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Vázquez-Medina A, Turnbull MT, James CL, Cowart JB, Lesser E, Carter RE, Ross OA, Miller DA, Meschia JF, De Jesús Espinosa A, Weinshilboum R, Freeman WD. Nimodipine-associated standard dose reductions and neurologic outcomes after aneurysmal subarachnoid hemorrhage: the era of pharmacogenomics. THE PHARMACOGENOMICS JOURNAL 2024; 24:19. [PMID: 38890281 DOI: 10.1038/s41397-024-00340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/16/2024] [Accepted: 06/03/2024] [Indexed: 06/20/2024]
Abstract
Nimodipine, an L-type cerebroselective calcium channel antagonist, is the only drug approved by the US Food and Drug Administration for the neuroprotection of patients with aneurysmal subarachnoid hemorrhage (aSAH). Four randomized, placebo-controlled trials of nimodipine demonstrated clinical improvement over placebo; however, these occurred before precision medicine with pharmacogenomics was readily available. The standard enteral dose of nimodipine recommended after aSAH is 60 mg every 4 h. However, up to 78% of patients with aSAH develop systemic arterial hypotension after taking the drug at the recommended dose, which could theoretically limit its neuroprotective role and worsen cerebral perfusion pressure and cerebral blood flow, particularly when concomitant vasospasm is present. We investigated the association between nimodipine dose changes and clinical outcomes in a consecutive series of 150 patients (mean age, 56 years; 70.7% women) with acute aSAH. We describe the pharmacogenomic relationship of nimodipine dose reduction with clinical outcomes. These results have major implications for future individualized dosing of nimodipine in the era of precision medicine.
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Affiliation(s)
- Adriana Vázquez-Medina
- University of Puerto Rico, Medical Sciences Campus School of Medicine, San Juan, Puerto Rico
| | | | - Courtney L James
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Jennifer B Cowart
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Elizabeth Lesser
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL, USA
| | - Rickey E Carter
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL, USA
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Owen A Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - David A Miller
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - W David Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.
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Serag I, Abouzid M, Elmoghazy A, Sarhan K, Alsaad SA, Mohamed RG. An updated systematic review of neuroprotective agents in the treatment of spinal cord injury. Neurosurg Rev 2024; 47:132. [PMID: 38546884 DOI: 10.1007/s10143-024-02372-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/03/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
This systematic review aims to summarize the findings from all clinical randomized trials assessing the efficacy of potential neuroprotective agents in influencing the outcomes of acute spinal cord injuries (SCI). Following the PRISMA guidelines, we conducted comprehensive searches in four electronic databases (PubMed, Scopus, Cochrane Library, and Web of Science) up to September 5th, 2023. Our analysis included a total of 30 studies. We examined the effects of 15 substances/drugs: methylprednisolone, tirilazad mesylate, erythropoietin, nimodipine, naloxone, Sygen, Rho protein antagonist, granulocyte colony-stimulating factor, autologous macrophages, autologous bone marrow cells, vitamin D, progesterone, riluzole, minocycline, and blood alcohol concentration. Notable improvements in neurological outcomes were observed with progesterone plus vitamin D and granulocyte colony-stimulating factor. In contrast, results for methylprednisolone, erythropoietin, Sygen, Rho Protein, and Riluzole were inconclusive, primarily due to insufficient sample size or outdated evidence. No significant differences were found in the remaining evaluated drugs. Progesterone plus vitamin D, granulocyte colony-stimulating factor, methylprednisolone, Sygen, Rho Protein, and Riluzole may enhance neurological outcomes in acute SCI cases. It is worth noting that different endpoints or additional subgroup analyses may potentially alter the conclusions of individual trials. Therefore, certain SCI grades may benefit more from these treatments than others, while the overall results may remain inconclusive.
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Affiliation(s)
- Ibrahim Serag
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St, 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
| | | | - Khalid Sarhan
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Rashad G Mohamed
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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You F, Tang WJ, Zhang C, Ye MQ, Fang XG, Zhou YF. Whole-brain CT Perfusion at Admission and During Delayed Time-window Detects the Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. Curr Med Sci 2023; 43:409-416. [PMID: 36864249 DOI: 10.1007/s11596-023-2703-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/23/2022] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To evaluate the utility of computed tomography perfusion (CTP) both at admission and during delayed cerebral ischemia time-window (DCITW) in the detection of delayed cerebral ischemia (DCI) and the change in CTP parameters from admission to DCITW following aneurysmal subarachnoid hemorrhage. METHODS Eighty patients underwent CTP at admission and during DCITW. The mean and extreme values of all CTP parameters at admission and during DCITW were compared between the DCI group and non-DCI group, and comparisons were also made between admission and DCITW within each group. The qualitative color-coded perfusion maps were recorded. Finally, the relationship between CTP parameters and DCI was assessed by receiver operating characteristic (ROC) analyses. RESULTS With the exception of cerebral blood volume (P=0.295, admission; P=0.682, DCITW), there were significant differences in the mean quantitative CTP parameters between DCI and non-DCI patients both at admission and during DCITW. In the DCI group, the extreme parameters were significantly different between admission and DCITW. The DCI group also showed a deteriorative trend in the qualitative color-coded perfusion maps. For the detection of DCI, mean transit time to the center of the impulse response function (Tmax) at admission and mean time to start (TTS) during DCITW had the largest area under curve (AUC), 0.698 and 0.789, respectively. CONCLUSION Whole-brain CTP can predict the occurrence of DCI at admission and diagnose DCI during DCITW. The extreme quantitative parameters and qualitative color-coded perfusion maps can better reflect the perfusion changes of patients with DCI from admission to DCITW.
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Affiliation(s)
- Feng You
- Department of Radiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China.,Department of Radiology, Affiliated Hangzhou First People's Hospital, Hangzhou, 310000, China
| | - Wen-Juan Tang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chao Zhang
- Department of Radiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China
| | - Ming-Quan Ye
- School of Medical Information, Wannan Medical College, Wuhu, 241001, China
| | - Xing-Gen Fang
- Department of Neurosurgery, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China
| | - Yun-Feng Zhou
- Department of Radiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China.
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Safety and Tolerability of Concentrated Intraventricular Nicardipine for Poor-Grade Aneurysmal Subarachnoid Hemorrhage–Related Vasospasm. J Pers Med 2023; 13:jpm13030428. [PMID: 36983610 PMCID: PMC10058919 DOI: 10.3390/jpm13030428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Objective: To report the preliminary safety, tolerability, and cerebral spinal fluid (CSF) sampling utility of serial injections of concentrated intraventricular nicardipine (IVN) in the treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: We report the clinical, radiographic, and laboratory safety and tolerability data of a retrospective case series from a single academic medical center. All patients with aSAH developed vasospasm despite enteral nimodipine and received serial injections of concentrated IVN (2.5 mg/mL). CSF injection safety, tolerability, and utility are defined and reported. Results: A total of 59 doses of concentrated IVN were administered to three patients with poor-grade SAH. In Case 1, a 33-year-old man with modified Fisher scale (mFS) grade 4 and Hunt-Hess scale (HH) score 4 received 26 doses; in Case 2, a 36-year-old woman with mFS grade 4 and HH score 5 received 13 doses; and in Case 3, a 70-year-old woman with mFS grade 3 and HH score 4 received 20 doses. No major safety or tolerability events occurred. Two patients were discharged to a rehabilitation facility, and one died after discharge from the hospital. Conclusions: A concentrated 4 mg IVN dose (2.5 mg/mL) in a 1.6 mL injection appears relatively safe and tolerable and potentially offers a second-line strategy for treating refractory vasospasm in poor-grade SAH without compromising intracranial pressure or cerebral perfusion pressure.
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Lim J, Cho YD, Byoun HS. Comparative Study of Vasodilatation After Intra-arterial Nicardipine or Dantrolene Infusion in Animal Model of Cerebral Vasospasm. Clin Neuroradiol 2022; 32:1011-1017. [PMID: 35294572 DOI: 10.1007/s00062-022-01151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/15/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Intra-arterial (IA) infusion of calcium channel blockers (CCBs) has been widely applied in treating medically refractory vasospasm; however, surprisingly little is known regarding their vasodilatory duration. This study was undertaken to compare attributes of nicardipine and dantrolene, focusing on efficacy and capacity for sustained vasodilation. METHODS In New Zealand white rabbits (N = 22), vasospasm was individually provoked through experimentally induced subarachnoid hemorrhage and confirmed via conventional angiography, grouping animals by IA-infused drug (nicardipine vs. dantrolene). Controls received normal saline. After chemoangioplasty, follow-up angiography was performed at intervals of 1-3 h for 6 h to compare vasospastic and dilated (i.e., treated) arterial diameters. Drug efficacy, duration of action, and changes in mean arterial pressure (relative to baseline) were analyzed by group. RESULTS Compared with controls, effective vasodilation was evident in both nicardipine and dantrolene test groups after IA infusion. Vasodilatory effects of nicardipine peaked at 1 h, returning to former vasospastic states at 3 h. In dantrolene recipients, vasodilation endured longer, lasting >6 h. Only the nicardipine group showed a significant 3‑h period of lowered blood pressure. CONCLUSION Unlike the vasodilatory action of a CCB, sustained for < 3 h after IA infusion, the effect of dantrolene endured for > 6 h. This outcome suggests that IA dantrolene infused alone or together with a conventional CCB infusion may be a new means of prolonging vasodilatory effect. Further research is needed to assess durations of IA-infused vasodilatory drug based on perfusion status.
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Affiliation(s)
- Jeongwook Lim
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Daejeon, Korea (Republic of)
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea (Republic of).
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Daejeon, Korea (Republic of)
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In Vivo Vasospasm Induction by Ultrasound Application in the Chicken Chorioallantoic Membrane Model. Transl Stroke Res 2022; 13:616-624. [PMID: 35061211 PMCID: PMC9232457 DOI: 10.1007/s12975-021-00960-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 10/01/2021] [Accepted: 10/26/2021] [Indexed: 11/29/2022]
Abstract
Cerebral vasospasm is a highly investigated phenomenon in neurovascular research. Experimental vasospasm models are irreplaceable for the evaluation of new antivasospastic drugs. In this study, we assessed the reliability of in vivo vasospasm induction by ultrasound application in the chicken chorioallantoic membrane (CAM) model. After incubation of fertilized chicken eggs for four days, a fenestration was performed to enable examination of the CAM vessels. On the thirteenth day, continuous-wave ultrasound (3 MHz, 1 W/cm2) was applied on the CAM vessels for 60 s. The ultrasound effect on the vessels was recorded by life imaging (5-MP HD-microscope camera, Leica®). The induced vessel diameter changes were evaluated in a defined time interval of 20 min using a Fiji macro. The vessel diameter before and after sonication was measured and the relative diameter reduction was determined. A first reduction of vessel diameter was observed after three minutes with an average vessel-diameter decrease to 77%. The maximum reduction in vessel diameter was reached eight minutes after sonication with an average vessel diameter decrease to 57% (mean relative diameter reduction of 43%, range 44–61%), ANOVA, p = 0.0002. The vasospasm persisted for all 20 recorded minutes post induction. Vasospasm can be reliably induced by short application of 3 MHz-ultrasound to the CAM vessels. This might be a suitable in vivo model for the evaluation of drug effects on vasospasm in an experimental setting as intermediary in the transition process from in vitro to in vivo assessment using animal models.
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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Barpujari A, Patel C, Zelmonovich R, Clark A, Patel D, Pierre K, Scott K, Lucke Wold B. Pharmaceutical Management for Subarachnoid Hemorrhage. RECENT TRENDS IN PHARMACEUTICAL SCIENCES AND RESEARCH 2021; 3:16-30. [PMID: 34984419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/28/2022]
Abstract
Aneurysmal subarachnoid hemorrhage can have deleterious consequences. Vasospasm, delayed cerebral ischemia, and re-hemorrhage can all cause delayed sequelae. Furthermore, severe headaches are common and require careful modulation of pain medications. Limited treatment options currently exist and are becoming more complex with the rising use of oral anticoagulants needing reversal. In this review, we highlight the current treatment options currently employed and address avenues of future discovery based on emerging preclinical data. Furthermore, we dive into the best treatment approach for managing headaches following subarachnoid hemorrhage. The review is designed to serve as a catalyst for further prospective investigation into this important topic.
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Affiliation(s)
- Arnav Barpujari
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Chhaya Patel
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Alec Clark
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Devan Patel
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kyle Scott
- Department of Neurosurgery, University of Florida, Gainesville, Florida
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Park SY, Lee JH, Shin IJ, Nogueira RG, Lee JS. Nimodipine-refractory reversible cerebral vasoconstriction syndrome treated effectively with verapamil. PRECISION AND FUTURE MEDICINE 2020. [DOI: 10.23838/pfm.2020.00198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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10
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Lim J, Cho YD, Kwon HJ, Byoun SH, Koh HS, Park B, Choi SW. Duration of Vasodilatory Action After Intra-arterial Infusions of Calcium Channel Blockers in Animal Model of Cerebral Vasospasm. Neurocrit Care 2020; 34:867-875. [PMID: 32978731 DOI: 10.1007/s12028-020-01112-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND In medically refractory vasospasm, invasive intervention may be required. A commonly used approach is intra-arterial (IA) drug infusion. Although calcium channel blockers (CCBs) have been widely applied in this setting, studies comparing their efficacies and durations of action have been few. This study was performed to compare attributes of three CCBs (nicardipine, nimodipine, and verapamil), focusing on duration of the vasodilatory action based on angiography. METHODS Vasospasm was produced in New Zealand white rabbits (N = 22) through experimentally induced subarachnoid hemorrhage and confirmed in each via conventional angiography, grouping them by IA-infused drug. After chemoangioplasty, angiography was performed hourly for 5 h to compare dilated and vasospastic arterial diameters. Drug efficacy, duration of action, and changes in mean arterial pressure (relative to baseline) were analyzed by group. RESULTS Effective vasodilation was evident in all three groups immediately after IA drug infusion. The vasodilative effects of nimodipine and nicardipine peaked at 1 h and were sustained at 2 h, returning to initial vasospastic states at 3 h. In verapamil recipients, effects were more transient by comparison, entirely dissipating at 1 h. Only the nicardipine group showed a significant 3-h period of lowered blood pressure. CONCLUSIONS Although nimodipine and nicardipine proved longer acting than verapamil in terms of vasodilation, their effects were not sustained beyond 2 h after IA infusion. Further study is required to confirm the vasodilatory duration of IA CCB based on perfusion status, and an effort should be made to find new alternative to extend the duration.
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Affiliation(s)
- Jeongwook Lim
- Department of Neurosurgery, School of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Hyon-Jo Kwon
- Department of Neurosurgery, School of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Soo Hyoung Byoun
- Department of Neurosurgery, School of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Hyeon-Song Koh
- Department of Neurosurgery, School of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Bumsoo Park
- Department of Neurosurgery, School of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Seung-Won Choi
- Department of Neurosurgery, School of Medicine, Chungnam National University Hospital, Daejeon, Korea
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Li F, Fei Q, Mao D, Si Q, Dai M, Ma Q, Zhang H, Bai L, He N. Comparative Pharmacokinetics of Nimodipine in Rat Plasma and Tissues Following Intraocular, Intragastric, and Intravenous Administration. AAPS PharmSciTech 2020; 21:234. [PMID: 32794077 DOI: 10.1208/s12249-020-01772-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022] Open
Abstract
We investigated the pharmacokinetics of nimodipine (NMD) in rats plasma and tissues following intraocular (io), intragastric (ig), and intravenous (iv) administration at doses of 5.0 mg/kg io and iv and 10.0 mg/kg ig. After a single dose of NMD, plasma, heart, liver, spleen, lung, kidney, and brain samples were collected at the scheduled time points. The concentration of NMD in rat plasma and tissues was determined by high-performance liquid chromatography, and the main pharmacokinetic parameters were calculated and compared. NMD was rapidly absorbed and reached the maximum plasma concentration in approximately 5 min after io administration. The absolute bioavailability after io administration was higher than that after ig administration (40.05% vs. 5.67%). There were significant differences in the tissue distribution of NMD with different administration routes. After io administration, NMD was distributed more in the lung, spleen, and brain tissues, and less in the kidney. The maximum drug concentration after io administration in the heart, liver, spleen, lung, kidney, and brain was 1.00, 0.47, 2.02, 1.47, 0.22, and 5.79 times higher than that after via ig administration, and the area under the curve value was 0.59, 0.78, 1.71, 1.84, 0.25, and 4.59 times greater, respectively. Nimodipine appears to achieve systemic effects via io administration. Compared with ig, io administration could significantly increase NMD distribution in the brain tissue, indicating that NMD could be delivered to the brain via io administration.
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Affiliation(s)
- Fang Li
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China.,College of Biology and Pharmaceutical Engineering, West Anhui University, Lu'an, 237012, China
| | - Qingsong Fei
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Dan Mao
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Qiaoyun Si
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Manman Dai
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Qun Ma
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Huimin Zhang
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Luyu Bai
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China
| | - Ning He
- Department of Pharmaceutics, College of Pharmacy, Anhui University of Chinese Medicine, No. 1, Qianjiang Road, Hefei, 230012, Anhui, China. .,Institute of Pharmaceutics, Anhui Academy of Chinese Medical Sciences, Hefei, 230012, China. .,Anhui Province Key Laboratory of Chinese Medicinal Formula, Hefei, 230012, China. .,Anhui Province Key Laboratory of Pharmaceutical Preparation Technology and Application, Hefei, 230012, China.
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James CL, Turnbull MT, Freeman WD. Nimodipine-induced junctional bradycardia in an elderly patient with subarachnoid hemorrhage. Pharmacogenomics 2020; 21:387-392. [PMID: 32284009 DOI: 10.2217/pgs-2019-0136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Subarachnoid hemorrhage is a devastating form of stroke with often detrimental outcomes for patients. Here we describe a patient with subarachnoid hemorrhage treated with nimodipine, which resulted in marked bradycardia with junctional atrioventricular heart block. Nimodipine is metabolized predominantly by the cytochrome P450 3A subfamily, and its use is often associated with adverse events, such as hypotension and bradycardia, which can be exacerbated by advanced age. Our patient had the CYP3A5*3/*3 genotype, possibly predisposing her to poor metabolism of this drug. Our case report demonstrates the potential for pharmacogenomics in patients with subarachnoid hemorrhage to help predict their response to nimodipine, minimize adverse drug reactions, and potentially individualize dosing to improve future clinical outcomes.
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Affiliation(s)
- Courtney L James
- Mayo Clinic Alix School of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Marion T Turnbull
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - William D Freeman
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.,Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.,Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
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13
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Livesay S, Fried H, Gagnon D, Karanja N, Lele A, Moheet A, Olm-Shipman C, Taccone F, Tirschwell D, Wright W, Claude Hemphill Iii J. Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2020; 32:5-79. [PMID: 31758427 DOI: 10.1007/s12028-019-00846-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. METHODS The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. RESULTS A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. CONCLUSIONS This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.
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Affiliation(s)
- Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA.
| | | | - David Gagnon
- Maine Medical Center Department of Pharmacy, Portland, ME, USA
| | - Navaz Karanja
- Departments of Neurosciences and Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Asma Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Casey Olm-Shipman
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Fabio Taccone
- Department of Intensive Care of Hospital Erasme, Brussels, Belgium
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Wendy Wright
- Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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14
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Pharmacogenomics of Cytochrome P450 of Nimodipine Metabolism After Aneurysmal Subarachnoid Hemorrhage. J Neurosci Nurs 2019; 51:238-242. [PMID: 31469704 DOI: 10.1097/jnn.0000000000000464] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that is life threatening with high rates of mortality, and many survivors are left with permanent neurologic deficits. Nimodipine is the treatment of choice for aSAH with the goal of reduction of delayed cerebral ischemia. It is the only evidence-based medication that has been shown to have improved outcomes for delayed cerebral ischemia; therefore, it is important for neuroscience nurses to be knowledgeable of the pharmacology and pharmacogenomics properties of this medication, including cytochrome P450 (CYP450) enzymes. METHODS AND RESULTS This article reviews the CYP450 enzyme system including a review of the pharmacotherapy and pharmacogenomics of nimodipine for patients with aSAH illustrated with case study of a patient with abnormal drug metabolism. CONCLUSION CYP450 enzymes can be inhibited or induced by multiple medications resulting in clinically significant differences in drug metabolism. Food and Drug Administration-approved medication nimodipine is the only medication shown to improve outcomes in patients with aSAH. Hence, it is important to have awareness of potential drug-to-drug interactions and pharmacogenomics of nimodipine when caring for critically ill patients with aSAH.
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15
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Griffiths S, Clark J, Adamides AA, Ziogas J. The role of haptoglobin and hemopexin in the prevention of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a review of current literature. Neurosurg Rev 2019; 43:1273-1288. [PMID: 31493061 DOI: 10.1007/s10143-019-01169-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 01/01/2023]
Abstract
Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major cause of mortality and morbidity. The pathophysiology of DCI after aSAH is thought to involve toxic mediators released from lysis of red blood cells within the subarachnoid space, including free haemoglobin and haem. Haptoglobin and hemopexin are endogenously produced acute phase proteins that are involved in the clearance of these toxic mediators. The aim of this review is to investigate the pathophysiological mechanisms involved in DCI and the role of both endogenous as well as exogenously administered haptoglobin and hemopexin in the prevention of DCI.
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Affiliation(s)
- Sean Griffiths
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia. .,Western Hospital, 160 Gordon St, Footscray, 3011, Australia.
| | - Jeremy Clark
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - Alexios A Adamides
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - James Ziogas
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, 3010, Australia
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16
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Ren C, Gao J, Xu GJ, Xu H, Liu G, Liu L, Zhang L, Cao JL, Zhang Z. The Nimodipine-Sparing Effect of Perioperative Dexmedetomidine Infusion During Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Controlled Trial. Front Pharmacol 2019; 10:858. [PMID: 31427968 PMCID: PMC6688624 DOI: 10.3389/fphar.2019.00858] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/05/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Nimodipine can block the influx of calcium into the vascular smooth muscle cell and prevent secondary ischemia in patients with aneurysmal subarachnoid hemorrhage. However, the reduction of blood pressure after long-term intravenous administration of nimodipine has been associated with neurological deterioration. Yet, no effective solutions have been suggested to address this phenomenon. The use of neuroprotective drug combinations may reduce the risk of sudden blood pressure loss. This prospective, randomized, controlled trial was performed to evaluate the nimodipine-sparing effect of perioperative dexmedetomidine infusion during aneurysmal subarachnoid hemorrhage. Methods: One hundred nine patients who underwent aneurysm embolization were divided into three groups: group C (n = 35, infused with 0.9% sodium chloride at the same rate as other two groups), group D1 (n = 38, dexmedetomidine infusion at 0.5 µg·kg–1 for 10 min, then adjusted to 0.2 µg·kg–1·h–1), and group D2 (n = 36, dexmedetomidine infusion at 0.5 µg·kg–1 for 10 min, then adjusted to 0.4 µg·kg–1·h–1). Patient-controlled analgesia was given for 48 h after surgery. The primary outcome measure was the total consumption of nimodipine during the first 48 h after surgery. The secondary outcome measures were recovery time at post-anesthesia care unit (PACU), postoperative pain intensity scores, dexmedetomidine and sufentanil consumption, hemodynamic, satisfaction of patients and neurosurgeon, neurologic examination (Glasgow Coma Scale, GCS), Bruggemann comfort scale, and adverse effects. Intraoperative hemodynamics were recorded at the following time-points: arrival at the operating room (T1); before intubation (T2); intubation (T3); 5 min (T4), 10 min (T5), and 15 min (T6) after intubation; suturing of femoral artery (T7); end of surgery (T8); extubation (T9); and 5 min (T10), 10 min (T11), and 15 min (T12) after arrival at the PACU. The level of sedation was recorded at 15 min, 30 min, 1 h, and 2 h after extubation. We also recorded the incidence of symptomatic cerebral vasospasm during 7 days after surgery, Glasgow Outcome Score (GOS) at 3 months, and incidence of cerebral infarction 30 days after surgery. Results: The consumption of nimodipine during the first 48 h after surgery was significantly lower in group D2 (P < 0.05). Compared with group C, HR and MAP were significantly decreased from T2 to T12 in group D1 and D2 (P < 0.05). Patients in group D2 showed a significantly decreased MAP from T5 to T9 compared with group D1 (P < 0.05). The consumption of sevoflurane, remifentanil, dexmedetomidine, and nimodipine were all significantly reduced in groups D1 and D2 during surgery (P < 0.05). Compared with group C, MAP was significantly decreased in groups D1 and D2 during the first 48 h after surgery (P < 0.05). Compared with group C, consumption of sufentanil and dexmedetomidine at 1 h, pain intensity at 1 h, and 8 h after surgery were significantly decreased in groups D1 and D2 (P < 0.05). FAS was significantly higher in group D2 at 8 h, 16 h, and 24 h after surgery. LOS was significantly lower only in group D2 at 0.5 h after surgery (P < 0.05). Compared with group C, BCS was significantly higher group D2 at 4 h and 8 h after surgery (P < 0.05). There were no significant differences among the three groups in consumption of propofol, cisatracurium, fentanyl, and vasoactive drugs during operation, recovery time at PACU, satisfaction of patients and neurosurgeon, and number of applied urapidil and GCS during the first 48 h after surgery. The incidence of symptomatic cerebral vasospasm during 7 days after surgery, GOS of 3 months, and cerebral infarction after 30 days were also comparable among the three groups. Conclusions: Dexmedetomidine (infusion at 0.5 µg·kg–1 for 10 min, then adjusted to 0.4 µg·kg–1·h–1 during the surgery) significantly reduced the total consumption of nimodipine during the first 48 h after surgery and promoted early rehabilitation of patients although the incidences of symptomatic cerebral vasospasm, GOS, and cerebral infarction were not reduced.
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Affiliation(s)
- Chunguang Ren
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Jian Gao
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Guang Jun Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Huiying Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Guoying Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Lei Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Jun-Li Cao
- Department of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Zongwang Zhang
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
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17
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Huebner EA, Budel S, Jiang Z, Omura T, Ho TSY, Barrett L, Merkel JS, Pereira LM, Andrews NA, Wang X, Singh B, Kapur K, Costigan M, Strittmatter SM, Woolf CJ. Diltiazem Promotes Regenerative Axon Growth. Mol Neurobiol 2018; 56:3948-3957. [PMID: 30232777 DOI: 10.1007/s12035-018-1349-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/11/2018] [Indexed: 12/31/2022]
Abstract
Axotomy results in permanent loss of function after brain and spinal cord injuries due to the minimal regenerative propensity of the adult central nervous system (CNS). To identify pharmacological enhancers of axon regeneration, 960 compounds were screened for cortical neuron axonal regrowth using an in vitro cortical scrape assay. Diltiazem, verapamil, and bromopride were discovered to facilitate axon regeneration in rat cortical cultures, in the presence of chondroitin sulfate proteoglycans (CSPGs). Diltiazem, an L-type calcium channel blocker (L-CCB), also promotes axon outgrowth in adult primary mouse dorsal root ganglion (DRG) and induced human sensory (iSensory) neurons.
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Affiliation(s)
- Eric A Huebner
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Cellular Neuroscience, Neurodegeneration and Repair Program, Departments of Neurology and Neuroscience, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Stéphane Budel
- Cellular Neuroscience, Neurodegeneration and Repair Program, Departments of Neurology and Neuroscience, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Zhaoxin Jiang
- Cellular Neuroscience, Neurodegeneration and Repair Program, Departments of Neurology and Neuroscience, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Takao Omura
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Tammy Szu-Yu Ho
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Lee Barrett
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Janie S Merkel
- Yale Center for Molecular Discovery, Yale University, West Haven, CT, 06516, USA
| | - Luis M Pereira
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Nick A Andrews
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Xingxing Wang
- Cellular Neuroscience, Neurodegeneration and Repair Program, Departments of Neurology and Neuroscience, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Bhagat Singh
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Kush Kapur
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Michael Costigan
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Stephen M Strittmatter
- Cellular Neuroscience, Neurodegeneration and Repair Program, Departments of Neurology and Neuroscience, Yale University School of Medicine, New Haven, CT, 06520, USA.
| | - Clifford J Woolf
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA.
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