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Veldeman M, Rossmann T, Haeren R, Vossen LV, Weiss M, Conzen C, Siironen JO, Korja M, Schmidt TP, Höllig A, Virta JJ, Satopää J, Luostarinen T, Wiesmann M, Clusmann H, Niemela M, Raj R. Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage: Location, Distribution Patterns, Infarct Load, and Effect on Outcome. Neurology 2024; 103:e209607. [PMID: 38950352 DOI: 10.1212/wnl.0000000000209607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Delayed cerebral ischemia (DCI) is one of the main contributing factors to poor clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). Unsuccessful treatment can cause irreversible brain injury in the form of DCI-related infarction. We aimed to assess the association between the location, distribution, and size of DCI-related infarction in relation to clinical outcome. METHODS Consecutive patients with SAH treated at 2 university hospitals between 2014 and 2019 (Helsinki, Finland) and between 2006 and 2020 (Aachen, Germany) were included. Size of DCI-related infarction was quantitatively measured as absolute volume (in milliliters). In a semiquantitative fashion, infarction in 14 regions of interest (ROIs) according to a modified Alberta Stroke Program Early CT Score (ASPECTS) was noted. The association of infarction in these ROIs along predefined regions of eloquent brain, with clinical outcome, was assessed. For this purpose, 1-year outcome was measured by the Glasgow Outcome Scale (GOS) and dichotomized into favorable (GOS 4-5) and unfavorable (GOS 1-3). RESULTS Of 1,190 consecutive patients with SAH, 155 (13%) developed DCI-related infarction. One-year outcome data were available for 148 (96%) patients. A median overall infarct volume of 103 mL (interquartile range 31-237) was measured. DCI-related infarction was significantly associated with 1-year unfavorable outcome (odds ratio [OR] 4.89, 95% CI 3.36-7.34, p < 0.001). In patients with 1-year unfavorable outcome, vascular territories more frequently affected were left middle cerebral artery (affected in 49% of patients with unfavorable outcome vs in 30% of patients with favorable outcome; p = 0.029), as well as left (44% vs 18%; p = 0.003) and right (52% vs 14%; p < 0.001) anterior cerebral artery supply areas. According to the ASPECTS model, the right M3 (OR 8.52, 95% CI 1.41-51.34, p = 0.013) and right A2 (OR 7.84, 95% CI 1.97-31.15, p = 0.003) regions were independently associated with unfavorable outcome. DISCUSSION DCI-related infarction was associated with a 5-fold increase in the odds of unfavorable outcome, after 1 year. Ischemic lesions in specific anatomical regions are more likely to contribute to unfavorable outcome. TRIAL REGISTRATION INFORMATION Data collection in Aachen was registered in the German Clinical Trial Register (DRKS00030505); on January 3, 2023.
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Affiliation(s)
- Michael Veldeman
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Tobias Rossmann
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Roel Haeren
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Laura V Vossen
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Miriam Weiss
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Catharina Conzen
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Jari O Siironen
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Miikka Korja
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Tobias P Schmidt
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Anke Höllig
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Jyri J Virta
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Jarno Satopää
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Teemu Luostarinen
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Martin Wiesmann
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Hans Clusmann
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Mika Niemela
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
| | - Rahul Raj
- From the Department of Neurosurgery (M.V., L.V.V., C.C., T.P.S., A.H., H.C.), RWTH Aachen University Hospital, Germany; Department of Neurosurgery (T.R.), Neuromed Campus, Kepler University Hospital, Linz, Austria; Department of Neurosurgery (R.H.), Maastricht University, Maastricht University Medical Center+, the Netherlands; Department of Neurosurgery (M. Weiss), Kantonsspital Aarau, Switzerland; Department of Neurosurgery (J.O.S., M.K., J.S., M.N., R.R.), University of Helsinki and Helsinki University Hospital; Division of Anesthesiology (J.J.V., T.L.), Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Finland; and Department of Neuroradiology (M. Wiesmann), RWTH Aachen University Hospital, Germany
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2
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Kole MJ, Martinez-Gutierrez JC, Zeineddine HA, Truong VTT, Chen PR. Utility of Surveillance Angiography in Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study of 223 Consecutive Patients. Neurocrit Care 2024; 40:1151-1159. [PMID: 38093091 DOI: 10.1007/s12028-023-01892-1] [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: 09/08/2023] [Accepted: 11/01/2023] [Indexed: 06/05/2024]
Abstract
BACKGROUND Patients with aneurysmal subarachnoid hemorrhage (aSAH) who survive the rupture are at risk for delayed neurologic deficits and cerebral infarction. The ideal method(s) of surveillance for cerebral vasospasm, and the link between radiographic vasospasm and delayed neurologic deficits, remain controversial. We instituted a postbleed day 7 angiography protocol with the stated goals of identification of vasospasm, improving neurologic outcomes, and possibly lowering cost of care. METHODS We conducted a quality improvement project in which we retrospectively analyzed consecutive cases of aSAH from a single institution over a 5-year period. Patients were excluded if they did not receive treatment for their aneurysm or were < 18 years of age. We analyzed demographic and outcome information for patients managed by protocolled angiography versus those who were managed by as-needed endovascular rescue therapy. Statistical tests were performed comparing means and proportions in both cohorts, as appropriate. RESULTS In total, 223 patients were identified who met inclusion criteria. In total, 157 patients were identified in the protocolled day 7 angiography group, and 66 were in the nonprotocolled angiography group. Demographics were similar between the day 7 angiogram and medical management cohorts, except for a higher mean age among the latter group (p = 0.016). The protocolled angiography group underwent a significantly greater number of angiograms (p < 0.001) and had a significantly higher cost of hospitalization ($240,327 vs. $205,719, p = 0.03), with no significant difference in rate of cerebral infarction, length of intensive care unit stay, length of hospital stay, discharge location, or discharge modified Rankin Score. CONCLUSIONS This cohort comparison analysis draws into question the practice of protocolized cerebral angiography in patients with aSAH.
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Affiliation(s)
- Matthew J Kole
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Department of Neurosurgery and Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA.
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA.
| | | | - Hussein A Zeineddine
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Van Thi Thanh Truong
- Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peng Roc Chen
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
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3
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Vitt JR, Mainali S. Artificial Intelligence and Machine Learning Applications in Critically Ill Brain Injured Patients. Semin Neurol 2024; 44:342-356. [PMID: 38569520 DOI: 10.1055/s-0044-1785504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
The utilization of Artificial Intelligence (AI) and Machine Learning (ML) is paving the way for significant strides in patient diagnosis, treatment, and prognostication in neurocritical care. These technologies offer the potential to unravel complex patterns within vast datasets ranging from vast clinical data and EEG (electroencephalogram) readings to advanced cerebral imaging facilitating a more nuanced understanding of patient conditions. Despite their promise, the implementation of AI and ML faces substantial hurdles. Historical biases within training data, the challenge of interpreting multifaceted data streams, and the "black box" nature of ML algorithms present barriers to widespread clinical adoption. Moreover, ethical considerations around data privacy and the need for transparent, explainable models remain paramount to ensure trust and efficacy in clinical decision-making.This article reflects on the emergence of AI and ML as integral tools in neurocritical care, discussing their roles from the perspective of both their scientific promise and the associated challenges. We underscore the importance of extensive validation in diverse clinical settings to ensure the generalizability of ML models, particularly considering their potential to inform critical medical decisions such as withdrawal of life-sustaining therapies. Advancement in computational capabilities is essential for implementing ML in clinical settings, allowing for real-time analysis and decision support at the point of care. As AI and ML are poised to become commonplace in clinical practice, it is incumbent upon health care professionals to understand and oversee these technologies, ensuring they adhere to the highest safety standards and contribute to the realization of personalized medicine. This engagement will be pivotal in integrating AI and ML into patient care, optimizing outcomes in neurocritical care through informed and data-driven decision-making.
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Affiliation(s)
- Jeffrey R Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, California
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
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Joya A, Plaza-García S, Padro D, Aguado L, Iglesias L, Garbizu M, Gómez-Vallejo V, Laredo C, Cossío U, Torné R, Amaro S, Planas AM, Llop J, Ramos-Cabrer P, Justicia C, Martín A. Multimodal imaging of the role of hyperglycemia following experimental subarachnoid hemorrhage. J Cereb Blood Flow Metab 2024; 44:726-741. [PMID: 37728631 PMCID: PMC11197138 DOI: 10.1177/0271678x231197946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023]
Abstract
Hyperglycemia has been linked to worsening outcomes after subarachnoid hemorrhage (SAH). Nevertheless, the mechanisms involved in the pathogenesis of SAH have been scarcely evaluated so far. The role of hyperglycemia was assessed in an experimental model of SAH by T2 weighted, dynamic contrast-enhanced magnetic resonance imaging (T2W and DCE-MRI), [18F]BR-351 PET imaging and immunohistochemistry. Measures included the volume of bleeding, the extent of cerebral infarction and brain edema, blood brain barrier disruption (BBBd), neutrophil infiltration and matrix metalloprotease (MMP) activation. The neurofunctional outcome, neurodegeneration and myelinization were also investigated. The induction of hyperglycemia increased mortality, the size of the ischemic lesion, brain edema, neurodegeneration and worsened neurological outcome during the first 3 days after SAH in rats. In addition, these results show for the first time the exacerbating effect of hyperglycemia on in vivo MMP activation, Intercellular Adhesion Molecule 1 (ICAM-1) expression and neutrophil infiltration together with increased BBBd, bleeding volume and fibrinogen accumulation at days 1 and 3 after SAH. Notably, these data provide valuable insight into the detrimental effect of hyperglycemia on early BBB damage mediated by neutrophil infiltration and MMP activation that could explain the worse prognosis in SAH.
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Affiliation(s)
- Ana Joya
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Sandra Plaza-García
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Daniel Padro
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Laura Aguado
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Leyre Iglesias
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- Neurovascular Group, Biocruces Health Research Institute, Barakaldo, Spain
| | - Maider Garbizu
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | | | - Carlos Laredo
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Unai Cossío
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Ramon Torné
- Institute of Neuroscience, Neurosurgery Department, Hospital Clinic of Barcelona, Spain
| | - Sergio Amaro
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Anna M Planas
- Area of Neurosciences. Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Neuroscience and Experimental Therapeutics, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
| | - Jordi Llop
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
- Centro de Investigación Biomédica en Red - Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Pedro Ramos-Cabrer
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
- Ikerbasque Basque Foundation for Science, Bilbao, Spain
| | - Carles Justicia
- Area of Neurosciences. Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Neuroscience and Experimental Therapeutics, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
| | - Abraham Martín
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- Ikerbasque Basque Foundation for Science, Bilbao, Spain
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Panicker S, Wilseck ZM, Lin LY, Gemmete JJ. CT Imaging Computed Tomography/Computed Tomography Angiography/Perfusion in Acute Ischemic Stroke and Vasospasm. Neuroimaging Clin N Am 2024; 34:175-189. [PMID: 38604703 DOI: 10.1016/j.nic.2024.01.004] [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] [Indexed: 04/13/2024]
Abstract
Computed tomography (CT), CT angiography (CTA), and CT perfusion (CTP) play crucial roles in the comprehensive evaluation and management of acute ischemic stroke, aneurysmal subarachnoid hemorrhage (SAH), and vasospasm. CTP provides functional data about cerebral blood flow, allowing radiologists, neurointerventionalists, and stroke neurologists to more accurately delineate the volume of core infarct and ischemic penumbra allowing for patient-specific treatment decisions to be made. CTA and CTP are used in tandem to evaluate for vasospasm associated with aneurysmal SAH and can help provide an insight into the physiologic impact of angiographic vasospasm, better triaging patients for medical and interventional treatment.
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Affiliation(s)
| | - Zachary M Wilseck
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Leanne Y Lin
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA; Department of Otolaryngology, University of Michigan, Ann Arbor, MI 48109, USA
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Dreier JP, Joerk A, Uchikawa H, Horst V, Lemale CL, Radbruch H, McBride DW, Vajkoczy P, Schneider UC, Xu R. All Three Supersystems-Nervous, Vascular, and Immune-Contribute to the Cortical Infarcts After Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01242-z. [PMID: 38689162 DOI: 10.1007/s12975-024-01242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/02/2024]
Abstract
The recently published DISCHARGE-1 trial supports the observations of earlier autopsy and neuroimaging studies that almost 70% of all focal brain damage after aneurysmal subarachnoid hemorrhage are anemic infarcts of the cortex, often also affecting the white matter immediately below. The infarcts are not limited by the usual vascular territories. About two-fifths of the ischemic damage occurs within ~ 48 h; the remaining three-fifths are delayed (within ~ 3 weeks). Using neuromonitoring technology in combination with longitudinal neuroimaging, the entire sequence of both early and delayed cortical infarct development after subarachnoid hemorrhage has recently been recorded in patients. Characteristically, cortical infarcts are caused by acute severe vasospastic events, so-called spreading ischemia, triggered by spontaneously occurring spreading depolarization. In locations where a spreading depolarization passes through, cerebral blood flow can drastically drop within a few seconds and remain suppressed for minutes or even hours, often followed by high-amplitude, sustained hyperemia. In spreading depolarization, neurons lead the event, and the other cells of the neurovascular unit (endothelium, vascular smooth muscle, pericytes, astrocytes, microglia, oligodendrocytes) follow. However, dysregulation in cells of all three supersystems-nervous, vascular, and immune-is very likely involved in the dysfunction of the neurovascular unit underlying spreading ischemia. It is assumed that subarachnoid blood, which lies directly on the cortex and enters the parenchyma via glymphatic channels, triggers these dysregulations. This review discusses the neuroglial, neurovascular, and neuroimmunological dysregulations in the context of spreading depolarization and spreading ischemia as critical elements in the pathogenesis of cortical infarcts after subarachnoid hemorrhage.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
| | - Alexander Joerk
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Hiroki Uchikawa
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Viktor Horst
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Helena Radbruch
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Devin W McBride
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Cantonal Hospital of Lucerne and University of Lucerne, Lucerne, Switzerland
| | - Ran Xu
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK, German Centre for Cardiovascular Research, Berlin, Germany
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Dreier JP, Lemale CL, Horst V, Major S, Kola V, Schoknecht K, Scheel M, Hartings JA, Vajkoczy P, Wolf S, Woitzik J, Hecht N. Similarities in the Electrographic Patterns of Delayed Cerebral Infarction and Brain Death After Aneurysmal and Traumatic Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01237-w. [PMID: 38396252 DOI: 10.1007/s12975-024-01237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
While subarachnoid hemorrhage is the second most common hemorrhagic stroke in epidemiologic studies, the recent DISCHARGE-1 trial has shown that in reality, three-quarters of focal brain damage after subarachnoid hemorrhage is ischemic. Two-fifths of these ischemic infarctions occur early and three-fifths are delayed. The vast majority are cortical infarcts whose pathomorphology corresponds to anemic infarcts. Therefore, we propose in this review that subarachnoid hemorrhage as an ischemic-hemorrhagic stroke is rather a third, separate entity in addition to purely ischemic or hemorrhagic strokes. Cumulative focal brain damage, determined by neuroimaging after the first 2 weeks, is the strongest known predictor of patient outcome half a year after the initial hemorrhage. Because of the unique ability to implant neuromonitoring probes at the brain surface before stroke onset and to perform longitudinal MRI scans before and after stroke, delayed cerebral ischemia is currently the stroke variant in humans whose pathophysiological details are by far the best characterized. Optoelectrodes located directly over newly developing delayed infarcts have shown that, as mechanistic correlates of infarct development, spreading depolarizations trigger (1) spreading ischemia, (2) severe hypoxia, (3) persistent activity depression, and (4) transition from clustered spreading depolarizations to a negative ultraslow potential. Furthermore, traumatic brain injury and subarachnoid hemorrhage are the second and third most common etiologies of brain death during continued systemic circulation. Here, we use examples to illustrate that although the pathophysiological cascades associated with brain death are global, they closely resemble the local cascades associated with the development of delayed cerebral infarcts.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
| | - Coline L Lemale
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Viktor Horst
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vasilis Kola
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Karl Schoknecht
- Medical Faculty, Carl Ludwig Institute for Physiology, University of Leipzig, Leipzig, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Hamming AL, van Dijck JTJM, Visser T, Baarse M, Verbaan D, Schenck H, Haeren RHL, Fakhry R, Dammers R, Aquarius R, Boogaarts JHD, Peul WC, Moojen WA. Study on prognosis of acutely ruptured intracranial aneurysms (SPARTA): a protocol for a multicentre prospective cohort study. BMC Neurol 2024; 24:68. [PMID: 38368355 PMCID: PMC10873988 DOI: 10.1186/s12883-024-03567-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Ruptured intracranial aneurysms resulting in subarachnoid haemorrhage can be treated by open surgical or endovascular treatment. Despite multiple previous studies, uncertainties on the optimal treatment practice still exists. The resulting treatment variation may result in a variable, potentially worse, patient outcome. To better inform future treatment strategies, this study aims to identify the effectiveness of different treatment strategies in patients with ruptured intracranial aneurysms by investigating long-term functional outcome, complications and cost-effectiveness. An explorative analysis of the diagnostic and prognostic value of radiological imaging will also be performed. METHODS This multi-centre observational prospective cohort study will have a follow-up of 10 years. A total of 880 adult patients with a subarachnoid haemorrhage caused by a ruptured intracranial aneurysm will be included. Calculation of sample size (N = 880) was performed to show non-inferiority of clip-reconstruction compared to endovascular treatment on 1 year outcome, assessed by using the ordinal modified Rankin Scale. The primary endpoint is the modified Rankin Scale score and mortality at 1 year after the initial subarachnoid haemorrhage. Patients will receive 'non-experimental' regular care during their hospital stay. For this study, health questionnaires and functional outcome will be assessed at baseline, before discharge and at follow-up visits. DISCUSSION Despite the major healthcare and societal burden, the optimal treatment strategy for patients with subarachnoid haemorrhage caused by ruptured intracranial aneurysms is yet to be determined. Findings of this comparative effectiveness study, in which in-between centre variation in practice and patient outcome are investigated, will provide evidence on the effectiveness of treatment strategies, hopefully contributing to future high value treatment standardisation. TRIAL REGISTRATION NUMBER NCT05851989 DATE OF REGISTRATION: May 10th, 2023.
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Affiliation(s)
- Alexander L Hamming
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Tjitske Visser
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Martine Baarse
- Department of Neurosurgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Hanna Schenck
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Roel H L Haeren
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rahman Fakhry
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - René Aquarius
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jeroen H D Boogaarts
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Wouter A Moojen
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands.
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9
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Ditz C, Matone MV, Schwachenwald B, Küchler J. Risks of nimodipine dose reduction during the high-risk period for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2024; 47:37. [PMID: 38191859 DOI: 10.1007/s10143-023-02273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/12/2023] [Accepted: 12/31/2023] [Indexed: 01/10/2024]
Abstract
Nimodipine dose reduction is recommended in case of high vasopressor demand after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess potential adverse effects of nimodipine reduction during the high-risk period for delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) between days 5 and 10 after hemorrhage. Demographic and clinical data as well as daily nimodipine dose of aSAH patients admitted between 2010 and 2019 were retrospectively analyzed. Univariable and multivariable regression analyses were performed to identify factors associated with DCI, angiographic CVS, DCI-related infarction, and unfavorable outcome. A total of 205 patients were included. Nimodipine dose reduction occurred in 108 (53%) patients ('nimodipine reduction group'), while 97 patients (47%) received the full dose ('no nimodipine reduction group'), Patients in the 'nimodipine reduction group' had significant worse WFNS and Fisher grades and developed significantly more often DCI and angiographic CVS. DCI-related infarction and unfavorable outcome were also significantly increased in the 'nimodipine reduction group.' 'Reduced nimodipine dose' was the only independent predictor for the occurrence of DCI and angiographic CVS in multivariable regression analysis. 'Poor WFNS grade' and 'reduced nimodipine dose' were identified as independent risk factors for DCI-related infarction while 'older age,' 'poor WFNS grade,' and 'reduced nimodipine dose' were associated with unfavorable outcome at 3 months after discharge. Nimodipine dose reduction during the high-risk period of DCI and CVS between days 5 and 10 after hemorrhage might abrogate the positive prognostic effects of nimodipine and should be critically evaluated.
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Affiliation(s)
- Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Maria V Matone
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Bram Schwachenwald
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Nishikawa Y, Yamada S, Uchida M, Yamanaka T, Hayashi Y, Katano H, Tanikawa M, Iwama T, Iihara K, Morioka M, Mase M. Japanese nationwide questionnaire survey on delayed cerebral infarction due to vasospasm after subarachnoid hemorrhage. Front Neurol 2023; 14:1296995. [PMID: 38020653 PMCID: PMC10654625 DOI: 10.3389/fneur.2023.1296995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background and purpose Various prophylactic drugs for cerebral vasospasm and delayed cerebral infarction (DCI) after subarachnoid hemorrhage (SAH) have been used in Japan. To investigate the treatment trends for cerebral vasospasm and frequency of DCI after SAH throughout Japan in 2021. Methods In 2021 we conducted an anonymous questionnaire survey on management for preventing cerebral vasospasm after aneurysmal SAH, and the frequency of DCI. The questionnaire was emailed to 955 certified neurosurgeons at 553 hospitals in Japan. Of them, 162 hospitals (29% response rate) responded to the questionnaire. Of these, 158 were included in this study, while four hospitals that responded insufficiently were excluded. The efficacy of treatments for reducing DCI were examined through a logistic regression analysis. Results Among 3,093 patients treated with aneurysmal SAH, 281 patients (9.1%) were diagnosed with DCI related to cerebral vasospasm. Coil embolization had significantly lower DCI frequency (6.9%), compared to microsurgical clipping (11.8%, odds ratio, 0.90; 95% confidential intervals, 0.84-0.96; P, 0.007). In addition, cilostazol administration was associated with significantly lower DCI frequency (0.48; 0.27-0.82; 0.026). The efficacy of cilostazol in reducing DCI remained unchanged after adjustment for covariates. The most effective combination of multiple prophylactic drugs in reducing DCI related to cerebral vasospasm was cilostazol, fasudil, and statin (0.38; 0.22-0.67; 0.005). Conclusions This study elucidated the trends in prophylactic drugs to prevent cerebral vasospasm and frequency of DCI after aneurysmal SAH in Japan. Coil embolization and cilostazol administration showed effectiveness in reducing DCI related to cerebral vasospasm in 2021.
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Affiliation(s)
- Yusuke Nishikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Shigeki Yamada
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
- Interfaculty Initiative in Information Studies, Institute of Industrial Science, The University of Tokyo, Tokyo, Japan
| | - Mitsuru Uchida
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Tomoyasu Yamanaka
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Yuki Hayashi
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Hiroyuki Katano
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Motoki Tanikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Iihara
- National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | | | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
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Abdulazim A, Heilig M, Rinkel G, Etminan N. Diagnosis of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage and Triggers for Intervention. Neurocrit Care 2023; 39:311-319. [PMID: 37537496 PMCID: PMC10542310 DOI: 10.1007/s12028-023-01812-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a major determinant for poor neurological outcome after aneurysmal subarachnoid hemorrhage (aSAH). Detection and treatment of DCI is a key component in the neurocritical care of patients with aSAH after initial aneurysm repair. METHODS Narrative review of the literature. RESULTS Over the past 2 decades, there has been a paradigm shift away from macrovascular (angiographic) vasospasm as a main diagnostic and therapeutic target. Instead, the pathophysiology of DCI is hypothesized to derive from several proischemic pathomechanisms. Clinical examination remains the most reliable means for monitoring and treatment of DCI, but its value is limited in comatose patients. In such patients, monitoring of DCI is usually based on numerous neurophysiological and/or radiological diagnostic modalities. Catheter angiography remains the gold standard for the detection of macrovascular spasm. Computed tomography (CT) angiography is increasingly used instead of catheter angiography because it is less invasive and may be combined with CT perfusion imaging. CT perfusion permits semiquantitative cerebral blood flow measurements, including the evaluation of the microcirculation. It may be used for prediction, early detection, and diagnosis of DCI, with yet-to-prove benefit on clinical outcome when used as a screening modality. Transcranial Doppler may be considered as an additional noninvasive screening tool for flow velocities in the middle cerebral artery, with limited accuracy in other cerebral arteries. Continuous electroencephalography enables detection of early signs of ischemia at a reversible stage prior to clinical manifestation. However, its widespread use is still limited because of the required infrastructure and expertise in data interpretation. Near-infrared spectroscopy, a noninvasive and continuous modality for evaluation of cerebral blood flow dynamics, has shown conflicting results and needs further validation. Monitoring techniques beyond neurological examinations may help in the detection of DCI, especially in comatose patients. However, these techniques are limited because of their invasive nature and/or restriction of measurements to focal brain areas. CONCLUSION The current literature review underscores the need for incorporating existing modalities and developing new methods to evaluate brain perfusion, brain metabolism, and overall brain function more accurately and more globally.
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Affiliation(s)
- Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Marina Heilig
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Gabriel Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Zhou Z, Wang F, Chen T, Wei Z, Chen C, Xiang L, Xiang L, Zhang Q, Huang K, Jiang F, Zhao Z, Zou J. Pre- and Post-Operative Online Prediction of Outcome in Patients Undergoing Endovascular Coiling after Aneurysmal Subarachnoid Hemorrhage: Visual and Dynamic Nomograms. Brain Sci 2023; 13:1185. [PMID: 37626541 PMCID: PMC10452244 DOI: 10.3390/brainsci13081185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/05/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) causes long-term functional dependence and death. Early prediction of functional outcomes in aSAH patients with appropriate intervention strategies could lower the risk of poor prognosis. Therefore, we aimed to develop pre- and post-operative dynamic visualization nomograms to predict the 1-year functional outcomes of aSAH patients undergoing coil embolization. METHODS Data were obtained from 400 aSAH patients undergoing endovascular coiling admitted to the People's Hospital of Hunan Province in China (2015-2019). The key indicator was the modified Rankin Score (mRS), with 3-6 representing poor functional outcomes. Multivariate logistic regression (MLR)-based visual nomograms were developed to analyze baseline characteristics and post-operative complications. The evaluation of nomogram performance included discrimination (measured by C statistic), calibration (measured by the Hosmer-Lemeshow test and calibration curves), and clinical usefulness (measured by decision curve analysis). RESULTS Fifty-nine aSAH patients (14.8%) had poor outcomes. Both nomograms showed good discrimination, and the post-operative nomogram demonstrated superior discrimination to the pre-operative nomogram with a C statistic of 0.895 (95% CI: 0.844-0.945) vs. 0.801 (95% CI: 0.733-0.870). Each was well calibrated with a Hosmer-Lemeshow p-value of 0.498 vs. 0.276. Moreover, decision curve analysis showed that both nomograms were clinically useful, and the post-operative nomogram generated more net benefit than the pre-operative nomogram. Web-based online calculators have been developed to greatly improve the efficiency of clinical applications. CONCLUSIONS Pre- and post-operative dynamic nomograms could support pre-operative treatment decisions and post-operative management in aSAH patients, respectively. Moreover, this study indicates that integrating post-operative variables into the nomogram enhanced prediction accuracy for the poor outcome of aSAH patients.
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Affiliation(s)
- Zhou Zhou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Fusang Wang
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510275, China
| | - Tingting Chen
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China
| | - Ziqiao Wei
- The Second Clinical Medicine School of Nanjing Medical University, Nanjing 211166, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha 410081, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha 410081, China
| | - Qian Zhang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Kaizong Huang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Fuping Jiang
- Department of Geriatrics, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Zhihong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha 410081, China
| | - Jianjun Zou
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China
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Vitt JR, Cheng RC, Chung J, Canton MT, Zhou B, Ko N, Meisel K, Amorim E. The Clinical Impact of Recent Methamphetamine Exposure in Aneurysmal Subarachnoid Patients. RESEARCH SQUARE 2023:rs.3.rs-2694424. [PMID: 37034745 PMCID: PMC10081452 DOI: 10.21203/rs.3.rs-2694424/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background Methamphetamines (MA) are a frequently used drug class with potent sympathomimetic properties that can affect cerebral vasculature. Conflicting reports in literature exist about the effect of exposure to MA on vasospasm risk and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to characterize the impact of recent MA use on the timing, severity and features of vasospasm in aneurysmal subarachnoid as well as neurological outcomes. Methods We retrospectively screened 441 consecutive patients admitted to a tertiary care hospital with a diagnosis of SAH who underwent at least one cerebral digital subtraction angiogram (DSA). Patients were excluded if no urinary toxicology screen was performed within 24 hours of admission, if there was a diagnosis of non-aneurysmal SAH, or if ictus was greater than 72 hours from hospital admission. Vasospasm characteristics were collected from DSA and transcranial doppler (TCD) studies and demographic as well as clinical outcome data was abstracted from the chart. Results 129 patients were included and 24 tested positive for MA. Among the 312 excluded patients, 281 did not have a urinary toxicology screen and 31 had a non-aneurysmal pattern of SAH or ictus occurring greater than 72 hours from hospital admission. No significant differences were found in respect to patient age, sex, or admission Hunt and Hess Score or Modified Fisher Scale based on MA use. There was no difference in the severity of vasospasm or time to peak severity using either TCD or DSA criteria on multivariate analysis. Aneurysms were more likely to be in the anterior circulation for both groups, however the MA cohort experienced less vasospasm involving the anterior circulation and more isolated posterior circulation vasospasm. There was no difference in delayed cerebral ischemia (DCI) incidence, length of ICU stay, need for ventriculoperitoneal shunt placement, functional outcome at discharge or hospital mortality. Interpretation Recent MA use was not associated with worse vasospasm severity, time to vasospasm, or DCI in aSAH patients. Further investigations about localized MA effects in the posterior circulation and impact on long-term functional outcomes are warranted.
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Affiliation(s)
| | | | - Jason Chung
- University of California San Francisco Department of Neurological Surgery
| | | | - Bo Zhou
- University of California San Francisco Weill Institute for Neurosciences
| | - Nerissa Ko
- University of California San Francisco Weill Institute for Neurosciences
| | - Karl Meisel
- University of California San Francisco Weill Institute for Neurosciences
| | - Ediberto Amorim
- University of California San Francisco Weill Institute for Neurosciences
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14
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Tabarestani A, Patel A, Reddy A, Sharaf R, Lucke-Wold B. Vasospasm Management Strategies. INTERNATIONAL JOURNAL OF MEDICAL AND PHARMACEUTICAL RESEARCH 2023; 4:150-160. [PMID: 37333905 PMCID: PMC10275511 DOI: 10.5281/zenodo.7791517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Aim- In this study, we present a broad presentation of the current state of cerebral vasospasm, including its pathogenesis, commonly used treatments, and future outlook. Methods- A literature review was conducted for cerebral vasospasms using the PubMed journal database (https://pubmed.ncbi.nlm.nih.gov). Relevant journal articles were narrowed down and selected using the Medical Subject Headings (MeSH) option in PubMed. Results- Cerebral vasospasm is the persistent narrowing of cerebral arteries days after experiencing a subarachnoid hemorrhage (SAH). Eventually, if not corrected, this can lead to cerebral ischemia with significant neurological deficits and/or death. Therefore, it is clinically beneficial to diminish or prevent the occurrence or reoccurrence of vasospasm in patients following a SAH to prevent unwanted comorbidities or fatalities. We discuss the pathogenesis and mechanism of development that have been implicated in the progression of vasospasms as well as the manner in which clinical outcomes are quantitively measured. Further, we mention and highlight commonly used treatments to inhibit and reverse the course of vasoconstriction within the cerebral arteries. Additionally, we mention innovations and techniques that are being used to treat vasospasms and the outlook of their therapeutic value. Conclusion- Overall, we give a comprehensive summary of the disease that encapsulates cerebral vasospasm and the current and future standards of care that are used to treat it.
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Affiliation(s)
- Arman Tabarestani
- College of Medicine, University of Florida, 1104 Newell Dr, Gainesville, FL 32601
| | - Aashay Patel
- College of Medicine, University of Florida, 1104 Newell Dr, Gainesville, FL 32601
| | - Akshay Reddy
- College of Medicine, University of Florida, 1104 Newell Dr, Gainesville, FL 32601
| | - Ramy Sharaf
- College of Medicine, University of Florida, 1104 Newell Dr, Gainesville, FL 32601
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, 1505 SW Archer Rd, Gainesville, FL 32608
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15
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Bruder N, Higashida R, Santin-Janin H, Dubois C, Aldrich EF, Marr A, Roux S, Mayer SA. The REACT study: design of a randomized phase 3 trial to assess the efficacy and safety of clazosentan for preventing deterioration due to delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. BMC Neurol 2022; 22:492. [PMID: 36539711 PMCID: PMC9763815 DOI: 10.1186/s12883-022-03002-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND For patients presenting with an aneurysmal subarachnoid hemorrhage (aSAH), delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality. The REACT study is designed to assess the safety and efficacy of clazosentan in preventing clinical deterioration due to DCI in patients with aSAH. METHODS REACT is a prospective, multicenter, randomized phase 3 study that is planned to enroll 400 patients with documented aSAH from a ruptured cerebral aneurysm, randomized 1:1 to 15 mg/hour intravenous clazosentan vs. placebo, in approximately 100 sites and 15 countries. Eligible patients are required to present at hospital admission with CT evidence of significant subarachnoid blood, defined as a thick and diffuse clot that is more than 4 mm in thickness and involves 3 or more basal cisterns. The primary efficacy endpoint is the occurrence of clinical deterioration due to DCI up to 14 days post-study drug initiation. The main secondary endpoint is the occurrence of clinically relevant cerebral infarction at Day 16 post-study drug initiation. Other secondary endpoints include the modified Rankin Scale (mRS) and the Glasgow Outcome Scale-Extended (GOSE) score at Week 12 post-aSAH, dichotomized into poor and good outcome. Radiological results and clinical endpoints are centrally evaluated by independent committees, blinded to treatment allocation. Exploratory efficacy endpoints comprise the assessment of cognition status at 12 weeks and quality of life at 12 and 24 weeks post aSAH. DISCUSSION In the REACT study, clazosentan is evaluated on top of standard of care to determine if it reduces the risk of clinical deterioration due to DCI after aSAH. The selection of patients with thick and diffuse clots is intended to assess the benefit/risk profile of clazosentan in a population at high risk of vasospasm-related ischemic complications post-aSAH. TRIAL REGISTRATION (ADDITIONAL FILE 1): ClinicalTrials.gov (NCT03585270). EU Clinical Trial Register (EudraCT Number: 2018-000241-39).
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Affiliation(s)
- Nicolas Bruder
- grid.5399.60000 0001 2176 4817Department of Anesthesia and Critical Care, Hôpital de la Timone, Aix-Marseille Université, 264 rue St-Pierre, 13005 Marseille, France
| | - Randall Higashida
- grid.413077.60000 0004 0434 9023Department of Neuro Interventional Radiology, University of California San Francisco Medical Center, San Francisco, USA
| | - Hugues Santin-Janin
- grid.508389.f0000 0004 6414 2411Biometry, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Cécile Dubois
- grid.508389.f0000 0004 6414 2411Biometry, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - E. François Aldrich
- grid.411024.20000 0001 2175 4264Department of Neurosurgery, University of Maryland, Baltimore, USA
| | - Angelina Marr
- grid.508389.f0000 0004 6414 2411Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Sébastien Roux
- grid.508389.f0000 0004 6414 2411Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Stephan A. Mayer
- grid.417052.50000 0004 0476 8324Neurocritical Care and Emergency Neurology Services, Westchester Medical Center Health Network, Valhalla, USA ,grid.260917.b0000 0001 0728 151XDepartment of Neurology and Neurosurgery, New York Medical College, New York, USA
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Ziebart A, Abdulazim A, Wenz F, Kleindienst N, Mocarz-Kleindienst M, Galea I, Rinkel GJE, Etminan N. Validation of the German version of the subarachnoid haemorrhage outcome tool (SAHOT). Eur Stroke J 2022; 8:320-327. [PMID: 37021152 PMCID: PMC10069186 DOI: 10.1177/23969873221144813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Objective: The subarachnoid haemorrhage (SAH) outcome tool (SAHOT) is the first SAH-specific patient reported outcome measure, and was developed in the UK. We aimed to validate the SAHOT outside the UK, and therefore endeavored to adapt the SAHOT into German and to test its psychometric properties. Methods: We adapted and pilot tested the German version. We applied the SAHOT, Quality of Life after Brain Injury, Hospital Anxiety and Depression Scale, and EuroQol questionnaires in a cohort of 89 patients with spontaneous SAH after discharge. We assessed internal consistency by Cronbach’s α, test-retest reliability by intraclass correlation, and validity by Pearson correlations with established measures. Sensitivity to change was evaluated following neurorehabilitation by effect sizes. Results: The translation of SAHOT resulted in a German version that is semantically and conceptually equivalent to the English version. Internal consistency was good regarding the physical domain (α = 0.83) and excellent for the other domains (α = 0.92–0.93). Test–retest reliability indicated a high level of stability with an intraclass correlation of 0.85 (95% CI: 0.83–0.86). All domains correlated moderately or strongly with established measures ( r = 0.41–0.74; p < 0.01). SAHOT total scores showed moderate sensitivity to change (Cohen’s d = −0.68), while mRS and GOSE showed no significant sensitivity to change. Conclusion: The SAHOT can be adapted to other health care systems and societies than the UK. The German version of the SAHOT is a reliable and valid instrument, and can be used in future clinical studies and individual assessment after spontaneous SAH.
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Affiliation(s)
- Andreas Ziebart
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian Wenz
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nikolaus Kleindienst
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maria Mocarz-Kleindienst
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Translation Studies and Slavic Languages, The John Paul II Catholic University of Lublin, Lublin, Poland
| | - Ian Galea
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Gabriel JE Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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17
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Zheng WL, Kim JA, Elmer J, Zafar SF, Ghanta M, Moura Junior V, Patel A, Rosenthal E, Brandon Westover M. Automated EEG-based prediction of delayed cerebral ischemia after subarachnoid hemorrhage. Clin Neurophysiol 2022; 143:97-106. [PMID: 36182752 PMCID: PMC9847346 DOI: 10.1016/j.clinph.2022.08.023] [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: 08/31/2021] [Revised: 08/01/2022] [Accepted: 08/31/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a leading complication of aneurysmal subarachnoid hemorrhage (SAH) and electroencephalography (EEG) is increasingly used to evaluate DCI risk. Our goal is to develop an automated DCI prediction algorithm integrating multiple EEG features over time. METHODS We assess 113 moderate to severe grade SAH patients to develop a machine learning model that predicts DCI risk using multiple EEG features. RESULTS Multiple EEG features discriminate between DCI and non-DCI patients when aligned either to SAH time or to DCI onset. DCI and non-DCI patients have significant differences in alpha-delta ratio (0.08 vs 0.05, p < 0.05) and percent alpha variability (0.06 vs 0.04, p < 0.05), Shannon entropy (p < 0.05) and epileptiform discharge burden (205 vs 91 discharges per hour, p < 0.05) based on whole brain and vascular territory averaging. Our model improves predictions by emphasizing the most informative features at a given time with an area under the receiver-operator curve of 0.73, by day 5 after SAH and good calibration between 48-72 hours (calibration error 0.13). CONCLUSIONS Our proposed model obtains good performance in DCI prediction. SIGNIFICANCE We leverage machine learning to enable rapid, automated, multi-featured EEG assessment and has the potential to increase the utility of EEG for DCI prediction.
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Affiliation(s)
- Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Jennifer A Kim
- Department of Neurology, Yale University, New Haven, CT 06520, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Aman Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
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18
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Kim JA, Zheng WL, Elmer J, Jing J, Zafar SF, Ghanta M, Moura V, Gilmore EJ, Hirsch LJ, Patel A, Rosenthal E, Westover MB. High epileptiform discharge burden predicts delayed cerebral ischemia after subarachnoid hemorrhage. Clin Neurophysiol 2022; 141:139-146. [PMID: 33812771 PMCID: PMC8429508 DOI: 10.1016/j.clinph.2021.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/30/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate whether epileptiform discharge burden can identify those at risk for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). METHODS Retrospective analysis of 113 moderate to severe grade SAH patients who had continuous EEG (cEEG) recordings during their hospitalization. We calculated the burden of epileptiform discharges (ED), measured as number of ED per hour. RESULTS We find that many SAH patients have an increase in ED burden during the first 3-10 days following rupture, the major risk period for DCI. However, those who develop DCI have a significantly higher hourly burden from days 3.5-6 after SAH vs. those who do not. ED burden is higher in DCI patients when assessed in relation to the onset of DCI (area under the receiver operator curve 0.72). Finally, specific trends of ED burden over time, assessed by group-based trajectory analysis, also help stratify DCI risk. CONCLUSIONS These results suggest that ED burden is a useful parameter for identifying those at higher risk of developing DCI after SAH. The higher burden rate associated with DCI supports the theory of metabolic supply-demand mismatch which contributes to this complication. SIGNIFICANCE ED burden is a novel biomarker for predicting those at high risk of DCI.
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Affiliation(s)
- Jennifer A Kim
- Department of Neurology, Yale University, New Haven, CT 06520, USA.
| | - Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Valdery Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University, New Haven, CT 06520, USA
| | | | - Aman Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
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19
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Han H, Chen Y, Li R, Lin F, Lu J, Chen X, Wang S. The value of early CT perfusion parameters for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:2517-2531. [PMID: 35377027 DOI: 10.1007/s10143-022-01779-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022]
Abstract
Delayed cerebral ischemia (DCI) is a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). We aim to investigate the efficacy of early CT perfusion (CTP) parameters for predicting DCI in patients with aSAH. The search was conducted in five databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and China Biology Medicine database). Studies were reviewed by two independent authors, and the included studies were assessed for methodological quality. Fifteen studies with 882 participants were included for the final analysis. The meta-analysis of quantitative parameters showed that mean transit time represented the most valuable predictor when the calculation of the mean value was uniformed (MD 0.30 s, 95% CI: 0.10 to 0.49 s, P = 0.003). Semi-quantitative parameters using relative values or index scores were also widely used to minimize undue variations derived from patients, operators, machines, and software. Studies also demonstrated that these relative parameters had better predictive accuracy than corresponding absolute parameters. Perfusion thresholds in each study were incomparable, and the results warranted further validation. The best threshold for the prediction was 0.9 using the relative cerebral blood flow parameter (sensitivity 97% and specificity 89%). We conclude that CTP in the early phase is a promising tool for predicting DCI in aSAH patients. However, the parameters require standardization. Future studies with prospective, multi-centered design and large sample size are needed to validate the thresholds and optimize the parameters.
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Affiliation(s)
- Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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20
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Revisiting the Timeline of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: Toward a Temporal Risk Profile. Neurocrit Care 2022; 37:735-743. [PMID: 35790670 DOI: 10.1007/s12028-022-01545-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/03/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is one of the main determinants of clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). The classical description of risk for DCI over time is currently based on the outdated concept of angiographic vasospasm. The goal of this study was to assess the temporal risk profile of DCI, defined by extended clinical and radiological criteria, as well as the impact the time point of DCI onset has on clinical outcome. METHODS All patients with aneurysmal SAH referred to a single tertiary care center between 2010 and 2018 were considered for inclusion. This study was designed as a retrospective cohort analysis and data were extracted from existing patient files. In conscious patients, DCI was diagnosed clinically, and in unconscious patients, diagnosis was based on perfusion computed tomography imaging and multimodal neuromonitoring. Extended Glasgow Outcome Scale scores were assessed after 12 months and compared between patients with early (< day 7) and late (≥ day 7) DCI onset. RESULTS The median delay from day of the hemorrhage (day 0) until detection of the first DCI event was 7.0 days, with an interquartile range of 5 days. The probability of DCI development over time demonstrated a bimodal distribution with a peak risk on day 5 (0.084; confidence interval 0.05.5-0.122) and a second peak on day 9 (0.077; confidence interval 0.045-0.120). A total of 27 patients (15.6%) suffered dominant hemispheric or severe bilateral DCI-related infarctions, resulting in the withdrawal of technical life support. Of those, the majority (20 patients, 22.2%) presented with early DCI onset (vs. late onset: 7 patients, 8.4%; p = 0.013). CONCLUSIONS The risk profile of DCI over time mirrors the description of angiographic vasospasm; however, it comes with an added timely delay of 1 to 2 days. Early occurrence of DCI (before day 7) is associated with a higher infarct load and DCI-related mortality. Although the exact causal relationship remains to be determined, the time point of DCI onset may serve as an independent prognostic criterion in decision-making.
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21
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Wang LX, Li WH, He F. Efficacy and Safety of Electroacupuncture in the Treatment of Cerebral Infarction: Systematic Review and Meta-Analysis. Appl Bionics Biomech 2022; 2022:1350501. [PMID: 35800118 PMCID: PMC9256421 DOI: 10.1155/2022/1350501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose The goal of this study was to see if electroacupuncture was effective and safe in the management of cerebral infarction. PubMed, Embase, Cochrane Library, and Web of Science were used to conduct a comprehensive literature survey. Methods Basic features of 7 studies were identified using the searching strategy. The investigation was found in PubMed, Embase, and Web of Science, with the most recent search being in March 2022. "Electroacupuncture," "cerebral infarction," and their permutations were among the MeSH terms and free words used. As literature, two reviewers independently used a standardized form to gather pertinent data from qualifying research. Results 157 literatures were identified and evaluated. Electroacupuncture improved the BI score in individuals with cerebral infarction (mean difference = 0.10, 95 percent CI: 0.00-0.20, p = 0.04). Electroacupuncture enhanced BI score in individuals with cerebral infarction (mean difference = 0.10, 95 percent CI: 0.00-0.20, p = 0.04). The effects of electroacupuncture increased Fugl-Meyer index in patients with cerebral infarction (mean difference = 25.92, 95% CI: 25.28-26.56, p < 0.00001). Electroacupuncture effects decreased CSS in patients with cerebral infarction in the experiment group (mean difference = -2.10, 95% CI: -2.53--1.67, p < 0.0001). Electroacupuncture also reduced CSS individuals with cerebral infarction in the control group; however, there was no statistically significant (risk difference = 0.06, 95 percent CI: 0.02-0.13, p = 0.12). Conclusion This study demonstrated that electroacupuncture helped decreased CSS in patients with cerebral infarction.
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Affiliation(s)
- Lan Xiang Wang
- Department of Rehabilitation Medicine, The 8th Medical Center of Chinese PLA General Hospital, China
| | - Wei Hong Li
- Beijing University of Chinese Medicine, China
| | - Fang He
- Department of Outpatient, The 8th Medical Center of Chinese PLA General Hospital, China
- Jia NO2 Niangniang Mansion, Xiangshan Road, Haidian District, Beijing 100093, China
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22
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Veldeman M, Weiss M, Daleiden L, Albanna W, Schulze-Steinen H, Nikoubashman O, Clusmann H, Hoellig A, Schubert GA. Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage-justifiable in light of long-term outcome? Acta Neurochir (Wien) 2022; 164:1815-1826. [PMID: 35597877 PMCID: PMC9233638 DOI: 10.1007/s00701-022-05250-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/09/2022] [Indexed: 12/26/2022]
Abstract
Purpose Decompressive hemicraniectomy (DHC) is a potentially lifesaving procedure in refractory intracranial hypertension, which can prevent death from brainstem herniation but may cause survival in a disabled state. The spectrum of indications is expanding, and we present long-term results in a series of patients suffering from aneurysmal subarachnoid hemorrhage (SAH). Methods We performed a retrospective analysis of previously registered data including all patients treated for SAH between 2010 and 2018 in a single institution. Patients treated with decompressive hemicraniectomy due to refractory intracranial hypertension were identified. Clinical outcome was assessed by means of the Glasgow outcome scale after 12 months. Results Of all 341 SAH cases, a total of 82 (24.0%) developed intracranial hypertension. Of those, 63 (18.5%) patients progressed into refractory ICP elevation and were treated with DHC. Younger age (OR 0.959, 95% CI 0.933 to 0.984; p = 0.002), anterior aneurysm location (OR 0.253, 95% CI 0.080 to 0.799; 0.019; p = 0.019), larger aneurysm size (OR 1.106, 95% CI 1.025 to 1.194; p = 0.010), and higher Hunt and Hess grading (OR 1.944, 95% CI 1.431 to 2.641; p < 0.001) were independently associated with the need for DHC. After 1 year, 10 (15.9%) patients after DHC were categorized as favorable outcome. Only younger age was independently associated with favorable outcome (OR 0.968 95% CI 0.951 to 0.986; p = 0.001). Conclusions Decompressive hemicraniectomy, though lifesaving, has only a limited probability of survival in a clinically favorable condition. We identified young age to be the sole independent predictor of favorable outcome after DHC in SAH. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05250-6.
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Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Lorina Daleiden
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
- Department of Neurosurgery, Military Hospital Koblenz, Koblenz, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | | | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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23
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Dreier JP, Winkler MKL, Major S, Horst V, Lublinsky S, Kola V, Lemale CL, Kang EJ, Maslarova A, Salur I, Lückl J, Platz J, Jorks D, Oliveira-Ferreira AI, Schoknecht K, Reiffurth C, Milakara D, Wiesenthal D, Hecht N, Dengler NF, Liotta A, Wolf S, Kowoll CM, Schulte AP, Santos E, Güresir E, Unterberg AW, Sarrafzadeh A, Sakowitz OW, Vatter H, Reiner M, Brinker G, Dohmen C, Shelef I, Bohner G, Scheel M, Vajkoczy P, Hartings JA, Friedman A, Martus P, Woitzik J. Spreading depolarizations in ischaemia after subarachnoid haemorrhage, a diagnostic phase III study. Brain 2022; 145:1264-1284. [PMID: 35411920 DOI: 10.1093/brain/awab457] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/18/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
Focal brain damage after aneurysmal subarachnoid haemorrhage predominantly results from intracerebral haemorrhage, and early and delayed cerebral ischaemia. The prospective, observational, multicentre, cohort, diagnostic phase III trial, DISCHARGE-1, primarily investigated whether the peak total spreading depolarization-induced depression duration of a recording day during delayed neuromonitoring (delayed depression duration) indicates delayed ipsilateral infarction. Consecutive patients (n = 205) who required neurosurgery were enrolled in six university hospitals from September 2009 to April 2018. Subdural electrodes for electrocorticography were implanted. Participants were excluded on the basis of exclusion criteria, technical problems in data quality, missing neuroimages or patient withdrawal (n = 25). Evaluators were blinded to other measures. Longitudinal MRI, and CT studies if clinically indicated, revealed that 162/180 patients developed focal brain damage during the first 2 weeks. During 4.5 years of cumulative recording, 6777 spreading depolarizations occurred in 161/180 patients and 238 electrographic seizures in 14/180. Ten patients died early; 90/170 developed delayed infarction ipsilateral to the electrodes. Primary objective was to investigate whether a 60-min delayed depression duration cut-off in a 24-h window predicts delayed infarction with >0.60 sensitivity and >0.80 specificity, and to estimate a new cut-off. The 60-min cut-off was too short. Sensitivity was sufficient [= 0.76 (95% confidence interval: 0.65-0.84), P = 0.0014] but specificity was 0.59 (0.47-0.70), i.e. <0.80 (P < 0.0001). Nevertheless, the area under the receiver operating characteristic (AUROC) curve of delayed depression duration was 0.76 (0.69-0.83, P < 0.0001) for delayed infarction and 0.88 (0.81-0.94, P < 0.0001) for delayed ischaemia (reversible delayed neurological deficit or infarction). In secondary analysis, a new 180-min cut-off indicated delayed infarction with a targeted 0.62 sensitivity and 0.83 specificity. In awake patients, the AUROC curve of delayed depression duration was 0.84 (0.70-0.97, P = 0.001) and the prespecified 60-min cut-off showed 0.71 sensitivity and 0.82 specificity for reversible neurological deficits. In multivariate analysis, delayed depression duration (β = 0.474, P < 0.001), delayed median Glasgow Coma Score (β = -0.201, P = 0.005) and peak transcranial Doppler (β = 0.169, P = 0.016) explained 35% of variance in delayed infarction. Another key finding was that spreading depolarization-variables were included in every multiple regression model of early, delayed and total brain damage, patient outcome and death, strongly suggesting that they are an independent biomarker of progressive brain injury. While the 60-min cut-off of cumulative depression in a 24-h window indicated reversible delayed neurological deficit, only a 180-min cut-off indicated new infarction with >0.60 sensitivity and >0.80 specificity. Although spontaneous resolution of the neurological deficit is still possible, we recommend initiating rescue treatment at the 60-min rather than the 180-min cut-off if progression of injury to infarction is to be prevented.
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Affiliation(s)
- Jens P Dreier
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Maren K L Winkler
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Robert Koch-Institute, Berlin, Germany
| | - Sebastian Major
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Viktor Horst
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Svetlana Lublinsky
- Department of Brain & Cognitive Sciences, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Physiology & Cell Biology, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel
| | - Vasilis Kola
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eun-Jeung Kang
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Maslarova
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany.,Department of Neurosurgery, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Irmak Salur
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany.,Department of Neurosurgery, KRH Klinikum Nordstadt, Hannover, Germany
| | - Janos Lückl
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.,Department of Neurology, University of Szeged, Szeged, Hungary
| | - Johannes Platz
- Department of Neurosurgery, Herz-Neuro-Zentrum Bodensee, Kreuzlingen, Switzerland
| | - Devi Jorks
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany.,Clienia Schlössli AG, Privatklinik für Psychiatrie und Psychotherapie, Oetwil am See, Switzerland
| | - Ana I Oliveira-Ferreira
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Neuro-Electronics Research Flanders, Leuven, Belgium.,VIB-KU, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium.,Laboratory of Neural Circuits, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Karl Schoknecht
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Carl Ludwig Institute for Physiology, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Clemens Reiffurth
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Denny Milakara
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Research Campus STIMULATE, Otto-von-Guericke-University, Magdeburg, Germany
| | - Dirk Wiesenthal
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Univention GmbH, Bremen, Germany
| | - Nils Hecht
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nora F Dengler
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Agustin Liotta
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Wolf
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christina M Kowoll
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - André P Schulte
- Department of Spinal Surgery, Krankenhaus der Augustinerinnen, Cologne, Germany
| | - Edgar Santos
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Asita Sarrafzadeh
- Division of Neurosurgery, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Medical Centre, Geneva, Switzerland
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Michael Reiner
- Medical Advisory Service of the Statutory Health Insurance of North Rhine, Germany
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Christian Dohmen
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Ilan Shelef
- Department of Brain & Cognitive Sciences, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Physiology & Cell Biology, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Institute of Radiology, Soroka University Medical Centre, Beer-Sheva, Israel
| | - Georg Bohner
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alon Friedman
- Department of Brain & Cognitive Sciences, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Physiology & Cell Biology, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Medical Neuroscience and Brain Repair Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Johannes Woitzik
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
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24
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Erdling A, Johansson SE, Radziwon‐Balicka A, Ansar S, Edvinsson L. Changes in P2Y 6 receptor-mediated vasoreactivity following focal and global ischemia. Physiol Rep 2022; 10:e15283. [PMID: 35466569 PMCID: PMC9035753 DOI: 10.14814/phy2.15283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 06/14/2023] Open
Abstract
Ischemia, both in the form of focal thromboembolic stroke and following subarachnoid hemorrhage (SAH), causes upregulation of vasoconstrictive receptor systems within the cerebral vasculature. Descriptions regarding changes in purinergic signaling following ischemia are lacking, especially when the importance of purinergic signaling in regulating vascular tone is taken into consideration. This prompted us to evaluate changes in P2Y6 -mediated vasomotor reactivity in two different stroke models in rat. We used wire myography to measure changes in cerebral vasoreactivity to the P2Y6 agonist UDP-β-S following either experimental SAH or transient middle cerebral artery occlusion. Changes in receptor localization or receptor expression were evaluated using immunohistochemistry and quantitative flow cytometry. Transient middle cerebral artery occlusion caused an increase in Emax when compared to sham (233.6 [206.1-258.5]% vs. 161.1 [147.1-242.6]%, p = 0.0365). No such change was seen following SAH. Both stroke models were associated with increased levels of P2Y6 receptor expression in the vascular smooth muscle cells (90.94 [86.99-99.15]% and 93.79 [89.96-96.39]% vs. 80.31 [70.80-80.86]%, p = 0.021) and p = 0.039 respectively. There was no change in receptor localization in either of the stroke models. Based on these findings, we conclude that focal ischemic stroke increases vascular sensitivity to UDP-β-S by upregulating P2Y6 receptors on vascular smooth muscle cells while experimental SAH did not induce changes in vasoreactivity in spite of increased P2Y6 receptor expression.
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Affiliation(s)
- André Erdling
- Department of Clinical SciencesDivision of Experimental Vascular ResearchLund UniversityLundSweden
- Department of Cardiothoracic Surgery, Anesthesiology and Intensive CareSkane University HospitalLundSweden
- Applied Neurovascular ResearchDepartment of Clinical SciencesLund UniversityLundSweden
| | - Sara Ellinor Johansson
- Department of Clinical Experimental ResearchGlostrup Research InstituteRigshospitalet‐GlostrupGlostrupDenmark
| | - Aneta Radziwon‐Balicka
- Department of Clinical Experimental ResearchGlostrup Research InstituteRigshospitalet‐GlostrupGlostrupDenmark
| | - Saema Ansar
- Applied Neurovascular ResearchDepartment of Clinical SciencesLund UniversityLundSweden
| | - Lars Edvinsson
- Department of Clinical SciencesDivision of Experimental Vascular ResearchLund UniversityLundSweden
- Department of Clinical Experimental ResearchGlostrup Research InstituteRigshospitalet‐GlostrupGlostrupDenmark
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25
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Fung C, Z'Graggen WJ, Jakob SM, Gralla J, Haenggi M, Rothen HU, Mordasini P, Lensch M, Söll N, Terpolilli N, Feiler S, Oertel MF, Raabe A, Plesnila N, Takala J, Beck J. Inhaled Nitric Oxide Treatment for Aneurysmal SAH Patients With Delayed Cerebral Ischemia. Front Neurol 2022; 13:817072. [PMID: 35250821 PMCID: PMC8894247 DOI: 10.3389/fneur.2022.817072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
Background We demonstrated experimentally that inhaled nitric oxide (iNO) dilates hypoperfused arterioles, increases tissue perfusion, and improves neurological outcome following subarachnoid hemorrhage (SAH) in mice. We performed a prospective pilot study to evaluate iNO in patients with delayed cerebral ischemia after SAH. Methods SAH patients with delayed cerebral ischemia and hypoperfusion despite conservative treatment were included. iNO was administered at a maximum dose of 40 ppm. The response to iNO was considered positive if: cerebral artery diameter increased by 10% in digital subtraction angiography (DSA), or tissue oxygen partial pressure (PtiO2) increased by > 5 mmHg, or transcranial doppler (TCD) values decreased more than 30 cm/sec, or mean transit time (MTT) decreased below 6.5 secs in CT perfusion (CTP). Patient outcome was assessed at 6 months with the modified Rankin Scale (mRS). Results Seven patients were enrolled between February 2013 and September 2016. Median duration of iNO administration was 23 h. The primary endpoint was reached in all patients (five out of 17 DSA examinations, 19 out of 29 PtiO2 time points, nine out of 26 TCD examinations, three out of five CTP examinations). No adverse events necessitating the cessation of iNO were observed. At 6 months, three patients presented with a mRS score of 0, one patient each with an mRS score of 2 and 3, and two patients had died. Conclusion Administration of iNO in SAH patients is safe. These results call for a larger prospective evaluation.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Ulrich Rothen
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Lensch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Sergej Feiler
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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26
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Multidisciplinary and standardized management of patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:2917-2926. [PMID: 36006507 PMCID: PMC9613736 DOI: 10.1007/s00701-022-05347-y] [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: 05/05/2022] [Accepted: 08/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The appropriate management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains uncertain. We aimed to evaluate the effect of implementing a standardized protocol for detection and management of DCI after aSAH on cerebral infarction and functional outcome. METHODS We studied two cohorts of aSAH patients, one before (pre-implementation cohort: January 2012 to August 2014) and one after (post-implementation cohort: January 2016 to July 2018) implementation of a multidisciplinary approach, with standardized neurological and radiological assessment and risk-based medical treatment of DCI. We assessed the presence of new hypodensities on CT within 6 weeks after aSAH and categorized cerebral infarction into overall and DCI-related infarctions (hypodensities not within 48 h after IA repair and not attributable to aneurysm occlusion or intraparenchymal hematoma). Functional outcome was assessed at 3 months using the extended Glasgow outcome scale (eGOS), dichotomized into unfavorable (eGOS: 1-5) and favorable (eGOS: 6-8). We calculated odds ratios (OR) with corresponding 95% confidence intervals (CI's), and adjusted for age, WFNS grade, Fisher score, and treatment modality (aOR). RESULTS In the post-implementation (n = 158) versus the pre-implementation (n = 143) cohort the rates for overall cerebral infarction were 29.1% vs 46.9% (aOR: 0.41 [0.24-0.69]), for DCI-related cerebral infarction 17.7% vs. 31.5% (aOR: 0.41 [0.23-0.76]), and for unfavorable functional outcome at 3 months 37.3% vs. 53.8% (aOR: 0.30 [0.17-0.54]). For patients with DCI, the rates for unfavorable functional outcomes at 3 months in the post-implementation versus the pre-implementation cohort were 42.3% vs. 77.8% (aOR: 0.1 [0.03-0.27]). CONCLUSIONS A multidisciplinary approach with more frequent and standardized neurological assessment, standardized CT and CT perfusion monitoring, as well as tailored application of induced hypertension and invasive rescue therapy strategies, is associated with a significant reduction of cerebral infarction and unfavorable functional outcome after aneurysmal aSAH.
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27
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Bhogal P, Simpanen T, Wong K, Bushi D, Sirakov MA, Sirakov S, Aggour M, Makalanda L. Use of the Cascade expandable net to treat cerebral vasospasm - initial clinical experience from a single centre with in vitro benchside tests. CVIR Endovasc 2021; 4:82. [PMID: 34878623 PMCID: PMC8655056 DOI: 10.1186/s42155-021-00275-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/01/2021] [Indexed: 11/11/2022] Open
Abstract
Background The use of self-expanding stents to treat post-hemorrhagic cerebral vasospasm was recently described. We sought to determine the clinical efficacy of the Cascade device to treat delayed cerebral vasospasm (DCV). We performed benchside tests to determine the chronic outward force exerted by the Cascade in comparison to the Solitaire. Methods The chronic outward force (COF) of the Cascade M agile and Cascade L Agile was tested with equivalent tests of the Solitaire 4x20mm. Further tests to determine the forces generated in pre-formed tubes of 1.5–6 mm were performed using both fully and partially unsheathed Cascades. A retrospective review to identify all patients with aSAH and DCV treated with a Cascade device between January 2020 and July 2021. We recorded the treatment arterial vessel diameters and hemorrhagic or ischemic complications. Results In vitro the Cascade generated greater radial force than the Solitaire. The force generated by the Cascade M Agile at 1.5 mm was approximately 64% higher than the Solitaire 6x40mm and approximately 350% higher than the Solitaire 4x20mm. 4 patients with DCV were identified all of whom were treated with a cascade device. In all cases there was a significant improvement in the diameter of the vasospastic vessels treated with an average diameter increase of approximately 300%. There were no complications from the Cascade. Delayed CT angiography showed persistent dilatation of the segments treated with the Cascade at 24 h. Conclusion The Cascade is a safe and effective device when used to treat DCV secondary to aSAH. Larger studies are required to validate our initial results.
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Affiliation(s)
- P Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, London, E1 1BB, UK.
| | - T Simpanen
- Department of Radiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - K Wong
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - D Bushi
- Perflow Medical, 4 Hatzoran St., 4250604, Netanya, Israel
| | - M A Sirakov
- Department of Interventional Neuroradiology, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - S Sirakov
- Department of Interventional Neuroradiology, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - M Aggour
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - L Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, London, E1 1BB, UK
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28
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Malinova V, Döring K, Psychogios MN, Rohde V, Mielke D. Impact of Implementing an Elaborated CT Perfusion Protocol for Aneurysmal SAH on Functional Outcome: CTP Protocol for SAH. AJNR Am J Neuroradiol 2021; 42:1956-1961. [PMID: 34556476 PMCID: PMC8583263 DOI: 10.3174/ajnr.a7279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/03/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE The acute phase of aneurysmal SAH is characterized by a plethora of impending complications with the potential to worsen patients' outcomes. The aim of this study was to evaluate whether an elaborated CTP-based imaging protocol during the acute aneurysmal SAH phase is able to prevent delayed infarctions and contribute to a better outcome. MATERIALS AND METHODS In 2012, an elaborated CTP-based protocol was implemented for the management of patients with aneurysmal SAH. Retrospective analysis of patients with aneurysmal SAH treated from 2010 to 2013 was performed, comparing the patients treated before (group one, 2010-2011) with those treated after the protocol implementation (group two, 2012-2013) with regard to delayed infarctions and outcome according to the mRS at 3-months' follow-up. RESULTS A total of 133 patients were enrolled, of whom 57 were included in group 1, and 76, in group 2. There were no significant differences between the groups concerning baseline characteristics. In the multivariate analysis, independent predictors of a good outcome (mRS ≤ 2) were younger age (P < .001), lower World Federation of Neurosurgical Societies grade (P < .001), absence of delayed infarction (P = .01), and management according to the CTP protocol (P = .01). Larger or multiple infarctions occurred significantly more often in group 1 compared with group 2 (88% versus 33% of all delayed infarctions, P = .03). The outcome in group 2 was significantly better compared with group 1 (P = .005). CONCLUSIONS The findings suggest that implementation of an elaborated CTP protocol is associated with a better outcome. An earlier initiation of further diagnostics and treatment with prevention of large territorial and/or multiple infarctions might have led to this finding.
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Affiliation(s)
- V. Malinova
- From the Departments of Neurosurgery (V.M., V.R., D.M.)
| | - K. Döring
- Neuroradiology (K.D., M.-N.P.), Georg-August-University, Göttingen, Germany
| | - M.-N. Psychogios
- Neuroradiology (K.D., M.-N.P.), Georg-August-University, Göttingen, Germany,Department of Neuroradiology (M.-N.P.), Clinic of Radiology and Nuclear Medicine, University Medicine Basel, Basel, Switzerland
| | - V. Rohde
- From the Departments of Neurosurgery (V.M., V.R., D.M.)
| | - D. Mielke
- From the Departments of Neurosurgery (V.M., V.R., D.M.)
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Non-Animal Models in Experimental Subarachnoid Hemorrhage Research: Potentials and the Dilemma of the Translation from Bench to Bedside. Transl Stroke Res 2021; 13:218-221. [PMID: 34714498 PMCID: PMC8918456 DOI: 10.1007/s12975-021-00950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/08/2022]
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CT Perfusion for the Detection of Delayed Cerebral Ischemia in the Presence of Neurologic Confounders. Neurocrit Care 2021; 33:317-322. [PMID: 32472333 PMCID: PMC7259436 DOI: 10.1007/s12028-020-01005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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31
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Veldeman M, Albanna W, Weiss M, Park S, Hoellig A, Clusmann H, Helbok R, Temel Y, Alexander Schubert G. Invasive Multimodal Neuromonitoring in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review. Stroke 2021; 52:3624-3632. [PMID: 34304602 DOI: 10.1161/strokeaha.121.034633] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal subarachnoid hemorrhage is a devastating disease leaving surviving patients often severely disabled. Delayed cerebral ischemia (DCI) has been identified as one of the main contributors to poor clinical outcome after subarachnoid hemorrhage. The objective of this review is to summarize existing clinical evidence assessing the diagnostic value of invasive neuromonitoring (INM) in detecting DCI and provide an update of evidence since the 2014 consensus statement on multimodality monitoring in neurocritical care. METHODS Three invasive monitoring techniques were targeted in the data collection process: brain tissue oxygen tension (ptiO2), cerebral microdialysis, and electrocorticography. Prospective and retrospective studies as well as case series (≥10 patients) were included as long as monitoring was used to detect DCI or guide DCI treatment. RESULTS Forty-seven studies reporting INM in the context of DCI were included (ptiO2: N=21; cerebral microdialysis: N=22; electrocorticography: N=4). Changes in brain oxygen tension are associated with angiographic vasospasm or reduction in regional cerebral blood flow. Metabolic monitoring with trend analysis of the lactate to pyruvate ratio using cerebral microdialysis, identifies patients at risk for DCI. Clusters of cortical spreading depolarizations are associated with clinical neurological worsening and cerebral infarction in selected patients receiving electrocorticography monitoring. CONCLUSIONS Data supports the use of INM for the detection of DCI in selected patients. Generalizability to all subarachnoid hemorrhage patients is limited by design bias of available studies and lack of randomized trials. Continuous data recording with trend analysis and the combination of INM modalities can provide tailored treatment support in patients at high risk for DCI. Future trials should test interventions triggered by INM in relation to cerebral infarctions.
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Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, NY (S.P.)
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.)
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Austria (R.H.)
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, the Netherlands (Y.T)
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.).,Department of Neurosurgery, Kantonsspital Aarau, Switzerland (G.A.S.)
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Veldeman M, Lepore D, Höllig A, Clusmann H, Stoppe C, Schubert GA, Albanna W. Procalcitonin in the context of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2021; 135:29-37. [PMID: 32886914 DOI: 10.3171/2020.5.jns201337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) initiates a deleterious cascade activating multiple inflammatory processes, which can contribute to delayed cerebral ischemia (DCI). Procalcitonin (PCT) is an established marker for sepsis treatment monitoring, and its time course in the context of DCI after aSAH remains unclear. The aim of this trial was to assess the predictive and confirmative value of PCT levels in the context of DCI. METHODS All patients admitted to the authors' institution with aSAH between 2014 and 2018 were prospectively screened for eligibility. Daily PCT levels were recorded alongside relevant aSAH characteristics. The predictive and confirmative values of PCT levels were assessed using a receiver operating characteristic and area under the curve (AUC) analysis. The course of PCT levels around the DCI event was evaluated in an infection-free subgroup of patients. RESULTS A total of 132 patients with aSAH were included. Early PCT levels (first 3 days post-aSAH) had a low predictive value for the development of DCI (AUC 0.661, standard error [SE] 0.050; p = 0.003) and unfavorable long-term outcome (i.e., Glasgow Outcome Scale-Extended scores 1-4; AUC 0.674, SE 0.054; p = 0.003). In a subgroup analysis of infection-free patients (n = 72), PCT levels were higher in patients developing DCI (p = 0.001) and DCI-related cerebral infarction (p = 0.002). PCT concentrations increased gradually after DCI and decreased with successful intervention. In refractory cases progressing to cerebral infarction, PCT levels showed a secondary increase. CONCLUSIONS Early higher PCT levels were associated with the later development of DCI and unfavorable outcome. Analysis of PCT beyond the first couple of days after hemorrhage is hampered by nosocomial infections. In infection-free patients, however, PCT levels rise during DCI and an additional increase develops in patients developing cerebral infarction. Clinical trial registration no.: NCT02142166 (clinicaltrials.gov).
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Affiliation(s)
| | - Daniel Lepore
- 2Intensive Care and Intermediate Care, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; and
- 3Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Universitaire de Liège, Belgium
| | | | | | - Christian Stoppe
- 2Intensive Care and Intermediate Care, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; and
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Veldeman M, Albanna W, Weiss M, Conzen C, Schmidt TP, Schulze-Steinen H, Wiesmann M, Clusmann H, Schubert GA. Invasive neuromonitoring with an extended definition of delayed cerebral ischemia is associated with improved outcome after poor-grade subarachnoid hemorrhage. J Neurosurg 2021; 134:1527-1534. [PMID: 32413866 DOI: 10.3171/2020.3.jns20375] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The current definition of delayed cerebral ischemia (DCI) is based on clinical characteristics precluding its use in patients with poor-grade subarachnoid hemorrhage (SAH). Additional concepts to evaluate the unconscious patient are required. Invasive neuromonitoring (INM) may allow timely detection of metabolic and oxygenation crises before irreversible damage has occurred. METHODS The authors present a cohort analysis of all consecutive SAH patients referred to a single tertiary care center between 2010 and 2018. The cohort (n = 190) was split into two groups: one before (n = 96) and one after (n = 94) the introduction of INM in 2014. A total of 55 poor-grade SAH patients were prospectively monitored using parenchymal oxygen saturation measurement and cerebral microdialysis. The primary outcome was the Glasgow Outcome Scale-Extended (GOSE) score after 12 months. RESULTS With neuromonitoring, the first DCI event was detected earlier (mean 2.2 days, p = 0.002). The overall rate of DCI-related infarctions decreased significantly (from 44.8% to 22.3%; p = 0.001) after the introduction of invasive monitoring. After 12 months, a higher rate of favorable outcome was observed in the post-INM group, compared to the pre-INM group (53.8% vs 39.8%), with a significant difference in the GOSE score distribution (OR 4.86, 95% CI -1.17 to -0.07, p = 0.028). CONCLUSIONS In this cohort analysis of poor-grade SAH patients, the introduction of INM and the extension of the classic DCI definition toward a functional dimension resulted in an earlier detection and treatment of DCI events. This led to an overall decrease in DCI-related infarctions and an improvement in outcome.
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Affiliation(s)
| | | | | | | | | | | | - Martin Wiesmann
- 3Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
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Veldeman M, Weiss M, Simon TP, Hoellig A, Clusmann H, Albanna W. Body mass index and leptin levels in serum and cerebrospinal fluid in relation to delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2021; 44:3547-3556. [PMID: 33866464 PMCID: PMC8593057 DOI: 10.1007/s10143-021-01541-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of a patient’s body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction, and clinical outcome. In total, 263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). A total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P = .410) or better clinical outcome (P = .643) was identified. Early leptin concentration in serum (P = .258) and CSF (P = .159) showed no predictive value in identifying patients at risk of unfavorable outcomes. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P = .049). In our data, no association between obesity and clinical outcome was detected. After DCI development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier. This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger-scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166
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Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tim Philipp Simon
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
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Roelz R, Schubach F, Coenen VA, Jenkner C, Scheiwe C, Grauvogel J, Niesen WD, Urbach H, Taschner C, Seufert J, Kätzler J, Beck J, Reinacher PC. Stereotactic cisternal lavage in patients with aneurysmal subarachnoid hemorrhage with urokinase and nimodipine for the prevention of secondary brain injury (SPLASH): study protocol for a randomized controlled trial. Trials 2021; 22:285. [PMID: 33858493 PMCID: PMC8048077 DOI: 10.1186/s13063-021-05208-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed cerebral infarction (DCI) is a major cause of death and poor neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Direct intrathecal therapies with fibrinolytic and spasmolytic drugs have appeared promising in clinical trials. However, access to the subarachnoid space for intrathecal drug administration is an unsolved problem so far, especially in patients with endovascular aneurysm securing. We investigate a therapy protocol based on stereotactic catheter ventriculocisternostomy (STX-VCS), a new approach to overcome this problem. The primary objective of this study is to assess whether cisternal lavage with urokinase, nimodipine, and Ringer's solution administered via a stereotactically implanted catheter into the basal cisterns (= investigational treatment (IT)) is safe and improves neurological outcome in patients with aSAH. METHODS This is a randomized, controlled, parallel-group, open-label phase II trial. Fifty-four patients with severe aSAH (WFNS grade ≥ 3) will be enrolled at one academic tertiary care center in Southern Germany. Patients will be randomized at a ratio of 1:1 to receive either standard of care only or standard of care plus the IT. The primary endpoint is the proportion of subjects with a favorable outcome on the Modified Rankin Scale (defined as mRS 0-3) at 6 months after aSAH. Further clinical and surrogate outcome parameters are defined as secondary endpoints. DISCUSSION New approaches for the prevention and therapy of secondary brain injury in patients with aSAH are urgently needed. We propose this RCT to assess the clinical safety and efficacy of a novel therapy protocol for intrathecal administration of urokinase, nimodipine, and Ringer's solution. TRIAL REGISTRATION Deutsches Register Klinischer Studien (German Clinical Trials Register), DRKS00015645 . Registered on 8 May 2019.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Fabian Schubach
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carolin Jenkner
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Taschner
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jochen Seufert
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Kätzler
- Department of Internal Medicine III, Clinical Trials Office, University Medical Center Ulm, Ulm, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
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Petzold GC, Dreier JP. Spreading depolarization evoked by endothelin-1 is inhibited by octanol but not by carbenoxolone. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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Bacigaluppi S, Ivaldi F, Bragazzi NL, Benvenuto F, Gallo F, D'Andrea A, Severi P, Uccelli A, Zona G. An Early Increase of Blood Leukocyte Subsets in Aneurysmal Subarachnoid Hemorrhage Is Predictive of Vasospasm. Front Neurol 2020; 11:587039. [PMID: 33408685 PMCID: PMC7779675 DOI: 10.3389/fneur.2020.587039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/10/2020] [Indexed: 12/28/2022] Open
Abstract
Objective: Vasospasm is a severe complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) and cannot be reliably predicted. Its pathophysiology remains elusive with the current body of evidence suggesting inflammation as one of the main driving forces. We here aimed to analyze circulating immune cell subsets over time in patients with aSAH with or without vasospasm. Methods: We performed a prospective observational study recruiting patients with spontaneous aSAH. Peripheral blood withdrawn at pre-specified time-points after aSAH, day 0, days 3–4, 6–8, 10–11, 13–15, and 18–21. Flow cytometry analysis, cell blood counts, and laboratory and diagnostic parameters were performed. Patients were monitored by transcranial Doppler for vasospasm as well as by advanced imaging and divided into a group with (VS) and without vasospasm VS (NVS). Results: We included 42 patients for study analysis, 21 VS and 21 NVS. An early significant increase at day 0 in platelet, leukocyte, neutrophil, lymphocyte, NK lymphocyte, monocyte, and CD 14++ CD16− DR+ monocyte counts was found in patients with later ensuing vasospasm. The early differences in platelets, leukocytes, lymphocytes, and NK lymphocytes remained significant on multivariate analysis. Conclusions: An early increase of immune cellular subsets in aSAH may contribute to predict VS.
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Affiliation(s)
- Susanna Bacigaluppi
- Department of Neurosurgery-IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,DINOGMI & CEBR, University of Genoa, Genoa, Italy.,Department of Neurosurgery-E.O. Ospedali Galliera, Genoa, Italy
| | | | - Nicola L Bragazzi
- DISSAL Department of Health Sciences, Università di Genova, Genoa, Italy
| | | | - Fabio Gallo
- DISSAL Department of Health Sciences, Università di Genova, Genoa, Italy
| | - Alessandro D'Andrea
- Department of Neurosurgery-IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Severi
- Department of Neurosurgery-E.O. Ospedali Galliera, Genoa, Italy
| | - Antonio Uccelli
- Department of Neurosurgery-IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,DINOGMI & CEBR, University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery-IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,DINOGMI & CEBR, University of Genoa, Genoa, Italy
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Caricato A, Silva S. Delayed cerebral ischemia: is it time to change our practice? Minerva Anestesiol 2020; 86:1266-1268. [DOI: 10.23736/s0375-9393.20.14820-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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40
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Männer A, Thomas D, Wagner M, Konczalla J, Steinmetz H, Brunkhorst R, Pfeilschifter W. Sphingosine 1-phosphate levels in cerebrospinal fluid after subarachnoid hemorrhage. Neurol Res Pract 2020; 2:49. [PMID: 33324946 PMCID: PMC7684722 DOI: 10.1186/s42466-020-00093-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 12/11/2022] Open
Abstract
Background and purpose Sphingosin-1-phosphate (S1P) plays a crucial role as a signaling molecule in the immune system and the vasculature. Previous studies suggested a role as a vasoconstrictor of cerebral arteries via the S1P3-Receptor. Cerebral vasospasm (VS) following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of disability and poor neurological outcome. Early detection of vasospasm could facilitate the prevention of cerebral ischemia in SAH patients. The aim of this prospective case-control study was to characterize the dynamics of S1P in the cerebrospinal fluid (CSF) of patients with SAH in relation to hemorrhage volume, the occurrence of VS, and neurological outcome. Methods S1P levels in CSF of 18 control subjects and 18 SAH patients with placement of an external ventricular drainage (EVD) were determined by high sensitivity mass spectrometry from day 1 through 14 after SAH onset. Hemorrhage volume, development of asymptomatic vasospasm (aVS) and symptomatic vasospasm (sVS), and neurological outcome were correlated to day 1 S1P levels. Results The intrathecal S1P levels of SAH patients were higher than those of the control subjects, and correlated with hemorrhage volume. There was no significant difference in S1P levels between patients with aVS and those with sVS. S1P levels significantly correlated with neurological outcome on a sliding modified Rankin scale. Conclusion S1P levels were highest directly after placement of the EVD and correlated strongly with hemorrhage volume, which may be caused by the intrathecal clot and subsequent lysis of red blood cells, an important source of S1P. We did not detect a second peak of S1P release over the course of the intensive care period.
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Affiliation(s)
- Anika Männer
- Frankfurt University Hospital, Department of Neurology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Dominique Thomas
- Pharmazentrum Frankfurt, Frankfurt University Hospital, Department of Clinical Pharmacology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Marlies Wagner
- Frankfurt University Hospital, Institute for Diagnostic and Interventional Neuroradiology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jürgen Konczalla
- Frankfurt University Hospital, Department of Neurosurgery, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Helmuth Steinmetz
- Frankfurt University Hospital, Department of Neurology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Robert Brunkhorst
- Frankfurt University Hospital, Department of Neurology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.,RWTH Uniklinik Aachen, Klinik für Neurologie, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Waltraud Pfeilschifter
- Frankfurt University Hospital, Department of Neurology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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Clarke JV, Suggs JM, Diwan D, Lee JV, Lipsey K, Vellimana AK, Zipfel GJ. Microvascular platelet aggregation and thrombosis after subarachnoid hemorrhage: A review and synthesis. J Cereb Blood Flow Metab 2020; 40:1565-1575. [PMID: 32345104 PMCID: PMC7370365 DOI: 10.1177/0271678x20921974] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) has been associated with numerous pathophysiological sequelae, including large artery vasospasm and microvascular thrombosis. The focus of this review is to provide an overview of experimental animal model studies and human autopsy studies that explore the temporal-spatial characterization and mechanism of microvascular platelet aggregation and thrombosis following SAH, as well as to critically assess experimental studies and clinical trials highlighting preventative therapeutic options against this highly morbid pathophysiological process. Upon review of the literature, we discovered that microvascular platelet aggregation and thrombosis occur after experimental SAH across multiple species and SAH induction techniques in a similar time frame to other components of DCI, occurring in the cerebral cortex and hippocampus across both hemispheres. We discuss the relationship of these findings to human autopsy studies. In the final section of this review, we highlight the important therapeutic options for targeting microvascular platelet aggregation and thrombosis, and emphasize why therapeutic targeting of this neurovascular pathology may improve patient care. We encourage ongoing research into the pathophysiology of SAH and DCI, especially in regard to microvascular platelet aggregation and thrombosis and the translation to randomized clinical trials.
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Affiliation(s)
- Julian V Clarke
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Julia M Suggs
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Deepti Diwan
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Jin V Lee
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Kim Lipsey
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Ananth K Vellimana
- Neurological Surgery, Washington University School of Medicine, , Saint Louis, MO, USA
| | - Gregory J Zipfel
- Neurological Surgery, Washington University School of Medicine, , Saint Louis, MO, USA
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Dhar R. Commentary on "Temporal Dynamics of Cerebral Blood Flow During the Acute Course of Severe Subarachnoid Hemorrhage Studied by Bedside Xenon-Enhanced CT". Neurocrit Care 2020; 30:291-292. [PMID: 30815775 DOI: 10.1007/s12028-019-00698-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Rajat Dhar
- Department of Neurology (Division of Neurocritical Care), Washington University in Saint Louis, 660 S Euclid Avenue, Campus Box 8111, Saint Louis, MO, 63110, USA.
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Vergouw LJM, Egal M, Bergmans B, Dippel DWJ, Lingsma HF, Vergouwen MDI, Willems PWA, Oldenbeuving AW, Bakker J, van der Jagt M. High Early Fluid Input After Aneurysmal Subarachnoid Hemorrhage: Combined Report of Association With Delayed Cerebral Ischemia and Feasibility of Cardiac Output-Guided Fluid Restriction. J Intensive Care Med 2020; 35:161-169. [PMID: 28934895 PMCID: PMC6927070 DOI: 10.1177/0885066617732747] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 08/01/2017] [Accepted: 08/31/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) recommend euvolemia, whereas hypervolemia may cause harm. We investigated whether high early fluid input is associated with delayed cerebral ischemia (DCI), and if fluid input can be safely decreased using transpulmonary thermodilution (TPT). METHODS We retrospectively included aSAH patients treated at an academic intensive care unit (2007-2011; cohort 1) or managed with TPT (2011-2013; cohort 2). Local guidelines recommended fluid input of 3 L daily. More fluids were administered when daily fluid balance fell below +500 mL. In cohort 2, fluid input in high-risk patients was guided by cardiac output measured by TPT per a strict protocol. Associations of fluid input and balance with DCI were analyzed with multivariable logistic regression (cohort 1), and changes in hemodynamic indices after institution of TPT assessed with linear mixed models (cohort 2). RESULTS Cumulative fluid input 0 to 72 hours after admission was associated with DCI in cohort 1 (n=223; odds ratio [OR] 1.19/L; 95% confidence interval 1.07-1.32), whereas cumulative fluid balance was not. In cohort 2 (23 patients), using TPT fluid input could be decreased from 6.0 ± 1.0 L before to 3.4 ± 0.3 L; P = .012), while preload parameters and consciousness remained stable. CONCLUSION High early fluid input was associated with DCI. Invasive hemodynamic monitoring was feasible to reduce fluid input while maintaining preload. These results indicate that fluid loading beyond a normal preload occurs, may increase DCI risk, and can be minimized with TPT.
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Affiliation(s)
- Leonie J. M. Vergouw
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mohamud Egal
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas Bergmans
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mervyn D. I. Vergouwen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter W. A. Willems
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan Bakker
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Inflammation, Cerebral Vasospasm, and Brain Injury in Subarachnoid Hemorrhage-A Shifting Paradigm and a New Beginning. Crit Care Med 2019; 46:1883-1885. [PMID: 30312238 DOI: 10.1097/ccm.0000000000003373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Shen J, Zhao Z, Shang W, Liu C, Zhang B, Xu Z, Cai H. Fabrication and evaluation a transferrin receptor targeting nano-drug carrier for cerebral infarction treatment. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:192-200. [PMID: 30663409 DOI: 10.1080/21691401.2018.1548471] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
After cerebral infarction, the regeneration of microvascular played an important role in the recovery. Ginsenoside Rg1 (Rg1) had good effects on promoting angiogenesis and neuro-protection in cerebral infarction treatment. However, the blood-brain barrier (BBB) restricted Rg1 to enter into cerebral tissue. Transferrin receptor (TfR) was over-expressed in the BBB. In this study, we fabricated a TfR targeting nano-carrier (PATRC) to penetrate the BBB for treatment of cerebral infarction. A TfR targeted peptide was conjugated with the nano-carrier wrapped hydrophobic Rg1. The nanoscale size (132 ± 12 nm), polydispersity index (PDI =0.29) and the zeta potential (-38mv) were tested with dynamic light scattering optical system. Surface morphology (ellipse, mean diameter 122 ± 26 nm) was detected by transmission electron microscope (TEM). PATRC implement cell targeting ability on rat brain microvascular endothelial cells RBE4 in vitro detected by immunofluorescence and flow cytometry methods. Comparing with Rg1 threated group, the PATRC exhibited more prominent ability on the tube formation ability (p < .05) in vitro. Comparing with the Rg1 treated group, PATRC penetrated BBB in vivo detected by HPLC, decreased the brain infarction volume tested with TTC staining and promoted regeneration of microvascular in infarction zone detected by CD31 immunofluorescence. PATRC has great potentiality for wide application in clinic.
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Affiliation(s)
- Junyi Shen
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
| | - Zhiming Zhao
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
| | - Wei Shang
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
| | - Chunli Liu
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
| | - Beibei Zhang
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
| | - Zihan Xu
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
| | - Hui Cai
- a Department of Integrated Traditional and Western Medicine, Jinling Hospital, School of Medicine , Nanjing University , Nanjing , China
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47
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Yu Z, Zheng J, Ma L, Li H, You C, Jiang Y. Predictive Value of Cerebral Autoregulation Impairment for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. World Neurosurg 2019; 126:e853-e859. [PMID: 30862594 DOI: 10.1016/j.wneu.2019.02.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) happens in about 30% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is related to higher mortality and disability. Some studies have shown cerebral autoregulation impairment can be a predictor of DCI in aneurysmal SAH. We conducted this meta-analysis to evaluate the predictive value of cerebral autoregulation impairment for DCI based on the current literature. METHODS A systematic literature search was performed in PubMed and Embase. According to inclusion and exclusion criteria, 2 authors screened the records and extracted data from the included studies. Pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained. To investigate the overall accuracy, a summary receiver operating characteristic (SROC) curve was built and the area under SROC curve was calculated. Deeks' linear regression was used to assess the publication bias. All statistical analyses were performed with Stata 14.0. RESULTS A total of 7 studies were finally included in this meta-analysis. The pooled sensitivity and specificity values of impaired cerebral autoregulation for DCI prediction were 0.79 (95% CI, 0.65-0.88) and 0.85 (95% CI, 0.615-0.96). Moreover, the area under the SROC curve of cerebral autoregulation impairment for DCI prediction was 0.87 (95% CI, 0.835-0.89). No obvious publication bias was found in Deeks' linear regression (P = 0.99). CONCLUSIONS Cerebral autoregulation impairment can be a helpful predictor of DCI in aneurysmal SAH. Its accuracy for DCI prediction should be verified by more studies in the future.
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Affiliation(s)
- Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Jiang
- Department of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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48
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Eriksen N, Rostrup E, Fabricius M, Scheel M, Major S, Winkler MKL, Bohner G, Santos E, Sakowitz OW, Kola V, Reiffurth C, Hartings JA, Vajkoczy P, Woitzik J, Martus P, Lauritzen M, Pakkenberg B, Dreier JP. Early focal brain injury after subarachnoid hemorrhage correlates with spreading depolarizations. Neurology 2018; 92:e326-e341. [PMID: 30593517 DOI: 10.1212/wnl.0000000000006814] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/11/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To investigate whether spreading depolarization (SD)-related variables at 2 different time windows (days 1-4 and 5-8) after aneurysmal subarachnoid hemorrhage (aSAH) correlate with the stereologically determined volume of early focal brain injury on the preinterventional CT scan. METHODS In this observational multicenter study of 54 patients, volumes of unaffected brain tissue, ventricles, cerebellum, aSAH, intracerebral hemorrhage, and focal parenchymal hypodensity were stereologically estimated. Patients were electrocorticographically monitored using subdural electrodes for 81.8 hours (median) (interquartile range: 70.6-90.5) during days 1-4 (n = 54) and for 75.9 (59.5-88.7) hours during days 5-8 (n = 51). Peak total SD-induced depression duration of a recording day (PTDDD) and peak numbers of (1) SDs, (2) isoelectric SDs, and (3) spreading depressions of a recording day were determined following the recommendations of the Co-Operative Studies on Brain Injury Depolarizations. RESULTS Thirty-three of 37 patients with early focal brain injury (intracerebral hemorrhage and/or hypodensity) in contrast to 7 of 17 without displayed SDs during days 1-4 (sensitivity: 89% [95% confidence interval, CI: 75%-97%], specificity: 59% [CI: 33%-82%], positive predictive value: 83% [CI: 67%-93%], negative predictive value: 71% [CI: 42%-92%], Fisher exact test, p < 0.001). All 4 SD-related variables during days 1-4 significantly correlated with the volume of early focal brain injury (Spearman rank order correlations). A multiple ordinal regression analysis identified the PTDDD as the most important predictor. CONCLUSIONS Our findings suggest that early focal brain injury after aSAH is associated with early SDs and further support the notion that SDs are a biomarker of focal brain lesions.
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Affiliation(s)
- Nina Eriksen
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Egill Rostrup
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Martin Fabricius
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Michael Scheel
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Sebastian Major
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Maren K L Winkler
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Georg Bohner
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Edgar Santos
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Oliver W Sakowitz
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Vasilis Kola
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Clemens Reiffurth
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Jed A Hartings
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Peter Vajkoczy
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Johannes Woitzik
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Peter Martus
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Martin Lauritzen
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Bente Pakkenberg
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany
| | - Jens P Dreier
- From the Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital (N.E., B.P.), University of Copenhagen; Departments of Clinical Physiology and Nuclear Medicine (E.R.) and Clinical Neurophysiology (M.F., M.L.), Rigshospitalet, University of Copenhagen, Denmark; Department of Neuroradiology (M.S., G.B.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany; Center for Stroke Research Berlin (S.M., M.K.L.W., V.K., C.R., P.V., J.W., J.P.D.) and Departments of Experimental Neurology (S.M., C.R., J.P.D.), Neurology (S.M., J.P.D.), and Neurosurgery (P.V., J.W.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Department of Neurosurgery (E.S., O.W.S.), University Hospital Heidelberg, Ruprecht Karls University Heidelberg; Neurosurgery Center Ludwigsburg-Heilbronn (O.W.S.), RKH Klinikum Ludwigsburg, Germany; UC Gardner Neuroscience Institute (J.A.H.) and Department of Neurosurgery (J.A.H.), University of Cincinnati (UC) College of Medicine, OH; Institute for Clinical Epidemiology and Applied Biostatistics (P.M.), University of Tübingen, Germany; Department of Neuroscience and Center for Healthy Aging, Panum Institute (M.L.), and Faculty of Health and Medical Sciences (B.P.), University of Copenhagen, Denmark; Bernstein Center for Computational Neuroscience Berlin (J.P.D.), Berlin; and Einstein Center for Neurosciences Berlin (J.P.D.), Germany.
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Petridis AK, Kamp MA, Cornelius JF, Beez T, Beseoglu K, Turowski B, Steiger HJ. Aneurysmal Subarachnoid Hemorrhage. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:226-236. [PMID: 28434443 DOI: 10.3238/arztebl.2017.0226] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 08/29/2016] [Accepted: 11/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living. METHODS This article is based on a selective review of pertinent literature retrieved by a PubMed search. RESULTS Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping). CONCLUSION SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.
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Affiliation(s)
- Athanasios K Petridis
- Department of Neurosurgery, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital
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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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