66.8% being female. Vasospasm occurred in 143 cases (51.6%), DCI in 70 (25.3%) and poor outcomes in 99 (35.7%), with a mortality rate of 20.6%. Lower ageAcc was linked to vasospasm in Horvath's and Levine's clocks, whereas increased ageAcc was associated with 12-month mortality in Hannum's clock. No significant differences in ageAcc were found for DCI or poor outcome at 12 months with other clocks. CONCLUSIONS Our study indicates that B-age is independently associated with vasospasm and 12-month mortality in patients with aSAH. These findings underscore the potential role of epigenetics in understanding the pathophysiology of aSAH-related complications and outcomes.
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Affiliation(s)
- Adrià Macias-Gómez
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Joan Jiménez-Balado
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Isabel Fernández-Pérez
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Antoni Suárez-Pérez
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Marta Vallverdú-Prats
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Leopoldo Guimaraens
- J.J. Merland of Therapeutic Neuroangiography, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Elio Vivas
- J.J. Merland of Therapeutic Neuroangiography, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Jesus Saldaña
- J.J. Merland of Therapeutic Neuroangiography, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Eva Giralt-Steinhauer
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Daniel Guisado-Alonso
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
| | - Gloria Villalba
- Neurosurgery Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Maria-Pilar Gracia
- Pompeu Fabra University, Barcelona, Catalunya, Spain
- Intensive Care Department, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Manel Esteller
- Cancer Epigenetics Group, Research Institute Against Leukemia Josep Carreras, Badalona, Catalunya, Spain
- Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Ana Rodriguez-Campello
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Jordi Jiménez-Conde
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Angel Ois
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Elisa Cuadrado-Godia
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
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Sakata H, Kanoke A, Uchida H, Haryu S, Omodaka S, Kimura N, Yoshida M, Niizuma K, Tominaga T, Endo H. Prophylactic management of cerebral vasospasm with clazosentan in real clinical practice: a single-center retrospective cohort study. Front Neurol 2024; 15:1413632. [PMID: 38903164 PMCID: PMC11187092 DOI: 10.3389/fneur.2024.1413632] [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: 04/07/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Clazosentan, a selective endothelin receptor subtype A antagonist, reduces vasospasm-related morbidity and all-cause mortality following aneurysmal subarachnoid hemorrhage (SAH) in the Japanese population, as demonstrated by a recent randomized phase 3 trial. However, evidence to suggest clazosentan should be prioritized over the current standard of care to prevent cerebral vasospasm is still lacking. Therefore, we investigated the efficacy and safety of clazosentan in comparison with conventional postoperative management in real-world clinical practice. Methods We conducted a single-center, retrospective, observational cohort study using prospectively collected data from consecutive patients with aneurysmal SAH. After clazosentan was approved for use in Japan, the conventional postoperative management protocol, composed of intravenous fasudil chloride and oral cilostazol (control group, April 2021 to March 2022), was changed to the clazosentan protocol (clazosentan group, April 2022 to March 2023). The primary endpoint was the incidence of vasospasm-related symptomatic infarction. The secondary endpoints were favorable functional outcomes (modified Rankin scale score < 3) at discharge, angiographic vasospasm, and the need for rescue therapy for delayed cerebral ischemia. Results The analysis included 100 and 81 patients in the control and clazosentan groups, respectively. The incidence of vasospasm-related symptomatic infarction was significantly lower in the clazosentan group than in the control group (6.2% vs. 16%, p = 0.032). Multiple logistic analyses demonstrated that the use of clazosentan was independently associated with fewer incidence of vasospasm-related symptomatic infarct (23.8% vs. 47.5%, odds ratio 0.34 [0.12-0.97], p = 0.032). Clazosentan was significantly associated with favorable outcomes at discharge (79% vs. 66%, p = 0.037). Moreover, both the incidence of angiographic vasospasm (25.9% vs. 44%, p = 0.013) and the need for rescue therapy (16.1% vs. 34%, p = 0.006) was lower in the clazosentan group. The occurrence of pulmonary edema was significantly higher with clazosentan use (19.8% vs. 5%, p = 0.002), which did not result in morbidity. Conclusion A postoperative management protocol centering on clazosentan was associated with the reduced vasospasm-related symptomatic infarction and improved clinical outcomes compared to the conventional management protocol in Japanese clinical practice. Clazosentan might be a promising treatment option for counteracting cerebral vasospasm after aneurysmal SAH.
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Affiliation(s)
- Hiroyuki Sakata
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Atsushi Kanoke
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Hiroki Uchida
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Shinya Haryu
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Shunsuke Omodaka
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Masahiro Yoshida
- Preemptive Medicine in the Community of the North Miyagi (Osaki Citizen Hospital), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Neurosurgical Engineering and Translational Neuroscience, Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
- Department of Neurosurgical Engineering and Translational Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
- Research Division of Advanced Diagnosis and Treatment for Subarachnoid Hemorrhage, Tohoku University Hospital, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Research Division of Advanced Diagnosis and Treatment for Subarachnoid Hemorrhage, Tohoku University Hospital, Sendai, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Research Division of Advanced Diagnosis and Treatment for Subarachnoid Hemorrhage, Tohoku University Hospital, Sendai, Japan
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10
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Lauzier DC, Athiraman U. Role of microglia after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2024; 44:841-856. [PMID: 38415607 DOI: 10.1177/0271678x241237070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Subarachnoid hemorrhage is a devastating sequela of aneurysm rupture. Because it disproportionately affects younger patients, the population impact of hemorrhagic stroke from subarachnoid hemorrhage is substantial. Secondary brain injury is a significant contributor to morbidity after subarachnoid hemorrhage. Initial hemorrhage causes intracranial pressure elevations, disrupted cerebral perfusion pressure, global ischemia, and systemic dysfunction. These initial events are followed by two characterized timespans of secondary brain injury: the early brain injury period and the delayed cerebral ischemia period. The identification of varying microglial phenotypes across phases of secondary brain injury paired with the functions of microglia during each phase provides a basis for microglia serving a critical role in both promoting and attenuating subarachnoid hemorrhage-induced morbidity. The duality of microglial effects on outcomes following SAH is highlighted by the pleiotropic features of these cells. Here, we provide an overview of the key role of microglia in subarachnoid hemorrhage-induced secondary brain injury as both cytotoxic and restorative effectors. We first describe the ontogeny of microglial populations that respond to subarachnoid hemorrhage. We then correlate the phenotypic development of secondary brain injury after subarachnoid hemorrhage to microglial functions, synthesizing experimental data in this area.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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11
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Chen J, Shi Z, Zhang C, Xiong K, Zhao W, Wang Y. Oroxin A alleviates early brain injury after subarachnoid hemorrhage by regulating ferroptosis and neuroinflammation. J Neuroinflammation 2024; 21:116. [PMID: 38702778 PMCID: PMC11069275 DOI: 10.1186/s12974-024-03099-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/10/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH), a severe subtype of stroke, is characterized by notably high mortality and morbidity, largely due to the lack of effective therapeutic options. Although the neuroprotective potential of PPARg and Nrf2 has been recognized, investigative efforts into oroxin A (OA), remain limited in preclinical studies. METHODS SAH was modeled in vivo through filament perforation in male C57BL/6 mice and in vitro by exposing HT22 cells to hemin to induce neuronal damage. Following the administration of OA, a series of methods were employed to assess neurological behaviors, brain water content, neuronal damage, cell ferroptosis, and the extent of neuroinflammation. RESULTS The findings indicated that OA treatment markedly improved survival rates, enhanced neurological functions, mitigated neuronal death and brain edema, and attenuated the inflammatory response. These effects of OA were linked to the suppression of microglial activation. Moreover, OA administration was found to diminish ferroptosis in neuronal cells, a critical factor in early brain injury (EBI) following SAH. Further mechanistic investigations uncovered that OA facilitated the translocation of nuclear factor erythroid 2-related factor 2 (Nrf-2) from the cytoplasm to the nucleus, thereby activating the Nrf2/GPX4 pathway. Importantly, OA also upregulated the expression of FSP1, suggesting a significant and parallel protective effect against ferroptosis in EBI following SAH in synergy with GPX4. CONCLUSION In summary, this research indicated that the PPARg activator OA augmented the neurological results in rodent models and diminished neuronal death. This neuroprotection was achieved primarily by suppressing neuronal ferroptosis. The underlying mechanism was associated with the alleviation of cellular death through the Nrf2/GPX4 and FSP1/CoQ10 pathways.
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Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, 904 th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, No. 101 Xingyuan North Road, Liangxi District, Wuxi, 214044, Jiangsu Province, China
- Department of Human Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, Hunan Province, China
| | - Zhonghua Shi
- Department of Neurosurgery, 904 th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, No. 101 Xingyuan North Road, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Chunlei Zhang
- Department of Neurosurgery, 904 th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, No. 101 Xingyuan North Road, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Kun Xiong
- Department of Human Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, Hunan Province, China.
| | - Wei Zhao
- Department of Neurosurgery, 904 th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, No. 101 Xingyuan North Road, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Yuhai Wang
- Department of Neurosurgery, 904 th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, No. 101 Xingyuan North Road, Liangxi District, Wuxi, 214044, Jiangsu Province, China.
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12
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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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13
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Früh A, Truckenmüller P, Wasilewski D, Vajkoczy P, Wolf S. Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2024:10.1007/s12028-024-01981-9. [PMID: 38622488 DOI: 10.1007/s12028-024-01981-9] [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: 11/04/2023] [Accepted: 03/12/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND After aneurysmal subarachnoid hemorrhage (aSAH), elevated intracranial pressure (ICP) due to disrupted cerebrospinal fluid (CSF) dynamics is a critical concern. An external ventricular drainage (EVD) is commonly employed for management; however, optimal strategies remain debated. The randomized controlled Earlydrain trial showed that an additional prophylactic lumbar drainage (LD) after aneurysm treatment improves neurological outcome. We performed a post hoc investigation on the impact of drainage volumes and critical ICP values on patient outcomes after aSAH. METHODS Using raw patient data from Earlydrain, we analyzed CSF drainage amounts and ICP measurements in the first 8 days after aSAH. Outcomes were the occurrence of secondary infarctions and the score on the modified Rankin scale after 6 months, dichotomized in values of 0-2 as favorable and 3-6 as unfavorable. Repeated measurements were considered with generalized estimation equations. RESULTS Earlydrain recruited 287 patients, of whom 221 received an EVD and 140 received an LD. Higher EVD volumes showed a trend to more secondary infarctions (p = 0.09), whereas higher LD volumes were associated with less secondary infarctions (p = 0.009). The mean total CSF drainage was 1052 ± 659 mL and did not differ concerning infarction and neurological outcome. Maximum ICP values were higher in patients with poor outcomes but not related to drainage volumes via EVD. After adjustment for aSAH severity and total CSF drainage, higher LD volume was linked to favorable outcome (per 100 mL: odds ratio 0.61 (95% confidence interval 0.39-0.95), p = 0.03), whereas higher EVD amounts were associated with unfavorable outcome (per 100 mL: odds ratio 1.63 (95% confidence interval 1.05-2.54), p = 0.03). CONCLUSIONS Findings indicate that effects of CSF drainage via EVD and LD differ. Higher amounts and higher proportions of LD volumes were associated with better outcomes, suggesting a potential quantity-dependent protective effect. Optimizing LD volume and mitigating ICP spikes may be a strategy to improve patient outcomes after aSAH. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01258257.
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Affiliation(s)
- Anton Früh
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- BIH Charité Junior Digital Clinician Scientist Program, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117, Berlin, Germany
| | - Peter Truckenmüller
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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14
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Uchikawa H, Uekawa K, Hasegawa Y. Perivascular macrophages in cerebrovascular diseases. Exp Neurol 2024; 374:114680. [PMID: 38185314 DOI: 10.1016/j.expneurol.2024.114680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/10/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
Cerebrovascular diseases are a major cause of stroke and dementia, both requiring long-term care. These diseases involve multiple pathophysiologies, with mitochondrial dysfunction being a crucial contributor to the initiation of inflammation, apoptosis, and oxidative stress, resulting in injuries to neurovascular units that include neuronal cell death, endothelial cell death, glial activation, and blood-brain barrier disruption. To maintain brain homeostasis against these pathogenic conditions, brain immune cells, including border-associated macrophages and microglia, play significant roles as brain innate immunity cells in the pathophysiology of cerebrovascular injury. Although microglia have long been recognized as significant contributors to neuroinflammation, attention has recently shifted to border-associated macrophages, such as perivascular macrophages (PVMs), which have been studied based on their crucial roles in the brain. These cells are strategically positioned around the walls of brain vessels, where they mainly perform critical functions, such as perivascular drainage, cerebrovascular flexibility, phagocytic activity, antigen presentation, activation of inflammatory responses, and preservation of blood-brain barrier integrity. Although PVMs act as scavenger and surveillant cells under normal conditions, these cells exert harmful effects under pathological conditions. PVMs detect mitochondrial dysfunction in injured cells and implement pathological changes to regulate brain homeostasis. Therefore, PVMs are promising as they play a significant role in mitochondrial dysfunction and, in turn, disrupt the homeostatic condition. Herein, we summarize the significant roles of PVMs in cerebrovascular diseases, especially ischemic and hemorrhagic stroke and dementia, mainly in correlation with inflammation. A better understanding of the biology and pathobiology of PVMs may lead to new insights on and therapeutic strategies for cerebrovascular diseases.
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Affiliation(s)
- Hiroki Uchikawa
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, Barrow Neurological Institute, Phoenix, AZ, USA; Department of Neurosurgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Kumamoto, Japan
| | - Ken Uekawa
- Department of Neurosurgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Kumamoto, Japan
| | - Yu Hasegawa
- Department of Pharmaceutical Science, School of Pharmacy at Fukuoka, International University of Health and Welfare, Okawa, Fukuoka, Japan.
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15
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Hofmann BB, Donaldson DM, Neyazi M, Abusabha Y, Beseoglu K, Hänggi D, Cornelius JF, Fischer I, Muhammad S. Clinical Outcome Prediction of Early Brain Injury in Aneurysmal Subarachnoid Hemorrhage: the SHELTER-Score. Neurocrit Care 2024; 40:438-447. [PMID: 38030877 PMCID: PMC10959788 DOI: 10.1007/s12028-023-01879-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Despite intensive research on preventing and treating vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH), mortality and morbidity rates remain high. Early brain injury (EBI) has emerged as possibly the major significant factor in aSAH pathophysiology, emphasizing the need to investigate EBI-associated clinical events for improved patient management and decision-making. This study aimed to identify early clinical and radiological events within 72 h after aSAH to develop a conclusive predictive EBI score for clinical practice. METHODS This retrospective analysis included 561 consecutive patients with aSAH admitted to our neurovascular center between 01/2014 and 09/2022. Fourteen potential predictors occurring within the initial 72 h after hemorrhage were analyzed. The modified Rankin Scale (mRS) score at 6 months, discretized to three levels (0-2, favorable; 3-5, poor; 6, dead), was used as the outcome variable. Univariate ordinal regression ranked predictors by significance, and forward selection with McFadden's pseudo-R2 determined the optimal set of predictors for multivariate proportional odds logistic regression. Collinear parameters were excluded, and fivefold cross-validation was used to avoid overfitting. RESULTS The analysis resulted in the Subarachnoid Hemorrhage Associated Early Brain Injury Outcome Prediction score (SHELTER-score), comprising seven clinical and radiological events: age (0-4 points), World Federation of Neurosurgical Societies (0-2.5 points), cardiopulmonary resuscitation (CPR) (2 points), mydriasis (1-2 points), midline shift (0.5-1 points), early deterioration (1 point), and early ischemic lesion (2 points). McFadden's pseudo-R2 = 0.339, area under the curve for death or disability 0.899 and 0.877 for death. A SHELTER-score below 5 indicated a favorable outcome (mRS 0-2), 5-6.5 predicted a poor outcome (mRS 3-5), and ≥ 7 correlated with death (mRS 6) at 6 months. CONCLUSIONS The novel SHELTER-score, incorporating seven clinical and radiological features of EBI, demonstrated strong predictive performance in determining clinical outcomes. This scoring system serves as a valuable tool for neurointensivists to identify patients with poor outcomes and guide treatment decisions, reflecting the great impact of EBI on the overall outcome of patients with aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, Germany
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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16
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Fürstenau E, Lindauer U, Koch H, Höllig A. Secondary Ischemia Assessment in Murine and Rat Preclinical Subarachnoid Hemorrhage Models: A Systematic Review. J Am Heart Assoc 2024; 13:e032694. [PMID: 38420758 PMCID: PMC10944078 DOI: 10.1161/jaha.123.032694] [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: 09/20/2023] [Accepted: 01/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Delayed cerebral ischemia represents a significant contributor to death and disability following aneurysmal subarachnoid hemorrhage. Although preclinical models have shown promising results, clinical trials have consistently failed to replicate the success of therapeutic strategies. The lack of standardized experimental setups and outcome assessments, particularly regarding secondary vasospastic/ischemic events, may be partly responsible for the translational failure. The study aims to delineate the procedural characteristics and assessment modalities of secondary vasospastic and ischemic events, serving as surrogates for clinically relevant delayed cerebral ischemia, in recent rat and murine subarachnoid hemorrhage models. METHODS AND RESULTS We conducted a systematic review of rat and murine in vivo subarachnoid hemorrhage studies (published: 2016-2020) using delayed cerebral ischemia/vasospasm as outcome parameters. Our analysis included 102 eligible studies. In murine studies (n=30), the endovascular perforation model was predominantly used, while rat studies primarily employed intracisternal blood injection to mimic subarachnoid hemorrhage. Particularly, the injection models exhibited considerable variation in injection volume, rate, and cerebrospinal fluid withdrawal. Peri-interventional monitoring was generally inadequately reported across all models, with body temperature and blood pressure being the most frequently documented parameters (62% and 34%, respectively). Vasospastic events were mainly assessed through microscopy of large cerebral arteries. In 90% of the rat and 86% of the murine studies, only male animals were used. CONCLUSIONS Our study underscores the substantial heterogeneity in procedural characteristics and outcome assessments of experimental subarachnoid hemorrhage research. To address these challenges, drafting guidelines for standardization and ensuring rigorous control of methodological and experimental quality by funders and journals are essential. REGISTRATION URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022337279.
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Affiliation(s)
- Elias Fürstenau
- Department of NeurosurgeryUniversity Hospital Aachen, RWTH Aachen UniversityAachenGermany
| | - Ute Lindauer
- Department of NeurosurgeryUniversity Hospital Aachen, RWTH Aachen UniversityAachenGermany
- Translational Neurosurgery and Neurobiology, Department of NeurosurgeryUniversity Hospital Aachen, RWTH Aachen UniversityAachenGermany
| | - Henner Koch
- Department of Epileptology and NeurologyRWTH Aachen UniversityAachenGermany
| | - Anke Höllig
- Department of NeurosurgeryUniversity Hospital Aachen, RWTH Aachen UniversityAachenGermany
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17
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Edvinsson L, Krause DN. Switching Off Vascular MAPK Signaling: A Novel Strategy to Prevent Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01234-z. [PMID: 38334872 DOI: 10.1007/s12975-024-01234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/12/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
Patients who initially survive the rupture and repair of a brain aneurysm often take a devastating turn for the worse some days later and die or suffer permanent neurologic deficits. This catastrophic sequela is attributed to a delayed phase of global cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH), but we lack effective treatment. Here we present our view, based on 20 years of research, that the initial drop in blood flow at the time of rupture triggers genomic responses throughout the brain vasculature that manifest days later as increased vasoconstriction and decreased cerebral blood flow. We propose a novel treatment strategy to prevent DCI by early inhibition of the vascular mitogen-activated protein kinase (MAPK) pathway that triggers expression of vasoconstrictor and inflammatory mediators. We summarize evidence from experimental SAH models showing early treatment with MAPK inhibitors "switches off" these detrimental responses, maintains flow, and improves neurological outcome. This promising therapy is currently being evaluated in clinical trials.
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Affiliation(s)
- Lars Edvinsson
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Sölvegatan 19, 22100, Lund, Sweden.
- Department of Experimental Research, Glostrup Research Institute, CopenhagenUniversity, Copenhagen, Denmark.
| | - Diana N Krause
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Sölvegatan 19, 22100, Lund, Sweden
- Department of Pharmaceutical Sciences, SchoolofPharmacy&PharmaceuticalSciences, University of California at Irvine, Irvine, CA, USA
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18
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Caylor MM, Macdonald RL. Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:159-169. [PMID: 37740138 DOI: 10.1007/s12028-023-01847-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/23/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries. METHODS Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan. RESULTS The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad. CONCLUSIONS We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.
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Affiliation(s)
- Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - R Loch Macdonald
- Community Neurosciences Institute, Community Health Partners, 7257 North Fresno Street, Fresno, CA, 93720, USA.
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19
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Dabbagh Ohadi MA, Maroufi SF, Mohammadi MR, Hosseini Siyanaki MR, Khorasanizadeh M, Kellner CP. Ferroptosis as a Therapeutic Target in Subarachnoid Hemorrhage. World Neurosurg 2024; 182:52-57. [PMID: 37979679 DOI: 10.1016/j.wneu.2023.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a cerebrovascular disorder with significant mortality and morbidity. Neural injury in SAH is mediated through a variety of pathophysiological processes. Currently available treatments are either nonspecific in targeting the basic pathophysiological mechanisms that result in neural damage in SAH, or merely focus on vasospasm. Ferroptosis is a type of programmed iron dependent cell death, which has received attention due to its possible role in neural injury in SAH. Herein, we review how intracellular iron overload mediates the production of reactive free radicals and lipid peroxidation through a variety of biochemical pathways in SAH. This in turn results in induction of ferroptosis, as well as exacerbation of vasospasm. We also discuss several therapeutic agents that have been shown to inhibit ferroptosis through targeting different steps of the process. Such agents have proven effective in ameliorating vasospasm, neural damage, and neurobehavioral outcomes in animal models of SAH. Human studies to test the safety and efficacy of intrathecal or parenteral administration of the inhibitors of ferroptosis in improving outcomes of SAH patients are warranted. There are currently a few ongoing clinical trials pursuing this therapeutic concept, the results of which will be critical to determine the value of ferroptosis as a novel therapeutic target in SAH.
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Affiliation(s)
- Mohammad Amin Dabbagh Ohadi
- Departments of Pediatric Neurosurgery Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City, New York, USA.
| | - Christopher P Kellner
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City, New York, USA
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20
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Takasugi Y, Hishikawa T, Shimizu T, Murai S, Haruma J, Hiramatsu M, Tokunaga K, Takeda Y, Sugiu K, Morimatsu H, Date I. Power suppression in EEG after the onset of SAH is a significant marker of early brain injury in rat models. Sci Rep 2024; 14:2277. [PMID: 38280926 PMCID: PMC10821948 DOI: 10.1038/s41598-024-52527-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 01/19/2024] [Indexed: 01/29/2024] Open
Abstract
We analyzed the correlation between the duration of electroencephalogram (EEG) recovery and histological outcome in rats in the acute stage of subarachnoid hemorrhage (SAH) to find a new predictor of the subsequent outcome. SAH was induced in eight rats by cisternal blood injection, and the duration of cortical depolarization was measured. EEG power spectrums were given by time frequency analysis, and histology was evaluated. The appropriate frequency band and recovery percentage of EEG (defined as EEG recovery time) to predict the neuronal damage were determined from 25 patterns (5 bands × 5 recovery rates) of receiver operating characteristic (ROC) curves. Probit regression curves were depicted to evaluate the relationships between neuronal injury and duration of depolarization and EEG recovery. The optimal values of the EEG band and the EEG recovery time to predict neuronal damage were 10-15 Hz and 40%, respectively (area under the curve [AUC]: 0.97). There was a close relationship between the percentage of damaged neurons and the duration of depolarization or EEG recovery time. These results suggest that EEG recovery time, under the above frequency band and recovery rate, may be a novel marker to predict the outcome after SAH.
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Affiliation(s)
- Yuji Takasugi
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Neurosurgery, Okayama City Hospital, Okayama, Japan
| | - Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomohisa Shimizu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Murai
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jun Haruma
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Tokunaga
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Neurosurgery, Okayama City Hospital, Okayama, Japan
| | - Yoshimasa Takeda
- Department of Anesthesiology, Faculty of Medicine, Toho University, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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21
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Mei Q, Shen H, Liu J. A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis. Front Neurol 2024; 14:1280047. [PMID: 38259653 PMCID: PMC10800534 DOI: 10.3389/fneur.2023.1280047] [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: 09/04/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation. Methods We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA). Results Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram. Conclusion We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.
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Affiliation(s)
- Qing Mei
- Department of Neurology, Beijing Pinggu Hospital, Beijing, China
| | - Hui Shen
- Department of Interventional Neuroradiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Functional Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Centre of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou, China
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22
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Chen J, Li M, Chen L, Xu Q, Yan T, Zhang C, Hu P, He J, Zhu X, Zhu X, Wang Y. Pioglitazone in spontaneous subarachnoid hemorrhage: study protocol of a multicenter, double-blind, randomized trial (PSSH). Front Pharmacol 2024; 14:1323292. [PMID: 38249343 PMCID: PMC10796591 DOI: 10.3389/fphar.2023.1323292] [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: 10/17/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction: Spontaneous subarachnoid hemorrhage (SAH), is a disorder that may be fatal and is primarily caused by a ruptured brain aneurysm. Despite significant leaps forward in the methods to produce aneurysms, the long-term outcomes did not much improve. Pioglitazone is a medication that has been authorized by the FDA as an agonist for the peroxisome proliferator-activated receptor-gamma (PPARγ). Pioglitazone or PPARγ has neuroprotective benefits in animal experiments both during and after traumatic brain injury (TBI) and SAH. Nevertheless, the treatment impact of Pioglitazone on humans is still unknown at this time. As a result, we will conduct a randomized, double-blind, placebo-controlled trial to explore the impact of pioglitazone on SAH. Methods/Design: This trial will recruit 400 patients with SAH from four Chinese hospitals. These patients will be equally and randomly assigned to Pioglitazone and placebo control groups for up to 30 days. Scores on the modified Rankin scale (mRS) are the primary outcomes. The secondary outcomes are a 30-day all-cause mortality rate, 6 months of Montreal cognitive assessment (Mo-CA), delayed cerebral ischemia, the requirement for intensive care, the incidence of sepsis, etc. All serious adverse events (SAEs) were recorded during the hospital. Every primary and safety analysis was conducted based on the intention-to-treat technique. The participants were given either a matching placebo or 15 mg of pioglitazone, with dose titrated to a target of 45 mg daily. Data on the therapeutic use of pioglitazone after SAH will be provided as a consequence of the findings of this experiment. In addition, this pilot trial is the first to prospectively investigate the effectiveness and safety of pioglitazone in patients with SAH. Ethics and dissemination: Ethics approval was obtained from the Medical Ethics Committee of 904th Hospital of Joint Logistic Support Force of PLA (Wuxi Taihu Hospital, approval No. 20220701). The findings of the trial will be presented at conferences, discussed in relevant patient groups, and published in peer-reviewed journals. Clinical Trial Registration: clinicaltrials.gov, identifier ChiCTR2200062954.
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Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, 904 Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
- Department of Human Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, Hunan Province, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lei Chen
- Department of Neurosurgery, 904 Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
- Department of Neurosurgery, Wuxi Huishan Peoples Hospital, Wuxi, Jiangsu, China
| | - Qinyi Xu
- Department of Neurosurgery, Wuxi Huishan Peoples Hospital, Wuxi, Jiangsu, China
| | - Tengfeng Yan
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chunlei Zhang
- Department of Neurosurgery, 904 Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
| | - Ping Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianqing He
- Department of Neurosurgery, 904 Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
| | - Xun Zhu
- Department of Neurosurgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xingen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuhai Wang
- Department of Neurosurgery, 904 Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
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23
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Cao C, Lu T, Cheng Q, Cui G, Wang Z, Li X, Li H, Gao H, Shen H, Sun Q. Restoring System xc- activity by xCT overexpression inhibited neuronal ferroptosis and improved neurological deficits after experimental subarachnoid hemorrhage. Brain Res 2023; 1820:148556. [PMID: 37648093 DOI: 10.1016/j.brainres.2023.148556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/09/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Ferroptosis is an important therapeutic target to alleviate early brain injury (EBI) after subarachnoid hemorrhage (SAH), yet the mechanism of neuronal ferroptosis after SAH remains unclear. System xc- dysfunction is one of the key pathways to induce ferroptosis. System xc- activity is mainly regulated by the expression of xCT. This study was designed to investigate the effect of xCT expression and System xc- activity on ferroptosis and EBI in an experimental SAH model both in vitro and in vivo. METHODS SAH was induced in adult male Sprague-Dawley rats by injecting autologous blood into the prechiasmatic cistern. Primary neurons treated with oxyhemoglobin (10 µM) were used to mimic SAH in vitro. Plasmid transfection was used to induce xCT overexpression. Western blotting, immunofluorescence staining, measurement of cystine uptake, enzyme-linked immunosorbent assay, transmission electron microscopy, Nissl staining, and a series of neurobehavioral tests were conducted to explore the role of xCT and System xc- activity in ferroptosis and EBI after SAH. RESULTS We found that System xc- dysfunction induced ferroptosis and exacerbated EBI after SAH in rats. xCT deficiency after SAH resulted in System xc- dysfunction, weakened neuronal antioxidant capacity and activated neuronal ferroptosis. xCT overexpression improved neuronal antioxidant capacity and inhibited neuronal ferroptosis by restoring System xc- activity. Rats with xCT overexpression after SAH presented with attenuated brain edema and inflammation, increased neuronal survival, and ameliorated neurological deficits. CONCLUSIONS Our study revealed that restoring System xc- activity by xCT overexpression inhibited neuronal ferroptosis and EBI and improved neurological deficits after SAH.
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Affiliation(s)
- Cheng Cao
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China; Department of Intensive Care Unit, The Affiliated Jiangyin Hospital of Nantong University, Jiangyin City 214400, Jiangsu Province, China; Department of Brain Center, The Affiliated Jiangyin Hospital of Nantong University, Jiangyin City 214400, Jiangsu Province, China.
| | - Ting Lu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Qian Cheng
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Gang Cui
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Xiang Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Haiying Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Heng Gao
- Department of Brain Center, The Affiliated Jiangyin Hospital of Nantong University, Jiangyin City 214400, Jiangsu Province, China.
| | - Haitao Shen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
| | - Qing Sun
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China.
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24
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Pontes JPM, Santos MDC, Gibram FC, Rodrigues NMV, Cavalcante-Neto JF, Barros ADM, Solla DJF. Efficacy and Safety of Clazosentan After Aneurysmal Subarachnoid Hemorrhage: An Updated Meta-Analysis. Neurosurgery 2023; 93:1208-1219. [PMID: 37462365 DOI: 10.1227/neu.0000000000002601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 05/18/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Clazosentan has been studied to treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH).This meta-analysis of randomized controlled trials updates the current knowledge regarding the efficacy and safety of clazosentan compared with placebo after aSAH. METHODS Databases were systematically searched for randomized controlled trials directly comparing the use of clazosentan and placebo for the treatment of cerebral vasospasm after aSAH. Additional eligibility criteria were the report of any of the outcomes of interest (vasospasm, morbidity, functional outcome, or mortality). The primary outcome was vasospasm-related delayed cerebral ischemia (DCI). The analyses were stratified by clazosentan dosage (low or high dose) and aneurysm treatment modality (clipping or coiling). The Cochrane RoB-2 tool was used for studies quality assessment. RESULTS Six studies comprising 7 clinical trials were included, involving 2778 patients. Clazosentan decreased the risk of vasospasm-related DCI (risk ratio [RR] 0.56, 95% CI 0.38-0.81) and delayed ischemic neurological deficit (RR 0.63, 95% 0.50-0.80). Angiographic vasospasm (RR 0.54, 95% CI 0.47-0.61) was also decreased. Functional outcomes (favorable Glasgow Outcome Scale, RR 0.99, 95% CI 0.79-1.24) and death (RR 1.03, 95% CI 0.71-1.49) did not change. Meanwhile, adverse events were increased by clazosentan (RR 1.54, 95% CI 1.35-1.76). CONCLUSION Clazosentan decreased vasospasm-related DCI and angiographic vasospasm but did not improve functional outcomes or mortality. Adverse events were increased by clazosentan.
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Affiliation(s)
- Julia Pereira Muniz Pontes
- Department of Surgical Specialties, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro , Rio de Janeiro , Brazil
| | | | - Franceliny Couto Gibram
- Department of Neurosurgery, University of Vale do Sapucai, Pouso Alegre , Minas Gerais , Brazil
| | | | | | | | - Davi J Fontoura Solla
- Division of Neurosurgery, Department of Neurology, Hospital das Clínicas da Faculdade de Medicina, University of São Paulo, São Paulo , Brazil
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25
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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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26
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Lei K, Wu R, Wang J, Lei X, Zhou E, Fan R, Gong L. Sirtuins as Potential Targets for Neuroprotection: Mechanisms of Early Brain Injury Induced by Subarachnoid Hemorrhage. Transl Stroke Res 2023:10.1007/s12975-023-01191-z. [PMID: 37779164 DOI: 10.1007/s12975-023-01191-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a prevalent cerebrovascular disease with significant global mortality and morbidity rates. Despite advancements in pharmacological and surgical approaches, the quality of life for SAH survivors has not shown substantial improvement. Traditionally, vasospasm has been considered a primary contributor to death and disability following SAH, but anti-vasospastic therapies have not demonstrated significant benefits for SAH patients' prognosis. Emerging studies suggest that early brain injury (EBI) may play a crucial role in influencing SAH prognosis. Sirtuins (SIRTs), a group of NAD + -dependent deacylases comprising seven mammalian family members (SIRT1 to SIRT7), have been found to be involved in neural tissue development, plasticity, and aging. They also exhibit vital functions in various central nervous system (CNS) processes, including cognition, pain perception, mood, behavior, sleep, and circadian rhythms. Extensive research has uncovered the multifaceted roles of SIRTs in CNS disorders, offering insights into potential markers for pathological processes and promising therapeutic targets (such as SIRT1 activators and SIRT2 inhibitors). In this article, we provide an overview of recent research progress on the application of SIRTs in subarachnoid hemorrhage and explore their underlying mechanisms of action.
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Affiliation(s)
- Kunqian Lei
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China
| | - Rui Wu
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China
| | - Jin Wang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China
| | - Xianze Lei
- Department of Neurology, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China
| | - Erxiong Zhou
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China
| | - Ruiming Fan
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China.
| | - Lei Gong
- Department of Pharmacy, Institute of Medical Biotechnology, Affiliated Hospital of Zunyi Medical University CN, Zunyi, China.
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Bombardieri AM, Heifets BD, Treggiari M, Albers GW, Steinberg GK, Heit JJ. Cervical sympathectomy to treat cerebral vasospasm: a scoping review. Reg Anesth Pain Med 2023; 48:513-519. [PMID: 36424089 DOI: 10.1136/rapm-2022-103999] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND/IMPORTANCE Delayed cerebral ischemia (DCI) is the second-leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (aSAH), and is associated with cerebral arterial vasospasm (CAV). Current treatments for CAV are expensive, invasive, and have limited efficacy. Cervical sympathetic block (CSB) is an underappreciated, but potentially highly effective therapy for CAV. OBJECTIVE To provide a comprehensive review of the preclinical and human literature pertinent to CSB in the context of CAV. EVIDENCE REVIEW This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a literature search using Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science until February 2022, to identify abstracts, conference proceedings, and full-text papers pertinent to cervical sympathectomy and CAV in animal/adult patients. FINDINGS We included six human and six experimental studies. Human studies were mostly prospective observational, except one retrospective and one randomized clinical trial, and used various imaging modalities to measure changes in arterial diameter after the block. Studies that used digital subtraction angiography showed an improvement in cerebral perfusion without change in vessel diameter. Transcranial Doppler studies found an approximately 15% statistically significant decrease in velocities consistent with arterial vasodilatation. Overall, the results suggest an increase in cerebral arterial diameter and neurological improvement in patients receiving a CSB. Animal studies demonstrate that sympathetic system ablation vasodilates cerebral vasculature and decreases the incidence of symptomatic vasospasm. CONCLUSIONS This scoping review suggests that CSB may be a viable option for treatment and prevention of CAV/DCI in patients with aSAH, although the included studies were heterogeneous, mostly observational, and with a small sample size. Further research is needed to standardize the technique and prove its effectiveness to treat patients suffering of CAV/DCI after aSAH.
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Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Boris D Heifets
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Treggiari
- Anesthesiology and Perioperative Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregory W Albers
- Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Stanford University School of Medicine, Stanford, California, USA
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28
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Deem S, Livesay S, Treggiari MM. Response to "Treating Vasospasm with IV Milrinone: RELAX (the Vessel) or DON'T DO IT!". Neurocrit Care 2023; 39:549. [PMID: 37434102 DOI: 10.1007/s12028-023-01790-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Steven Deem
- Neurocritical Care Unit, Swedish Medical Center, Seattle, WA, USA.
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- College of Nursing, Rush University, Chicago, IL, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical School, Durham, NC, USA
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29
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Abdulazim A, Heilig M, Rinkel G, Etminan N. Diagnosis of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage and Triggers for Intervention. Neurocrit Care 2023; 39:311-319. [PMID: 37537496 PMCID: PMC10542310 DOI: 10.1007/s12028-023-01812-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a major determinant for poor neurological outcome after aneurysmal subarachnoid hemorrhage (aSAH). Detection and treatment of DCI is a key component in the neurocritical care of patients with aSAH after initial aneurysm repair. METHODS Narrative review of the literature. RESULTS Over the past 2 decades, there has been a paradigm shift away from macrovascular (angiographic) vasospasm as a main diagnostic and therapeutic target. Instead, the pathophysiology of DCI is hypothesized to derive from several proischemic pathomechanisms. Clinical examination remains the most reliable means for monitoring and treatment of DCI, but its value is limited in comatose patients. In such patients, monitoring of DCI is usually based on numerous neurophysiological and/or radiological diagnostic modalities. Catheter angiography remains the gold standard for the detection of macrovascular spasm. Computed tomography (CT) angiography is increasingly used instead of catheter angiography because it is less invasive and may be combined with CT perfusion imaging. CT perfusion permits semiquantitative cerebral blood flow measurements, including the evaluation of the microcirculation. It may be used for prediction, early detection, and diagnosis of DCI, with yet-to-prove benefit on clinical outcome when used as a screening modality. Transcranial Doppler may be considered as an additional noninvasive screening tool for flow velocities in the middle cerebral artery, with limited accuracy in other cerebral arteries. Continuous electroencephalography enables detection of early signs of ischemia at a reversible stage prior to clinical manifestation. However, its widespread use is still limited because of the required infrastructure and expertise in data interpretation. Near-infrared spectroscopy, a noninvasive and continuous modality for evaluation of cerebral blood flow dynamics, has shown conflicting results and needs further validation. Monitoring techniques beyond neurological examinations may help in the detection of DCI, especially in comatose patients. However, these techniques are limited because of their invasive nature and/or restriction of measurements to focal brain areas. CONCLUSION The current literature review underscores the need for incorporating existing modalities and developing new methods to evaluate brain perfusion, brain metabolism, and overall brain function more accurately and more globally.
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Affiliation(s)
- Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Marina Heilig
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Gabriel Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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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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Hofmann BB, Karadag C, Rubbert C, Schieferdecker S, Neyazi M, Abusabha Y, Fischer I, Boogaarts HD, Muhammad S, Beseoglu K, Hänggi D, Turowski B, Kamp MA, Cornelius JF. Novel Insights into Pathophysiology of Delayed Cerebral Ischemia: Effects of Current Rescue Therapy on Microvascular Perfusion Heterogeneity. Biomedicines 2023; 11:2624. [PMID: 37892998 PMCID: PMC10603935 DOI: 10.3390/biomedicines11102624] [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: 08/16/2023] [Revised: 09/11/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
General microvascular perfusion and its heterogeneity are pathophysiological features of delayed cerebral ischemia (DCI) that are gaining increasing attention. Recently, CT perfusion (CTP) imaging has made it possible to evaluate them radiologically using mean transit time (MTT) and its heterogeneity (measured by cvMTT). This study evaluates the effect of multimodal rescue therapy (intra-arterial nimodipine administration and elevation of blood pressure) on MTT and cvMTT during DCI in aneurysmal subarachnoid haemorrhage (aSAH) patients. A total of seventy-nine aSAH patients who underwent multimodal rescue therapy between May 2012 and December 2019 were retrospectively included in this study. CTP-based perfusion impairment (MTT and cvMTT) on the day of DCI diagnosis was compared with follow-up CTP after initiation of combined multimodal therapy. The mean MTT was significantly reduced in the follow-up CTP compared to the first CTP (3.7 ± 0.7 s vs. 3.3 ± 0.6 s; p < 0.0001). However, no significant reduction of cvMTT was observed (0.16 ± 0.06 vs. 0.15 ± 0.06; p = 0.44). Mean arterial pressure was significantly increased between follow-up and first CTP (98 ± 17 mmHg vs. 104 ± 15 mmHg; p < 0.0001). The combined multimodal rescue therapy was effective in addressing the general microvascular perfusion impairment but did not affect the mechanisms underlying microvascular perfusion heterogeneity. This highlights the need for research into new therapeutic approaches that also target these pathophysiological mechanisms of DCI.
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Affiliation(s)
- Björn B. Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Simon Schieferdecker
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Hieronymus D. Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, 6525 GA Nijmegen, The Netherlands
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, International Neuroscience Institute, 30625 Hannover, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcel A. Kamp
- Centre for Palliative and Neuropalliative Care, Brandenburg Medical School Theodor Fontane, Campus Rüdersdorf, 15562 Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
| | - Jan F. Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
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Topcu A, Ozkul A, Yilmaz A, Yi HJ, Shin DS, Kim B. The impact of collateral status on cerebral vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2023; 25:288-296. [PMID: 37232069 PMCID: PMC10555627 DOI: 10.7461/jcen.2023.e2022.11.005] [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: 11/16/2022] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE Cerebral collateral circulation may affect subarachnoid hemorrhage (SAH) induced cerebral vasospasm and delayed cerebral ischemia. In this study our aim was to investigate the relationship between collateral status, vasospasm and delayed cerebral ischemia (DCI) in both aneurysmal and nonaneurysmal SAH. METHODS Patients diagnosed as SAH with and without aneurysm were included and their data investigated retrospectively. After the patients diagnosed as SAH according to cerebral computed tomography (CT)/magnetic resonance imaging (MRI), they underwent cerebral angiography to check for cerebral aneurysm. The diagnosis of DCI was made according to the neurological examination and control CT/MRI. All the patients had their control cerebral angiography on days 7 to 10 in order to assess vasospasm and also collateral circulation. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System was modified to measure collateral circulation. RESULTS A total of 59 patients data were analyzed. Patients with aneurysmal SAH had higher Fisher scores and DCI was more common. Although there was no statistically significant difference between the patients with and without DCI in terms of demographics and mortality, patients with DCI had worse collateral circulation and more severe vasospasm. These patients had higher Fisher scores and more cerebral aneurysm overall. CONCLUSIONS According to our data, patients with higher Fisher scores, more severe vasospasm, and poor cerebral collateral circulation may experience DCI more frequently. Additionally aneurysmal SAH had higher Fisher scores and DCI was seen more common. To improve the clinical results for SAH patients, we believe that physicians should be aware of the DCI risk factors.
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Affiliation(s)
- Abdullah Topcu
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ayca Ozkul
- Department of Neurology, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ali Yilmaz
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Seong Shin
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - BumTae Kim
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
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Liu M, Chen Z, Zhang H, Cai Z, Liu T, Zhang M, Wu X, Ai F, Liu G, Zeng C, Shen J. Urolithin A alleviates early brain injury after subarachnoid hemorrhage by regulating the AMPK/mTOR pathway-mediated autophagy. Neurochirurgie 2023; 69:101480. [PMID: 37598622 DOI: 10.1016/j.neuchi.2023.101480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE Unfavorable outcomes in patients with subarachnoid hemorrhage (SAH) are mainly attributed to early brain injury (EBI). Reduction of neuronal death can improve the prognosis in SAH patients. Autophagy and apoptosis are critical players in neuronal death. Urolithin A (UA) is a natural compound produced by gut bacteria from ingested ellagitannins and ellagic acid. Here, we detected the role of UA in EBI post-SAH. METHODS We established an animal model of SAH in rats by endovascular perforation, with administration of UA, 3-methyladenine (3-MA) and Compound C. SAH grading, neurological function, brain water content, western blotting analysis of levels of proteins related to apoptosis, autophagy and pathways, blood-brain barrier (BBB) integrity, TUNEL staining, and immunofluorescence staining of LC3 were evaluated at 24h after SAH. RESULTS SAH induction led to neurological dysfunctions, BBB disruption, and cerebral edema at 24h post-SAH in rats, which were relieved by UA. Additionally, cortical neuronal apoptosis in SAH rats was also attenuated by UA. Moreover, UA restored autophagy level in SAH rats. Mechanistically, UA activated the AMPK/mTOR pathway. Furthermore, inhibition of autophagy and AMPK limited UA-mediated protection against EBI post-SAH CONCLUSION: UA alleviates neurological deficits, BBB permeability, and cerebral edema by inhibiting cortical neuronal apoptosis through regulating the AMPK/mTOR pathway-dependent autophagy in rats following SAH.
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Affiliation(s)
- Meiqiu Liu
- Department of Neurosurgery, Ningde Municipal Hospital of Ningde Normal University, Ningde 352000, China
| | - Zhen Chen
- Department of Emergency, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Huan Zhang
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Zhiji Cai
- Department of Neurosurgery, Ningde Municipal Hospital of Ningde Normal University, Ningde 352000, China
| | - Tiancheng Liu
- Department of Emergency, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Mengli Zhang
- Department of Emergency, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Xian Wu
- Department of Emergency, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Fen Ai
- Department of Emergency, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Ganzhe Liu
- Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Chao Zeng
- Department of Neurosurgery, Ningde Municipal Hospital of Ningde Normal University, Ningde 352000, China.
| | - Jiancheng Shen
- Department of Neurosurgery, Ningde Municipal Hospital of Ningde Normal University, Ningde 352000, China.
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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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Muraoka S, Asai T, Fukui T, Ota S, Shimato S, Koketsu N, Nishizawa T, Araki Y, Saito R. Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study. Neurosurg Rev 2023; 46:195. [PMID: 37555872 DOI: 10.1007/s10143-023-02104-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/10/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.
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Affiliation(s)
- Shinsuke Muraoka
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan.
| | - Takumi Asai
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takahiko Fukui
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shinji Ota
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Shinji Shimato
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Naoki Koketsu
- Department of Neurosurgery, Tosei General Hospital, Seto, Aichi, Japan
| | - Toshihisa Nishizawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Smith CA, Carpenter KLH, Hutchinson PJ, Smielewski P, Helmy A. Candidate neuroinflammatory markers of cerebral autoregulation dysfunction in human acute brain injury. J Cereb Blood Flow Metab 2023; 43:1237-1253. [PMID: 37132274 PMCID: PMC10369156 DOI: 10.1177/0271678x231171991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 05/04/2023]
Abstract
The loss of cerebral autoregulation (CA) is a common and detrimental secondary injury mechanism following acute brain injury and has been associated with worse morbidity and mortality. However patient outcomes have not as yet been conclusively proven to have improved as a result of CA-directed therapy. While CA monitoring has been used to modify CPP targets, this approach cannot work if the impairment of CA is not simply related to CPP but involves other underlying mechanisms and triggers, which at present are largely unknown. Neuroinflammation, particularly inflammation affecting the cerebral vasculature, is an important cascade that occurs following acute injury. We hypothesise that disturbances to the cerebral vasculature can affect the regulation of CBF, and hence the vascular inflammatory pathways could be a putative mechanism that causes CA dysfunction. This review provides a brief overview of CA, and its impairment following brain injury. We discuss candidate vascular and endothelial markers and what is known about their link to disturbance of the CBF and autoregulation. We focus on human traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH), with supporting evidence from animal work and applicability to wider neurologic diseases.
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Affiliation(s)
- Claudia A Smith
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Keri LH Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Wolf S, Mielke D, Barner C, Malinova V, Kerz T, Wostrack M, Czorlich P, Salih F, Engel DC, Ehlert A, Staykov D, Alturki AY, Sure U, Bardutzky J, Schroeder HWS, Schürer L, Beck J, Juratli TA, Fritsch M, Lemcke J, Pohrt A, Meyer B, Schwab S, Rohde V, Vajkoczy P. Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial. JAMA Neurol 2023; 80:833-842. [PMID: 37330974 PMCID: PMC10277935 DOI: 10.1001/jamaneurol.2023.1792] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/31/2023] [Indexed: 06/20/2023]
Abstract
Importance After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. Objective To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. Design, Setting, and Participants The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. Intervention A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Main Outcomes and Measures Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Results Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). Conclusion and Relevance In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. Trial Registration ClinicalTrials.gov Identifier: NCT01258257.
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Affiliation(s)
- Stefan Wolf
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Barner
- Department of Anesthesiology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Farid Salih
- Department of Neurology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Doortje C. Engel
- Department of Neurosurgery, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St Georg, Hamburg, Germany
| | - Dimitre Staykov
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Hospital of the Brothers of St John, Eisenstadt, Austria
| | - Abdulrahman Y. Alturki
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Neurovascular Surgery Section, Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | | | - Ludwig Schürer
- Department of Neurosurgery, Klinikum Bogenhausen, Technical University Munich, Munich, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Inselspital, University of Bern, Switzerland
| | - Tareq A. Juratli
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Anne Pohrt
- Department of Medical Biometrics, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Stefan Schwab
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Li X, Zeng L, Lu X, Chen K, Yu M, Wang B, Zhao M. Early Brain Injury and Neuroprotective Treatment after Aneurysmal Subarachnoid Hemorrhage: A Literature Review. Brain Sci 2023; 13:1083. [PMID: 37509013 PMCID: PMC10376973 DOI: 10.3390/brainsci13071083] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Early brain injury (EBI) subsequent to subarachnoid hemorrhage (SAH) is strongly associated with delayed cerebral ischemia and poor patient prognosis. Based on investigations into the molecular mechanisms underlying EBI, neurovascular dysfunction resulting from SAH can be attributed to a range of pathological processes, such as microvascular alterations in brain tissue, ionic imbalances, blood-brain barrier disruption, immune-inflammatory responses, oxidative stress, and activation of cell death pathways. Research progress presents a variety of promising therapeutic approaches for the preservation of neurological function following SAH, including calcium channel antagonists, endothelin-1 receptor blockers, antiplatelet agents, anti-inflammatory agents, and anti-oxidative stress agents. EBI can be mitigated following SAH through neuroprotective measures. To enhance our comprehension of the relevant molecular pathways involved in brain injury, including brain ischemia-hypoxic injury, neuroimmune inflammation activation, and the activation of various cell-signaling pathways, following SAH, it is essential to investigate the evolution of these multifaceted pathophysiological processes. Facilitating neural repair following a brain injury is critical for improving patient survival rates and quality of life.
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Affiliation(s)
- Xiaopeng Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lang Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xuanzhen Lu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Kun Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Maling Yu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Baofeng Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Min Zhao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Galea I, Bandyopadhyay S, Bulters D, Humar R, Hugelshofer M, Schaer DJ. Haptoglobin Treatment for Aneurysmal Subarachnoid Hemorrhage: Review and Expert Consensus on Clinical Translation. Stroke 2023; 54:1930-1942. [PMID: 37232189 PMCID: PMC10289236 DOI: 10.1161/strokeaha.123.040205] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating form of stroke frequently affecting young to middle-aged adults, with an unmet need to improve outcome. This special report focusses on the development of intrathecal haptoglobin supplementation as a treatment by reviewing current knowledge and progress, arriving at a Delphi-based global consensus regarding the pathophysiological role of extracellular hemoglobin and research priorities for clinical translation of hemoglobin-scavenging therapeutics. After aneurysmal subarachnoid hemorrhage, erythrocyte lysis generates cell-free hemoglobin in the cerebrospinal fluid, which is a strong determinant of secondary brain injury and long-term clinical outcome. Haptoglobin is the body's first-line defense against cell-free hemoglobin by binding it irreversibly, preventing translocation of hemoglobin into the brain parenchyma and nitric oxide-sensitive functional compartments of cerebral arteries. In mouse and sheep models, intraventricular administration of haptoglobin reversed hemoglobin-induced clinical, histological, and biochemical features of human aneurysmal subarachnoid hemorrhage. Clinical translation of this strategy imposes unique challenges set by the novel mode of action and the anticipated need for intrathecal drug administration, necessitating early input from stakeholders. Practising clinicians (n=72) and scientific experts (n=28) from 5 continents participated in the Delphi study. Inflammation, microvascular spasm, initial intracranial pressure increase, and disruption of nitric oxide signaling were deemed the most important pathophysiological pathways determining outcome. Cell-free hemoglobin was thought to play an important role mostly in pathways related to iron toxicity, oxidative stress, nitric oxide, and inflammation. While useful, there was consensus that further preclinical work was not a priority, with most believing the field was ready for an early phase trial. The highest research priorities were related to confirming haptoglobin's anticipated safety, individualized versus standard dosing, timing of treatment, pharmacokinetics, pharmacodynamics, and outcome measure selection. These results highlight the need for early phase trials of intracranial haptoglobin for aneurysmal subarachnoid hemorrhage, and the value of early input from clinical disciplines on a global scale during the early stages of clinical translation.
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Affiliation(s)
- Ian Galea
- Department of Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Hampshire, United Kingdom (I.G., S.B., D.B.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom (I.G., S.B., D.B.)
| | - Soham Bandyopadhyay
- Department of Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Hampshire, United Kingdom (I.G., S.B., D.B.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom (I.G., S.B., D.B.)
| | - Diederik Bulters
- Department of Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Hampshire, United Kingdom (I.G., S.B., D.B.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom (I.G., S.B., D.B.)
| | - Rok Humar
- Division of Internal Medicine (R.H., D.J.S.), Universitätsspital and University of Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center (M.H.), Universitätsspital and University of Zurich, Switzerland
| | - Dominik J. Schaer
- Division of Internal Medicine (R.H., D.J.S.), Universitätsspital and University of Zurich, Switzerland
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Kastenholz N, Megjhani M, Conzen-Dilger C, Albanna W, Veldeman M, Nametz D, Kwon SB, Schulze-Steinen H, Ridwan H, Clusmann H, Schubert GA, Park S, Weiss M. The oxygen reactivity index indicates disturbed local perfusion regulation after aneurysmal subarachnoid hemorrhage: an observational cohort study. Crit Care 2023; 27:235. [PMID: 37312192 PMCID: PMC10265851 DOI: 10.1186/s13054-023-04452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/19/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Cerebral autoregulation (CA) can be impaired in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The Pressure Reactivity Index (PRx, correlation of blood pressure and intracranial pressure) and Oxygen Reactivity Index (ORx, correlation of cerebral perfusion pressure and brain tissue oxygenation, PbtO2) are both believed to estimate CA. We hypothesized that CA could be poorer in hypoperfused territories during DCI and that ORx and PRx may not be equally effective in detecting such local variances. METHODS ORx and PRx were compared daily in 76 patients with aSAH with or without DCI until the time of DCI diagnosis. The ICP/PbtO2-probes of DCI patients were retrospectively stratified by being in or outside areas of hypoperfusion via CT perfusion image, resulting in three groups: DCI + /probe + (DCI patients, probe located inside the hypoperfused area), DCI + /probe- (probe outside the hypoperfused area), DCI- (no DCI). RESULTS PRx and ORx were not correlated (r = - 0.01, p = 0.56). Mean ORx but not PRx was highest when the probe was located in a hypoperfused area (ORx DCI + /probe + 0.28 ± 0.13 vs. DCI + /probe- 0.18 ± 0.15, p < 0.05; PRx DCI + /probe + 0.12 ± 0.17 vs. DCI + /probe- 0.06 ± 0.20, p = 0.35). PRx detected poorer autoregulation during the early phase with relatively higher ICP (days 1-3 after hemorrhage) but did not differentiate the three groups on the following days when ICP was lower on average. ORx was higher in the DCI + /probe + group than in the other two groups from day 3 onward. ORx and PRx did not differ between patients with DCI, whose probe was located elsewhere, and patients without DCI (ORx DCI + /probe- 0.18 ± 0.15 vs. DCI- 0.20 ± 0.14; p = 0.50; PRx DCI + /probe- 0.06 ± 0.20 vs. DCI- 0.08 ± 0.17, p = 0.35). CONCLUSIONS PRx and ORx are not interchangeable measures of autoregulation, as they likely measure different homeostatic mechanisms. PRx represents the classical cerebrovascular reactivity and might be better suited to detect disturbed autoregulation during phases with moderately elevated ICP. Autoregulation may be poorer in territories affected by DCI. These local perfusion disturbances leading up to DCI may be more readily detected by ORx than PRx. Further research should investigate their robustness to detect DCI and to serve as a basis for autoregulation-targeted treatment after aSAH.
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Affiliation(s)
- Nick Kastenholz
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Murad Megjhani
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Daniel Nametz
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Soon Bin Kwon
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Henna Schulze-Steinen
- Department of Intensive Care Medicine and Perioperative Care, RWTH Aachen University, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Soojin Park
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
- Department of Biomedical Informatics, Columbia University, New York City, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
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Romoli M, Giammello F, Mosconi MG, De Mase A, De Marco G, Digiovanni A, Ciacciarelli A, Ornello R, Storti B. Immunological Profile of Vasospasm after Subarachnoid Hemorrhage. Int J Mol Sci 2023; 24:ijms24108856. [PMID: 37240207 DOI: 10.3390/ijms24108856] [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: 03/25/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) carries high mortality and disability rates, which are substantially driven by complications. Early brain injury and vasospasm can happen after SAH and are crucial events to prevent and treat to improve prognosis. In recent decades, immunological mechanisms have been implicated in SAH complications, with both innate and adaptive immunity involved in mechanisms of damage after SAH. The purpose of this review is to summarize the immunological profile of vasospasm, highlighting the potential implementation of biomarkers for its prediction and management. Overall, the kinetics of central nervous system (CNS) immune invasion and soluble factors' production critically differs between patients developing vasospasm compared to those not experiencing this complication. In particular, in people developing vasospasm, a neutrophil increase develops in the first minutes to days and pairs with a mild depletion of CD45+ lymphocytes. Cytokine production is boosted early on after SAH, and a steep increase in interleukin-6, metalloproteinase-9 and vascular endothelial growth factor (VEGF) anticipates the development of vasospasm after SAH. We also highlight the role of microglia and the potential influence of genetic polymorphism in the development of vasospasm and SAH-related complications.
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Affiliation(s)
- Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, 47521 Cesena, Italy
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, 98122 Messina, Italy
| | - Maria Giulia Mosconi
- Emergency and Vascular Medicine, University of Perugia-Santa Maria Della Misericordia Hospital, 06129 Perugia, Italy
| | - Antonio De Mase
- Neurology and Stroke Unit, AORN Cardarelli, 80131 Napoli, Italy
| | - Giovanna De Marco
- Department of Biomedical and NeuroMotor Sciences of Bologna, University of Bologna, 40126 Bologna, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66013 Chieti, Italy
| | - Antonio Ciacciarelli
- Stroke Unit, Department of Emergency Medicine, University of Roma La Sapienza-Umberto I Hospital, 00161 Rome, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Benedetta Storti
- Cerebrovascular Diseases Unit, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milano, Italy
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Lauzier DC, Jayaraman K, Yuan JY, Diwan D, Vellimana AK, Osbun J, Chatterjee AR, Athiraman U, Dhar R, Zipfel GJ. Early Brain Injury After Subarachnoid Hemorrhage: Incidence and Mechanisms. Stroke 2023; 54:1426-1440. [PMID: 36866673 PMCID: PMC10243167 DOI: 10.1161/strokeaha.122.040072] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Aneurysmal subarachnoid hemorrhage is a devastating condition causing significant morbidity and mortality. While outcomes from subarachnoid hemorrhage have improved in recent years, there continues to be significant interest in identifying therapeutic targets for this disease. In particular, there has been a shift in emphasis toward secondary brain injury that develops in the first 72 hours after subarachnoid hemorrhage. This time period of interest is referred to as the early brain injury period and comprises processes including microcirculatory dysfunction, blood-brain-barrier breakdown, neuroinflammation, cerebral edema, oxidative cascades, and neuronal death. Advances in our understanding of the mechanisms defining the early brain injury period have been accompanied by improved imaging and nonimaging biomarkers for identifying early brain injury, leading to the recognition of an elevated clinical incidence of early brain injury compared with prior estimates. With the frequency, impact, and mechanisms of early brain injury better defined, there is a need to review the literature in this area to guide preclinical and clinical study.
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Affiliation(s)
- David C. Lauzier
- Department of Neurological Surgery, Washington University School of Medicine
| | - Keshav Jayaraman
- Department of Neurological Surgery, Washington University School of Medicine
| | - Jane Y. Yuan
- Department of Neurological Surgery, Washington University School of Medicine
| | - Deepti Diwan
- Department of Neurological Surgery, Washington University School of Medicine
| | - Ananth K. Vellimana
- Department of Neurological Surgery, Washington University School of Medicine
- Department of Neurology, Washington University School of Medicine
- Mallinckrodt Institute of Radiology, Washington University School of Medicine
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University School of Medicine
- Department of Neurology, Washington University School of Medicine
- Mallinckrodt Institute of Radiology, Washington University School of Medicine
| | - Arindam R. Chatterjee
- Department of Neurological Surgery, Washington University School of Medicine
- Department of Neurology, Washington University School of Medicine
- Mallinckrodt Institute of Radiology, Washington University School of Medicine
| | | | - Rajat Dhar
- Department of Neurology, Washington University School of Medicine
| | - Gregory J. Zipfel
- Department of Neurological Surgery, Washington University School of Medicine
- Department of Neurology, Washington University School of Medicine
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Tartara F, Montalbetti A, Crobeddu E, Armocida D, Tavazzi E, Cardia A, Cenzato M, Boeris D, Garbossa D, Cofano F. Compartmental Cerebrospinal Fluid Events Occurring after Subarachnoid Hemorrhage: An "Heparin Oriented" Systematic Review. Int J Mol Sci 2023; 24:7832. [PMID: 37175544 PMCID: PMC10178276 DOI: 10.3390/ijms24097832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) represents a severe acute event with high morbidity and mortality due to the development of early brain injury (EBI), secondary delayed cerebral ischemia (DCI), and shunt-related hydrocephalus. Secondary events (SSE) such as neuroinflammation, vasospasm, excitotoxicity, blood-brain barrier disruption, oxidative cascade, and neuronal apoptosis are related to DCI. Despite improvement in management strategies and therapeutic protocols, surviving patients frequently present neurological deficits with neurocognitive impairment. The aim of this paper is to offer to clinicians a practical review of the actually documented pathophysiological events following subarachnoid hemorrhage. To reach our goal we performed a literature review analyzing reported studies regarding the mediators involved in the pathophysiological events following SAH occurring in the cerebrospinal fluid (CSF) (hemoglobin degradation products, platelets, complement, cytokines, chemokines, leucocytes, endothelin-1, NO-synthase, osteopontin, matricellular proteins, blood-brain barrier disruption, microglia polarization). The cascade of pathophysiological events secondary to SAH is very complex and involves several interconnected, but also distinct pathways. The identification of single therapeutical targets or specific pharmacological agents may be a limited strategy able to block only selective pathophysiological paths, but not the global evolution of SAH-related events. We report furthermore on the role of heparin in SAH management and discuss the rationale for use of intrathecal heparin as a pleiotropic therapeutical agent. The combination of the anticoagulant effect and the ability to interfere with SSE theoretically make heparin a very interesting molecule for SAH management.
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Affiliation(s)
- Fulvio Tartara
- IRCCS Fondazione Istituto Neurologico Nazionale C. Mondino, 27100 Pavia, Italy
| | - Andrea Montalbetti
- A.O.U. Maggiore della Carità University Hospital, Department of Neurosurgery, 28100 Novara, Italy
| | - Emanuela Crobeddu
- A.O.U. Maggiore della Carità University Hospital, Department of Neurosurgery, 28100 Novara, Italy
| | - Daniele Armocida
- A.U.O. Policlinico Umberto I, Neurosurgery Division, Human Neurosciences Department, Sapienza University, 00185 Rome, Italy
- IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Eleonora Tavazzi
- IRCCS Fondazione Istituto Neurologico Nazionale C. Mondino, 27100 Pavia, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Neurocenter of Southern Switzerland, EOC, 6900 Lugano, Switzerland
| | - Marco Cenzato
- Ospedale Niguarda Ca’ Granda, Department of Neurosurgery, 20162 Milan, Italy
| | - Davide Boeris
- Ospedale Niguarda Ca’ Granda, Department of Neurosurgery, 20162 Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience Rita Levi Montalcini, Neurosurgery Unit, University of Turin, 10095 Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience Rita Levi Montalcini, Neurosurgery Unit, University of Turin, 10095 Turin, Italy
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Yu W. Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: Recent Advances and Future Directions in Translational Research. Transl Stroke Res 2023; 14:119-120. [PMID: 35501554 DOI: 10.1007/s12975-022-01028-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California, Irvine, USA.
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Katiyar V, Kale A, Sharma R, Ganeshkumar A, Borkar SA. Letter: Clinical Benefit of Clazosentan in Vasospasm After Subarachnoid Hemorrhage: Are We There Yet? Neurosurgery 2023; 92:e37-e40. [PMID: 36637286 DOI: 10.1227/neu.0000000000002277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/29/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Varidh Katiyar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ameya Kale
- Kasturba Medical College, Manipal, India
| | - Ravi Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Ganeshkumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin A Borkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Lu GD, Wang C, Wang B, Zhao LB, Liu S. Higher Levels of Admission N-Terminal Pro-brain Natriuretic Peptide are Associated with Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 38:52-59. [PMID: 35799092 DOI: 10.1007/s12028-022-01556-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) greatly influences the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to determine whether higher levels of admission N-terminal pro-brain natriuretic peptide (NT-pro BNP) were related to neurogenic cardiac injury and predicted DCI occurrence in patients with aSAH. METHODS We retrospectively reviewed consecutive patients with aSAH between January 2018 and April 2021 in our department. Patients with admission NT-pro BNP were included for analysis. The associations between admission NT-pro BNP levels and admission cardiac troponin T levels and electrocardiogram characteristics, as well as the incidence of DCI, were investigated. RESULTS A total of 415 patients with aSAH were included, among whom DCI occurred in 53 (12.8%). The admission NT-pro BNP levels were positively correlated with the cardiac troponin T levels and were significantly higher in patients with abnormal electrocardiogram characteristics. The admission log NT-pro BNP levels were higher in patients with DCI than in those without DCI. Multivariable analysis revealed that admission log NT-pro BNP levels and modified Fisher scale were independent predictors of the incidence of DCI. Compared with the modified Fisher scale alone (area under the curve = 0.739), combining the modified Fisher scale with admission NT-pro BNP (area under the curve = 0.794) significantly improved the prediction accuracy for DCI (p < 0.001). CONCLUSIONS Higher admission levels of NT-pro BNP correlated with neurogenic cardiac injury and predicted the occurrence of DCI in patients with aSAH. A combination of the modified Fisher scale and admission NT-pro BNP significantly improved the prediction accuracy for DCI.
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Affiliation(s)
- Guang-Dong Lu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Cheng Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Bin Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China.
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Messina R, de Gennaro L, De Robertis M, Pop R, Chibbaro S, Severac F, Blagia M, Balducci MT, Bozzi MT, Signorelli F. Cerebrospinal Fluid Lactate and Glucose Levels as Predictors of Symptomatic Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 170:e596-e602. [PMID: 36403937 DOI: 10.1016/j.wneu.2022.11.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a complex neurovascular syndrome with profound systemic effects associated with high rates of disability and mortality. Delayed cerebral ischemia (DCI), which encompasses all neurobiological events occurring in the subacute-late stage after aSAH, has a complex pathogenesis and can occur in the absence of instrumental vasospasm. Our aim was to assess the correlation between cerebrospinal fluid (CSF) lactate and glucose levels measured on the second or third day after aSAH with clinical deterioration caused by DCI and with 3-month functional outcome. METHODS This prospective study included all aSAH patients admitted between January 2020 and December 2021 who underwent external ventricular drain placement and CSF lactate and glucose measurement. RESULTS Among 133 aSAH patients, 48 had an external ventricular drain placed and early CSF lactate and glucose assessment. Independent predictors of symptomatic DCI were World Federation of Neurosurgical Societies grade IV-V (adjusted odds ratio [aOR] 25.8, 95% confidence interval [CI] 2.9-649.2, P = 0.012), elevated CSF glucose (aOR 28.8, 95% CI 3.3-775.2, P = 0.010), and elevated CSF lactate (aOR 14.7, 95% CI 1.9-205.7, P = 0.018). The only independent predictor of 3-month functional outcome was occurrence of symptomatic DCI (aOR 0.02, 95% CI 0.0-0.2, P = 0.01). CONCLUSIONS Elevated CSF lactate and glucose levels in the first 3 days following aSAH were independent predictors of subsequent DCI-related neurological impairment; the presence of instrumental vasospasm was not significantly correlated with DCI after multivariate adjustment. CSF lactate and glucose monitoring may represent a point-of-care test, which could potentially improve prediction of subacute neurological worsening and guide therapeutic choices. Further research with larger prospective cohorts is warranted.
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Affiliation(s)
- Raffaella Messina
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Luigi de Gennaro
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Mario De Robertis
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France; Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France
| | - Salvatore Chibbaro
- Neurosurgery Department, Strasbourg University Hospitals, Strasbourg, France
| | - François Severac
- Public Healthcare Department, Strasbourg University Hospitals, Strasbourg, France
| | - Maria Blagia
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | | | - Maria Teresa Bozzi
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy.
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Alsbrook DL, Di Napoli M, Bhatia K, Desai M, Hinduja A, Rubinos CA, Mansueto G, Singh P, Domeniconi GG, Ikram A, Sabbagh SY, Divani AA. Pathophysiology of Early Brain Injury and Its Association with Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Review of Current Literature. J Clin Med 2023; 12:jcm12031015. [PMID: 36769660 PMCID: PMC9918117 DOI: 10.3390/jcm12031015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
Background: Delayed cerebral ischemia (DCI) is a common and serious complication of aneurysmal subarachnoid hemorrhage (aSAH). Though many clinical trials have looked at therapies for DCI and vasospasm in aSAH, along with reducing rebleeding risks, none have led to improving outcomes in this patient population. We present an up-to-date review of the pathophysiology of DCI and its association with early brain injury (EBI). Recent Findings: Recent studies have demonstrated that EBI, as opposed to delayed brain injury, is the main contributor to downstream pathophysiological mechanisms that play a role in the development of DCI. New predictive models, including advanced monitoring and neuroimaging techniques, can help detect EBI and improve the clinical management of aSAH patients. Summary: EBI, the severity of subarachnoid hemorrhage, and physiological/imaging markers can serve as indicators for potential early therapeutics in aSAH. The microcellular milieu and hemodynamic pathomechanisms should remain a focus of researchers and clinicians. With the advancement in understanding the pathophysiology of DCI, we are hopeful that we will make strides toward better outcomes for this unique patient population.
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Affiliation(s)
- Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, 67039 L'Aquila, Italy
| | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Masoom Desai
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences, University of Campania, 80138 Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala 147002, India
| | - Gustavo G Domeniconi
- Unidad de Cuidados Intensivos, Sanatorio de la Trinidad San Isidro, Buenos Aires 1640, Argentina
| | - Asad Ikram
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
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