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Wang X, Gan Q, You C, Ma L. Effect of Statin Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage: A Network Meta-Analysis. Neurocrit Care 2024; 41:49-58. [PMID: 38565835 DOI: 10.1007/s12028-024-01957-9] [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: 05/01/2023] [Accepted: 02/06/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND There are knowledge gaps regarding the relative efficacy of statins for aneurysmal subarachnoid hemorrhage (aSAH). This study aims to examine the comparative effectiveness and determine the ranking of different statins with network meta‑analysis in patients with aSAH. METHODS MEDLINE, Embase, Pubmed, and Cochrane Central Register of Controlled Trials were searched from database inception until December 15, 2022. Outcomes included delayed cerebral ischemia (DCI), functional recovery, and mortality. Relative risk (RRs) ratios and associated 95% confidence intervals (CIs) were estimated. The values derived from surface under the cumulative ranking curve were obtained to rank the treatment hierarchy in the analysis. RESULTS We identified 13 trials involving 1,885 patients. Atorvastatin 20 mg (RR 0.68, 95% CI 0.53-0.86), pravastatin 40 mg (RR 0.51, 95% CI 0.31-0.77), and simvastatin 80 mg (RR 0.54, 95% CI 0.40-0.70) were superior to the placebo in preventing DCI. Additionally, simvastatin 80 mg (RR 0.60, 95% CI 0.42-0.84) and pravastatin 40 mg (RR 0.56, 95% CI 0.32-0.93) were associated with a decreased risk of DCI than simvastatin 40 mg. Comparisons across treatment durations suggested that short-term (RR 0.62, 95% CI 0.50-0.76) statin therapy reduced risk of DCI. CONCLUSIONS Simvastatin 80 mg might be the most effective intervention in reducing DCI. Additionally, short-term therapy might provide more benefits. Further research with longer follow-up is warranted to validate the current findings in patients with aSAH who are at high risk of DCI.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qi Gan
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
- West China Brain Research Centre, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
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Pan T, Shi Y, Yu G, Mamtimin A, Zhu W. Intracranial Aneurysms and Lipid Metabolism Disorders: From Molecular Mechanisms to Clinical Implications. Biomolecules 2023; 13:1652. [PMID: 38002334 PMCID: PMC10669412 DOI: 10.3390/biom13111652] [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: 10/08/2023] [Revised: 10/23/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
Many vascular diseases are linked to lipid metabolism disorders, which cause lipid accumulation and peroxidation in the vascular wall. These processes lead to degenerative changes in the vessel, such as phenotypic transformation of smooth muscle cells and dysfunction and apoptosis of endothelial cells. In intracranial aneurysms, the coexistence of lipid plaques is often observed, indicating localized lipid metabolism disorders. These disorders may impair the function of the vascular wall or result from it. We summarize the literature on the relationship between lipid metabolism disorders and intracranial aneurysms below.
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Affiliation(s)
- Tonglin Pan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Abdureshid Mamtimin
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
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Andersen S, Western E, Sorteberg W, Sorteberg A. The impact of pre-ictal statin use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3325-3338. [PMID: 37792050 PMCID: PMC10624707 DOI: 10.1007/s00701-023-05812-2] [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: 05/29/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Pleiotropic effects of statins may be beneficial in alleviating cerebral vasospasm (VS) and improving outcome after aneurysmal subarachnoid hemorrhage (aSAH). Initiation of statin treatment at aSAH is not recommended; however, the effect of pre-ictal and continued statin use is not fully investigated. METHODS Retrospective study comparing aSAH patients admitted in 2012 to 2021 with pre-ictal statin use versus those not using statins. Patient entry variables, radiological/sonological VS, symptomatic VS, and radiologically documented delayed cerebral ischemia (DCI) were registered. Outcome was scored in terms of mortality, modified Rankin score, Glasgow outcome score extended, and levels of fatigue. Patients were compared on group level and in a case-control design. RESULTS We included 961 patients, with 204 (21.2%) statin users. Statin users were older and had more often hypertension. Severe radiological/sonological VS, symptomatic VS, and DCI were less frequent in statin users, and their length of stay was shorter. Mortality, functional outcome, and levels of fatigue were similar in both groups. When analyzing 89 pairs of statin users and non-statin users matched for age, aSAH severity, gender, and hypertension, we confirmed decreased radiological/sonological and symptomatic VS as well as shorter length of stay in statin users. They also had more often a favorable functional outcome and lower levels of fatigue. CONCLUSIONS Patients with pre-ictal and continued use of statins have a reduced occurrence of radiological/sonological and symptomatic VS, shorter length of stay, and more often favorable functional outcome, whereas mortality is similar to non-statin users. Even though larger multicenter studies with common, strict protocols for prevention, diagnosis, and treatment of vasospasm are needed to finally establish the value of statins in aSAH, continuation of pre-ictal statin use seems worthwhile.
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Affiliation(s)
- S Andersen
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway
| | - E Western
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Nydalen, P.B. 4950, 0424, Oslo, Norway
| | - W Sorteberg
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway
| | - A Sorteberg
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway.
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Zhong S, Liu T, Zhai Q, Zhang X, Jing H, Li K, Liu S, Liu G, Wang L, Li L, Tao S, Ren L, Shi X, Bao Y. Impacts of Statin Therapy Strategies on Incidence of Ischemic Cerebrovascular Events in Patients With Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Bayesian Network Meta-Analysis. Neurosurgery 2023; 93:24-32. [PMID: 36794961 DOI: 10.1227/neu.0000000000002392] [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: 05/13/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The exacerbation of neurological outcomes often occurs in aneurysmal subarachnoid hemorrhage (aSAH). Statins have been commonly used for aSAH; however, there is lack of evidence of the pharmacological efficacy of different dosages and types of statins. OBJECTIVE To apply the Bayesian network meta-analysis to analyze the optimal dosage and type of statins for the amelioration of ischemic cerebrovascular events (ICEs) in patients with aSAH. METHODS We developed the Bayesian network meta-analysis and systemic review to analyze the effects of statins on functional prognosis and the impacts of optimal dosage and type of statins on ICEs in patients with aSAH. The outcome variables of the analysis were the incidence of ICEs and functional prognosis. RESULTS A total of 2569 patients with aSAH across 14 studies were included. Analysis of 6 randomized controlled trials showed that statin use significantly improved functional prognosis in patients with aSAH (risk ratio [RR], 0.73; 95% CI, 0.55-0.97). Statins significantly reduced the incidence of ICEs (RR, 0.78; 95% CI, 0.67-0.90). Pravastatin (40 mg/d) decreased the incidence ICEs compared with placebo (RR, 0.14; 95% CI, 0.03-0.65) and was ranked the most effective, presenting with a significantly lower rate of the incidence ICEs than the worst-ranked simvastatin (40 mg/d) (RR, 0.13; 95% CI, 0.02-0.79). CONCLUSION Statins could significantly diminish the incidence of ICEs and enhance functional prognosis in patients with aSAH. Various types and dosages of statins show distinct efficacies.
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Affiliation(s)
- Shiyu Zhong
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Qingqing Zhai
- School of Management, Shanghai University, Shanghai, China
| | - Xudong Zhang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Huiquan Jing
- School of Public Health, Capital Medical University, Beijing, China
| | - Kunhang Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shengyu Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Guojun Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Liang Wang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Lishuai Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shanwei Tao
- Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, China
| | - Lijie Ren
- Neurology Department of Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Futian, Shenzhen, China
| | - Xin Shi
- School of Maths and Information Science, Shandong University of Technology and Business, Yantai, Shandong, China
- Business School, All Saints Campus, Manchester Metropolitan University, Manchester, United Kingdom
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
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Wach J, Vychopen M, Güresir A, Güresir E. Anti-Inflammatory Drug Therapy in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Prospective Randomized and Placebo-Controlled Trials. J Clin Med 2023; 12:4165. [PMID: 37373858 DOI: 10.3390/jcm12124165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
Emerging evidence suggests that neuroinflammation may play a potential role in aneurysmal subarachnoid hemorrhage (aSAH). We aim to analyze the influence of anti-inflammatory therapy on survival and outcome in aSAH. Eligible randomized placebo-controlled prospective trials (RCTs) were searched in PubMed until March 2023. After screening the available studies for inclusion and exclusion criteria, we strictly extracted the main outcome measures. Dichotomous data were determined and extracted by odds ratio (OR) with 95% confidence intervals (CIs). Neurological outcome was graded using the modified Rankin Scale (mRS). We created funnel plots to analyze publication bias. From 967 articles identified during the initial screening, we included 14 RCTs in our meta-analysis. Our results illustrate that anti-inflammatory therapy yields an equivalent probability of survival compared to placebo or conventional management (OR: 0.81, 95% CI: 0.55-1.19, p = 0.28). Generally, anti-inflammatory therapy trended to be associated with a better neurologic outcome (mRS ≤ 2) compared to placebo or conventional treatment (OR: 1.48, 95% CI: 0.95-2.32, p = 0.08). Our meta-analysis showed no increased mortality form anti-inflammatory therapy. Anti-inflammatory therapy in aSAH patients tends to improve the neurological outcome. However, multicenter, rigorous, designed, prospective randomized studies are still needed to investigate the effect of fighting inflammation in improving neurological functioning after aSAH.
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Affiliation(s)
- Johannes Wach
- Department of Neurosurgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Martin Vychopen
- Department of Neurosurgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Agi Güresir
- Department of Neurosurgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Leipzig, 04103 Leipzig, Germany
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Prado Y, Aravena D, Llancalahuen FM, Aravena C, Eltit F, Echeverría C, Gatica S, Riedel CA, Simon F. Statins and Hemostasis: Therapeutic Potential Based on Clinical Evidence. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1408:25-47. [PMID: 37093420 DOI: 10.1007/978-3-031-26163-3_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Hemostasis preserves blood fluidity and prevents its loss after vessel injury. The maintenance of blood fluidity requires a delicate balance between pro-coagulant and fibrinolytic status. Endothelial cells (ECs) in the inner face of blood vessels maintain hemostasis through balancing anti-thrombotic and pro-fibrinolytic activities. Dyslipidemias are linked to hemostatic alterations. Thus, it is necessary a better understanding of the underlying mechanisms linking hemostasis with dyslipidemia. Statins are drugs that decrease cholesterol levels in the blood and are the gold standard for treating hyperlipidemias. Statins can be classified into natural and synthetic molecules, approved for the treatment of hypercholesterolemia. The classical mechanism of action of statins is by competitive inhibition of a key enzyme in the synthesis pathway of cholesterol, the HMG-CoA reductase. Statins are frequently administrated by oral ingestion and its interaction with other drugs and food supplements is associated with altered bioavailability. In this review we deeply discuss the actions of statins beyond the control of dyslipidemias, focusing on the actions in thrombotic modulation, vascular and cardiovascular-related diseases, metabolic diseases including metabolic syndrome, diabetes, hyperlipidemia, and hypertension, and chronic diseases such as cancer, chronic obstructive pulmonary disease, and chronic kidney disease. Furthermore, we were prompted to delved deeper in the molecular mechanisms by means statins regulate coagulation acting on liver, platelets, and endothelium. Clinical evidence show that statins are effective regulators of dyslipidemia with a high impact in hemostasis regulation and its deleterious consequences. However, studies are required to elucidate its underlying molecular mechanism and improving their therapeutical actions.
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Affiliation(s)
- Yolanda Prado
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Diego Aravena
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Felipe M Llancalahuen
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Cristobal Aravena
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Felipe Eltit
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
- Vancouver Prostate Centre, Vancouver, Canada
| | - Cesar Echeverría
- Laboratory of Molecular Biology, Nanomedicine and Genomics, Faculty of Medicine, University of Atacama, Copiapo, Chile
| | - Sebastian Gatica
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Claudia A Riedel
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Felipe Simon
- Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile.
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile.
- Millennium Nucleus of Ion Channel-Associated Diseases, Santiago, Chile.
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Costa BBSD, Windlin IC, Koterba E, Yamaki VN, Rabelo NN, Solla DJF, Samaia da Silva Coelho AC, Telles JPM, Teixeira MJ, Figueiredo EG. Glibenclamide in aneurysmal subarachnoid hemorrhage: a randomized controlled clinical trial. J Neurosurg 2022; 137:121-128. [PMID: 34798604 DOI: 10.3171/2021.7.jns21846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/26/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Glibenclamide has been shown to improve outcomes in cerebral ischemia, traumatic brain injury, and subarachnoid hemorrhage (SAH). The authors sought to evaluate glibenclamide's impact on mortality and functional outcomes of patients with aneurysmal SAH (aSAH). METHODS Patients with radiologically confirmed aSAH, aged 18 to 70 years, who presented to the hospital within 96 hours of ictus were randomly allocated to receive 5 mg of oral glibenclamide for 21 days or placebo, in a modified intention-to-treat analysis. Outcomes were mortality and functional status at discharge and 6 months, evaluated using the modified Rankin Scale (mRS). RESULTS A total of 78 patients were randomized and allocated to glibenclamide (n = 38) or placebo (n = 40). Baseline characteristics were similar between groups. The mean patient age was 53.1 years, and the majority of patients were female (75.6%). The median Hunt and Hess, World Federation of Neurosurgical Societies (WFNS), and modified Fisher scale (mFS) scores were 3 (IQR 2-4), 3 (IQR 3-4), and 3 (IQR 1-4), respectively. Glibenclamide did not improve the functional outcome (mRS) after 6 months (ordinal analysis, unadjusted common OR 0.66 [95% CI 0.29-1.48], adjusted common OR 1.25 [95% CI 0.46-3.37]). Similar results were found for analyses considering the dichotomized 6-month mRS score (favorable score 0-2), as well as for the secondary outcomes of discharge mRS score (either ordinal or dichotomized), mortality, and delayed cerebral ischemia. Hypoglycemia was more frequently observed in the glibenclamide group (5.3%). CONCLUSIONS In this study, glibenclamide was not associated with better functional outcomes after aSAH. Mortality and delayed cerebral ischemia rates were also similar compared with placebo.
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Xu Y, Chen A, Wu J, Wan Y, You M, Gu X, Guo H, Tan S, He Q, Hu B. Nanomedicine: An Emerging Novel Therapeutic Strategy for Hemorrhagic Stroke. Int J Nanomedicine 2022; 17:1927-1950. [PMID: 35530973 PMCID: PMC9075782 DOI: 10.2147/ijn.s357598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yating Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Anqi Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Jiehong Wu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Yan Wan
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Xinmei Gu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Hongxiu Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Sengwei Tan
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Correspondence: Bo Hu; Quanwei He, Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China, Tel +86-27-87542857, Fax +86-27-87547063, Email ;
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Dayyani M, Sadeghirad B, Grotta JC, Zabihyan S, Ahmadvand S, Wang Y, Guyatt GH, Amin-Hanjani S. Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials. Stroke 2022; 53:1993-2005. [PMID: 35354302 DOI: 10.1161/strokeaha.121.035699] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials. METHODS We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence. RESULTS We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia. CONCLUSIONS Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.
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Affiliation(s)
- Mojtaba Dayyani
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, TX (M.D.).,Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.).,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. (B.S.).,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada. (B.S.)
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center (J.C.G.)
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Saba Ahmadvand
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
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Lukito PP, Lie H, Helsa K, July J. Heparin in the treatment of aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E9. [DOI: 10.3171/2021.12.focus21419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Cerebral vasospasm and the resulting infarction remain the most devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Limited treatment options are available, with nimodipine as the only approved prophylactic medication. In addition to its anticoagulant properties, heparin also has a pleiotropic and anti-inflammatory effect that could be beneficial in vasospasm. In this study, the authors sought to evaluate the efficacy and safety of heparin in the treatment of aSAH.
METHODS
The PubMed, EBSCOhost, Europe PMC, and Cochrane Central databases were searched to find studies including patients with aSAH who were treated with intravenous unfractionated heparin (UFH) after an aneurysm-securing procedure. Studies that did not include a comparison with UFH or low-molecular-weight heparin in deep vein thrombosis prophylactic doses were excluded. The primary outcome was cerebral vasospasm, and the secondary outcomes were cerebral infarction, clinical deterioration caused by delayed cerebral ischemia, bleeding complications, and thromboembolism complications.
RESULTS
Overall, 5 nonrandomized studies were included; 4 studies evaluated the safety and 3 studies evaluated the efficacy of intravenous heparin. From the analysis of 3 studies with a total of 895 patients, administration of intravenous UFH for > 48 hours was related to a significantly lower rate of cerebral infarction (OR 0.44, 95% CI 0.25–0.79). No significant association was found with other efficacy outcomes. Regarding cognitive outcome, one study found a significant improvement in Montreal Cognitive Assessment scores; however, the functional outcome as indicated by the modified Rankin Scale score was not improved by heparin administration. From the analysis of 4 studies with 1099 patients, no significant increases in bleeding and other complications were found.
CONCLUSIONS
Administration of intravenous UFH for more than 48 hours reduced the rate of cerebral infarction with a good safety profile. This result supports the ongoing clinical trial.
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Affiliation(s)
| | | | | | - Julius July
- Department of Neurosurgery, Neuroscience Centre Siloam Hospital, Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
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11
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Beyond Lipid-Lowering: Effects of Statins on Cardiovascular and Cerebrovascular Diseases and Cancer. Pharmaceuticals (Basel) 2022; 15:ph15020151. [PMID: 35215263 PMCID: PMC8877351 DOI: 10.3390/ph15020151] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 12/15/2022] Open
Abstract
The 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, also known as statins, are administered as first-line therapy for hypercholesterolemia, both as primary and secondary prevention. Besides the lipid-lowering effect, statins have been suggested to inhibit the development of cardiovascular disease through anti-inflammatory, antioxidant, vascular endothelial function-improving, plaque-stabilizing, and platelet aggregation-inhibiting effects. The preventive effect of statins on atherothrombotic stroke has been well established, but statins can influence other cerebrovascular diseases. This suggests that statins have many neuroprotective effects in addition to lowering cholesterol. Furthermore, research suggests that statins cause pro-apoptotic, growth-inhibitory, and pro-differentiation effects in various malignancies. Preclinical and clinical evidence suggests that statins inhibit tumor growth and induce apoptosis in specific cancer cell types. The pleiotropic effects of statins on cardiovascular and cerebrovascular diseases have been well established; however, the effects of statins on cancer patients have not been fully elucidated and are still controversial. This review discusses the recent evidence on the effects of statins on cardiovascular and cerebrovascular diseases and cancer. Additionally, this study describes the pharmacological action of statins, focusing on the aspect of ‘beyond lipid-lowering’.
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12
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Chen J, Zheng ZV, Lu G, Chan WY, Zhang Y, Wong GKC. Microglia activation, classification and microglia-mediated neuroinflammatory modulators in subarachnoid hemorrhage. Neural Regen Res 2021; 17:1404-1411. [PMID: 34916410 PMCID: PMC8771101 DOI: 10.4103/1673-5374.330589] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Subarachnoid hemorrhage is a devastating disease with significant mortality and morbidity, despite advances in treating cerebral aneurysms. There has been recent progress in the intensive care management and monitoring of patients with subarachnoid hemorrhage, but the results remain unsatisfactory. Microglia, the resident immune cells of the brain, are increasingly recognized as playing a significant role in neurological diseases, including subarachnoid hemorrhage. In early brain injury following subarachnoid hemorrhage, microglial activation and neuroinflammation have been implicated in the development of disease complications and recovery. To understand the disease processes following subarachnoid hemorrhage, it is important to focus on the modulators of microglial activation and the pro-inflammatory/anti-inflammatory cytokines and chemokines. In this review, we summarize research on the modulators of microglia-mediated inflammation in subarachnoid hemorrhage, including transcriptome changes and the neuroinflammatory signaling pathways. We also describe the latest developments in single-cell transcriptomics for microglia and summarize advances that have been made in the transcriptome-based classification of microglia and the implications for microglial activation and neuroinflammation.
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Affiliation(s)
- Junfan Chen
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Zhiyuan Vera Zheng
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region; Department of Neurosurgery, Hainan Branch of Chinese People's Liberation Army General Hospital, Sanya, Hainan Province, China
| | - Gang Lu
- CUHK-SDU Joint Laboratory on Reproductive Genetics, School of Biomedical Sciences, The Chinese University of Hong Kong; Bioinformatics Unit, SDIVF R&D Centre, Hong Kong Science and Technology Parks, Hong Kong Special Administrative Region, China
| | - Wai Yee Chan
- CUHK-SDU Joint Laboratory on Reproductive Genetics, School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - George Kwok Chu Wong
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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13
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Liu T, Zhong S, Zhai Q, Zhang X, Jing H, Li K, Liu S, Han S, Li L, Shi X, Bao Y. Optimal Course of Statins for Patients With Aneurysmal Subarachnoid Hemorrhage: Is Longer Treatment Better? A Meta-Analysis of Randomized Controlled Trials. Front Neurosci 2021; 15:757505. [PMID: 34759796 PMCID: PMC8573116 DOI: 10.3389/fnins.2021.757505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
Statins are used in clinical practice to prevent from complications such as cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). However, the efficacy and safety of statins are still controversial due to insufficient evidence from randomized controlled trials and inconsistent results of the existing studies. This meta-analysis aimed to systematically review the latest evidence on the time window and complications of statins in aSAH. The randomized controlled trials in the databases of The Cochrane Library, PubMed, Web of Science, Embase, CNKI, and Wanfang from January 2005 to April 2021 were searched and analyzed systematically. Data analysis was performed using Stata version 16.0. The fixed-effects model (M-H method) with effect size risk ratio (RR) was used for subgroups with homogeneity, and the random-effects model (D-L method) with effect size odds ratio (OR) was used for subgroups with heterogeneity. The primary outcomes were poor neurological prognosis and all-cause mortality, and the secondary outcomes were cerebral vasospasm (CVS) and statin-related complications. This study was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42021247376). Nine studies comprising 1,464 patients were included. The Jadad score of the patients was 5–7. Meta-analysis showed that poor neurological prognosis was reduced in patients who took oral statins for 14 days (RR, 0.73 [0.55–0.97]; I2 = 0%). Surprisingly, the continuous use of statins for 21 days had no significant effect on neurological prognosis (RR, 1.04 [0.89–1.23]; I2 = 17%). Statins reduced CVS (OR, 0.51 [0.36–0.71]; I2 = 0%) but increased bacteremia (OR, 1.38 [1.01–1.89]; I2 = 0%). In conclusion, a short treatment course of statins over 2 weeks may improve neurological prognosis. Statins were associated with reduced CVS. Based on the pathophysiological characteristics of CVS and the evaluation of prognosis, 2 weeks could be the optimal time window for statin treatment in aSAH, although bacteremia may increase.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shiyu Zhong
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Qingqing Zhai
- School of Management, Shanghai University, Shanghai, China
| | - Xudong Zhang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Huiquan Jing
- School of Public Health, Capital Medical University, Beijing, China
| | - Kunhang Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shengyu Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shuo Han
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Lishuai Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Xin Shi
- School of Maths and Information Science, Shandong Institute of Business and Technology, Yantai, China.,Business School, Manchester Metropolitan University, Manchester, United Kingdom
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
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14
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Mishra S, Garg K, Gaonkar VB, Singh PM, Singh M, Suri A, Chandra PS, Kale SS. Effects of Various Therapeutic Agents on Vasospasm and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage-Results of a Network Meta-Analysis. World Neurosurg 2021; 155:41-53. [PMID: 34339892 DOI: 10.1016/j.wneu.2021.07.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH. METHODS A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH. RESULTS Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63-56.71), decreasing mortality (OR, 0.08; 95% CrI, 0-0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057-0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97-6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12-1.15). Fasudil (OR, 0.16; 95% CrI, 0.03-0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057-1.0) in preventing delayed ischemic neurologic deficits. CONCLUSIONS Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.
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Affiliation(s)
- Sandeep Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.
| | - Vishwa Bharathi Gaonkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Preet Mohinder Singh
- Department of Anesthesia, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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15
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Yu W, Huang Y, Zhang X, Luo H, Chen W, Jiang Y, Cheng Y. Effectiveness comparisons of drug therapies for postoperative aneurysmal subarachnoid hemorrhage patients: network meta‑analysis and systematic review. BMC Neurol 2021; 21:294. [PMID: 34311705 PMCID: PMC8314452 DOI: 10.1186/s12883-021-02303-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/26/2021] [Indexed: 01/01/2023] Open
Abstract
Objective To compare the effectiveness of various drug interventions in improving the clinical outcome of postoperative patients after aneurysmal subarachnoid hemorrhage (aSAH) and assist in determining the drugs of definite curative effect in improving clinical prognosis. Methods Eligible Randomized Controlled Trials (RCTs) were searched in databases of PubMed, EMBASE, and Cochrane Library (inception to Sep 2020). Glasgow Outcome Scale (GOS) score, Extended Glasgow Outcome Scale (GOSE) score or modified Rankin Scale (mRS) score was used as the main outcome measurements to evaluate the efficacy of various drugs in improving the clinical outcomes of postoperative patients with aSAH. The network meta-analysis (NMA) was conducted based on a random-effects model, dichotomous variables were determined by using odds ratio (OR) with 95% confidence interval (CI), and a surface under the cumulative ranking curve (SUCRA) was generated to estimate the ranking probability of comparative effectiveness among different drug therapies. Results From the 493 of initial citation screening, forty-four RCTs (n = 10,626 participants) were eventually included in our analysis. Our NMA results showed that cilostazol (OR = 3.35,95%CI = 1.50,7.51) was the best intervention to improve the clinical outcome of patients (SUCRA = 87.29%, 95%CrI 0.07–0.46). Compared with the placebo group, only two drug interventions [nimodipine (OR = 1.61, 95%CI 1.01,2.57) and cilostazol (OR = 3.35, 95%CI 1.50, 7.51)] achieved significant statistical significance in improving the clinical outcome of patients. Conclusions Both nimodipine and cilostazol have exact curative effect to improve the outcome of postoperative patients with aSAH, and cilostazol may be the best drug to improve the outcome of patients after aSAH operation. Our study provides implications for future studies that, the combination of two or more drugs with relative safety and potential benefits (e.g., nimodipine and cilostazol) may improve the clinical outcome of patients more effectively. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02303-8.
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Affiliation(s)
- Wanli Yu
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yizhou Huang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaolin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Huirong Luo
- Department of Psychiatry, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Weifu Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yongxiang Jiang
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
| | - Yuan Cheng
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
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16
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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17
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Shafiee S, Zali A, Shafizad M, Emami Zeydi A, Ehteshami S, Rezaii F, Tafakhori A, Ertiaei A, Darvishi-Khezri H, Khademloo M, Khoshnood RJ. The Effect of Oral Simvastatin on the Clinical Outcome of Patients with Severe Traumatic Brain Injury: A Randomized Clinical Trial. Ethiop J Health Sci 2021; 31:807-816. [PMID: 34703180 PMCID: PMC8512953 DOI: 10.4314/ejhs.v31i4.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background Despite recent promising pharmacological and technological advances in neurosurgical intensive care, the overall TBI-related mortality and morbidity remain high and still pose a major clinical problem. The aim of this study was to evaluate the effect of oral simvastatin on the clinical outcome of patients with severe TBI. Methods In a double-blind placebo-controlled randomized clinical trial a total of 98 patients with severe TBI in Imam Khomeini Hospital in Sari, Iran, were evaluated. Patients who meet the inclusion criteria were randomly allocated into two groups (n=49). In addition to supportive therapies, the intervention group received oral simvastatin (40 mg, daily) for 10 days, and the control group received the placebo (10 days). Patients' Glasgow coma scale (GCS) score, in hospital mortality, duration of mechanical ventilation and length of ICU and neurosurgery ward stay were evaluated during three-time intervals (T1: admission, T2: discharge and T3: one month after discharge). Results The percentage of conscious patients was 18.9% (7 cases) in the simvastatin group and 3.1% (1 case) in controls (P=0.06) at T2. One month after discharge (T3) the proportion of conscious patients significantly increased in the simvastatin group compared to control group (64.9 % versus 28.1 %; P=0.002). There was no significant difference for the mean of GCS score between the simvastatin group and control group at T1 (6.41 ± 1.30 versus 6.41 ± 1.28, respectively; P = 0.98). However, the mean score of GCS in patients who received simvastatin was significantly greater than controls at T2 and T3 (p<0.05). There was no significant differences between two group in-terms of length of mechanical ventilation, ICU and neurosurgery ward stay. Conclusion According to the results of this study it seems that using simvastatin may be an effective and promising therapeutic modality for improving GCS score during TBI recovery.
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Affiliation(s)
- Sajad Shafiee
- Department of Neurosurgery, Orthopedics Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Zali
- Functional Neurosurgery Research Center, Shohadaye Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Misagh Shafizad
- Department of Neurosurgery, Orthopedics Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Amir Emami Zeydi
- Department of Medical-Surgical Nursing, Nasibeh School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Saeid Ehteshami
- Department of Neurosurgery, Orthopedics Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Rezaii
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abbas Tafakhori
- Iranian Center of Neurological Research (ICNR), Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolhasan Ertiaei
- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Hadi Darvishi-Khezri
- Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Khademloo
- Department of Community Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Jalili Khoshnood
- Functional Neurosurgery Research Center, Shohadaye Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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18
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Bohara S, Gaonkar VB, Garg K, Rajpal PMS, Singh PK, Singh M, Suri A, Chandra PS, Kale SS. Effect of statins on functional outcome and mortality following aneurysmal subarachnoid hemorrhage - Results of a meta-analysis, metaregression and trial sequential analysis. Clin Neurol Neurosurg 2021; 207:106787. [PMID: 34225002 DOI: 10.1016/j.clineuro.2021.106787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Cerebral vasospasm (CVS) and delayed ischemic neurological deficits (DIND) are a common cause of morbidity following aneurysmal subarachnoid hemorrhage (SAH). Statins have been shown to decrease CVS. The objective of this article was to ascertain the effect of statins on functional outcome and mortality following aneurysmal SAH by performing meta-analysis. METHODS A comprehensive search of different databases was performed to retrieve randomized controlled trials. Meta-analysis with subgroup analysis and metaregression was done. Trial sequential analysis (TSA) was performed to determine if the cumulative sample size was appropriately powered for the obtained pooled effect values and to avoid random error. RESULTS Twelve articles were selected for meta-analysis. Pooled OR for the change in favorable outcome, mortality, CVS, DIND and elevated transaminases was 1.07 (p = 0.55), 0.78 (p = 0.17), 0.58 (p = 0.0004), 0.54 (p = 0.0293) and 0.68 (p = 0.1774) respectively. Further, subgroup analysis and metaregression showed that the use of different statin or dose did not result in significant variation in results in the parameters studied. TSA showed that more trials and patients are required to reach to a definitive conclusion regarding any effect on statins on functional outcome and mortality as the current studies neither reached the level of confidence nor crossed the futility boundary. CONCLUSION Use of statins in patients with aneurysmal SAH resulted in marginal but non-significant favorable impact on functional outcome and mortality. TSA showed that more studies are required to get conclusive evidence in this regard.
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Affiliation(s)
- Sandeep Bohara
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | | | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India.
| | | | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - P S Chandra
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - S S Kale
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
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19
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Weiland J, Beez A, Westermaier T, Kunze E, Sirén AL, Lilla N. Neuroprotective Strategies in Aneurysmal Subarachnoid Hemorrhage (aSAH). Int J Mol Sci 2021; 22:5442. [PMID: 34064048 PMCID: PMC8196706 DOI: 10.3390/ijms22115442] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) remains a disease with high mortality and morbidity. Since treating vasospasm has not inevitably led to an improvement in outcome, the actual emphasis is on finding neuroprotective therapies in the early phase following aSAH to prevent secondary brain injury in the later phase of disease. Within the early phase, neuroinflammation, thromboinflammation, disturbances in brain metabolism and early neuroprotective therapies directed against delayed cerebral ischemia (DCI) came into focus. Herein, the role of neuroinflammation, thromboinflammation and metabolism in aSAH is depicted. Potential neuroprotective strategies regarding neuroinflammation target microglia activation, metalloproteases, autophagy and the pathway via Toll-like receptor 4 (TLR4), high mobility group box 1 (HMGB1), NF-κB and finally the release of cytokines like TNFα or IL-1. Following the link to thromboinflammation, potential neuroprotective therapies try to target microthrombus formation, platelets and platelet receptors as well as clot clearance and immune cell infiltration. Potential neuroprotective strategies regarding metabolism try to re-balance the mismatch of energy need and supply following aSAH, for example, in restoring fuel to the TCA cycle or bypassing distinct energy pathways. Overall, this review addresses current neuroprotective strategies in aSAH, hopefully leading to future translational therapy options to prevent secondary brain injury.
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Affiliation(s)
- Judith Weiland
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Alexandra Beez
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
- Department of Neurosurgery, Helios-Amper Klinikum Dachau, Krankenhausstr. 15, 85221 Dachau, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Anna-Leena Sirén
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
- Department of Neurosurgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
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20
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Kashefiolasl S, Wagner M, Brawanski N, Seifert V, Wanderer S, Andereggen L, Konczalla J. Statins Improve Clinical Outcome After Non-aneurysmal Subarachnoid Hemorrhage: A Translational Insight From a Systematic Review of Experimental Studies. Front Neurol 2021; 12:620096. [PMID: 34054685 PMCID: PMC8160298 DOI: 10.3389/fneur.2021.620096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
The efficacy of statin-treatment in aneurysmal subarachnoid hemorrhage (SAH) remains controversial. We aimed to investigate the effects of statin-treatment in non-aneurysmal (na)SAH in accordance with animal research data illustrating the pathophysiology of naSAH. We systematically searched PubMed using PRISMA-guidelines and selected experimental studies assessing the statin-effect on SAH. Detecting the accordance of the applied experimental models with the pathophysiology of naSAH, we analyzed our institutional database of naSAH patients between 1999 and 2018, regarding the effect of statin treatment in these patients and creating a translational concept. Patient characteristics such as statin-treatment (simvastatin 40 mg/d), the occurrence of cerebral vasospasm (CVS), delayed infarction (DI), delayed cerebral ischemia (DCI), and clinical outcome were recorded. In our systematic review of experimental studies, we found 13 studies among 18 titles using blood-injection-animal-models to assess the statin-effect in accordance with the pathophysiology of naSAH. All selected studies differ on study-setting concerning drug-administration, evaluation methods, and neurological tests. Patients from the Back to Bedside project, including 293 naSAH-patients and 51 patients with simvastatin-treatment, were recruited for this analysis. Patients under treatment were affected by a significantly lower risk of CVS (p < 0.01; OR 3.7), DI (p < 0.05; OR 2.6), and DCI (p < 0.05; OR 3). Furthermore, there was a significant association between simvastatin-treatment and favorable-outcome (p < 0.05; OR 3). However, dividing patients with statin-treatment in pre-SAH (n = 31) and post-SAH (n = 20) treatment groups, we only detected a tenuously significant higher chance for a favorable outcome (p < 0.05; OR 0.05) in the small group of 20 patients with statin post-SAH treatment. Using a multivariate-analysis, we detected female gender (55%; p < 0.001; OR 4.9), Hunt&Hess ≤III at admission (p < 0.002; OR 4), no anticoagulant-therapy (p < 0.0001; OR 0.16), and statin-treatment (p < 0.0001; OR 24.2) as the main factors improving the clinical outcome. In conclusion, we detected a significantly lower risk for CVS, DCI, and DI in naSAH patients under statin treatment. Additionally, a significant association between statin treatment and favorable outcome 6 months after naSAH onset could be confirmed. Nevertheless, unified animal experiments should be considered to create the basis for developing new therapeutic schemes.
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Affiliation(s)
- Sepide Kashefiolasl
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marlies Wagner
- Institute of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Nina Brawanski
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
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21
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Aldrich EF, Higashida R, Hmissi A, Le EJ, Macdonald RL, Marr A, Mayer SA, Roux S, Bruder N. Thick and diffuse cisternal clot independently predicts vasospasm-related morbidity and poor outcome after aneurysmal subarachnoid hemorrhage. J Neurosurg 2021; 134:1553-1561. [PMID: 32442971 DOI: 10.3171/2020.3.jns193400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. The presence of thick, diffuse subarachnoid blood may portend a worse clinical course and outcome, independently of other known prognostic factors such as age, aneurysm size, and initial clinical grade. METHODS In this post hoc analysis, patients with aSAH undergoing surgical clipping (n = 383) or endovascular coiling (n = 189) were pooled from the placebo arms of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS)-2 and CONSCIOUS-3 randomized, double-blind, placebo-controlled phase 3 studies, respectively. Patients without and with thick, diffuse SAH (≥ 4 mm thick and involving ≥ 3 basal cisterns) on admission CT scans were compared. Clot size was centrally adjudicated. All-cause mortality and vasospasm-related morbidity at 6 weeks and Glasgow Outcome Scale-Extended (GOSE) scores at 12 weeks after aSAH were assessed. The effect of the thick and diffuse cisternal aSAH on vasospasm-related morbidity and mortality, and on poor clinical outcome at 12 weeks, was evaluated using logistic regression models. RESULTS Overall, 294 patients (51.4%) had thick and diffuse aSAH. Compared to patients with less hemorrhage burden, these patients were older (median age 55 vs 50 years) and more often had World Federation of Neurosurgical Societies (WFNS) grade III-V SAH at admission (24.1% vs 16.5%). At 6 weeks, all-cause mortality and vasospasm-related morbidity occurred in 36.1% (95% CI 30.6%-41.8%) of patients with thick, diffuse SAH and in 14.7% (95% CI 10.8%-19.5%) of those without thick, diffuse SAH. Individual event rates were 7.5% versus 2.5% for all-cause death, 19.4% versus 6.8% for new cerebral infarct, 28.2% versus 9.4% for delayed ischemic neurological deficit, and 24.8% versus 10.8% for rescue therapy due to cerebral vasospasm, respectively. Poor clinical outcome (GOSE score ≥ 4) was observed in 32.7% (95% CI 27.3%-38.3%) and 16.2% (95% CI 12.1%-21.1%) of patients with and without thick, diffuse SAH, respectively. CONCLUSIONS In a large, centrally adjudicated population of patients with aSAH, WFNS grade at admission and thick, diffuse SAH independently predicted vasospasm-related morbidity and poor 12-week clinical outcome. Patients with thick, diffuse cisternal SAH may be an important cohort to target in future clinical trials of treatment for vasospasm.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Anthropometry
- Blood Coagulation
- Brain Damage, Chronic/etiology
- Clinical Trials, Phase III as Topic
- Computed Tomography Angiography
- Double-Blind Method
- Embolization, Therapeutic
- Endovascular Procedures
- Female
- Glasgow Outcome Scale
- Humans
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/diagnostic imaging
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Male
- Middle Aged
- Prognosis
- Randomized Controlled Trials as Topic
- Risk
- Subarachnoid Hemorrhage/blood
- Subarachnoid Hemorrhage/complications
- Subarachnoid Hemorrhage/diagnostic imaging
- Survival Analysis
- Treatment Outcome
- Vasospasm, Intracranial/blood
- Vasospasm, Intracranial/diagnostic imaging
- Vasospasm, Intracranial/etiology
- Young Adult
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Affiliation(s)
- E François Aldrich
- 1Department of Neurosurgery, University of Maryland, Baltimore, Maryland
| | - Randall Higashida
- 2Department of Neurointerventional Radiology, University of California San Francisco Medical Center, San Francisco, California
| | - Abdel Hmissi
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Elizabeth J Le
- 1Department of Neurosurgery, University of Maryland, Baltimore, Maryland
| | - R Loch Macdonald
- 4Department of Neurological Surgery, University of California San Francisco, Fresno, California
- 5Department of Surgery, University of Toronto, Ontario, Canada
| | - Angelina Marr
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Stephan A Mayer
- 6Department of Neurology, Henry Ford Neuroscience Institute, Wayne State School of Medicine, Detroit, Michigan; and
| | - Sébastien Roux
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Nicolas Bruder
- 7Department of Anesthesia and Critical Care, Hôpital de la Timone, Aix-Marseille Université, Marseille, France
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22
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Maruhashi T, Higashi Y. An overview of pharmacotherapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage. Expert Opin Pharmacother 2021; 22:1601-1614. [PMID: 33823726 DOI: 10.1080/14656566.2021.1912013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Survival from aneurysmal subarachnoid hemorrhage has increased in the past few decades. However, functional outcome after subarachnoid hemorrhage is still suboptimal. Delayed cerebral ischemia (DCI) is one of the major causes of morbidity.Areas covered: Mechanisms underlying vasospasm and DCI after aneurysmal subarachnoid hemorrhage and pharmacological treatment are summarized in this review.Expert opinion: Oral nimodine, an L-type dihydropyridine calcium channel blocker, is the only FDA-approved drug for the prevention and treatment of neurological deficits after aneurysmal subarachnoid hemorrhage. Fasudil, a potent Rho-kinase inhibitor, has also been shown to improve the clinical outcome and has been approved in some countries for use in patients with aneurysmal subarachnoid hemorrhage. Although other drugs, including nicardipine, cilostazol, statins, clazosentan, magnesium and heparin, have been expected to have beneficial effects on DCI, there has been no convincing evidence supporting the routine use of those drugs in patients with aneurysmal subarachnoid hemorrhage in clinical practice. Further elucidation of the mechanisms underlying DCI and the development of effective therapeutic strategies for DCI, including combination therapy, are necessary to further improve the functional outcome and mortality after subarachnoid hemorrhage.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
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23
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Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older. PLoS One 2020; 15:e0230953. [PMID: 32271814 PMCID: PMC7145106 DOI: 10.1371/journal.pone.0230953] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
Objective We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. Methods We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3–6 at discharge) and mortality using multivariable analysis. Results The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2–1.7) despite a lower proportion of poor outcomes (0.84, 0.75–0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17–0.24), statin (0.63, 0.50–0.79), ozagrel sodium (0.72, 0.60–0.86), and cilostazol (0.63, 0.51–0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51–0.68), statin (0.84, 0.75–0.94), and EPA (0.83, 0.72–0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. Conclusions In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.
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24
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Chen J, Li M, Zhu X, Chen L, Yang S, Zhang C, Wu T, Feng X, Wang Y, Chen Q. Atorvastatin reduces cerebral vasospasm and infarction after aneurysmal subarachnoid hemorrhage in elderly Chinese adults. Aging (Albany NY) 2020; 12:2939-2951. [PMID: 32035420 PMCID: PMC7041764 DOI: 10.18632/aging.102788] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/19/2020] [Indexed: 05/02/2023]
Abstract
We explored whether acute atorvastatin treatment would improve clinical outcomes and reduce the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage in elderly Chinese adults. Patients (60 to 90 years old) were admitted to intensive care units after surgery to clip or embolize their aneurysms. We assessed 592 patients and assigned 159 to receive atorvastatin (20 mg/day) and 158 to receive placebo once daily for up to 14 days. The primary outcome was the Glasgow outcome scale at 6 months, and secondary outcomes were cerebral vasospasm, 30-days all-cause mortality, cerebral infarction, and delayed ischemic neurological deficit. The incidence of postoperative cerebral vasospasm (39.3% vs 56%, P =0.004) and cerebral infarction (18.7% vs 27.3%, P=0.027) were significantly lower in the atorvastatin group. The study did not detect benefits in the use of atorvastatin for 6 months clinical outcome or 30-day all-cause mortality, but it suggests that atorvastatin together with nimodipine can reduce cerebral vasospasm and cerebral infarction after subarachnoid hemorrhage.
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Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, China
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, China
| | - Xun Zhu
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Lei Chen
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Shuo Yang
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Chunlei Zhang
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Ting Wu
- Department of Cardiology, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Xiaoyan Feng
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Yuhai Wang
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, China
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25
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Santos-Teles AG, Ramalho C, Ramos JGR, Passos RDH, Gobatto A, Farias S, Batista PBP, Caldas JR. Efficacy and safety of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage: a systematic review. Rev Bras Ter Intensiva 2020; 32:592-602. [PMID: 33470361 PMCID: PMC7853682 DOI: 10.5935/0103-507x.20200097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 03/17/2020] [Indexed: 12/30/2022] Open
Abstract
Objective To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage. Methods The Pubmed®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies. Results Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm. Conclusion The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.
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Affiliation(s)
- Alex Goes Santos-Teles
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil
| | - Clara Ramalho
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | | | - André Gobatto
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | - Suzete Farias
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | - Juliana Ribeiro Caldas
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil.,Universidade de Salvador - Salvador (BA), Brasil
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26
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Shen J, Shen J, Zhu K, Zhou H, Tian H, Yu G. Efficacy of Statins in Cerebral Vasospasm, Mortality, and Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2019; 131:e65-e73. [DOI: 10.1016/j.wneu.2019.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 11/26/2022]
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27
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Savarraj J, Parsha K, Hergenroeder G, Ahn S, Chang TR, Kim DH, Choi HA. Early Brain Injury Associated with Systemic Inflammation After Subarachnoid Hemorrhage. Neurocrit Care 2019; 28:203-211. [PMID: 29043545 DOI: 10.1007/s12028-017-0471-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH) is defined as brain injury occurring within 72 h of aneurysmal rupture. Although EBI is the most significant predictor of outcomes after aSAH, its underlying pathophysiology is not well understood. We hypothesize that EBI after aSAH is associated with an increase in peripheral inflammation measured by cytokine expression levels and changes in associations between cytokines. METHODS aSAH patients were enrolled into a prospective observational study and were assessed for markers of EBI: global cerebral edema (GCE), subarachnoid hemorrhage early brain edema score (SEBES), and Hunt-Hess grade. Serum samples collected at ≤ 48 h of admission were analyzed using multiplex bead-based assays to determine levels of 13 pro- and anti-inflammatory cytokines. Pairwise correlation coefficients between cytokines were represented as networks. Cytokine levels and differences in correlation networks were compared between EBI groups. RESULTS Of the 71 patients enrolled in the study, 17 (24%) subjects had GCE, 31 (44%) subjects had SEBES ≥ 3, and 21 (29%) had HH ≥ 4. IL-6 was elevated in groups with GCE, SEBES ≥ 3, and HH ≥ 4. MIP1β was independently associated with high-grade SEBES. Correlation network analysis suggests higher systematic inflammation in subjects with SEBES ≥ 3. CONCLUSIONS EBI after SAH is associated with increased levels of specific cytokines. Peripheral levels of IL-10, IL-6, and MIP1β may be important markers of EBI. Investigating systematic correlations in addition to expression levels of individual cytokines may offer deeper insight into the underlying mechanisms related to EBI.
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Affiliation(s)
- Jude Savarraj
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Kaushik Parsha
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Georgene Hergenroeder
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Sungho Ahn
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Tiffany R Chang
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Dong H Kim
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - H Alex Choi
- Department of Neurosurgery, University of Texas Health Science Center at Houston-McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA.
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28
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Teoh RJJ, Huang CJ, Chan CP, Chien LY, Chung CP, Sung SH, Chen CH, Chiang CE, Cheng HM. Does statin increase the risk of intracerebral hemorrhage in stroke survivors? A meta-analysis and trial sequential analysis. Ther Adv Neurol Disord 2019; 12:1756286419864830. [PMID: 31384308 PMCID: PMC6657129 DOI: 10.1177/1756286419864830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/30/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It remains debatable whether statin increases the risk of intracerebral hemorrhage (ICH) in poststroke patients. METHODS We systematically searched PubMed, EMBASE, and CENTRAL for randomized controlled trials. Trial sequential analysis (TSA) was conducted to assess the reliability and conclusiveness of the available evidence in the meta-analysis. To evaluate the overall effectiveness, the net composite endpoints were derived by totaling ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), myocardial infarction, and cardiovascular mortality. RESULTS A total of 17 trials with 11,576 subjects with previous ischemic stroke, TIA, or ICH were included, in which statin therapy increased the risk of hemorrhagic stroke (risk ratio [RR], 1.42; 95% confidence interval [CI], 1.07-1.87), but reduced the risk of ischemic stroke (RR, 0.85; 95% CI, 0.75-0.95). For the net composite endpoints, statin therapy was associated with a 17% risk reduction (95% CI, 12-21%; number needed to treat = 6). With a control event rate 2% and RR increase 40%, the TSA suggested a conclusive signal of an increased risk of hemorrhagic stroke in stroke survivors taking statin. However, with the sensitivity analysis by changing assumptions, the conclusions about hemorrhagic stroke risk were less robust. CONCLUSIONS Statin therapy in poststroke patients increased the risk of hemorrhagic stroke but effectively reduced ischemic stroke risk. Weighing the benefits and potential harms, statin has an overall beneficial effect in patients with previous stroke or TIA. However, more studies are required to investigate the conclusiveness of the increased hemorrhagic stroke risk revealed in our study.
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Affiliation(s)
| | - Chi-Jung Huang
- Center for Evidence-based Medicine, Taipei
Veterans General Hospital, Taipei
| | - Chi Peng Chan
- Royal Infirmary of Edinburgh, NHS Lothian,
Edinburgh, UK
| | - Li-Yin Chien
- International Health Program, National Yang-Ming
University, Taipei
- Institute of Community Health Care, National
Yang-Ming University, Taipei
| | - Chih-Ping Chung
- Department of Neurology, National Yang-Ming
University, Taipei
- Department of Neurology, Taipei Veterans General
Hospital, Taipei
| | - Shih-Hsien Sung
- Department of Medicine, National Yang-Ming
University, Taipei
- Department of Internal Medicine, Taipei Veterans
General Hospital, Taipei
- Institute of Public Health and Community
Medicine Research Center, National Yang-Ming University, Taipai
| | - Chen-Huan Chen
- Department of Internal Medicine, Taipei
Veterans General Hospital, Taipei
- Institute of Public Health and Community
Medicine Research Center, National Yang-Ming University, Taipei
- Department of Medical Education, Taipei
Veterans General Hospital, Taipei
| | - Chern-En Chiang
- Department of Medicine, National Yang-Ming
University, Taipei
- General Clinical Research Center, Taipei
Veterans General Hospital, Taipei
| | - Hao-Min Cheng
- Center for Evidence-based Medicine, Taipei
Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District,
Taipei 11217
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29
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Naraoka M, Matsuda N, Shimamura N, Asano K, Akasaka K, Takemura A, Hasegawa S, Ohkuma H. Long-acting statin for aneurysmal subarachnoid hemorrhage: A randomized, double-blind, placebo-controlled trial. J Cereb Blood Flow Metab 2018; 38:1190-1198. [PMID: 28762878 PMCID: PMC6434445 DOI: 10.1177/0271678x17724682] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Statins have pleiotropic effects that are considered beneficial in preventing cerebral vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH). Many studies using statins have been performed but failed to show remarkable effects. We hypothesized that a long-acting statin would be more effective, due to a longer half-life and stronger pleiotropic effects. Patients with aSAH were randomly assigned to a pitavastatin group (4 mg daily; n = 54) and a placebo group ( n = 54) after repair of a ruptured aneurysm. The primary efficacy end point was vasospasm-related delayed ischemic neurological deficits (DIND), and the secondary end points were cerebral vasospasm evaluated by digital subtraction angiography (DSA), vasospasm-related new cerebral infarctions, and outcome at three months. Severe cerebral vasospasms on DSA were statistically fewer in the pitavastatin group than in the placebo group (14.8% vs. 33.3%; odds ratio, 0.32; 95% confidence interval, 0.11-0.87, p = 0.042); however, the occurrence of DIND and new infarctions and outcome showed no statistically significant differences between the groups. The present study is the first to prove the definite, statin-induced amelioration of cerebral vasospasm on DSA. However, administration of any type of statin at the acute phase of aSAH is not recommended.
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Affiliation(s)
- Masato Naraoka
- 1 Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Naoya Matsuda
- 1 Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Norihito Shimamura
- 1 Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Kenichiro Asano
- 1 Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Kenichi Akasaka
- 2 Department of Neurosurgery, Towada City Hospital, Towada, Japan
| | | | - Seiko Hasegawa
- 4 Department of Neurosurgery, Kuroishi City Hospital, Kuroishi, Japan
| | - Hiroki Ohkuma
- 1 Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
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Dose-Dependent Effects of Statins for Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Regression Analysis. World Neurosurg 2018; 113:153-162. [PMID: 29425980 DOI: 10.1016/j.wneu.2018.01.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/26/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The study uses meta-regression analysis to quantify the dose-dependent effects of statin pharmacotherapy on vasospasm, delayed ischemic neurologic deficits (DIND), and mortality in aneurysmal subarachnoid hemorrhage. METHODS Prospective, retrospective observational studies, and randomized controlled trials (RCTs) were retrieved by a systematic database search. Summary estimates were expressed as absolute risk (AR) for a given statin dose or control (placebo). Meta-regression using inverse variance weighting and robust variance estimation was performed to assess the effect of statin dose on transformed AR in a random effects model. Dose-dependence of predicted AR with 95% confidence interval (CI) was recovered by using Miller's Freeman-Tukey inverse. RESULTS The database search and study selection criteria yielded 18 studies (2594 patients) for analysis. These included 12 RCTs, 4 retrospective observational studies, and 2 prospective observational studies. Twelve studies investigated simvastatin, whereas the remaining studies investigated atorvastatin, pravastatin, or pitavastatin, with simvastatin-equivalent doses ranging from 20 to 80 mg. Meta-regression revealed dose-dependent reductions in Freeman-Tukey-transformed AR of vasospasm (slope coefficient -0.00404, 95% CI -0.00720 to -0.00087; P = 0.0321), DIND (slope coefficient -0.00316, 95% CI -0.00586 to -0.00047; P = 0.0392), and mortality (slope coefficient -0.00345, 95% CI -0.00623 to -0.00067; P = 0.0352). CONCLUSIONS The present meta-regression provides weak evidence for dose-dependent reductions in vasospasm, DIND and mortality associated with acute statin use after aneurysmal subarachnoid hemorrhage. However, the analysis was limited by substantial heterogeneity among individual studies. Greater dosing strategies are a potential consideration for future RCTs.
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Abstract
PURPOSE OF REVIEW With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm. RECENT FINDINGS Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome. SUMMARY Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.
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Liu H, Xu X. Effect of simvastatin in patients with aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Am J Emerg Med 2017; 35:1940-1945. [PMID: 28966073 DOI: 10.1016/j.ajem.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/03/2017] [Accepted: 09/04/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Simvastatin might be beneficial to the patients with aneurysmal subarachnoid hemorrhage. However, the results remained controversial. We conducted a systematic review and meta-analysis to explore the efficacy of simvastatin for aneurysmal subarachnoid hemorrhage. METHODS PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of simvastatin versus placebo on aneurysmal subarachnoid hemorrhage were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were delayed ischaemic deficit and delayed cerebral infarction. Meta-analysis was performed using the random-effect model. RESULTS Six RCTs involving 1053 patients were included in the meta-analysis. Overall, compared with control intervention, simvastatin intervention had no influence on delayed ischaemic deficit (RR=0.99; 95% CI=0.78 to 1.27; P=0.96), delayed cerebral infarction (RR=1.17; 95% CI=0.60 to 2.29; P=0.65), mRS≤2 (RR=0.97; 95% CI=0.87 to 1.09; P=0.61), vasospasm (RR=0.79; 95% CI=0.49 to 1.29; P=0.35), ICU stay (Std. mean difference=0.04; 95% CI=-0.54 to 0.63; P=0.88), hospital stay (Std. mean difference=0.01; 95% CI=-0.13 to 0.14; P=0.90) and mortality (RR=0.71; 95% CI=0.25 to 2.05; P=0.53) after aneurysmal subarachnoid hemorrhage. CONCLUSIONS Compared to control intervention, simvastatin intervention was found to have no influence on delayed ischaemic deficit, delayed cerebral infarction, mRS≤2, vasospasm, ICU stay, hospital stay, and mortality in patients with acute aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Hongju Liu
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xiaoli Xu
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing 100029, China.
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Lin J, Liu H, Jiang J, Jia C, Zhang B, Gao X. Clinical evidence of efficacy of simvastatin for aneurysmal subarachnoid hemorrhage. J Int Med Res 2017; 45:2128-2138. [PMID: 28661267 PMCID: PMC5805215 DOI: 10.1177/0300060517713803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective The present study was performed to explore the therapeutic potential of
simvastatin in subarachnoid hemorrhage (SAH) in the context of the
Simvastatin in Aneurysmal Subarachnoid Hemorrhage (STASH) trial. Methods MEDLINE, EMBASE, and the Cochrane Library were searched for all randomized
controlled trials (RCTs) investigating the therapeutic effect of simvastatin
on aneurysmal SAH. We applied a random-effects model to calculate the
data. Results Five RCTs involving 951 patients met the eligibility criteria. We found no
statistically significant effects on vasospasm detected by transcranial
cerebral Doppler (relative risk [RR], 0.91; 95% confidence interval [CI],
0.55–1.49), delayed cerebral ischemia (DCI) (RR, 0.85; 95% CI, 0.63–1.14),
or all-cause mortality (RR, 1.02; 95% CI, 0.67–1.54). Subgroup analysis
showed that these consolidated results were stable at different doses,
different times to start of treatment, and different courses of treatment in
all included RCTs. Sensitivity analysis showed that the STASH trial, which
had a large population, did not influence the consolidated results of all
three outcomes. Conclusions Simvastatin showed no benefits in decreasing the incidence of vasospasm, DCI,
or all-cause mortality after aneurysmal SAH. We conclude that patients with
SAH should not be treated routinely with simvastatin during the acute
stage.
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Affiliation(s)
- Jinghui Lin
- Department of Neurosurgery, Fenghua
People’s Hospital, Ningbo, Zhejiang, China
| | - Houxian Liu
- Department of Neurosurgery, Fenghua
People’s Hospital, Ningbo, Zhejiang, China
| | - Jianjun Jiang
- Department of Neurosurgery, Ningbo First
Hospital, Ningbo, Zhejiang, China
| | - Conglin Jia
- Department of Neurosurgery, Fenghua
People’s Hospital, Ningbo, Zhejiang, China
| | - Bin Zhang
- Department of Neurosurgery, Fenghua
People’s Hospital, Ningbo, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo First
Hospital, Ningbo, Zhejiang, China
- Xiang Gao, Department of Neurosurgery,
Ningbo First Hospital, 59 Liuting Road, Ningbo, Zhejiang 315000, China.
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Cholesterol-Reducing Agents for Treatment of Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2017; 101:476-485. [DOI: 10.1016/j.wneu.2017.01.125] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 11/20/2022]
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Dose-related effect of statins in patients with endovascular coiling or microsurgical clipping for aneurysmal subarachnoid hemorrhage: updated study-level meta-analysis. Eur J Clin Pharmacol 2017; 73:1071-1081. [PMID: 28293714 DOI: 10.1007/s00228-017-2221-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/17/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE We aimed to quantitatively assess the effects of short-term statin use on delayed ischemic neurologic deficits (DINDs) and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH) through a meta-analysis of the available evidence. METHODS We searched the electronic databases up to April 8, 2016 to retrieve relevant studies comparing the outcomes between immediate statin-treated in statin-naïve patients and untreated patients following aneurysmal SAH. Meta-analysis was performed using Review Manager 5.3. RESULTS Eight randomized controlled clinical trials (RCTs) and 5 observational studies involving 2148 patients met the eligibility criteria. In the RCTs, statins were found to significantly reduce the occurrence of DINDs (relative risk (RR), 0.76; 95% confidence interval (CI), 0.61-0.94; P = 0.01), but did not significantly reduce poor functional outcomes (RR, 1.01; 95% CI, 0.87-1.16; P = 0.93) or mortality (RR, 0.80; 95% CI, 0.58-1.11; P = 0.18). In observational studies, statin use was not associated with any reduction in DINDs, poor outcome, or mortality. Meta-analysis of RCTs indicated a significant reduction in DINDs and mortality in patients with high-dose statin use (RR, 0.63; 95% CI, 0.42-0.95; P = 0.03; I 2 = 0%; and RR, 0.36; 95% CI, 0.15-0.86; P = 0.02; I 2 = 0%, respectively). CONCLUSION The present meta-analysis suggests that statin use may prevent DINDs in patients with aneurysmal SAH. Based on our findings, the role of statins in improving neurological outcome was limited. However, the risk of DINDs and mortality decreased with higher statin doses in a dose-dependent manner. Hence, further well-designed RCTs with modified protocols in specific patients are required.
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Czorlich P, Sauvigny T, Ricklefs F, Abboud T, Nierhaus A, Vettorazzi E, Reuter DA, Regelsberger J, Westphal M, Schmidt NO. Impact of dexamethasone in patients with aneurysmal subarachnoid haemorrhage. Eur J Neurol 2017; 24:645-651. [DOI: 10.1111/ene.13265] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/11/2017] [Indexed: 11/27/2022]
Affiliation(s)
- P. Czorlich
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - T. Sauvigny
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - F. Ricklefs
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - T. Abboud
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - A. Nierhaus
- Department of Intensive Care Medicine; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - E. Vettorazzi
- Department of Medical Biometry and Epidemiology; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - D. A. Reuter
- Department of Anaesthesiology; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - J. Regelsberger
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - M. Westphal
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - N. O. Schmidt
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
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Grasso G, Alafaci C, Macdonald RL. Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives. Surg Neurol Int 2017; 8:11. [PMID: 28217390 PMCID: PMC5288992 DOI: 10.4103/2152-7806.198738] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 12/01/2016] [Indexed: 12/25/2022] Open
Abstract
Background: Aneurysmal subarachnoid hemorrhage (SAH) accounts for 5% of strokes and carries a poor prognosis. It affects around 6 cases per 100,000 patient years occurring at a relatively young age. Methods: Common risk factors are the same as for stroke, and only in a minority of the cases, genetic factors can be found. The overall mortality ranges from 32% to 67%, with 10–20% of patients with long-term dependence due to brain damage. An explosive headache is the most common reported symptom, although a wide spectrum of clinical disturbances can be the presenting symptoms. Brain computed tomography (CT) allow the diagnosis of SAH. The subsequent CT angiography (CTA) or digital subtraction angiography (DSA) can detect vascular malformations such as aneurysms. Non-aneurysmal SAH is observed in 10% of the cases. In patients surviving the initial aneurysmal bleeding, re-hemorrhage and acute hydrocephalus can affect the prognosis. Results: Although occlusion of an aneurysm by surgical clipping or endovascular procedure effectively prevents rebleeding, cerebral vasospasm and the resulting cerebral ischemia occurring after SAH are still responsible for the considerable morbidity and mortality related to such a pathology. A significant amount of experimental and clinical research has been conducted to find ways in preventing these complications without sound results. Conclusions: Even though no single pharmacological agent or treatment protocol has been identified, the main therapeutic interventions remain ineffective and limited to the manipulation of systemic blood pressure, alteration of blood volume or viscosity, and control of arterial dioxide tension.
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Affiliation(s)
- Giovanni Grasso
- Department of Experimental Biomedicine and Clinical Neurosciences (BIONEC), Section of Neurosurgery, University of Palermo, Palermo, Italy
| | | | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Boulouis G, Labeyrie MA, Raymond J, Rodriguez-Régent C, Lukaszewicz AC, Bresson D, Ben Hassen W, Trystram D, Meder JF, Oppenheim C, Naggara O. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Eur Radiol 2016; 27:3333-3342. [PMID: 28004163 DOI: 10.1007/s00330-016-4702-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To examine the clinical outcome of aneurysmal subarachnoid haemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS)-targeted treatments in a meta-analysis and to evaluate the efficacy of intra-arterial (IA) approaches in patients with severe/refractory vasospasm. METHODS Randomised controlled trials, prospective and retrospective observational studies reporting clinical outcomes of aSAH patients exposed to CVS targeted treatments, published between 2006-2016 were searched using PubMed, EMBASE and the Cochrane Library. The main endpoint was the proportion of unfavourable outcomes, defined as a modified Rankin score of 3-6 at last follow-up. RESULTS Sixty-two studies, including 26 randomised controlled trials, were included (8,976 patients). At last follow-up 2,490 of the 8,976 patients had an unfavourable outcome, including death (random-effect weighted-average, 33.7%; 99% confidence interval [CI], 28.1-39.7%; Q value, 806.0; I 2 = 92.7%). The RR of unfavourable outcome was lower in patients treated with Cilostazol (RR = 0.46; 95% CI, 0.25-0.85; P = 0.001; Q value, 1.5; I 2 = 0); and in refractory CVS patients treated by IA intervention (RR = 0.68; 95% CI, 0.57-0.80; P < 0.0001; number needed to treat with IA intervention, 6.2; 95% CI, 4.3-11.2) when compared with the best available medical treatment. CONCLUSIONS Endovascular treatment may improve the outcome of patients with severe-refractory vasospasm. Further studies are needed to confirm this result. KEY POINTS • 33.7% of patients with cerebral Vasospasm following aneurysmal subarachnoid-hemorrhage have an unfavorable outcome. • Refractory vasospasm patients treated using endovascular interventions have lower relative risk of unfavourable outcome. • Subarachnoid haemorrhage patients with severe vasospasm may benefit from endovascular interventions. • The relative risk of unfavourable outcome is lower in patients treated with Cilostazol.
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Affiliation(s)
- Grégoire Boulouis
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France.
- DHU NeuroVasc Paris Sorbonne, Paris, France.
| | - Marc Antoine Labeyrie
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Christine Rodriguez-Régent
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Anne Claire Lukaszewicz
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Damien Bresson
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Wagih Ben Hassen
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Denis Trystram
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Jean Francois Meder
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Catherine Oppenheim
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Olivier Naggara
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
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Shen J, Huang KY, Zhu Y, Pan JW, Jiang H, Weng YX, Zhan RY. Effect of statin treatment on vasospasm-related morbidity and functional outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg 2016; 127:291-301. [PMID: 27715439 DOI: 10.3171/2016.5.jns152900] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The efficacy of statin therapy in treating aneurysmal subarachnoid hemorrhage (SAH) remains controversial. In this meta-analysis, the authors investigated whether statin treatment significantly reduced the incidence of cerebral vasospasm and delayed neurological deficits, promoting a better outcome after aneurysmal SAH. METHODS A literature search of the PubMed, Ovid, and Cochrane Library databases was performed for randomized controlled trials (RCTs) and prospective cohort studies investigating the effect of statin treatment. The end points of cerebral vasospasm, delayed ischemic neurological deficit (DIND), delayed cerebral infarction, mortality, and favorable outcome were statistically analyzed. RESULTS Six RCTs and 2 prospective cohort studies met the eligibility criteria, and a total of 1461 patients were included. The meta-analysis demonstrated a significant decrease in the incidence of cerebral vasospasm (relative risk [RR] 0.76, 95% confidence interval [CI] 0.61-0.96) in patients treated with statins after aneurysmal SAH. However, no significant benefit was observed for DIND (RR 0.88, 95% CI 0.70-1.12), delayed cerebral infarction (RR 0.66, 95% CI 0.33-1.31), mortality (RR 0.69, 95% CI 0.39-1.24) or favorable outcome, according to assessment by the modified Rankin Scale or Glasgow Outcome Scale (RR 0.99, 95% CI 0.92-1.17). CONCLUSIONS Treatment with statins significantly decreased the occurrence of vasospasm after aneurysmal SAH. The incidence of DIND, delayed cerebral infarction, and mortality were not affected by statin treatment. Future research should focus on DIND and how statins influence DIND.
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Affiliation(s)
- Jian Shen
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Kai-Yuan Huang
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Yu Zhu
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Jian-Wei Pan
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Hao Jiang
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Yu-Xiang Weng
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Ren-Ya Zhan
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
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Abstract
OPINION STATEMENT New neuroprotective treatments aimed at preventing or minimizing "delayed brain injury" are attractive areas of investigation and hold the potential to have substantial beneficial effects on aneurysmal subarachnoid hemorrhage (aSAH) survivors. The underlying mechanisms for this "delayed brain injury" are multi-factorial and not fully understood. The most ideal treatment strategies would have the potential for a pleotropic effect positively modulating multiple implicated pathophysiological mechanisms at once. My personal management (RFJ) of patients with aneurysmal subarachnoid hemorrhage closely follows those treatment recommendations contained in modern published guidelines. However, over the last 5 years, I have also utilized a novel treatment strategy, originally developed at the University of Maryland, which consists of a 14-day continuous low-dose intravenous heparin infusion (LDIVH) beginning 12 h after securing the ruptured aneurysm. In addition to its well-known anti-coagulant properties, unfractionated heparin has potent anti-inflammatory effects and through multiple mechanisms may favorably modulate the neurotoxic and neuroinflammatory processes prominent in aneurysmal subarachnoid hemorrhage. In my personal series of patients treated with LDIVH, I have found significant preservation of neurocognitive function as measured by the Montreal Cognitive Assessment (MoCA) compared to a control cohort of my patients treated without LDIVH (RFJ unpublished data presented at the 2015 AHA/ASA International Stroke Conference symposium on neuroinflammation in aSAH and in abstract format at the 2015 AANS/CNS Joint Cerebrovascular Section Annual Meeting). It is important for academic physicians involved in the management of these complex patients to continue to explore new treatment options that may be protective against the potentially devastating "delayed brain injury" following cerebral aneurysm rupture. Several of the treatment options included in this review show promise and could be carefully adopted as the level of evidence for each improves. Other proposed neuroprotective treatments like statins and magnesium sulfate were previously thought to be very promising and to varying degrees were adopted at numerous institutions based on somewhat limited human evidence. Recent clinical trials and meta-analysis have shown no benefit for these treatments, and I currently no longer utilize either treatment as prophylaxis in my practice.
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Chen JH, Yang LK, Chen L, Wang YH, Wu Y, Jiang BJ, Zhu J, Li PP. Atorvastatin ameliorates early brain injury after subarachnoid hemorrhage via inhibition of AQP4 expression in rabbits. Int J Mol Med 2016; 37:1059-66. [PMID: 26935263 DOI: 10.3892/ijmm.2016.2506] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 02/11/2016] [Indexed: 12/13/2022] Open
Abstract
The therapeutic effects of atorvastatin on early brain injury (EBI), cerebral edema and its association with aquaporin 4 (AQP4) were studied in rabbits after subarachnoid hemorrhage (SAH) using western blot analysis and the dry-wet method. Seventy-two healthy male New Zealand rabbits weighing between 2.5 and 3.2 kg were randomly divided into three groups: the SAH group (n=24), sham-operated group (n=24) and the SAH + atorvastatin group (n=24). A double SAH model was employed. The sham-operated group were injected with the same dose of saline solution, the SAH + atorvastatin group received atorvastatin 20 mg/kg/day after SAH. All rabbit brain samples were taken at 72 h after the SAH model was established successfully. Brain edema was detected using the dry-wet method after experimental SAH was induced; AQP4 and caspase-3 expression was measured by western blot analysis, and neuronal apoptosis was detected by terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling (TUNEL) staining at 72 h after SAH. The results indicated that brain edema and injury appeared soon after SAH, while brain edema and EBI were ameliorated and increased behavior scores were noted after prophylactic use of atorvastatin. Compared with the SAH group, the level of AQP4 and the cerebral content of water was significantly decreased (P<0.01) by atorvastatin, and TUNEL staining and studying the expression of caspase-3 showed that the apoptosis of neurons was reduced markedly both in the hippocampus and brain cortex by atorvastatin. The results suggest that atorvastatin ameliorated brain edema and EBI after SAH, which was related to its inhibition of AQP4 expression. Our findings provide evidence that atorvastatin is an effective and well-tolerated approach for treating SAH in various clinical settings.
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Affiliation(s)
- Jun-Hui Chen
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Li-Kun Yang
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Lei Chen
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Yu-Hai Wang
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Yun Wu
- Department of Anesthesia, The First Affiliated Hospital of Gannan Medical College, Jiangxi 341000, P.R. China
| | - Bing-Jie Jiang
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Jie Zhu
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Pei-Pei Li
- Department of Neurosurgery, l01st Hospital of PLA (Wuxi Taihu Hospital), Clinical Medical School of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
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Woo SW, Kim JH, Kang HI, Kim DR, Moon BG, Kim JS. High-Dose Simvastatin Is Effective in Preventing Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study in Korean Patients. J Korean Neurosurg Soc 2015; 58:328-33. [PMID: 26587185 PMCID: PMC4651992 DOI: 10.3340/jkns.2015.58.4.328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/12/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022] Open
Abstract
Objective The goal of this study was to assess the effect of high-dose simvastatin on cerebral vasospasm and its clinical outcome after aneurysmal subarachnoid hemorrhage (SAH) in Korean patients. Methods This study was designed as a prospective observational cohort study. Its subjects were aneurysmal SAH patients who had undergone aneurysm clipping or coiling. They were assigned to 1 of 3 groups : the 20 mg, 40 mg, and 80 mg simvastatin groups. The primary end-point was the occurrence of symptomatic vasospasm. The clinical outcome was assessed with the modified Rankin Scale (mRS) score after 1 month and 3 months. The risk factors of the development of vasospasm were assessed by logistic regression analysis. Results Ninety nine patients with aneurysmal SAH were treated and screened. They were sequentially assigned to the 20 mg (n=22), 40 mg (n=34), and 80 mg (n=31) simvastatin groups. Symptomatic vasospasm occurred in 36.4% of the 20 mg group, 8.8% of the 40 mg group, and 3.2% of the 80 mg group (p=0.003). The multiple logistic regression analysis showed that poor Hunt-Hess grades (OR=5.4 and 95% CI=1.09-26.62) and high-dose (80 mg) simvastatin (OR=0.09 and 95% CI=0.1-0.85) were independent factors of symptomatic vasospasm. The clinical outcomes did not show a significant difference among the three groups. Conclusion This study demonstrated that 80 mg simvastatin treatment was effective in preventing cerebral vasospasm after aneurysmal SAH, but did not improve the clinical outcome in Korean patients.
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Affiliation(s)
- Sung Woong Woo
- Department of Neurosurgery, Eulji University School of Medicine, Seoul, Korea
| | - Jae Hoon Kim
- Department of Neurosurgery, Eulji University School of Medicine, Seoul, Korea
| | - Hee In Kang
- Department of Neurosurgery, Eulji University School of Medicine, Seoul, Korea
| | - Deok Ryeong Kim
- Department of Neurosurgery, Eulji University School of Medicine, Seoul, Korea
| | - Byung Gwan Moon
- Department of Neurosurgery, Eulji University School of Medicine, Seoul, Korea
| | - Joo Seung Kim
- Department of Neurosurgery, Eulji University School of Medicine, Seoul, Korea
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Abstract
AbstractCerebral vasospasm is a prolonged but reversible narrowing of cerebral arteries beginning days after subarachnoid hemorrhage. Progression to cerebral ischemia is tied mostly to vasospasm severity, and its pathogenesis lies in artery encasement by blood clot, although the complex interactions between hematoma and surrounding structures are not fully understood. The delayed onset of vasospasm provides a potential opportunity for its prevention. It is disappointing that recent randomized, controlled trials did not demonstrate that the endothelin antagonist clazosentan, the cholesterol-lowering agent simvastatin, and the vasodilator magnesium sulfate improve patient outcome. Minimizing ischemia by avoiding inadequate blood volume and pressure, administering the calcium antagonist nimodipine, and intervention with balloon angioplasty, when necessary, constitutes current best management. Over the past two decades, our ability to manage vasospasm has led to a significant decline in patient morbidity and mortality from vasospasm, yet it still remains an important determinant of outcome after aneurysm rupture.
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Serrone JC, Maekawa H, Tjahjadi M, Hernesniemi J. Aneurysmal subarachnoid hemorrhage: pathobiology, current treatment and future directions. Expert Rev Neurother 2015; 15:367-80. [PMID: 25719927 DOI: 10.1586/14737175.2015.1018892] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aneurysmal subarachnoid hemorrhage is the most devastating form of stroke. Many pathological mechanisms ensue after cerebral aneurysm rupture, including hydrocephalus, apoptosis of endothelial cells and neurons, cerebral edema, loss of blood-brain barrier, abnormal cerebral autoregulation, microthrombosis, cortical spreading depolarization and macrovascular vasospasm. Although studied extensively through experimental and clinical trials, current treatment guidelines to prevent delayed cerebral ischemia is limited to oral nimodipine, maintenance of euvolemia, induction of hypertension if ischemic signs occur and endovascular therapy for patients with continued ischemia after induced hypertension. Future investigations will involve agents targeting vasodilation, anticoagulation, inhibition of apoptosis pathways, free radical neutralization, suppression of cortical spreading depolarization and attenuation of inflammation.
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Affiliation(s)
- Joseph C Serrone
- Department of Neurosurgery, Töölö Hospital, University of Helsinki, Topeliuksenkatu 5, PO Box 266, 00029 HUS, Helsinki, Finland
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Kiser TH. Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions? Hosp Pharm 2014; 49:923-41. [PMID: 25477565 DOI: 10.1310/hpj4910-923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.
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Affiliation(s)
- Tyree H Kiser
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital, University of Colorado Anschutz Medical Campus , 12850 E. Montview Boulevard, C238, Aurora, CO 80045 ; phone: 303-724-2883 ; fax: 303-724-0979 ; e-mail:
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Budohoski KP, Guilfoyle M, Helmy A, Huuskonen T, Czosnyka M, Kirollos R, Menon DK, Pickard JD, Kirkpatrick PJ. The pathophysiology and treatment of delayed cerebral ischaemia following subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2014; 85:1343-53. [PMID: 24847164 DOI: 10.1136/jnnp-2014-307711] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cerebral vasospasm has traditionally been regarded as an important cause of delayed cerebral ischaemia (DCI) which occurs after aneurysmal subarachnoid haemorrhage, and often leads to cerebral infarction and poor neurological outcome. However, data from recent studies argue against a pure focus on vasospasm as the cause of delayed ischaemic complications. Findings that marked reduction in the incidence of vasospasm does not translate to a reduction in DCI, or better outcomes has intensified research into other possible mechanisms which may promote ischaemic complications. Early brain injury and cell death, blood-brain barrier disruption and initiation of an inflammatory cascade, microvascular spasm, microthrombosis, cortical spreading depolarisations and failure of cerebral autoregulation, have all been implicated in the pathophysiology of DCI. This review summarises the current knowledge about the mechanisms underlying the development of DCI. Furthermore, it aims to describe and categorise the known pharmacological treatment options with respect to the presumed mechanism of action and its role in DCI.
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Affiliation(s)
- Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Mathew Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Terhi Huuskonen
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK Department of Neurosurgery, Kuopio Neurocenter, Kuopio University Hospital, Kuopio, Finland
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ramez Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Department of Anaesthesiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Vivancos J, Gilo F, Frutos R, Maestre J, García-Pastor A, Quintana F, Roda J, Ximénez-Carrillo A, Díez Tejedor E, Fuentes B, Alonso de Leciñana M, Álvarez-Sabin J, Arenillas J, Calleja S, Casado I, Castellanos M, Castillo J, Dávalos A, Díaz-Otero F, Egido J, Fernández J, Freijo M, Gállego J, Gil-Núñez A, Irimia P, Lago A, Masjuan J, Martí-Fábregas J, Martínez-Sánchez P, Martínez-Vila E, Molina C, Morales A, Nombela F, Purroy F, Ribó M, Rodríguez-Yañez M, Roquer J, Rubio F, Segura T, Serena J, Simal P, Tejada J. Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2012.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Biomarkers of vasospasm development and outcome in aneurysmal subarachnoid hemorrhage. J Neurol Sci 2014; 341:119-27. [DOI: 10.1016/j.jns.2014.04.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 03/20/2014] [Accepted: 04/14/2014] [Indexed: 12/30/2022]
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Bauer AM, Rasmussen PA. Treatment of intracranial vasospasm following subarachnoid hemorrhage. Front Neurol 2014; 5:72. [PMID: 24904517 PMCID: PMC4032992 DOI: 10.3389/fneur.2014.00072] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/27/2014] [Indexed: 12/03/2022] Open
Abstract
Vasospasm has been a long known source of delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage patients. Delayed ischemic neurologic deficits associated with vasospasm may account for as high as 50% of the deaths in patients who survive the initial period after aneurysm rupture and its treatment. The diagnosis and treatment of vasospasm has still been met with some controversy. It is clear that subarachnoid hemorrhage is best cared for in tertiary care centers with modern resources and access to cerebral angiography. Ultimately, a high degree of suspicion for vasospasm must be kept during ICU care, and any signs or symptoms must be investigated and treated immediately to avoid permanent stroke and neurologic deficit. Treatment for vasospasm can occur through both ICU intervention and endovascular administration of intra-arterial vasodilators and balloon angioplasty. The best outcomes are often attained when these methods are used in conjunction. The following article reviews the literature on cerebral vasospasm and its treatment and provides the authors’ approach to treatment of these patients.
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Affiliation(s)
- Andrew M Bauer
- Cerebrovascular Center, Cleveland Clinic Foundation , Cleveland, OH , USA
| | - Peter A Rasmussen
- Cerebrovascular Center, Cleveland Clinic Foundation , Cleveland, OH , USA
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Kirkpatrick PJ, Turner CL, Smith C, Hutchinson PJ, Murray GD. Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial. Lancet Neurol 2014; 13:666-75. [PMID: 24837690 DOI: 10.1016/s1474-4422(14)70084-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The benefit of statins in patients with acute aneurysmal subarachnoid haemorrhage is unclear. We aimed to determine whether simvastatin 40 mg could improve the long-term outcome in patients with this disorder. METHODS In this international, multicentre, randomised, double-blind trial, we enrolled patients aged 18-65 years with confirmatory evidence of an aneurysmal subarachnoid haemorrhage and presenting less than 96 h from ictus from 35 acute neurosurgical centres in nine countries. Patients were randomly allocated (1:1) to receive either simvastatin 40 mg or placebo once a day for up to 21 days. We used a computer-generated randomisation code to randomise patients in every centre by blocks of ten (five simvastatin, five placebo). Participants and investigators were masked to treatment assignment. The primary outcome was the distribution of modified Rankin Scale (mRS) score obtained by questionnaire at 6 months. Analyses were done on the intention-to-treat population. This trial has been completed and is registered with Current Controlled Trials, number ISRCTN75948817. FINDINGS Between Jan 6, 2007, and Feb 1, 2013, apart from the period between May 15, 2009, and Feb 8, 2011, when recruitment was on hold, 803 patients were randomly assigned to receive either simvastatin 40 mg (n=391) or placebo (n=412). All patients were included in the intention-to-treat population. 782 (97%) patients had outcome data recorded at 6 months, of whom 560 (72%) were classed as having a favourable outcome, mRS 0-2 (271 patients in the simvastatin group vs 289 in the placebo group). The primary ordinal analysis of the mRS, adjusted for age and World Federation of Neurological Surgeons grade on admission, gave a common odds ratio (OR) of 0·97, 95% CI 0·75-1·25; p=0·803. At 6 months, we recorded 37 (10%) deaths in the simvastatin group compared with 35 (9%) in the placebo group (log-rank p=0·592). 70 (18%) serious adverse events were reported in the simvastatin group compared with 74 (18%) in the placebo group. No suspected unexpected serious adverse reactions were reported. INTERPRETATION The STASH trial did not detect any benefit in the use of simvastatin for long-term or short-term outcome in patients with aneurysmal subarachnoid haemorrhage. Despite demonstrating no safety concerns, we conclude that patients with subarachnoid haemorrhage should not be treated routinely with simvastatin during the acute stages. FUNDING British Heart Foundation.
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Affiliation(s)
- Peter J Kirkpatrick
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carole L Turner
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Christopher Smith
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gordon D Murray
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
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