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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [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: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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Rass V, Kindl P, Lindner A, Kofler M, Altmann K, Putnina L, Ianosi BA, Schiefecker AJ, Beer R, Pfausler B, Helbok R. Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:104-115. [PMID: 37308727 PMCID: PMC10499738 DOI: 10.1007/s12028-023-01760-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Nimodipine is recommended to prevent delayed cerebral ischemia in patients with spontaneous subarachnoid hemorrhage (SAH). Here, we studied hemodynamic side effects of different nimodipine formulations (per os [PO] and intravenous [IV]) in patients with SAH undergoing continuous blood pressure monitoring. METHODS This observational cohort study includes consecutive patients with SAH (271 included in the IV group, 49 in the PO group) admitted to a tertiary care center between 2010 and 2021. All patients received prophylactic IV or PO nimodipine. Hemodynamic responses were evaluated based on median values within the first hour after continuous IV nimodipine initiation or PO nimodipine application (601 intakes within 15 days). Significant changes were defined as > 10% drop in systolic blood pressure (SBP) or diastolic blood pressure from baseline (median values 30 min before nimodipine application). With the use of multivariable logistic regression, risk factors associated with SBP drops were identified. RESULTS Patients were admitted with a median Hunt & Hess score of 3 (2-5; IV 3 [2-5], PO 1 [1-2], p < 0.001) and were 58 (49-69) years of age. Initiation of IV nimodipine was associated with a > 10% SBP drop in 30% (81/271) of patients, with a maximum effect after 15 min. A start or increase in noradrenaline was necessary in 136/271 (50%) patients, and colloids were administered in 25/271 (9%) patients within 1 h after IV nimodipine initiation. SBP drops > 10% occurred after 53/601 (9%) PO nimodipine intakes, with a maximum effect after 30-45 min in 28/49 (57%) patients. Noradrenaline application was uncommon (3% before and 4% after nimodipine PO intake). Hypotensive episodes to an SBP < 90 mm Hg were not observed after IV or PO nimodipine application. In multivariable analysis, only a higher SBP at baseline was associated with a > 10% drop in SBP after IV (p < 0.001) or PO (p = 0.001) nimodipine application, after adjusting for the Hunt & Hess score on admission, age, sex, mechanical ventilation, days after intensive care unit admission, and delayed cerebral ischemia. CONCLUSIONS Significant drops in SBP occur in one third of patients after the start of IV nimodipine and after every tenth PO intake. Early recognition and counteracting with vasopressors or fluids seems necessary to prevent hypotensive episodes.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Philipp Kindl
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Klaus Altmann
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
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3
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Zanaty M, Allan L, Samaniego EA, Piscopo A, Ryan E, Torner JC, Hasan D. Phase 1/2a Trial of ISPASM. Stroke 2021; 52:3750-3758. [PMID: 34470496 DOI: 10.1161/strokeaha.121.034578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Microthrombosis could play a role in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Tirofiban has shown promising results in reducing delayed cerebral ischemia in retrospective studies. However, the safety of using tirofiban in aneurysmal subarachnoid hemorrhage is not rigorously established. METHODS A phase 1/2a double-blinded randomized controlled trial (2:1 randomization) to assess the safety of a 7-day intravenous infusion of tirofiban compared with placebo, in patients with aneurysmal subarachnoid hemorrhage treated with ventriculostomy placed in the operative room and coiling was conducted. The primary end point was any intracranial hemorrhage during the hospital stay. The secondary end points were: incidence of radiographic and clinical vasospasm, incidence of delayed cerebral ischemia, and incidence of cerebral ischemic changes noted on magnetic resonance imaging or computed tomography. RESULTS Eighteen patients received intravenous tirofiban and 12 received placebo. There was no difference in baseline characteristics except for higher male proportions in the tirofiban group. There was no difference in death, in development of new or change in existing intracranial hemorrhages, in thrombocytopenia, and need for shunts in the two arms. However, the tirofiban arm had a lower incidence of delayed cerebral ischemia compared with placebo (6% [1/18] versus 33% [4/12]; P=0.04), and less radiographic vasospasm as detected by catheter angiogram or computed tomography angiography (P=0.01) and computed tomography perfusion (P=0.01). CONCLUSIONS The above preliminary results support proceeding with further testing of the safety and efficacy of 7-day intravenous infusion of tirofiban in a pragmatic (placing external ventricular drain by the bedside), multicenter setting, and using a larger population. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03691727.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
| | - Lauren Allan
- Department of General Surgery, Department of Surgical and Neuroscience Intensive Care Unit (L.A.), University of Iowa Hospital and Clinics
| | - Edgar A Samaniego
- Department of Neurology, Neuro Interventional Radiology (E.A.S.), University of Iowa Hospital and Clinics
| | - Anthony Piscopo
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
| | - Eleanor Ryan
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
| | - James C Torner
- Department of Epidemiology and Public Health (J.C.T.), University of Iowa Hospital and Clinics
| | - David Hasan
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
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Maruhashi T, Higashi Y. An overview of pharmacotherapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage. Expert Opin Pharmacother 2021; 22:1601-1614. [PMID: 33823726 DOI: 10.1080/14656566.2021.1912013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Survival from aneurysmal subarachnoid hemorrhage has increased in the past few decades. However, functional outcome after subarachnoid hemorrhage is still suboptimal. Delayed cerebral ischemia (DCI) is one of the major causes of morbidity.Areas covered: Mechanisms underlying vasospasm and DCI after aneurysmal subarachnoid hemorrhage and pharmacological treatment are summarized in this review.Expert opinion: Oral nimodine, an L-type dihydropyridine calcium channel blocker, is the only FDA-approved drug for the prevention and treatment of neurological deficits after aneurysmal subarachnoid hemorrhage. Fasudil, a potent Rho-kinase inhibitor, has also been shown to improve the clinical outcome and has been approved in some countries for use in patients with aneurysmal subarachnoid hemorrhage. Although other drugs, including nicardipine, cilostazol, statins, clazosentan, magnesium and heparin, have been expected to have beneficial effects on DCI, there has been no convincing evidence supporting the routine use of those drugs in patients with aneurysmal subarachnoid hemorrhage in clinical practice. Further elucidation of the mechanisms underlying DCI and the development of effective therapeutic strategies for DCI, including combination therapy, are necessary to further improve the functional outcome and mortality after subarachnoid hemorrhage.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
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5
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McDaid J, Briggs CA, Barrington NM, Peterson DA, Kozlowski DA, Stutzmann GE. Sustained Hippocampal Synaptic Pathophysiology Following Single and Repeated Closed-Head Concussive Impacts. Front Cell Neurosci 2021; 15:652721. [PMID: 33867941 PMCID: PMC8044326 DOI: 10.3389/fncel.2021.652721] [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: 01/13/2021] [Accepted: 03/11/2021] [Indexed: 11/24/2022] Open
Abstract
Traumatic brain injury (TBI), and related diseases such as chronic traumatic encephalopathy (CTE) and Alzheimer’s (AD), are of increasing concern in part due to enhanced awareness of their long-term neurological effects on memory and behavior. Repeated concussions, vs. single concussions, have been shown to result in worsened and sustained symptoms including impaired cognition and histopathology. To assess and compare the persistent effects of single or repeated concussive impacts on mediators of memory encoding such as synaptic transmission, plasticity, and cellular Ca2+ signaling, a closed-head controlled cortical impact (CCI) approach was used which closely replicates the mode of injury in clinical cases. Adult male rats received a sham procedure, a single impact, or three successive impacts at 48-hour intervals. After 30 days, hippocampal slices were prepared for electrophysiological recordings and 2-photon Ca2+ imaging, or fixed and immunostained for pathogenic phospho-tau species. In both concussion groups, hippocampal circuits showed hyper-excitable synaptic responsivity upon Schaffer collateral stimulation compared to sham animals, indicating sustained defects in hippocampal circuitry. This was not accompanied by sustained LTP deficits, but resting Ca2+ levels and voltage-gated Ca2+ signals were elevated in both concussion groups, while ryanodine receptor-evoked Ca2+ responses decreased with repeat concussions. Furthermore, pathogenic phospho-tau staining was progressively elevated in both concussion groups, with spreading beyond the hemisphere of injury, consistent with CTE. Thus, single and repeated concussions lead to a persistent upregulation of excitatory hippocampal synapses, possibly through changes in postsynaptic Ca2+ signaling/regulation, which may contribute to histopathology and detrimental long-term cognitive symptoms.
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Affiliation(s)
- John McDaid
- Center for Neurodegenerative Disease and Therapeutics, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Clark A Briggs
- Center for Neurodegenerative Disease and Therapeutics, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Nikki M Barrington
- Center for Neurodegenerative Disease and Therapeutics, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Daniel A Peterson
- Center for Neurodegenerative Disease and Therapeutics, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Center for Stem Cell and Regenerative Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Dorothy A Kozlowski
- Department of Biological Sciences and Neuroscience Program, DePaul University, Chicago, IL, United States
| | - Grace E Stutzmann
- Center for Neurodegenerative Disease and Therapeutics, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.,Center for Stem Cell and Regenerative Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
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6
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Dienel A, Ammassam Veettil R, Hong SH, Matsumura K, Kumar T P, Yan Y, Blackburn SL, Ballester LY, Marrelli SP, McCullough LD, McBride DW. Microthrombi Correlates With Infarction and Delayed Neurological Deficits After Subarachnoid Hemorrhage in Mice. Stroke 2020; 51:2249-2254. [PMID: 32539672 DOI: 10.1161/strokeaha.120.029753] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Delayed neurological deficits are a devastating consequence of subarachnoid hemorrhage (SAH), which affects about 30% of surviving patients. Although a very serious concern, delayed deficits are understudied in experimental SAH models; it is not known whether rodents recapitulate the delayed clinical decline seen in SAH patients. We hypothesized that mice with SAH develop delayed functional deficits and that microthrombi and infarction correlate with delayed decline. METHODS Adult C57BL/6J mice of both sexes were subjected to endovascular perforation to induce SAH. Mice were allowed to survive for up to 1 week post-ictus and behavioral performance was assessed daily. Postmortem microthrombi, large artery diameters (to assess vasospasm), and infarct volume were measured. These measures were analyzed for differences between SAH mice that developed delayed deficits and SAH mice that did not get delayed deficits. Correlation analyses were performed to identify which measures correlated with delayed neurological deficits, sex, and infarction. RESULTS Twenty-three percent of males and 47% of females developed delayed deficits 3 to 6 days post-SAH. Female mice subjected to SAH had a significantly higher incidence of delayed deficits than male mice with SAH. Mice that developed delayed deficits had significantly more microthrombi and larger infarct volumes than SAH mice that did not get delayed deficits. Microthrombi positively correlated with infarct volume, and both microthrombi and infarction correlated with delayed functional deficits. Vasospasm did not correlate with either infarction delayed functional deficits. CONCLUSIONS We discovered that delayed functional deficits occur in mice following SAH. Sex differences were seen in the prevalence of delayed deficits. The mechanism by which microthrombi cause delayed deficits may be via formation of infarcts.
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Affiliation(s)
- Ari Dienel
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
| | - Remya Ammassam Veettil
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
| | - Sung-Ha Hong
- Department of Neurology, McGovern Medical School (S.-H.H., S.P.M., L.D.M.), The University of Texas Health Science Center at Houston
| | - Kanako Matsumura
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
| | - Peeyush Kumar T
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
| | - Yuanqing Yan
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
| | - Spiros L Blackburn
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
| | - Leomar Y Ballester
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston.,Department of Pathology and Laboratory Medicine (L.Y.B.), The University of Texas Health Science Center at Houston
| | - Sean P Marrelli
- Department of Neurology, McGovern Medical School (S.-H.H., S.P.M., L.D.M.), The University of Texas Health Science Center at Houston
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School (S.-H.H., S.P.M., L.D.M.), The University of Texas Health Science Center at Houston
| | - Devin W McBride
- Vivian L. Smith Department of Neurosurgery (A.D., R.A.V., K.M., P.K.T., Y.Y., S.L.B., L.Y.B., D.W.M.), The University of Texas Health Science Center at Houston
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Cerebrospinal Fluid Concentrations of Nimodipine Correlate With Long-term Outcome in Aneurysmal Subarachnoid Hemorrhage: Pilot Study. Clin Neuropharmacol 2020; 42:157-162. [PMID: 31306217 DOI: 10.1097/wnf.0000000000000356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim was to evaluate plasma and cerebrospinal fluid (CSF) nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage and their correlation with clinical outcome. METHODS Nimodipine infusion was started at 1 mg/h and increased up to 2 mg/h and continued up to 21 days in surviving patients. Arterial and CSF samples were collected at least after 24 hours of stable nimodipine dosing. Delayed cerebral ischemia and vasospasm were documented by new neurological deficits and neuroimaging. The clinical outcome was assessed at 9 months by the modified Rankin scale. RESULTS Twenty-three patients were enrolled. Nimodipine dose was 13 to 38 μg/kg per hour. Nimodipine arterial and CSF concentrations were 24.9 to 71.8 ng/mL and 37 to 530 pg/mL, respectively. Dose did not correlate with arterial or CSF concentrations. Arterial concentrations did not correlate with corresponding CSF concentrations. Doses and arterial concentrations did not correlate with the clinical outcome and were not associated with the occurrence of delayed cerebral ischemia. However, patients with no significant disability after 9 months of hemorrhage showed significantly higher CSF nimodipine concentrations (P = 0.015) and CSF-to-plasma ratios (P = 0.011) compared with patients who showed some degree of disability or who died. CONCLUSIONS Cerebrospinal fluid nimodipine concentrations measured during hospital drug infusion showed a correlation with long-term clinical outcome in patients with aneurysmal subarachnoid hemorrhage. These very preliminary data suggest that CSF concentrations monitoring may have some value in managing these patients.
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Hostettler IC, Alg VS, Shahi N, Jichi F, Bonner S, Walsh D, Bulters D, Kitchen N, Brown MM, Houlden H, Grieve J, Werring DJ. Characteristics of Unruptured Compared to Ruptured Intracranial Aneurysms: A Multicenter Case-Control Study. Neurosurgery 2019; 83:43-52. [PMID: 28973585 DOI: 10.1093/neuros/nyx365] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 06/05/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Only a minority of intracranial aneurysms rupture to cause subarachnoid hemorrhage. OBJECTIVE To test the hypothesis that unruptured aneurysms have different characteristics and risk factor profiles compared to ruptured aneurysms. METHODS We recruited patients with unruptured aneurysms or aneurysmal subarachnoid hemorrhages at 22 UK hospitals between 2011 and 2014. Demographic, clinical, and imaging data were collected using standardized case report forms. We compared risk factors using multivariable logistic regression. RESULTS A total of 2334 patients (1729 with aneurysmal subarachnoid hemorrhage, 605 with unruptured aneurysms) were included (mean age 54.22 yr). In multivariable analyses, the following variables were independently associated with rupture status: black ethnicity (odds ratio [OR] 2.42; 95% confidence interval [CI] 1.29-4.56, compared to white) and aneurysm location (anterior cerebral artery/anterior communicating artery [OR 3.21; 95% CI 2.34-4.40], posterior communicating artery [OR 3.92; 95% CI 2.67-5.74], or posterior circulation [OR 3.12; 95% CI 2.08-4.70], compared to middle cerebral artery). The following variables were inversely associated with rupture status: antihypertensive medication (OR 0.65; 95% CI 0.49-0.84), hypercholesterolemia (0.64 OR; 95% CI 0.48-0.85), aspirin use (OR 0.28; 95% CI 0.20-0.40), internal carotid artery location (OR 0.53; 95% CI 0.38-0.75), and aneurysm size (per mm increase; OR 0.76; 95% CI 0.69-0.84). CONCLUSION We show substantial differences in patient and aneurysm characteristics between ruptured and unruptured aneurysms. These findings support the hypothesis that different pathological mechanisms are involved in the formation of ruptured aneurysms and incidentally detected unruptured aneurysms. The potential protective effect of aspirin might justify randomized prevention trials in patients with unruptured aneurysms.
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Affiliation(s)
- Isabel C Hostettler
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Varinder S Alg
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Nichole Shahi
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Fatima Jichi
- Biostatistics Group, University College London Research Support Centre, University College London, UK
| | - Stephen Bonner
- Department of Anaesthesia, The James Cook University Hospital, Middlesbrough, UK
| | - Daniel Walsh
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Diederik Bulters
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Neil Kitchen
- Department of Neurosurgery, The National Hospital of Neurology and Neurosurgery, London, UK
| | - Martin M Brown
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Henry Houlden
- Neurogenetics Laboratory, The National Hospital of Neurology and Neurosurgery, London, UK
| | - Joan Grieve
- Department of Neurosurgery, The National Hospital of Neurology and Neurosurgery, London, UK
| | - David J Werring
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
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9
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Hajizadeh Barfejani A, Rabinstein AA, Wijdicks EF, Clark SL. Poor Utilization of Nimodipine in Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:2155-2158. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/12/2019] [Accepted: 04/18/2019] [Indexed: 11/24/2022] Open
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10
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Al-Mufti F, Amuluru K, Damodara N, El-Ghanem M, Nuoman R, Kamal N, Al-Marsoummi S, Morris NA, Dangayach NS, Mayer SA. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2018; 390:44-51. [DOI: 10.1016/j.jns.2018.02.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 11/27/2022]
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11
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de Oliveira Manoel AL, Macdonald RL. Neuroinflammation as a Target for Intervention in Subarachnoid Hemorrhage. Front Neurol 2018; 9:292. [PMID: 29770118 PMCID: PMC5941982 DOI: 10.3389/fneur.2018.00292] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/16/2018] [Indexed: 01/09/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a sub-type of hemorrhagic stroke associated with the highest rates of mortality and long-term neurological disabilities. Despite the improvement in the management of SAH patients and the reduction in case fatality in the last decades, disability and mortality remain high in this population. Brain injury can occur immediately and in the first days after SAH. This early brain injury can be due to physical effects on the brain such as increased intracranial pressure, herniations, intracerebral, intraventricular hemorrhage, and hydrocephalus. After the first 3 days, angiographic cerebral vasospasm (ACV) is a common neurological complication that in severe cases can lead to delayed cerebral ischemia and cerebral infarction. Consequently, the prevention and treatment of ACV continue to be a major goal. However, most treatments for ACV are vasodilators since ACV is due to arterial vasoconstriction. Other targets also have included those directed at the underlying biochemical mechanisms of brain injury such as inflammation and either independently or as a consequence, cerebral microthrombosis, cortical spreading ischemia, blood–brain barrier breakdown, and cerebral ischemia. Unfortunately, no pharmacologic treatment directed at these processes has yet shown efficacy in SAH. Enteral nimodipine and the endovascular treatment of the culprit aneurysm, remain the only treatment options supported by evidence from randomized clinical trials to improve patients’ outcome. Currently, there is no intervention directly developed and approved to target neuroinflammation after SAH. The goal of this review is to provide an overview on anti-inflammatory drugs tested after aneurysmal SAH.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Adult Critical Care Unit, Hospital Paulistano - United Health Group, São Paulo, Brazil.,Keenan Research Center for Biomedical Science, Department of Surgery, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science, Department of Surgery, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
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12
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Wessell A, Kole MJ, Badjatia N, Parikh G, Albrecht JS, Schreibman DL, Simard JM. High Compliance with Scheduled Nimodipine Is Associated with Better Outcome in Aneurysmal Subarachnoid Hemorrhage Patients Cotreated with Heparin Infusion. Front Neurol 2017. [PMID: 28649230 PMCID: PMC5465287 DOI: 10.3389/fneur.2017.00268] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction We sought to determine whether compliance with scheduled nimodipine in subarachnoid hemorrhage patients impacted patient outcomes, with the intent of guiding future nimodipine management in patients who experience nimodipine-induced hypotension. Methods We performed a retrospective analysis of 118 consecutive aneurysmal subarachnoid hemorrhage patients treated with the Maryland Low-Dose IV Heparin Infusion Protocol. Patients were categorized into three independent nimodipine compliance groups: ≥1 dose held, ≥1 dose split, and no missed or split-doses. A split-dose was defined as 30 mg of nimodipine administered every 2 h. Our primary outcome was discharge to home. Bivariate and multivariable logistic regression analyses were used to assess predictors of discharge disposition as a function of nimodipine compliance. Results Of the 118 patients, 20 (17%) received all nimodipine doses, 6 (5%) received split-doses but never had a full dose held, and 92 (78%) had ≥1 dose held. Forty-five percent of patients were discharged to home, including 75% who received all doses, 67% who received ≥1 split-doses, and 37% with ≥1 missed doses (p = 0.003). Multivariable analysis showed that, along with age and World Federation of Neurosurgical Societies grade, nimodipine compliance was an independent predictor of clinical outcome; compared to missing one or more nimodipine doses, full dosing compliance was associated with increased odds of discharge to home (odds ratio 5.20; 95% confidence intervals 1.46–18.56). Conclusion In aneurysmal subarachnoid hemorrhage patients with modified Fisher scores 2 through 4 who are cotreated with a low-dose heparin infusion, full compliance with nimodipine dosing was associated with increased odds of discharge to home.
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Affiliation(s)
- Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Matthew J Kole
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neeraj Badjatia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gunjan Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - David L Schreibman
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, United States
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13
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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14
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Hänggi D, Etminan N, Aldrich F, Steiger HJ, Mayer SA, Diringer MN, Hoh BL, Mocco J, Faleck HJ, Macdonald RL. Randomized, Open-Label, Phase 1/2a Study to Determine the Maximum Tolerated Dose of Intraventricular Sustained Release Nimodipine for Subarachnoid Hemorrhage (NEWTON [Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage]). Stroke 2016; 48:145-151. [PMID: 27932607 PMCID: PMC5176000 DOI: 10.1161/strokeaha.116.014250] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/17/2016] [Accepted: 11/08/2016] [Indexed: 11/17/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— We conducted a randomized, open-label, phase 1/2a, dose-escalation study of intraventricular sustained-release nimodipine (EG-1962) to determine safety, tolerability, pharmacokinetics, and clinical effects in aneurysmal subarachnoid hemorrhage. Methods— Subjects with aneurysmal subarachnoid hemorrhage repaired by clipping or coiling were randomized to EG-1962 or enteral nimodipine. Subjects were World Federation of Neurological Surgeons grade 2 to 4 and had an external ventricular drain. Cohorts of 12 subjects received 100 to 1200 mg EG-1962 (9 per cohort) or enteral nimodipine (3 per cohort). The primary objective was to determine the maximum tolerated dose. Results— Fifty-four subjects in North America were randomized to EG-1962, and 18 subjects were randomized to enteral nimodipine. The maximum tolerated dose was 800 mg. One serious adverse event related to EG-1962 (400 mg) and 2 EG-1962 dose-limiting toxicities were without clinical sequelae. There was no EG-1962-related hypotension compared with 17% (3/18) with enteral nimodipine. Favorable outcome at 90 days on the extended Glasgow outcome scale occurred in 27/45 (60%, 95% confidence interval 46%–74%) EG-1962 subjects (5/9 with 100, 6/9 with 200, 7/9 with 400, 4/9 with 600, and 5/9 with 800 mg) and 5/18 (28%, 95% confidence interval 7%–48%, relative risk reduction of unfavorable outcome; 1.45, 95% confidence interval 1.04–2.03; P=0.027) enteral nimodipine subjects. EG-1962 reduced delayed cerebral ischemia (14/45 [31%] EG-1962 versus 11/18 [61%] enteral nimodipine) and rescue therapy (11/45 [24%] versus 10/18 [56%]). Conclusions— EG-1962 was safe and tolerable to 800 mg, and in this, aneurysmal subarachnoid hemorrhage population was associated with reduced delayed cerebral ischemia and rescue therapy. Overall, the rate of favorable clinical outcome was greater in the EG-1962-treated group. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01893190.
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Affiliation(s)
- Daniel Hänggi
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.).
| | - Nima Etminan
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Francois Aldrich
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Hans Jakob Steiger
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Stephan A Mayer
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Michael N Diringer
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Brian L Hoh
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - J Mocco
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - Herbert J Faleck
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
| | - R Loch Macdonald
- From the Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (D.H., N.E.); Neurological Surgery, University of Maryland Medical Center, Baltimore (F.A.); Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany (H.J.S.); Institute for Critical Care Medicine and Department of Neurosurgery, Mount Sinai Hospital, New York (S.A.M., J.M.); Neurological Critical Care, Washington University School of Medicine, St. Louis, MO (M.N.D.); Department of Neurosurgery, University of Florida, Gainesville (B.L.H.); Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada (R.L.M.); and Edge Therapeutics, Berkeley Heights, NJ (R.L.M., H.J.F.)
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Hänggi D, Etminan N, Macdonald RL, Steiger HJ, Mayer SA, Aldrich F, Diringer MN, Hoh BL, Mocco J, Strange P, Faleck HJ, Miller M. NEWTON: Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage. Neurocrit Care 2016; 23:274-84. [PMID: 25678453 DOI: 10.1007/s12028-015-0112-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. EG-1962 is a sustained-release microparticle formulation of nimodipine that has shown preclinical efficacy when administered intraventricularly or intracisternally to dogs with SAH, without evidence of toxicity at doses in the anticipated therapeutic range. Thus, we propose to administer EG-1962 to humans in order to assess safety and tolerability and determine a dose to investigate efficacy in subsequent clinical studies. METHODS We describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the maximum tolerated dose (MTD) and assess the safety and tolerability of EG-1962 in patients with aSAH. The study will comprise two parts: a dose escalation period (Part 1) to determine the MTD of EG-1962 and a treatment period (Part 2) to assess the safety and tolerability of the selected dose of EG-1962. Patients with a ruptured saccular aneurysm treated by neurosurgical clipping or endovascular coiling will be considered for enrollment. Patients will be randomized to receive either EG-1962 (study drug: nimodipine microparticles) or oral nimodipine in the approved dose regimen (active control) within 60 h of aSAH. RESULTS Primary objectives are to determine the MTD and the safety and tolerability of the selected dose of intraventricular EG-1962 as compared to enteral nimodipine. The secondary objective is to determine release and distribution by measuring plasma and CSF concentrations of nimodipine. Exploratory objectives are to determine the incidence of delayed cerebral infarction on computed tomography, clinical features of delayed cerebral ischemia, angiographic vasospasm, and incidence of rescue therapy and clinical outcome. Clinical outcome will be determined at 90 days after aSAH using the extended Glasgow outcome scale, modified Rankin scale, Montreal cognitive assessment, telephone interview of cognitive status, and Barthel index. CONCLUSION Here, we describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the MTD and assess the safety and tolerability of EG-1962 in patients with aSAH.
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Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany,
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16
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Hänggi D, Etminan N, Steiger HJ, Johnson M, Peet MM, Tice T, Burton K, Hudson B, Turner M, Stella A, Heshmati P, Davis C, Faleck HJ, Macdonald RL. A Site-Specific, Sustained-Release Drug Delivery System for Aneurysmal Subarachnoid Hemorrhage. Neurotherapeutics 2016; 13:439-49. [PMID: 26935204 PMCID: PMC4824023 DOI: 10.1007/s13311-016-0424-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Nimodipine is the only drug approved for use by the Food and Drug Administration for improving outcome after aneurysmal subarachnoid hemorrhage (SAH). It has less than optimal efficacy, causes dose-limiting hypotension in a substantial proportion of patients, and is administered enterally 6 times daily. We describe development of site-specific, sustained-release nimodipine microparticles that can be delivered once directly into the subarachnoid space or cerebral ventricles for potential improvement in outcome of patients with aneurysmal SAH. Eight injectable microparticle formulations of nimodipine in poly(DL-lactide-co-glycolide) (PLGA) polymers of varying composition were tested in vitro, and 1 was advanced into preclinical studies and clinical application. Intracisternal or intraventricular injection of nimodipine-PLGA microparticles in rats and beagles demonstrated dose-dependent, sustained concentrations of nimodipine in plasma and cerebrospinal fluid for up to 29 days with minimal toxicity in the brain or systemic tissues at doses <2 mg in rats and 51 mg in beagles, which would be equivalent of up to 612-1200 mg in humans, based on scaling relative to cerebrospinal fluid volumes. Efficacy was tested in the double-hemorrhage dog model of SAH. Nimodipine-PLGA microparticles significantly attenuated angiographic vasospasm. This therapeutic approach shows promise for improving outcome after SAH and may have broader applicability for similar diseases that are confined to body cavities or spaces, are self-limited, and lack effective treatments.
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Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, University Medical Center Mannheim, Ruprecht-Karls-University Heidelberg, Germany, Mannheim, Germany.
| | - Nima Etminan
- Department of Neurosurgery, University Medical Center Mannheim, Ruprecht-Karls-University Heidelberg, Germany, Mannheim, Germany
| | - Hans Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | | | | | - Tom Tice
- Evonik Industries, Birmingham, AL, USA
| | | | | | | | | | | | | | | | - R Loch Macdonald
- Edge Therapeutics, Inc., Berkeley Heights, NJ, USA
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Toronto, ON, Canada
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de Oliveira Manoel AL, Goffi A, Marotta TR, Schweizer TA, Abrahamson S, Macdonald RL. The critical care management of poor-grade subarachnoid haemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:21. [PMID: 26801901 PMCID: PMC4724088 DOI: 10.1186/s13054-016-1193-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50% to 35% in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada. .,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Alberto Goffi
- Toronto Western Hospital MSNICU, 2nd Floor McLaughlin Room 411-H, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Tom R Marotta
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Simon Abrahamson
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - R Loch Macdonald
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
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18
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Flynn L, Andrews P. Advances in the understanding of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage. F1000Res 2015; 4:F1000 Faculty Rev-1200. [PMID: 26937276 PMCID: PMC4752028 DOI: 10.12688/f1000research.6635.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2015] [Indexed: 12/23/2022] Open
Abstract
Delayed cerebral ischaemia has been described as the single most important cause of morbidity and mortality in patients who survive the initial aneurysmal subarachnoid haemorrhage. Our understanding of the pathophysiology of delayed cerebral ischaemia is meagre at best and the calcium channel blocker nimodipine remains the only intervention to consistently improve functional outcome after aneurysmal subarachnoid haemorrhage. There is substantial evidence to support cerebral vessel narrowing as a causative factor in delayed cerebral ischaemia, but contemporary research demonstrating improvements in vessel narrowing has failed to show improved functional outcomes. This has encouraged researchers to investigate other potential causes of delayed cerebral ischaemia, such as early brain injury, microthrombosis, and cortical spreading depolarisation. Adherence to a common definition of delayed cerebral ischaemia is needed in order to allow easier assessment of studies using multiple different terms. Furthermore, improved recognition of delayed cerebral ischaemia would not only allow for faster treatment but also better assessment of interventions. Finally, understanding nimodipine's mechanism of action may allow us to develop similar agents with improved efficacy.
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Affiliation(s)
- Liam Flynn
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Serrone JC, Maekawa H, Tjahjadi M, Hernesniemi J. Aneurysmal subarachnoid hemorrhage: pathobiology, current treatment and future directions. Expert Rev Neurother 2015; 15:367-80. [PMID: 25719927 DOI: 10.1586/14737175.2015.1018892] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aneurysmal subarachnoid hemorrhage is the most devastating form of stroke. Many pathological mechanisms ensue after cerebral aneurysm rupture, including hydrocephalus, apoptosis of endothelial cells and neurons, cerebral edema, loss of blood-brain barrier, abnormal cerebral autoregulation, microthrombosis, cortical spreading depolarization and macrovascular vasospasm. Although studied extensively through experimental and clinical trials, current treatment guidelines to prevent delayed cerebral ischemia is limited to oral nimodipine, maintenance of euvolemia, induction of hypertension if ischemic signs occur and endovascular therapy for patients with continued ischemia after induced hypertension. Future investigations will involve agents targeting vasodilation, anticoagulation, inhibition of apoptosis pathways, free radical neutralization, suppression of cortical spreading depolarization and attenuation of inflammation.
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Affiliation(s)
- Joseph C Serrone
- Department of Neurosurgery, Töölö Hospital, University of Helsinki, Topeliuksenkatu 5, PO Box 266, 00029 HUS, Helsinki, Finland
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20
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Etminan N, Macdonald RL, Davis C, Burton K, Steiger HJ, Hänggi D. Intrathecal application of the nimodipine slow-release microparticle system eg-1962 for prevention of delayed cerebral ischemia and improvement of outcome after aneurysmal subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:281-6. [PMID: 25366637 DOI: 10.1007/978-3-319-04981-6_47] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The effective reduction of delayed cerebral ischemia (DCI), a main contributor for poor outcome following aneurysmal subarachnoid hemorrhage (SAH), remains challenging. Previous clinical trials on systemic pharmaceutical treatment of SAH mostly failed to improve outcome, probably because of insensitive pharmaceutical targets and outcome measures, small sample size, insufficient subarachnoid drug concentrations and also detrimental, systemic effects of the experimental treatment per se. Interestingly, in studies that are more recent, intrathecal administration of nicardipine pellets following surgical aneurysm repair was suggested to have a beneficial effect on DCI and neurological outcome. However, this positive effect remained restricted to patients who were treated surgically for a ruptured aneurysm. Because of the favorable results of the preclinical data on DCI and neurological outcome in the absence of neurotoxicity or systemic side effects, we are initiating clinical trials. The PROMISE (Prolonged Release nimOdipine MIcro particles after Subarachnoid hemorrhage) trial is designed as an unblinded, nonrandomized, single-center, single-dose, dose-escalation safety and tolerability phase 1 study in patients surgically treated for aSAH and will investigate the effect of intracisternal EG-1962 administration. The NEWTON (Nimodipine microparticles to Enhance recovery While reducing TOxicity after subarachNoid hemorrhage) trial is a phase 1/2a multicenter, controlled, randomized, open-label, dose-escalation, safety, tolerability, and pharmacokinetic study comparing EG-1962 and nimodipine in patients with aneurysmal SAH.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstr.5, 40225, Düsseldorf, Germany,
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Loch Macdonald R. Vasospasm: my first 25 years-what worked? what didn't? what next? ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:1-10. [PMID: 25366591 DOI: 10.1007/978-3-319-04981-6_1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Angiographic vasospasm as a complication of aneurysmal and other types of subarachnoid hemorrhage (SAH) was identified about 62 years ago. It is now hypothesized that angiographic vasospasm contributes to delayed cerebral ischemia (DCI) by multiple pathways, including reduced blood flow from angiographic vasospasm as well as microcirculatory constriction, microthrombosis, cortical spreading ischemia, and delayed effects of early brain injury. It is likely that other factors, such as systemic complications, effects of the subarachnoid blood, brain collateral and anastomotic blood flow, and the genetic and epigenetic makeup of the patient, contribute to the individual's response to SAH. Treatment of aneurysmal SAH and DCI includes neurocritical care management, early aneurysm repair, prophylactic administration of nimodipine, and rescue therapies (induced hypertension and balloon or pharmacologic angioplasty) if the patient develops DCI. Well-designed clinical trials of tirilazad, clasozentan, antiplatelet drugs, and magnesium have been conducted using more than a 1,000 patients each. Some of these drugs have almost purely vascular effects; other drugs are theoretically neuroprotective as well, but they share in common the ability to reduce angiographic vasospasm and, in many cases, DCI, but have no effect on clinical outcome. Experimental research in SAH continues to identify new targets for therapy. Challenges for the future will be to identify the most promising drugs to advance from preclinical studies and to understand why clinical trials have so frequently failed to show drug benefit on clinical outcome. Similar issues with treatment of ischemic stroke are being addressed by suggestions for improving the quality of experimental studies, collaborative preclinical trials, and multinational, multicenter clinical studies that can rapidly include many patients and be large enough to account for numerous factors that conspire to disrupt clinical trials.
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada,
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Ding D. Contribution of cerebral vasospasm to delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2014; 336:293-4. [PMID: 24238998 DOI: 10.1016/j.jns.2013.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 10/25/2013] [Accepted: 10/29/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurological Surgery, P.O. Box 800212, Charlottesville, VA 22908, United States.
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Kahandal SS, Kale SR, Gawande MB, Jayaram RV. A mild route for one pot synthesis of 5,6-unsubstituted 1,4-dihydropyridines catalyzed by sulphated mixed metal oxides. Catal Sci Technol 2014. [DOI: 10.1039/c3cy00651d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Brathwaite S, Macdonald RL. Current management of delayed cerebral ischemia: update from results of recent clinical trials. Transl Stroke Res 2013; 5:207-26. [PMID: 24338266 DOI: 10.1007/s12975-013-0316-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/23/2013] [Accepted: 11/29/2013] [Indexed: 01/19/2023]
Abstract
Subarachnoid hemorrhage (SAH) accounts for 5-7% of all strokes worldwide and is associated with high mortality and morbidity. Even after surgical intervention, approximately 30% of patients develop long-term cognitive and neurological deficits that significantly affect their capacity to return to work or daily life unassisted. Much of this stems from a secondary ischemic phenomenon referred to as delayed cerebral ischemia (DCI). While DCI has been historically attributed to the narrowing of the large basal cerebral arteries, it is now recognized that numerous pathways contribute to its pathogenesis, including microcirculatory dysfunction, microthrombosis, cortical spreading depression, and early brain injury. This paper seeks to summarize some of the key pathophysiological events that are associated with poor outcome after SAH, provide a general overview of current methods of treating SAH patients, and review the results of recent clinical trials directed at improving outcome after SAH. The scientific basis of these studies will be discussed, in addition to the available results and recommendations for effective patient management. Therapeutic methods under current clinical investigation will also be addressed. In particular, the mechanisms by which they are expected to elicit improved outcome will be investigated, as well as the specific study designs and anticipated time lines for completion.
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Affiliation(s)
- Shakira Brathwaite
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada, M5B 1W8
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SAHIT Investigators--on the outcome of some subarachnoid hemorrhage clinical trials. Transl Stroke Res 2013; 4:286-96. [PMID: 24323299 DOI: 10.1007/s12975-012-0242-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/18/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
Abstract
Outcome of patients with aneurysmal subarachnoid hemorrhage (SAH) has improved over the last decades. Yet, case fatality remains nearly 40% and survivors often have permanent neurological, cognitive and/or behavioural sequelae. Other than nimodipine drug or clinical trials have not consistently improved outcome. We formed a collaboration of SAH investigators to create a resource for prognostic analysis and for studies aimed at optimizing the design and analysis of phase 3 trials in aneurysmal SAH. We identified investigators with data from randomized, clinical trials of patients with aneurysmal SAH or prospectively collected single- or multicentre databases of aneurysmal SAH patients. Data are being collected and proposals to use the data and to design future phase 3 clinical trials are being discussed. This paper reviews some issues discussed at the first meeting of the SAH international trialists (SAHIT) repository meeting. Investigators contributed or have agreed to contribute data from several phase 3 trials including the tirilazad trials, intraoperative hypothermia for aneurysmal SAH trial, nicardipine clinical trials, international subarachnoid aneurysm trial, intravenous magnesium sulphate for aneurysmal SAH, magnesium for aneurysmal SAH and from prospectively-collected data from four institutions. The number of patients should reach 15,000. Some industry investigators refused to provide data and others reported that their institutional research ethics boards would not permit even deidentified or anonymized data to be included. Others reported conflict of interest that prevented them from submitting data. The problems with merging data were related to lack of common definitions and coding of variables, differences in outcome scales used, and times of assessment. Some questions for investigation that arose are discussed. SAHIT demonstrates the possibility of SAH investigators to contribute data for collaborative research. The problems are similar to those already documented in other similar collaborative efforts such as in head injury research. We encourage clinical trial and registry investigators to contact us and participate in SAHIT. Key issues moving forward will be to use common definitions (common data elements), outcomes analysis, and to prioritize research questions, among others.
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Angiographic vasospasm versus cerebral infarction as outcome measures after aneurysmal subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 115:33-40. [PMID: 22890640 DOI: 10.1007/978-3-7091-1192-5_8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Despite a significant reduction of angiographic vasospasm, the reduction of poor functional outcome in clinical trials on aneurysmal subarachnoid hemorrhage (SAH) remains challenging. While there is general consensus that vasospasm is associated with delayed cerebral ischemia (DCI), cerebral infarction, poor functional outcome, and mortality after SAH, causal relationships are subject to discussion. Therefore, it was the aim of our study to investigate the relationship between various outcome measures and poor functional outcome in clinical trials on pharmaceutical treatment of SAH. METHODS Based on data from two systematic reviews and a post hoc exploratory analysis, the relationship between the following outcome measures was investigated: (1) radiographic vasospasm, (2) DCI, (3) cerebral infarction, (4) poor functional outcome, and (5) death. RESULTS A reduction of angiographic vasospasm did not correlate with an improvement on dichotomous Glasgow Outcome Scale/modified Rankin Scale (GOS/mRS). In contrast, a reduction of cerebral infarction correlated with better neurological outcomes. The heterogeneous definition of DCI in previous clinical trials did not allow pooling of the data. CONCLUSION Future clinical trials may use cerebral infarction and functional outcome as main outcome measures to -investigate the true impact of an intervention, assuming that the intervention targets cerebral infarction and hereby improves outcome.
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Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KTS. Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm. Br J Anaesth 2012; 109:315-29. [PMID: 22879655 DOI: 10.1093/bja/aes264] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite improvements in the clinical management of aneurysmal subarachnoid haemorrhage over the last decade, delayed cerebral ischaemia (DCI) remains the single most important cause of morbidity and mortality in those patients who survive the initial bleed. The pathological mechanisms underlying DCI are still unclear and the calcium channel blocker nimodipine remains the only therapeutic intervention proven to improve functional outcomes after SAH. The recent failure of the drug clazosentan to improve functional outcomes despite reducing vasoconstriction has moved the focus of research into DCI away from cerebral artery constriction towards a more multifactorial aetiology. Novel pathological mechanisms have been suggested, including damage to cerebral tissue in the first 72 h after aneurysm rupture ('early brain injury'), cortical spreading depression, and microthrombosis. A greater understanding of the significance of these pathophysiological mechanisms and potential genetic risk factors is required, if new approaches to the prophylaxis, diagnosis, and treatment of DCI are to be developed. Furthermore, objective and reliable biomarkers are needed for the diagnosis of DCI in poor grade SAH patients requiring sedation and to assess the efficacy of new therapeutic interventions. The purpose of this article is to appraise these recent advances in research into DCI, relate them to current clinical practice, and suggest potential novel avenues for future research.
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Affiliation(s)
- M J Rowland
- Nuffield Division of Anaesthetics and FMRIB Centre, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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Abstract
Tice and colleagues pioneered site-specific, sustained-release drug delivery to the brain almost 30 years ago. Currently there is one drug approved for use in this manner. Clinical trials in subarachnoid hemorrhage have led to approval of nimodipine for oral and intravenous use, but other drugs, such as clazosentan, hydroxymethylglutaryl CoA reductase inhibitors (statins) and magnesium, have not shown consistent clinical efficacy. We propose that intracranial delivery of drugs such as nimodipine, formulated in sustained-release preparations, are good candidates for improving outcome after subarachnoid hemorrhage because they can be administered to patients that are already undergoing surgery and who have a self-limited condition from which full recovery is possible.
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Ozkan G, Ulusoy S, Sönmez M, Karahan SC, Menteşe A, Kaynar K, Bektaş O. Thrombin activatable fibrinolysis inhibitor (TAFI) levels in hypertensive patients and a comparison of the effects of amlodipine and ramipril on TAFI levels. Clin Exp Hypertens 2012; 35:134-40. [PMID: 22799880 DOI: 10.3109/10641963.2012.702833] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hypertension is associated with fibrinolysis abnormality. Thrombin-activatable fibrinolysis inhibitor (TAFI) is a novel molecule-linking coagulation and fibrinolysis. The aim of this study was to investigate the levels of TAFI in primary hypertensive patients and to compare the effects of amlodipine and ramipril on TAFI levels. The study was performed with 58 hypertensive subjects and 27 healthy volunteers. Biochemical and hematological parameters and TAFI levels were measured at baseline and after 1-month follow-up. TAFI concentrations increased in hypertensive patients compared with the controls (P = .030). Additionally, TAFI levels decreased with blood pressure control at 1-month follow-up (P = .026). There was no significant difference between TAFI levels in the amlodipine and ramipril groups at baseline. However, after 1-month follow-up, TAFI levels were decreased in the amlodipine group (P = .037) but not in the ramipril group. Our study is the first in the literature to determine increased TAFI levels in primary hypertension patients. In addition, we determined a decrease in TAFI levels in the amlodipine group after 1 month, but none in the ramipril group.
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Affiliation(s)
- Gulsum Ozkan
- Department of Nephrology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey.
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30
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Macdonald RL. Nimodipine—Oral or Intravenous? No—Subarachnoid. World Neurosurg 2012; 78:50-2. [DOI: 10.1016/j.wneu.2011.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 10/06/2011] [Indexed: 11/26/2022]
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Macdonald RL. Site-Specific, Sustained-Release Drug Delivery for Subarachnoid Hemorrhage. Transl Stroke Res 2012. [DOI: 10.1007/978-1-4419-9530-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pisapia JM, Xu X, Kelly J, Yeung J, Carrion G, Tong H, Meghan S, El-Falaky OM, Grady MS, Smith DH, Zaitsev S, Muzykantov VR, Stiefel MF, Stein SC. Microthrombosis after experimental subarachnoid hemorrhage: time course and effect of red blood cell-bound thrombin-activated pro-urokinase and clazosentan. Exp Neurol 2011; 233:357-63. [PMID: 22079156 DOI: 10.1016/j.expneurol.2011.10.029] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/24/2011] [Accepted: 10/28/2011] [Indexed: 10/15/2022]
Abstract
Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality for patients surviving the rupture of an intracranial aneurysm. Despite an association between vasospasm and DCI, thrombosis and thromboembolism may also contribute to DCI. In this study we investigate the time course of intravascular microclot formation after experimental subarachnoid hemorrhage (SAH) and assess the effects of the following two drugs on microclot burden: mutant thrombin-activated urokinase-type plasminogen activator (scFv/uPA-T), which is bound to red blood cells for use as a thromboprophylactic agent, and clazosentan, an endothelin antagonist. In the first study, adult male C57BL/6 mice were sacrificed at 24 (n=5), 48 (n=6), 72 (n=8), and 96 (n=3) hours after SAH induced by filament perforation of the anterior cerebral artery. Sham animals (n=5) underwent filament insertion without puncture. In the second study, animals received scFv/uPA-T (n=5) 3 hours after hemorrhage, clazosentan (n=5) by bolus and subcutaneous pump after SAH just prior to skin closure, or a combination of scFv/uPA-T and clazosentan (n=4). Control (n=6) and sham (n=5) animals received saline alone. All animals were sacrificed at 48 hours and underwent intra-cardiac perfusion with 4% paraformaldehyde. The brains were then extracted and sliced coronally on a cryostat and processed for immunohistochemistry. An antibody recognizing thrombin-anti-thrombin complexes was used to detect microclots on coronal slices. Microclot burden was calculated for each animal and compared among groups. Following SAH, positive anti-thrombin staining was detected bilaterally in the following brain regions, in order of decreasing frequency: cortex; hippocampus; hypothalamus; basal ganglia. Few microclots were found in the shams. Microclot burden peaked at 48 hours and then decreased gradually. Animals receiving scFv/uPA-T and scFv/uPA-T+clazosentan had a lower microclot burden than controls, whereas animals receiving clazosentan alone had a higher microclot burden (p<0.005). The overall mortality rate in the time course study was 40%; mortality was highest among control animals in the second study. Intravascular microclots form in a delayed fashion after experimental SAH. Microclots may be safely reduced using a novel form of thromboprophylaxis provided by RBC-targeted scFv/uPA-T and represent a potential target for therapeutic intervention in the treatment of DCI.
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Affiliation(s)
- Jared M Pisapia
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Etminan N, Vergouwen MDI, Ilodigwe D, Macdonald RL. Effect of pharmaceutical treatment on vasospasm, delayed cerebral ischemia, and clinical outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Cereb Blood Flow Metab 2011; 31:1443-51. [PMID: 21285966 PMCID: PMC3130329 DOI: 10.1038/jcbfm.2011.7] [Citation(s) in RCA: 193] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As it is often assumed that delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is caused by vasospasm, clinical trials often focus on prevention of vasospasm with the aim to improve clinical outcome. However, the role of vasospasm in the pathogenesis of DCI and clinical outcome is possibly smaller than previously assumed. We performed a systematic review and meta-analysis on all randomized, double-blind, placebo-controlled trials that studied the effect of pharmaceutical preventive strategies on vasospasm, DCI, and clinical outcome in SAH patients to further investigate the relationship between vasospasm and clinical outcome. Effect sizes were expressed in pooled risk ratio (RR) estimates with corresponding 95% confidence intervals (CI). A total of 14 studies randomizing 4,235 patients were included. Despite a reduction of vasospasm (RR 0.80 (95% CI 0.70 to 0.92)), no statistically significant effect on poor outcome was observed (RR 0.93 (95% CI 0.85 to 1.03)). The variety of DCI definitions did not justify pooling the DCI data. We conclude that pharmaceutical treatments have significantly decreased the incidence of vasospasm, but not of poor clinical outcome. This dissociation between vasospasm and clinical outcome could result from methodological problems, sample size, insensitivity of clinical outcome measures, or from mechanisms other than vasospasm that also contribute to poor outcome.
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Affiliation(s)
- Nima Etminan
- Division of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada.
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Nikitina E, Kawashima A, Takahashi M, Zhang ZD, Shang X, Ai J, Macdonald RL. Alteration in voltage-dependent calcium channels in dog basilar artery after subarachnoid hemorrhage. J Neurosurg 2010; 113:870-80. [DOI: 10.3171/2010.2.jns091038] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The L-type Ca++ channel antagonists like nimodipine have limited efficacy against vasospasm after subarachnoid hemorrhage (SAH). The authors tested the hypothesis that this is because SAH alters these channels, rendering them less responsible for contraction.
Methods
Basilar artery smooth muscle cells were isolated 4, 7, and 21 days after SAH in dogs, and Ca++ channel currents were recorded in 10-mmol/L barium. Proteins for α1 subunits of L-type Ca++ channels were measured by immunoblotting and isometric tension recordings done on rings of the basilar artery.
Results
High voltage–activated (HVA) Ca++ channel currents were significantly decreased and low voltage–activated (LVA) currents increased during vasospasm 4, 7, and 21 days after SAH (p < 0.05). Vasospasm was associated with a significant decrease in the number of cells with negligible LVA current while the number of cells in which the LVA current formed greater than 50% of the maximal current increased (p < 0.01). Window currents through LVA and HVA channels were significantly reduced. All changes correlated with the severity of vasospasm. There was an increase in protein for Cav3.1 and Cav3.3 α1 subunits that comprise T-type Ca++ channels, a decrease in L-type (Cav1.2 and Cav1.3) and an increase in R-type (Cav2.3) Ca++ channel α1 subunits. Functionally, however, isometric tension studies showed vasospastic arteries still relaxed with nimodipine.
Conclusions
Voltage-dependent Ca++ channels are altered in cerebral arteries after SAH. While decreased L-type channels may account for the lack of efficacy of nimodipine clinically, there may be other reasons such as inadequate dose, effect of nimodipine on other cellular targets, and mechanisms of vasospasm other than smooth muscle contraction mediated by activation of L-type Ca++ channels.
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Affiliation(s)
- Elena Nikitina
- 1Department of Surgery, University of Chicago Medical Center and Pritzker School of Medicine, Chicago, Illinois; and
| | - Ayako Kawashima
- 2Division of Neurosurgery, Keenan Research Centre and the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Ontario, Canada
| | - Masataka Takahashi
- 1Department of Surgery, University of Chicago Medical Center and Pritzker School of Medicine, Chicago, Illinois; and
| | - Zhen-Du Zhang
- 1Department of Surgery, University of Chicago Medical Center and Pritzker School of Medicine, Chicago, Illinois; and
| | - Xueyuan Shang
- 2Division of Neurosurgery, Keenan Research Centre and the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Ontario, Canada
| | - Jinglu Ai
- 2Division of Neurosurgery, Keenan Research Centre and the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Ontario, Canada
| | - R. Loch Macdonald
- 2Division of Neurosurgery, Keenan Research Centre and the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Ontario, Canada
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van den Bergh WM. Is There a Future for Neuroprotective Agents in Cardiac Surgery? Semin Cardiothorac Vasc Anesth 2010; 14:123-35. [DOI: 10.1177/1089253210370624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article gives an overview of neuroprotective drugs that were recently tested in clinical trials in cardiac surgery. Also, recommendations are given for successful translational research and considerations for management during cardiac surgery.
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Saraf S, Christopoulos C, Salha IB, Stott DJ, Gorog DA. Impaired Endogenous Thrombolysis in Acute Coronary Syndrome Patients Predicts Cardiovascular Death and Nonfatal Myocardial Infarction. J Am Coll Cardiol 2010; 55:2107-15. [DOI: 10.1016/j.jacc.2010.01.033] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 12/23/2009] [Accepted: 01/06/2010] [Indexed: 10/19/2022]
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Viale M, Cordazzo C, de Totero D, Budriesi R, Rosano C, Leoni A, Ioan P, Aiello C, Croce M, Andreani A, Rambaldi M, Russo P, Chiarini A, Spinelli D. Inhibition of MDR1 activity and induction of apoptosis by analogues of nifedipine and diltiazem: an in vitro analysis. Invest New Drugs 2009; 29:98-109. [DOI: 10.1007/s10637-009-9340-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 09/28/2009] [Indexed: 11/29/2022]
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Jeon H, Ai J, Sabri M, Tariq A, Shang X, Chen G, Macdonald RL. Neurological and neurobehavioral assessment of experimental subarachnoid hemorrhage. BMC Neurosci 2009; 10:103. [PMID: 19706182 PMCID: PMC2749856 DOI: 10.1186/1471-2202-10-103] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 08/25/2009] [Indexed: 01/14/2023] Open
Abstract
About 50% of humans with aneurysmal subarachnoid hemorrhage (SAH) die and many survivors have neurological and neurobehavioral dysfunction. Animal studies usually focused on cerebral vasospasm and sometimes neuronal injury. The difference in endpoints may contribute to lack of translation of treatments effective in animals to humans. We reviewed prior animal studies of SAH to determine what neurological and neurobehavioral endpoints had been used, whether they differentiated between appropriate controls and animals with SAH, whether treatment effects were reported and whether they correlated with vasospasm. Only a few studies in rats examined learning and memory. It is concluded that more studies are needed to fully characterize neurobehavioral performance in animals with SAH and assess effects of treatment.
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Affiliation(s)
- Hyojin Jeon
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Ducruet AF, Grobelny BT, Zacharia BE, Hickman ZL, Yeh ML, Connolly ES. Pharmacotherapy of cerebral ischemia. Expert Opin Pharmacother 2009; 10:1895-906. [DOI: 10.1517/14656560903055095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Vergouwen MDI, Vermeulen M, Coert BA, Stroes ESG, Roos YBWEM. Microthrombosis after aneurysmal subarachnoid hemorrhage: an additional explanation for delayed cerebral ischemia. J Cereb Blood Flow Metab 2008; 28:1761-70. [PMID: 18628782 DOI: 10.1038/jcbfm.2008.74] [Citation(s) in RCA: 239] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with aneurysmal subarachnoid hemorrhage (SAH) who experience delayed cerebral ischemia (DCI) have an increased risk of poor outcome. Delayed cerebral ischemia is considered to be caused by vasospasm. However, not all patients with DCI have vasospasm. Inversely, not all patients with vasospasm develop clinical symptoms and signs of DCI. In the past, treatments aiming at vasospasm were not successful in preventing ischemia. The purpose of this review is to give an overview of clinical data showing that DCI cannot always be attributed to vasospasm, and to present an in-depth analysis of clinical and autopsy studies on the role of microthrombosis in the pathogenesis of DCI. Clinical studies show that DCI is associated with an activation of the coagulation cascade within a few days after SAH, preceding the time window during which vasospasm occurs. Furthermore, impaired fibrinolytic activity, and inflammatory and endothelium-related processes, lead to the formation of microthrombi, which ultimately result in DCI. The presence of microthrombi is confirmed by autopsy studies. Insight in the pathophysiology of DCI is crucial for the development of effective therapies against this complication. Because multiple pathways are involved, future research should focus on drugs with pleiotropic effects.
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Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Luszczki JJ, Trojnar MK, Trojnar MP, Kimber-Trojnar Z, Szostakiewicz B, Zadrozniak A, Borowicz KK, Czuczwar SJ. Effects of amlodipine, diltiazem, and verapamil on the anticonvulsant action of topiramate against maximal electroshock-induced seizures in micePresented in part at the 11th Congress of the European Federation of Neurological Societies, Brussels, Belgium, 25–28 August 2007. Can J Physiol Pharmacol 2008; 86:113-21. [DOI: 10.1139/y08-007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To assess the effect of 3 calcium channel antagonists (amlodipine, diltiazem, and verapamil) on the anticonvulsant action of topiramate (a new generation antiepileptic drug) in the mouse maximal electroshock seizure (MES) model. Amlodipine (20 mg/kg) significantly enhanced the anticonvulsant activity of topiramate in the MES test in mice, reducing its ED50 value from 54.83 to 33.10 mg/kg (p < 0.05). Similarly, diltiazem (5 and 10 mg/kg) markedly potentiated the antiseizure action of topiramate against MES, lowering its ED50 value from 54.83 to 32.48 mg/kg (p < 0.05) and 28.68 mg/kg (p < 0.01), respectively. In contrast, lower doses of amlodipine (5 and 10 mg/kg) and diltiazem (2.5 mg/kg) and all doses of verapamil (5, 10, and 20 mg/kg) had no significant impact on the antiseizure action of topiramate. Pharmacokinetic verification of the interaction of topiramate with amlodipine and diltiazem revealed that neither amlodipine nor diltiazem affected total brain topiramate concentration in experimental animals, and thus, the observed interactions were concluded to be pharmacodynamic in nature. The favorable combinations of topiramate with amlodipine or diltiazem deserve more attention from a clinical viewpoint because the enhanced antiseizure action of topiramate was not associated with any pharmacokinetic changes in total brain topiramate concentration.
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Affiliation(s)
- Jarogniew J. Luszczki
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Michal K. Trojnar
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Marcin P. Trojnar
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Zaneta Kimber-Trojnar
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Beata Szostakiewicz
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Anna Zadrozniak
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Kinga K. Borowicz
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
| | - Stanislaw J. Czuczwar
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, PL 20-950 Lublin, Poland
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090 Lublin, Poland
- Department of Internal Medicine, Medical University of Lublin, Staszica 16, PL 20-081 Lublin, Poland
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