1
|
Zaeske C, Zopfs D, Laukamp K, Lennartz S, Kottlors J, Goertz L, Stetefeld H, Hof M, Abdullayev N, Kabbasch C, Schlamann M, Schönfeld M. Immediate angiographic control after intra-arterial nimodipine administration underestimates the vasodilatory effect. Sci Rep 2024; 14:6154. [PMID: 38486099 PMCID: PMC10940303 DOI: 10.1038/s41598-024-56807-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 03/11/2024] [Indexed: 03/18/2024] Open
Abstract
Intra-arterial nimodipine administration is a widely used rescue therapy for cerebral vasospasm. Although it is known that its effect sets in with delay, there is little evidence in current literature. Our aim was to prove that the maximal vasodilatory effect is underestimated in direct angiographic controls. We reviewed all cases of intra-arterial nimodipine treatment for subarachnoid hemorrhage-related cerebral vasospasm between January 2021 and December 2022. Inclusion criteria were availability of digital subtraction angiography runs before and after nimodipine administration and a delayed run for the most affected vessel at the end of the procedure to decide on further escalation of therapy. We evaluated nimodipine dose, timing of administration and vessel diameters. Delayed runs were performed in 32 cases (19 patients) with a mean delay of 37.6 (± 16.6) min after nimodipine administration and a mean total nimodipine dose of 4.7 (± 1.2) mg. Vessel dilation was more pronounced in delayed vs. immediate controls, with greater changes in spastic vessel segments (n = 31: 113.5 (± 78.5%) vs. 32.2% (± 27.9%), p < 0.0001) vs. non-spastic vessel segments (n = 32: 23.1% (± 13.5%) vs. 13.3% (± 10.7%), p < 0.0001). In conclusion intra-arterially administered nimodipine seems to exert a delayed vasodilatory effect, which should be considered before escalation of therapy.
Collapse
Affiliation(s)
- Charlotte Zaeske
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany.
| | - David Zopfs
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Kai Laukamp
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Simon Lennartz
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Jonathan Kottlors
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Lukas Goertz
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Marion Hof
- Department of Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Nuran Abdullayev
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Christoph Kabbasch
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Marc Schlamann
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Michael Schönfeld
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| |
Collapse
|
2
|
Murayama H, Kanemaru K, Yoshioka H, Fukamachi A, Shimizu T, Omata T, Fukasawa I, Nagasaka M, Nakano S, Asari Y, Kinouchi H. Chronological Change of the Clinical Features and Treatment Outcomes for Subarachnoid Hemorrhage in Japan: A Multicenter Retrospective Study. Neurol Med Chir (Tokyo) 2023; 63:464-472. [PMID: 37612120 PMCID: PMC10687669 DOI: 10.2176/jns-nmc.2023-0004] [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: 01/13/2023] [Accepted: 06/08/2023] [Indexed: 08/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) treatment has progressed, and patients are rapidly aging in Japan. Consequently, dynamic changes must have emerged in the clinical practice of SAH. This study aimed to elucidate chronological changes of aneurysmal SAH and the prognostic factors in the previous quarter century in Japan. We conducted a retrospective survey regarding aneurysmal SAH in eight institutions in Japan. The study included 848, 863, and 781 patients in the first (1989-1993), second (1999-2003), and third (2009-2013) periods, respectively. The chronological changes of factors that influenced the poor outcomes and differences between the nonelderly (<75 years) and elderly patients were investigated. Mean age was significantly higher in patients in the third period (61.4 years) than in those in the other two periods (first, 57.8 years; second, 59.5 years). During these periods, the proportion of good outcomes did not change; however, the mortality rate significantly decreased from 19% in the first period to 11% and 9.2% in the second and third periods, respectively. The poor outcome was mainly caused by the significantly higher incidence of systemic complication and procedural complication in the first period and the significantly lower incidence of delayed ischemic neurological deficit in the third period. The elderly patients had significantly poorer clinical outcomes than the nonelderly ones. During the last 25 years, the age of patients with aneurysmal SAH has rapidly increased. The study results may contribute to the improvement of the treatment strategy of SAH in advanced countries with a rapidly aging population.
Collapse
Affiliation(s)
- Hiroaki Murayama
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Kazuya Kanemaru
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Akira Fukamachi
- Department of Neurosurgery and Radiology, Nasu Neurosurgical Center
| | - Tsuneo Shimizu
- Department of Neurosurgery, Kanto Neurosurgical Hospital
| | | | | | | | - Shin Nakano
- Department of Neurosurgery, Yamanashi Prefectural Central Hospital
| | | | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| |
Collapse
|
3
|
Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
Collapse
Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
| |
Collapse
|
4
|
Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
|
5
|
Thiery L, Carle X, Testud B, Boulouis G, Habert P, Tradi F, Reyre A, Lehmann P, Dory-Lautrec P, Stellmann JP, Girard N, Brunel H, Hak JF. Distal cerebral vasospasm treatment following aneurysmal subarachnoid hemorrhage using the Comaneci device: technical feasibility and single-center preliminary results. J Neurointerv Surg 2023; 15:325-329. [PMID: 35584908 DOI: 10.1136/neurintsurg-2022-018699] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Balloon-assisted mechanical angioplasty for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) has a number of limitations, including transient occlusion of the spastic blood vessel. Comaneci is an FDA-approved device for temporary coil embolization assistance which has recently also been approved for the treatment of distal symptomatic refractory vasospasm. We aimed to report the feasibility, efficacy and safety of our experience with Comaneci angioplasty for refractory distal vasospasm (up to the second segment of the cerebral arteries) following aSAH. METHODS This is a retrospective analysis of a prospective series of 18 patients included between April 2019 and June 2021 with aSAH and symptomatic vasospasm refractory to medical therapy, who were treated using Comaneci-17-asssisted mechanical distal angioplasty. Immediate angiographic results, procedure-related complications, and clinical outcomes were assessed. Inter-rater reliability of the scores was determined using the intraclass correlation coefficient. RESULTS Comaneci-assisted distal angioplasty was performed in 18 patients, corresponding to 31 target arteries. All distal anterior segments were easily accessible with the Comaneci-17 device. Vasospasm improvement after Comaneci mechanical angioplasty was seen in 22 distal arteries (71%) (weighted Cohen's kappa (κw) 0.73, 95% CI 0.69 to 0.93). Vasospasm recurrence occurred in three patients (16.67%) and delayed cerebral infarction in three patients (16.67%), with a mean±SD delay between onset of symptoms and imaging follow-up (MRI/CT) of 32.61±8.93 days (κw 0.98, 95% CI 0.88 to 1). CONCLUSION This initial experience suggests that distal mechanical angioplasty performed with the Comaneci-17 device for refractory vasospasm following aSAH seems to be safe, with good feasibility and efficacy.
Collapse
Affiliation(s)
- Louis Thiery
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Xavier Carle
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Benoit Testud
- Department of Neuroradiology, APHM La Timone, Marseille, France.,CEMEREM, Aix Marseille University, Marseille, France.,CNRS, CRMBM, Aix Marseille University, Marseille, France
| | | | - Paul Habert
- Department of Medical Imaging, APHM La Timone, Marseille, France.,LIIE, Aix Marseille University, Marseille, France.,CERIMED, Aix Marseille University, Marseille, France
| | - Farouk Tradi
- Department of Medical Imaging, APHM La Timone, Marseille, France.,LIIE, Aix Marseille University, Marseille, France.,CERIMED, Aix Marseille University, Marseille, France
| | - Anthony Reyre
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Pierre Lehmann
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | | | - Jan-Patrick Stellmann
- Department of Neuroradiology, APHM La Timone, Marseille, France.,CEMEREM, Aix Marseille University, Marseille, France.,CNRS, CRMBM, Aix Marseille University, Marseille, France
| | - Nadine Girard
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Herve Brunel
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Jean-Francois Hak
- Department of Neuroradiology, APHM La Timone, Marseille, France.,LIIE, Aix Marseille University, Marseille, France.,CERIMED, Aix Marseille University, Marseille, France
| |
Collapse
|
6
|
Lee CY, Jang KM, Wui SH, Park SW. The Benefits and Feasibility of External Lumbar Cerebrospinal Fluid Drainage for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis and Trial Sequential Analysis. World Neurosurg 2022; 167:e549-e560. [PMID: 35977676 DOI: 10.1016/j.wneu.2022.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral vasospasm after aneurysmal subarachnoid hemorrhage is a main cause contributing to poor outcomes. Removal of blood from the subarachnoid may decrease development of cerebral vasospasm. The purpose of this study is to determine the effect of lumbar cerebrospinal fluid (CSF) drainage on cerebral vasospasm and related complications through meta-analysis and trial sequential analysis (TSA). METHODS A systematic search of the literature was performed. Case-control studies of the effects of external lumbar drainage in patients with subarachnoid hemorrhage were included. The association between lumbar drain and vasospasm, cerebral infarction, subsequent treatment, and mortality were evaluated. RESULTS Eleven of 122 articles were included in the meta-analysis. Lumbar CSF drainage reduces occurrence of vasospasm and related complications. In meta-analysis, the pooled odds ratio for symptomatic vasospasm, cerebral infarct, endovascular treatment for vasospasm, and mortality was 0.40 (95% confidence interval [CI], 0.31-0.51; P = 0.00001), 0.47 (95% CI, 0.35-0.62; P < 0.0001), 0.29 (95% CI, 0.18-0.46; P < 0.0001), and 0.41, (95% CI, 0.23-0.74; P = 0.003), respectively, compared with the non-lumbar drainage group. In TSA, the cumulative Z line crossed α-spending boundaries and reached the required sample size in analysis of symptomatic vasospasm and endovascular treatment for vasospasm. CONCLUSIONS Lumbar CSF drainage can decrease symptomatic vasospasm, cerebral infarction, subsequent endovascular treatment, and mortality. Through TSA, the accuracy and reliability of the effect of lumbar CSF drainage-related cerebral vasospasm and endovascular treatment are increased. Further studies of the association between lumbar drain and cerebral infarction and mortality are required to confirm the generalization of the results.
Collapse
Affiliation(s)
- Cheol Young Lee
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea.
| | - Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seong Hyun Wui
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| |
Collapse
|
7
|
Barbosa S, Jorge N, Silva ML, Maia I, Dias C, Pereira E, Paiva JA. Treatment of Cerebral Vasospasm With Continuous Intra-Arterial Nimodipine: A Case Report. Cureus 2022; 14:e30507. [DOI: 10.7759/cureus.30507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
|
8
|
Dalai S, Limaye US, Maturu MVS, Kolli SR, Pati R, Marthati MB, Modi S, Datla AV, Anantamakula S, Donkada R. Role of Transluminal Balloon Angioplasty for the Treatment of Vasospasm Due to Aneurysmal Subarachnoid Haemorrhage: A Multicentric Indian Experience. Cureus 2022; 14:e29311. [PMID: 36277540 PMCID: PMC9579828 DOI: 10.7759/cureus.29311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2022] [Indexed: 11/29/2022] Open
Abstract
Background Aneurysmal Subarachnoid Haemorrhage (aSAH) is a complex and critical neurological condition associated with significant mortality and morbidity. Apart from the initial insult due to the aneurysmal rupture itself, re-bleeding and severe cerebral vasospasm are some of the complications of aSAH that result in overall poor outcomes. Cerebral vasospasm in post-aSAH can result in delayed ischaemic neurological deficits. In the absence of timely interventions, it can lead to grave consequences for the patient. Management of cerebral vasospasm has been evolving over the years to prevent mortality and morbidity in aSAH patients. Materials and methods During 36 months from January 2018 to December 2020, 164 patients were admitted with aSAH in multiple Indian centres. Endovascular methods were used to treat all the aneurysms. Patients were observed for clinically symptomatic cerebral vasospasm. Patients with suspected vasospasm were further evaluated with a transcranial Doppler (TCD), brain computed tomography (CT) or magnetic resonance imaging (MRI) scan. In addition, digital subtraction angiography (DSA) of cerebral vessels was performed to evaluate vasospasm further. Twenty-two patients had clinically and angiographically significant vasospasm, and 20 patients were treated with transluminal balloon angioplasty (TBA). Results Satisfactory lumen dilation was achieved in 79 out of the 91 (86.81%) vasospastic segments, namely, distal internal carotid arteries (ICAs) 100%; middle cerebral arteries (MCA) 97.56% (M1=100%, M2=100%, M3=87.5%); vertebral arteries-100%; basilar arteries-100%; anterior cerebral arteries (ACA) 67.64% (A1=75%, A2=57.14%). The mean Modified Rankin Scale (mRS) score at 90 days was 0.75. 17 patients (85%) had an overall good outcome with no new neurological deficits. There were no cases of vessel rupture, dissection or thromboembolic complications. Conclusion TBA is a valuable, safe and effective option for managing clinically significant vasospasm caused by aSAH, adjuvant to medical management.
Collapse
|
9
|
Delayed cerebral ischemia: A look at the role of endothelial dysfunction, emerging endovascular management, and glymphatic clearance. Clin Neurol Neurosurg 2022; 218:107273. [PMID: 35537284 DOI: 10.1016/j.clineuro.2022.107273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/08/2022] [Accepted: 04/27/2022] [Indexed: 12/12/2022]
|
10
|
Yindeedej V, Nimmannitya P, Noiphithak R, Punyarat P, Tantongtip D. Clinical Outcome in Cerebral Vasospasm Patients Treated with and without Intra-Arterial Nimodipine Infusion. J Neurol Surg A Cent Eur Neurosurg 2021; 83:420-426. [PMID: 34808678 DOI: 10.1055/s-0041-1735860] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is still a problem. Hypertension, hypervolemia, and hemodilution (triple-H) therapy and oral nimodipine only a modest effect on patients. Intra-arterial treatment, including nimodipine, has been studied, but only as retrospective and single-arm prospective studies. We compared the outcomes between CV patients who received an adjunct intra-arterial nimodipine infusion (IANI) and those who received the standard medical treatment alone in a prospective randomized controlled trial. METHODS In this study, patients between the age of 18 and 80 years, who underwent angiography within 14 days after aneurysm obliteration, were recruited and randomized to receive adjunct IANI or not, if they were identified with angiographic vasospasm. All the angiographic and neurologic data were recorded and analyzed during their admission, at the discharge date, and during the 6-month follow-up period. RESULTS From June 2016 to December 2018, we enrolled 68 patients who were randomized into two groups, 36 in the intervention group and 32 in the control group. The patients' characteristics, aneurysm data, and modalities of treatment were similar between the two groups. Within 24 hours after IANI, Glasgow Coma Scale (GCS) score and motor strength revealed a significant improvement of 33.33 and 38.89%, respectively, in the intervention group versus 12.5 and 9.38%, respectively, in the control group. At discharge, the intervention group still had significant motor improvement (58.33 vs. 21.88%; p = 0.002). CONCLUSION IANI could be considered an effective treatment for CV without significant complications. This is the first RCT demonstrating statistically significant motor strength improvement within 24 hours and at discharge.
Collapse
Affiliation(s)
- Vich Yindeedej
- Department of Neurosurgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Pree Nimmannitya
- Department of Neurosurgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Raywat Noiphithak
- Department of Neurosurgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Prachya Punyarat
- Department of Neurosurgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Dilok Tantongtip
- Department of Neurosurgery, Thammasat University Hospital, Pathumthani, Thailand
| |
Collapse
|
11
|
Neumann A, Küchler J, Ditz C, Krajewski K, Leppert J, Schramm P, Schacht H. Non-compliant and compliant balloons for endovascular rescue therapy of cerebral vasospasm after spontaneous subarachnoid haemorrhage: experiences of a single-centre institution with radiological follow-up of the treated vessel segments. Stroke Vasc Neurol 2021; 6:16-24. [PMID: 32709603 PMCID: PMC8005899 DOI: 10.1136/svn-2020-000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/06/2020] [Accepted: 06/24/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND For endovascular rescue therapy (ERT) of cerebral vasospasm (CVS) due to spontaneous subarachnoid haemorrhage (sSAH), non-compliant (NCB) and compliant (CB) balloons are used with both balloon types bearing the risk of vessel injury due to specific mechanical properties. Although severe delayed arterial narrowing after transluminal balloon angioplasty (TBA) for CVS has sporadically been described, valid data concerning incidence and relevance are missing. Our aim was to analyse the radiological follow-up (RFU) of differently TBA-treated arteries (CB or NCB). METHODS Twelve patients with utilisation of either NCB or CB for CVS were retrospectively analysed for clinical characteristics, ERT, functional outcome after 3 months and RFU. Compared with the initial angiogram, we classified delayed arterial narrowing as mild, moderate and severe (<30%, 30%-60%, respectively >60% calibre reduction). RESULTS Twenty-three arteries were treated with CB, seven with NCB. The median first RFU was 11 months after TBA with CB and 10 after NCB. RFU was performed with catheter angiography in 18 arteries (78%) treated with CB and in five (71%) after NCB; magnetic resonance angiography was acquired in five vessels (22%) treated with CB and in two (29%) after NCB. Mild arterial narrowing was detected in three arteries (13%) after CB and in one (14%) after NCB. Moderate or severe findings were neither detected after use of CB nor NCB. CONCLUSION We found no relevant delayed arterial narrowing after TBA for CVS after sSAH. Despite previous assumptions that CB provides for more dilatation in segments adjacent to CVS, we observed no disadvantages concerning long-term adverse effects. Our data support TBA as a low-risk treatment option.
Collapse
Affiliation(s)
- Alexander Neumann
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Küchler
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Claudia Ditz
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Kara Krajewski
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Leppert
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Peter Schramm
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Hannes Schacht
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| |
Collapse
|
12
|
Dawley T, Claus CF, Tong D, Rajamand S, Sigler D, Bahoura M, Garmo L, Soo TM, Kelkar P, Richards B. Efficacy and safety of cilostazol-nimodipine combined therapy on delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a prospective, randomised, double-blinded, placebo-controlled trial protocol. BMJ Open 2020; 10:e036217. [PMID: 33020083 PMCID: PMC7537439 DOI: 10.1136/bmjopen-2019-036217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 07/28/2020] [Accepted: 08/07/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Delayed cerebral ischaemia (DCI) due to cerebral vasospasm (cVS) remains the foremost contributor to morbidity and mortality following aneurysmal subarachnoid haemorrhage (aSAH). Past efforts in preventing and treating DCI have failed to make any significant progress. To date, our most effective treatment involves the use of nimodipine, a calcium channel blocker. Recent studies have suggested that cilostazol, a platelet aggregation inhibitor, may prevent cVS. Thus far, no study has evaluated the effect of cilostazol plus nimodipine on the rate of DCI following aSAH. METHODS AND ANALYSIS This is a multicentre, double-blinded, randomised, placebo-controlled superiority trial investigating the effect of cilostazol on DCI. Data concerning rates of DCI, symptomatic and radiographic vasospasm, length of intensive care unit stay, and long-term functional and quality-of-life (QoL) outcomes will be recorded. All data will be collected with the aim of demonstrating that the use of cilostazol plus nimodipine will safely decrease the incidence of DCI, and decrease the rates of both radiographic and symptomatic vasospasm with subsequent improvement in long-term functional and QoL outcomes when compared with nimodipine alone. ETHICS AND DISSEMINATION Ethical approval was obtained from all participating hospitals by the Ascension Providence Hospital Institutional Review Board. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04148105.
Collapse
Affiliation(s)
- Troy Dawley
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Chad F Claus
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Doris Tong
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Sina Rajamand
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Diana Sigler
- Department of Pharmacy, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Matthew Bahoura
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Lucas Garmo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Teck M Soo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Prashant Kelkar
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Boyd Richards
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| |
Collapse
|
13
|
Elarjani T, Almutairi OT, Alhussinan M, Alzhrani G, Alotaibi FE, Bafaquh M, Orz Y, AlYamany M, Alturki AY. Bibliometric Analysis of the Top 100 Most Cited Articles on Cerebral Vasospasm. World Neurosurg 2020; 145:e68-e82. [PMID: 32980568 DOI: 10.1016/j.wneu.2020.09.099] [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] [Received: 06/29/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Bibliometric analysis reflects the scientific recognition and influential performance of a published article within its field. Our aim is to identify and analyze the top 100 most-cited articles on cerebral vasospasm. METHODS A title-specific search was carried out using the Scopus database. The top 100 cited articles including the keywords "Cerebral Vasospasm" AND "Vasospasm" were retrieved and stratified in a descending order: title, authors, institution, publishing journal, country of origin, year of publication, and topic of each article were studied. RESULTS The top 100 articles have an accumulative citation count of 20,972, with 209 average citations per article. Publication dates ranged from 1968 to 2012, with the most productive years between 1998 and 2005. Clinical studies are the most frequent category, followed by pathophysiology. The list includes 7 clinical trials, which received accumulative citations of 1525. The top cited article had received 2109 citations, with 52.7 citations per year. The top 100 articles were published across 14 countries, with most originating from the United States. The lead research institution was the University of Alberta. The most used journal was Journal of Neurosurgery. CONCLUSIONS Bibliometric analysis has garnered major interest in recent years. It shows the publication trends, knowledge evolution, and evidence-based practice throughout the years. The collection of highly cited articles may assist physicians in gaining a better understanding of the nature of cerebral vasospasm and optimize their clinical practice.
Collapse
Affiliation(s)
- Turki Elarjani
- Department of Neurological Surgery, University of Miami, Miami, Florida USA
| | - Othman T Almutairi
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Gmaan Alzhrani
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad E Alotaibi
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Bafaquh
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Yasser Orz
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mahmoud AlYamany
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Y Alturki
- Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia; Neurocritical Care Divison, Adult Intensive Care Department, Critical Care Services Administration, King Fahad Medical City, Riyadh, Saudi Arabia.
| |
Collapse
|
14
|
Omoto K, Nakagawa I, Nishimura F, Yamada S, Motoyama Y, Nakase H. Computed tomography perfusion imaging after aneurysmal subarachnoid hemorrhage can detect cerebral vasospasm and predict delayed cerebral ischemia after endovascular treatment. Surg Neurol Int 2020; 11:233. [PMID: 32874736 PMCID: PMC7451166 DOI: 10.25259/sni_14_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background Endovascular treatment (ET) can improve angiographic cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage, but was unrelated to clinical outcomes in previous analyses. Appropriate detection of CV and precise indications for ET are required. This study investigated whether changes in computed tomography perfusion (CTP) parameter can determine indications for ET in CV and predict its effectiveness. Methods Participants comprised 140 patients who underwent neck clipping or coil embolization. CTP was performed a week after aneurysmal treatment or when clinical deterioration had occurred. Patients were divided into ET and non-ET groups by propensity score matching. In addition, the ET group was divided into subgroups with and without new cerebral infarction (CI). All CTP images in the three groups were retrospectively investigated qualitatively and quantitatively. CI was diagnosed from CT at 3 months postoperatively. Results Of the 121 patients examined, 15 patients (11%) needed ET. In qualitative analysis, all ET group patients displayed extension of time-to-peak (TTP) at the region of vasospastic change, regardless of the presence of CI. Quantitative analysis showed significant decreases in cerebral blood volume (P < 0.01), cerebral blood flow (CBF) (P < 0.001), and extension in TTP (P < 0.01) in the ET group compared with the non-ET group. A significant decrease in CBF (P < 0.001) and extension in mean transit time (P < 0.001) was seen in the ET with CI subgroup compared with the ET without CI subgroup. Conclusion CTP in the vasospastic period may be an indication for ET and predict the effectiveness of ET for CV to improve clinical outcomes.
Collapse
Affiliation(s)
- Koji Omoto
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| |
Collapse
|
15
|
Salazar-Díaz LC, Lozano-Castillo A, Neira-Escobar F, Grillo-Ardila CF, Arevalo-Espejo O, Krings T. Endovascular treatment versus standard management for cerebral vasospasm after aneurysmal subarachnoid haemorrhage. Hippokratia 2020. [DOI: 10.1002/14651858.cd013713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Luis C Salazar-Díaz
- Department of Diagnostic Imaging; Faculty of Medicine, Universidad Nacional de Colombia; Bogotá Colombia
| | - Alfonso Lozano-Castillo
- Department of Diagnostic Imaging, Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
- Division of Neuroradiology; Hospital Universitario Nacional de Colombia; Bogota Colombia
| | - Fabian Neira-Escobar
- Department of Diagnostic Imaging, Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
- Division of Interventional Radiology; Hospital Universitario Nacional de Colombia; Bogota Colombia
| | - Carlos F Grillo-Ardila
- Department of Obstetrics and Gynecology; Faculty of Medicine, Universidad Nacional de Colombia; Bogota Colombia
| | - Octavio Arevalo-Espejo
- Department of Diagnostic and Interventional Imaging; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Timo Krings
- Department of Medical Imaging; University of Toronto; Toronto Canada
| |
Collapse
|
16
|
Su YS, Ali MS, Pukenas BA, Favilla CG, Zanaty M, Hasan DM, Kung DK. Novel Treatment of Cerebral Vasospasm Using Solitaire Stent Retriever-Assisted Angioplasty: Case Series. World Neurosurg 2019; 135:e657-e663. [PMID: 31881345 DOI: 10.1016/j.wneu.2019.12.097] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Endovascular procedures such as intraarterial (IA) vasodilator injection and balloon angioplasty are used to treat medically refractory cerebral vasospasm. The effects of IA therapy may be short lived and thus require multiple treatments. Balloon angioplasty also has limitations including transient occlusion of the spastic blood vessel, possible endothelial injury, and limited access to proximal vessels. We aim to demonstrate a novel technique using a stent retriever for the management of medically refractory vasospasm, especially in distal vessels. Compared with balloon angioplasty, stent retrievers provide a passive, self-limiting expansion of blood vessels. Other benefits over balloon angioplasty include 1) ability to simultaneously inject IA vasodilators, 2) limited contact and damage to vessel wall, 3) nonocclusive expansion, and 4) technical ease. METHODS Fourteen blood vessels from 6 patients with symptomatic vasospasm after subarachnoid hemorrhage were identified. We injected 5 mg of IA vasodilator medication into the vasospastic segments without radiographic improvement in vessel diameter and blood flow. The stent retriever was deployed for 2-5 minutes in each vasospastic segment. RESULTS Distal anterior and posterior circulation segments were easily accessible with the stent retriever system. It resulted in improved vessel diameter and blood flow with subsequent improvement in neurologic examination. All patients demonstrated radiographic resolution of vasospasm. No procedural-related complications were noted. CONCLUSIONS We demonstrate the safety and efficacy of a novel technique for the treatment of medically refractory cerebral vasospasm using stent retriever angioplasty in distal vessels. Stent angioplasty can be used as an additional tool in the management of subarachnoid hemorrhage-induced cerebral vasospasm.
Collapse
Affiliation(s)
- YouRong S Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Muhammad S Ali
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Bryan A Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher G Favilla
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David K Kung
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
17
|
Transluminal balloon angioplasty for cerebral vasospasm after spontaneous subarachnoid hemorrhage: A single-center experience. Clin Neurol Neurosurg 2019; 188:105590. [PMID: 31759310 DOI: 10.1016/j.clineuro.2019.105590] [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: 08/31/2019] [Revised: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES After spontaneous subarachnoid hemorrhage (sSAH), cerebral vasospasm (CVS) is a common complication, potentially resulting in infarction mainly responsible for a poor outcome. Intra-arterial vasodilators lead to transient increase of brain perfusion, but only transluminal balloon angioplasty (TBA) promises longer-lasting effects, though it poses the risk of severe complications. Until now, the precise impact of TBA on the course of CVS is not yet finally clarified. Thus we aimed to identify risk factors of recurrent CVS and vasospasm-related infarction following TBA. PATIENTS AND METHODS We analyzed 35 patients with CVS after sSAH who received TBA (41 procedures, 99 vessel segments). Gender, age, WFNS grade and Fisher scale, occurrence of intraventricular and intracerebral hemorrhage, localization of the aneurysm and the initial treatment modality were obtained. We assessed functional outcome after 3 months and in-hospital mortality. TBA was analyzed concerning time point, localization, technique, complications and angiographic response. Furthermore, recurrence of CVS and vasospasm-related infarction after TBA were described and risk factors were identified with logistic regression analyses. RESULTS In 7 of 35 patients (20%) and in 16 of 99 vessel segments (16%) previously treated with TBA, we found recurrent CVS. Vasospasm-related infarction occurred in 18 cases (18%) in the arterial territories of the TBA-treated vessel segments. The angiographic effect after TBA was mostly classified as good (87%), good response was negatively associated with recurrent CVS (p = 0.004) and vasospasm-related infarction (p = 0.001). We identified only the male gender as a risk factor for vasospasm-related infarction after TBA (p = 0.040). In connection with TBA, only one complication occurred (intracranial dissection). CONCLUSION Our data support TBA as a safe and effective therapy for CVS. Nevertheless, recurrent CVS and vasospasm-related infarction were common after TBA and not predictable by clinical conditions on admission or the localization of CVS. A moderate or poor angiographic response after TBA was identified as a risk factor for both, recurrent CVS and vasospasm-related infarction, while male gender was associated with a higher risk of vasospasm-related infarction. Our results augment the still sparse evidence concerning optimal patient selection for this method and provide new aspects for individual therapy decisions.
Collapse
|
18
|
Suero Molina E, Di Somma A, Stummer W, Briganti F, Cavallo LM. Clinical Vasospasm After an Extended Endoscopic Endonasal Approach for Recurrent Pituitary Adenoma: Illustrative Case and Systematic Review of the Literature. World Neurosurg 2019; 128:29-36. [DOI: 10.1016/j.wneu.2019.04.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/15/2022]
|
19
|
Labeyrie MA, Gaugain S, Boulouis G, Zetchi A, Brami J, Saint-Maurice JP, Civelli V, Froelich S, Houdart E. Distal Balloon Angioplasty of Cerebral Vasospasm Decreases the Risk of Delayed Cerebral Infarction. AJNR Am J Neuroradiol 2019; 40:1342-1348. [PMID: 31320465 DOI: 10.3174/ajnr.a6124] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/05/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Conventional angioplasty of cerebral vasospasm combines proximal balloon angioplasty (up to the first segment of cerebral arteries) with chemical angioplasty for distal arteries. Distal balloon angioplasty (up to the second segment of cerebral arteries) has been used in our center instead of chemical angioplasty since January 2015. We aimed to assess the effect of this new approach in patients with aneurysmal SAH. MATERIALS AND METHODS The occurrence, date, territory, and cause of any cerebral infarction were retrospectively determined and correlated to angioplasty procedures. Delayed cerebral infarction, new angioplasty in the territory of a previous angioplasty, angioplasty complications, 1-month mortality, and 6- to 12-month modified Rankin Scale ≤ 2 were compared between 2 periods (before-versus-after January 2015, from 2012 to 2017) with adjustment for age, sex, World Federation of Neurosurgical Societies score, and the modified Fisher grade. RESULTS Three-hundred-ninety-two patients were analyzed (160 before versus 232 after January 2015). Distal balloon angioplasty was associated with the following: higher rates of angioplasty (43% versus 27%, P < .001) and intravenous milrinone (31% versus 9%, P < .001); lower rates of postangioplasty delayed cerebral infarction (2.2% versus 7.5%, P = .01) and new angioplasty (8% versus 19%, P = .003) independent of the rate of patients treated by angioplasty and milrinone; and the same rates of stroke related to angioplasty (3.6% versus 3.1%, P = .78), delayed cerebral infarction (7.7% versus 12.5%, P = .12), mortality (10% versus 11%, P = .81), and favorable outcome (79% versus 73%, P = .21). CONCLUSIONS Our study suggests that distal balloon angioplasty is safe and decreases the risk of delayed cerebral infarction and the recurrence of vasospasm compared with conventional angioplasty. It fails to show a clinical benefit possibly because of confounding changes in adjuvant therapies of vasospasm during the study period.
Collapse
Affiliation(s)
- M-A Labeyrie
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.) .,EA 7334 REMES (M.-A.L., E.H.), L'Université Paris Diderot, Paris, France
| | - S Gaugain
- Emergency Care Unit (S.G.), Hôpital Lariboisière, Paris, France
| | - G Boulouis
- Department of Radiology (G.B.), Centre Hospitalier Sainte-Anne, Paris, France
| | - A Zetchi
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | - J Brami
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | - J-P Saint-Maurice
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | - V Civelli
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | | | - E Houdart
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.).,EA 7334 REMES (M.-A.L., E.H.), L'Université Paris Diderot, Paris, France
| |
Collapse
|
20
|
Koga M, Aoki T, Negoto T, Makizono T, Sugi K, Fujimori K, Kajiwara S, Komaki S, Yoshitomi M, Sugita Y, Morioka M. Leptomeningeal Carcinomatosis After Neoplastic Cerebral Aneurysm Rupture. World Neurosurg 2019; 126:281-284. [PMID: 30822576 DOI: 10.1016/j.wneu.2019.02.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several possible mechanisms exist for the spread of a primary tumor to the leptomeninges in leptomeningeal carcinomatosis. This report describes a case caused by direct bleeding in the subarachnoid space from a neoplastic cerebral aneurysm rupture. CASE DESCRIPTION A 48-year-old Japanese woman, who was diagnosed with breast carcinoma (pT3 pN2 M0) at the age of 45 years and underwent mastectomy and chemotherapy, was admitted in a coma following a sudden-onset severe headache. Computed tomography revealed diffuse hemorrhage in the subarachnoid space, and angiography revealed an aneurysm at the distal middle cerebral artery. Superficial temporal artery-middle cerebral artery bypass, aneurysmal trapping, and aneurysm resection were performed within 24 hours of admission. Staining for AE1/AE3 revealed accumulation of atypical cells with a high nuclear-cytoplasmic ratio in the aneurysmal wall. After showing initial improvement, she developed disturbed consciousness due to complicated ventricular enlargement on day 45. Although the cerebrospinal fluid in the acute phase had no atypical cells, subsequent testing revealed atypical cells, which supported a diagnosis of leptomeningeal carcinomatosis due to breast cancer dissemination. The patient died on day 78 after receiving standard endocrine therapy and radiation therapy. CONCLUSIONS Tumor cells reach the leptomeninges via hematogenous spread or direct extension from preexisting lesions and can undergo neuraxis dissemination via the cerebrospinal fluid. Subarachnoid hemorrhage and leptomeningeal carcinomatosis are both devastating conditions with extremely poor prognoses. This patient experienced delayed disturbed consciousness leptomeningeal carcinomatosis with decreased performance status, which made it difficult to justify aggressive treatment on the basis of her poor prognosis.
Collapse
Affiliation(s)
- Motohisa Koga
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Takachika Aoki
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Tetsuya Negoto
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
| | - Takehiro Makizono
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Keisuke Sugi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Kana Fujimori
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Munetake Yoshitomi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Yasuo Sugita
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| |
Collapse
|
21
|
Weiss M, Conzen C, Mueller M, Wiesmann M, Clusmann H, Albanna W, Schubert GA. Endovascular Rescue Treatment for Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Is Safe and Effective. Front Neurol 2019; 10:136. [PMID: 30858818 PMCID: PMC6398410 DOI: 10.3389/fneur.2019.00136] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/01/2019] [Indexed: 12/21/2022] Open
Abstract
Background: The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is also unclear. Objective: The present study evaluates the safety and efficacy of endovascular rescue treatment (ERT, continuous intraarterial nimodipine; IAN, transcutaneous balloon angioplasty, TBA). Methods: In this prospective observational study, we assessed periprocedural complications and side effects in context of ERT. We evaluated neurological status, multimodal neuromonitoring (ptiO2, lactate/pyruvate ratio, transcranial doppler), and cranial imaging (CTP, DSA). All parameters were included into multivariate analysis to determine predictors for the need of retreatment. Results: We included 33 consecutive patients with 54 ERT (IAN n = 35; TBA n = 13; TBA + IAN n = 6). We recorded no serious complications and initial improvement in all parameters (neurostatus 72.3% of patients; ptiO2 15.0 ± 11.7 to 25.8 ± 15.5 mmHg, p < 0.0001; lactate/pyruvate ratio 46.3 ± 27.5 to 31.0 ± 9.7, p <0.05; transcranial doppler 139.0 ± 46.3 to 98.9 ± 29.6 cm/s, p < 0.05; CTP 81.6% of patients; DSA 93.1% of patients). Retreatment (n = 16, 48.5%) was independently associated with preinterventional ptiO2 < 5 mmHg (p <0.01) and early (<72 h) discontinuation of IAN treatment (p = 0.08). DCI related cerebral infarction was noted in n = 8 patients (24.2%). At 3 months after discharge, favorable outcome was noted for n = 11 (35.5%) patients. Conclusion: Provided a detailed decision tree, timely ERT can provide a relatively safe and effective treatment option in those highly-selected patients undergoing multimodality monitoring where conservative treatment options are exhausted. Continuous treatment in particular may be suitable to surpass sustained DCI and was associated with a low rate of DCI related infarction and comparably high percentage of good outcome.
Collapse
Affiliation(s)
- Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Marguerite Mueller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | |
Collapse
|
22
|
Yamaki VN, Cavalcanti DD, Figueiredo EG. Delayed Ischemic Neurologic Deficit after Aneurysmal Subarachnoid Hemorrhage. Asian J Neurosurg 2019; 14:641-647. [PMID: 31497080 PMCID: PMC6703066 DOI: 10.4103/ajns.ajns_15_19] [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] [Indexed: 01/02/2023] Open
Abstract
Delayed ischemic neurologic deficit (DIND) is the main preventable cause of poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Of 50% of survivors from a SAH, approximately 30% of patients will present clinical vasospasm (VS). The cornerstone of the DIND management comprises prevention and early identification. Several diagnostic methods have been proposed differing in efficacy, invasiveness, and costs. Serial neurological examination is the most reliable method to detect a new neurological deficit. On the other hand, comatose patients require advanced monitoring methods which identify changes in the microcirculatory environment, brain autoregulation, and spreading depolarization. Multimodality monitoring with continuous electroencephalography, microdialysis, and intracranial pressure monitoring represents altogether the current state-of-art technology for the intensive care of SAH patients. Moreover, advances in genetic biomarkers to predict clinical VS have shown consistent accuracy which may in the near future allow the early prediction of DIND through a simple blood test. Several clinical trials have tested drugs with theoretical effects on DIND prevention or treatment. Nevertheless, nimodipine remains the Holy Grail in the prevention of clinical VS. Among rescue therapies, the endovascular treatment through intra-arterial vasodilator (verapamil or nicardipine) infusion is the most employed method for DIND reversal; however, there is no good quality evidence comparing results of intra-arterial infusion of vasodilators versus balloon angioplasty. Although we have addressed the most refined technology in the management of SAH and DIND, the clinical experience and strict follow-up in neurointensive care will be determinant for favorable long-term outcomes.
Collapse
Affiliation(s)
- Vitor Nagai Yamaki
- Department of Neurosurgery, Universidade De Sao Paulo, São Paulo, SP, Brazil
| | | | | |
Collapse
|
23
|
Imamura H, Sakai N, Satow T, Iihara K. Endovascular Treatment for Vasospasm after Aneurysmal Subarachnoid Hemorrhage Based on Data of JR-NET3. Neurol Med Chir (Tokyo) 2018; 58:495-502. [PMID: 30464151 PMCID: PMC6300693 DOI: 10.2176/nmc.oa.2018-0212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Endovascular treatments for vasospasm after subarachnoid hemorrhage are typically performed for patients who are refractory to recommended medical therapies. We analyzed the current status of endovascular treatments based on the data of Japanese Registry of Neuroendovascular Therapy (JR-NET)3, and evaluated factors related to improvement of imaging findings and neurological condition, and to mechanical hemorrhage complications. We collected data of 1211 treatments performed from 2010 to 2014. Target vessels for treatments were anterior circulation (n = 1079), posterior circulation (n = 91), and both (n = 32); the distribution of vasospasm was the proximal vessel (n = 754) to the Circle of Willis, distal vessel (n = 329), and both (n = 119). Of the treatments, 948 cases (78.3%) were intra-arterial administration of vasodilators and 259 (21.4%) were percutaneous transluminal angioplasty (PTA); 879 cases were the first intervention. The treatment time from onset was within 3 h in 378 (31.2%) cases, between 3 and 6 h in 349 (28.8%) cases, and over 6 h in 245 (20.2%) cases. The statistically significant factors associated with improvement on imaging findings was the first treatment, and treatment within 3 h from onset compared with that after 6 h. Additionally, the first and early treatments after the symptoms were associated with significantly improved neurological condition. All complications of mechanical hemorrhage occurred along with PTA. The findings show that endovascular treatment for vasospasm was effective, especially for cases who suffered from symptomatic vasospasm with a short interval after onset.
Collapse
Affiliation(s)
- Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | | |
Collapse
|
24
|
Sorrell K, Harris S, Carpenter J, Lugo A, Wills S, Tuvell N. The Role of Transcranial Color Duplex Ultrasound in Endovascular Treatment of Cerebral Vasospasm. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/154431670302700402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Recent advances in neuroradiology have made it possible to perform superselective catheterization of the intracranial arteries. Intra-arterial papaverine infusion (PI) or percutaneous transluminal balloon angioplasty (PTA) can then be performed to treat vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to determine the correlation between the angiographic result and transcranial color duplex ultrasound (TCDU) and to define a velocity threshold that could be used to predict the success of endovascular treatment for vasospasm. Methods Seven patients with SAH and symptomatic cerebral vasospasm underwent endovascular therapy and daily TCDU. PTA and/or PI was performed on a total of 23 arterial segments. Fifteen arterial segments were treated once, and eight segments required a second or third intervention. Preintervention and postintervention TCDU velocities were compared with angiographic results. Results Good to excellent relief of spasm was reported in 15 segments on the basis of postintervention angiography. The average preintervention TCDU velocity for these 15 responders was 170 cm/sec. Velocities dropped to an average of 96.5 cm/sec immediately after intervention. For the eight nonresponders, the average velocity pretreatment was 128 cm/sec. Angiography demonstrated modest or no relief of spasm after PTA or PI, and the average velocity after treatment was 130 cm/sec. When a change of >25 cm/sec was used, TCDU correctly predicted angiographic responders with a p value of < 0.01. Conclusions Our data demonstrate a strong correlation between the angiographic result and the drop in velocity after endovascular therapy for vasospasm. Postintervention TCDU values can be used as a point of reference from which to monitor further progression or regression of vasospasm. We believe that TCDU has significant value in the management decisions of endovascular interventions for the treatment of cerebral vasospasm.
Collapse
Affiliation(s)
- Kathryn Sorrell
- From Sentara Norfolk General Hospital Peripheral Vascular Laboratory Norfolk, Virginia
| | - Shelley Harris
- From Sentara Norfolk General Hospital Peripheral Vascular Laboratory Norfolk, Virginia
| | - Julora Carpenter
- From Sentara Norfolk General Hospital Peripheral Vascular Laboratory Norfolk, Virginia
| | - Alex Lugo
- From Sentara Norfolk General Hospital Peripheral Vascular Laboratory Norfolk, Virginia
| | - Shelly Wills
- From Sentara Norfolk General Hospital Peripheral Vascular Laboratory Norfolk, Virginia
| | - Nancy Tuvell
- From Sentara Norfolk General Hospital Peripheral Vascular Laboratory Norfolk, Virginia
| |
Collapse
|
25
|
Albanna W, Weiss M, Müller M, Brockmann MA, Rieg A, Conzen C, Clusmann H, Höllig A, Schubert GA. Endovascular Rescue Therapies for Refractory Vasospasm After Subarachnoid Hemorrhage: A Prospective Evaluation Study Using Multimodal, Continuous Event Neuromonitoring. Neurosurgery 2018; 80:942-949. [PMID: 28201539 DOI: 10.1093/neuros/nyw132] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 07/16/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Critical hypoperfusion and metabolic derangement are frequently encountered with refractory vasospasm. Endovascular rescue therapies (ERT) have proven beneficial in selected cases. However, angioplasty (AP) and intraarterial lysis (IAL) are measures of last resort and prospective, quantitative results regarding the efficacy (cerebral oxygenation, metabolism) are largely lacking. OBJECTIVE To evaluate the efficacy of ERTs for medically refractory vasospasm using multimodal, continuous event neuromonitoring. METHODS To detect cerebral compromise in a timely fashion, sedated patients with aneurysmal subarachnoid hemorrhage received continuous neuromonitoring (p ti O 2 measurement, intraparenchymal microdialysis). ERT (AP and/or IAL) was considered in cases of clinically relevant vasospasm refractory to conservative treatment measures. Oxygen saturation and cerebral and systemic metabolism before and after events of ERT was recorded. RESULTS We prospectively included 13 consecutive patients and recorded a total of 25 ERT events: AP (n = 10), IAL (n = 11), or both (AP + IAL, n = 4). Average cerebral p ti O 2 was 10 ± 11 torr before and 49 ± 22 torr after ERT ( P < .001), with a lactate-pyruvate ratio decreasing from 146.6 ± 119.0 to 27.9 ± 10.7 after ERT ( P < .001). Comparable improvement was observed for each type of intervention (AP, IAL, or both). No significant alterations in systemic metabolism could be detected after ERT. CONCLUSION Multimodal event neuromonitoring is able to quantify treatment efficacy in subarachnoid hemorrhage-related vasospasm. In our small cohort of highly selected cases, ERT was associated with improvement in cerebral oxygenation and metabolism with reasonable outcome. Event neuromonitoring may facilitate individual and timely optimization of treatment modality according to the individual clinical course.
Collapse
Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Marguerite Müller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Marc Alexander Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Annette Rieg
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | |
Collapse
|
26
|
Borkar SA, Singh M, Kale SS, Suri A, Chandra PS, Kumar R, Sharma BS, Gaikwad S, Mahapatra AK. Spinal Cerebrospinal Fluid Drainage for prevention of Vasospasm in Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized controlled study. Asian J Neurosurg 2018; 13:238-246. [PMID: 29682015 PMCID: PMC5898086 DOI: 10.4103/1793-5482.228512] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of mortality and morbidity. Despite various treatment modalities, the optimal management of vasospasm remains elusive. In this regard; we undertook a prospective, randomized controlled study to evaluate the effectiveness of lumbar cerebrospinal fluid drainage (LCSFD) for prevention of cerebral vasospasm and its sequelae. Materials and Methods Patients with aneurysmal SAH who met the inclusion criteria were randomized into two groups - Group I (30 patients) underwent LCSFD whereas Group II (30 patients) did not undergo LCSFD. All patients underwent aneurysmal clipping. Both the groups received standard neurosurgical treatment except for LCSFD. The outcome was measured in terms of (1) clinically evident vasospasm; (2) vasospasm-related cerebral infarction; (3) condition of the patient at the time of discharge; and (4) Glasgow outcome score (GOS) at 1- and 3-month follow-up. Results LCSFD conferred a statistically significant benefit reducing the incidence of clinical vasospasm from 63% (in non-LCSFD group) to 30% (in LCSFD group) (P = 0.01) and incidence of vasospasm-related cerebral infarction from 53% (in non-LCSFD group) to 20% (in LCSFD group) (P = 0.007). Incidence of vasospasm was quantitatively lower in LCSFD group across all Hunt and Hess grades; however, it was statistically significant in SAH Grade III (P = 0.008). Mean duration of hospital stay was slightly lower in LCSFD group compared to non-LCSFD group; however, it did not reach statistical significance. A higher incidence of meningitis in LCSFD group was not statistically significant. A higher GOS was observed in LCSFD group at 1- and 3-month follow-up as compared to non-LCSFD group. Conclusion Drainage of CSF through a lumbar drain following aneurysmal SAH caused a statistically significant reduction in the incidence of clinical and radiological vasospasm and its sequelae. It also shortens the overall duration of hospital stay and improves the outcome as evidenced by a better GOS score at 1- and 3-month follow-up. The results of this prospective, randomized study establish the efficacy of LCSFD in prevention of vasospasm following aneurysmal SAH.
Collapse
Affiliation(s)
- Sachin Anil Borkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohanjit Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rajender Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shailesh Gaikwad
- Department of Neuroradiolgy, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok Kumar Mahapatra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
27
|
Park ES, Kim DW, Kang SD. Endovascular Treatment of Symptomatic Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Three-year Experience. J Cerebrovasc Endovasc Neurosurg 2017; 19:155-161. [PMID: 29159148 PMCID: PMC5680078 DOI: 10.7461/jcen.2017.19.3.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/28/2017] [Accepted: 09/17/2017] [Indexed: 11/23/2022] Open
Abstract
Objective The cause of severe clinical vasospasm after aneurysmal subarachnoid hemorrhage remains unknown, despite extensive research over the past 30 years. However, the intra-arterial administration of vasodilating agents and balloon angioplasty have been successfully used in severe refractory cerebral vasospasm. Materials and Methods We retrospectively analyzed the data of 233 patients admitted to our institute with aneurysmal subarachnoid hemorrhage (SAH) over the past 3 years. Results Of these, 27 (10.6%) developed severe symptomatic vasospasm, requiring endovascular therapy. Vasospasm occurred at an average of 5.3 days after SAH. A total of 46 endovascular procedures were performed in 27 patients. Endovascular therapy was performed once in 18 (66.7%) patients, 2 times in 4 (14.8%) patients, 3 or more times in 5 (18.5%) patients. Intra-arterial vasodilating agents were used in 44 procedures (27 with nimodipine infusion, 17 with nicardipine infusion). Balloon angioplasty was performed in only 2 (7.4%) patients. The Average nimodipine infusion volume was 2.47 mg, and nicardipine was 3.78 mg. Most patients recovered after the initial emergency room visit. Two patients (7.4%) worsened, but there were no deaths. Conclusion With advances in endovascular techniques, administration of vasodilating agents and balloon angioplasty reduces the morbidity and mortality of vasospasm after aneurysmal SAH.
Collapse
Affiliation(s)
- Eun-Sung Park
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| |
Collapse
|
28
|
Gross BA, Tonetti DA, Weiner GM, Panczykowski DM, Ares WJ, Kenmuir CL, Jadhav AP, Jovin TG, Jankowitz BT. Septoplasty: Scepter Balloon Angioplasty for Vasospasm after Aneurysmal Subarachnoid Hemorrhage. INTERVENTIONAL NEUROLOGY 2017; 6:229-235. [PMID: 29118800 DOI: 10.1159/000477467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction Balloon angioplasty can be a requisite approach for the treatment of symptomatic and/or severe vasospasm. Dual-lumen microcatheter balloons have multiple potential advantages for this indication including accommodating a 0.014-inch wire and the potential to deliver superselective vasodilators directly via the microcatheter prior to angioplasty. Methods The authors reviewed a 3-year institutional experience with the Scepter XC balloon (Microvention, Tustin, CA, USA) in the treatment of postaneurysmal subarachnoid hemorrhage vasospasm, focusing on treatment methods, angiographic, and clinical results. Results Sixty-four vessels were treated in 18 patients. Fifteen cases were performed under intravenous (i.v.) conscious sedation (83%). The mean pretreatment stenosis was 59% (range 40-80), and the mean post-treatment stenosis was 12% (range 0-40). Five vessels in 3 patients were subsequently retreated via angioplasty for recurrent vasospasm (8%). There were no complications related to the passage of the balloon microcatheter or inflation of the balloon such as dissection or vessel rupture. Of 14 patients with delayed cerebral ischemia, 7 had complete symptomatic resolution after treatment, and 3 had significant symptomatic improvement. Four patients did not improve after treatment though 3 already had confirmed infarcts on imaging prior to angiography. Conclusion The Scepter XC is a safe and effective balloon microcatheter for angioplasty of cerebral vasospasm after subarachnoid hemorrhage, allowing for superselective delivery of a vasodilator. Its ease of deliverability and visibility often allows for the performance of the procedure under i.v. conscious sedation.
Collapse
Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cynthia L Kenmuir
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
29
|
von der Brelie C, Doukas A, Stopfer A, Larsen N, Mehdorn M, Synowitz M, Jansen O. Clinical Course and Monitoring Parameters After Continuous Interventional Intra-Arterial Treatment in Patients with Refractory Cerebral Vasospasm. World Neurosurg 2017; 100:504-513. [DOI: 10.1016/j.wneu.2016.12.110] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 11/16/2022]
|
30
|
Ryu J, Ko N, Hu X, Shadden SC. Numerical Investigation of Vasospasm Detection by Extracranial Blood Velocity Ratios. Cerebrovasc Dis 2017; 43:214-222. [PMID: 28241122 DOI: 10.1159/000454992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/04/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early diagnosis of vasospasm following subarachnoid hemorrhage can prevent cerebral ischemia and improve neurological outcomes. This study numerically evaluates the relevance of extracranial blood velocity indices to detect vasospasm. METHODS A numerical model of cerebral blood flow was used to evaluate the hemodynamics associated with anterior and posterior vasospasm under normal and impaired cerebral autoregulation conditions. Extracranial blood velocities at the carotid and vertebral arteries and their ratios between ipsilateral and contralateral, anterior and posterior, and downstream and upstream arteries were monitored during vasospasm progression. RESULTS For current clinical indices that track blood velocities at vasospastic arterial segments using transcranial Doppler (TCD), we observed that velocities increased initially and then decreased with vasospasm progression. This nonmonotonic behavior can lead to false-negative decisions in moderate to severe vasospasm. Alternatively, volumetric flow decreased monotonically at the affected arteries, leading to blood velocities upstream of the vasospastic artery also decreasing monotonically. Based on this principle, we demonstrate that velocity ratios between the carotid and vertebral arteries may better identify moderate to severe vasospasm and improve sensitivity and specificity of vasospasm detection. CONCLUSION The velocity indices proposed in this study may enable new or improved noninvasive diagnosis of vasospasm using extracranial Doppler ultrasound. Compared to current clinical indices, the new indices may improve the handling of (1) scenarios of severe vasospasm or impaired cerebral autoregulation, (2) systemic changes in blood pressure and cardiac output, (3) vasospasm occurring in arteries distal to the cerebral circle region, and (4) cases with insufficient acoustic bone window for TCD. The results provide a concrete basis for future clinical evaluation of extracranial indices for vasospasm detection.
Collapse
Affiliation(s)
- Jaiyoung Ryu
- School of Mechanical Engineering, Chung-Ang University, Seoul, Korea
| | | | | | | |
Collapse
|
31
|
Durrant JC, Hinson HE. Rescue therapy for refractory vasospasm after subarachnoid hemorrhage. Curr Neurol Neurosci Rep 2015; 15:521. [PMID: 25501582 DOI: 10.1007/s11910-014-0521-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia.
Collapse
Affiliation(s)
- Julia C Durrant
- Department of Neurology and Neurocritical Care, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, CR-127, Portland, OR, 97239, USA,
| | | |
Collapse
|
32
|
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
Collapse
Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
| |
Collapse
|
33
|
Park S, Yang N, Seo E. The effectiveness of lumbar cerebrospinal fluid drainage to reduce the cerebral vasospasm after surgical clipping for aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2015; 57:167-73. [PMID: 25810855 PMCID: PMC4373044 DOI: 10.3340/jkns.2015.57.3.167] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 07/21/2014] [Accepted: 12/15/2014] [Indexed: 11/28/2022] Open
Abstract
Objective Removal of blood from subarachnoid space with a lumbar drainage (LD) may decrease development of cerebral vasospasm. We evaluated the effectiveness of a LD for a clinical vasospasm and outcomes after clipping of aneurysmal subarachnoid hemorrhage (SAH). Methods Between July 2008 and July 2013, 234 patients were included in this study. The LD group consisted of 126 patients, 108 patients in the non LD group. We investigated outcomes as follow : 1) clinical vasospasm, 2) angioplasty, 3) cerebral infarction, 4) Glasgow outcome scale (GOS) score at discharge, 5) GOS score at 6-month follow-up, and 6) mortality. Results Clinical vasospasm occurred in 19% of the LD group and 42% of the non LD group (p<0.001). Angioplasty was performed in 17% of the LD group and 38% of the non LD group (p=0.001). Cerebral infarctions were detected in 29% and 54% of each group respectively (p<0.001). The proportion of GOS score 5 at 6 month follow-up in the LD group was 69%, and it was 58% in the non LD group (p=0.001). Mortality rate showed 5% and 10% in each group respectively. But, there was no difference in shunt between the two groups. Conclusion LD after aneurysmal SAH shows marked reduction of clinical vasospasm and need for angioplasty. With this technique we have shown favorable GOS score at 6 month follow-up.
Collapse
Affiliation(s)
- Soojeong Park
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Narae Yang
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Euikyo Seo
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| |
Collapse
|
34
|
Abstract
Cerebral vasospasm causes delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage. This is a well-established clinical entity with significant associated morbidity and mortality. The underlying patholphysiology is highly complex and poorly understood. Large-vessel vasospasm, autoregulatory dysfunction, inflammation, genetic predispositions, microcirculatory failure, and spreading cortical depolarization are aspects of delayed neurologic deterioration that have been described in the literature. This article presents a perspective on cerebral vasospasm, as guided by the literature to date, specifically examining the mechanism, diagnosis, and treatment of cerebral vasospasm.
Collapse
|
35
|
Tekle WG, Chaudry SA, Hassan AE, Qaiser H, Grigoryan M, Rodriguez GJ, Qureshi AI. High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm. Neurocrit Care 2015; 20:399-405. [PMID: 23463421 DOI: 10.1007/s12028-013-9825-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.
Collapse
Affiliation(s)
- Wondwossen G Tekle
- Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, 420 Delaware St. SE. MMC 295, Minneapolis, MN, 55455, USA,
| | | | | | | | | | | | | |
Collapse
|
36
|
Kimura H, Okamura Y, Chiba Y, Shigeru M, Ishii T, Hori T, Shiomi R, Yamamoto Y, Fujimoto Y, Maeyama M, Kohmura E. Cilostazol administration with combination enteral and parenteral nutrition therapy remarkably improves outcome after subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:147-52. [PMID: 25366615 DOI: 10.1007/978-3-319-04981-6_25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In order to prevent cerebral vasospasm (VS) following aneurysmal subarachnoid hemorrhage (SAH), we introduced combined enteral nutrition (EN) and parenteral nutrition (PN) with oral cilostazol administration to the postoperative patient after SAH and investigated the effect on VS. METHODS After aneurysmal SAH, 130 postoperative patients were enrolled in this study between April 2008 and March 2012. The patients enrolled before April 2010 were treated by conventional therapy (control group). The patients enrolled after April 2010 were administrated cilostazol 200 mg/day and received EN and PN simultaneously (combined group). RESULTS The combined group consisted of 62 patients and the control group of 68 patients. Angiographic VS occurred in 33.9 % (n = 21) of the combined group and in 51.5 % (n = 35) of the control group (p = 0.051, Fisher exact test). The incidence of symptomatic VS was significantly lower in the combined group (p = 0.001). The incidence of new cerebral infarctions was also significantly lower in the combined group (p = 0.0006). Clinical outcome at discharge was also significantly better in the combined group than in control group (p = 0.031). CONCLUSIONS Cilostazol administration with combination EN and PN is remarkably effective in preventing cerebral VS after aneurysmal SAH.
Collapse
Affiliation(s)
- Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1, Kusuniki-cho, Chuo-ku, Kobe, 650-0017, Japan,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Endothelin-1 expression and alterations of cerebral microcirculation after experimental subarachnoid hemorrhage. Neuroradiology 2014; 57:63-70. [DOI: 10.1007/s00234-014-1435-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
|
38
|
Alaraj A, Wallace A, Dashti R, Patel P, Aletich V. Balloons in endovascular neurosurgery: history and current applications. Neurosurgery 2014; 74 Suppl 1:S163-90. [PMID: 24402485 DOI: 10.1227/neu.0000000000000220] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The use of balloons in the field of neurosurgery is currently an essential part of our clinical practice. The field has evolved over the last 40 years since Serbinenko used balloons to test the feasibility of occluding cervical vessels for intracranial pathologies. Since that time, indications have expanded to include sacrificing cervical and intracranial vessels with detachable balloons, supporting the coil mass in wide-necked aneurysms (balloon remodeling technique), and performing intracranial and cervical angioplasty for atherosclerotic disease, as well as an adjunct to treat arteriovenous malformations. With the rapid expansion of endovascular technologies, it appears that the indications and uses for balloons will continue to expand. In this article, we review the history of balloons, the initial applications, the types of balloons available, and the current applications available for endovascular neurosurgeons.
Collapse
Affiliation(s)
- Ali Alaraj
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago. Chicago, Illinois
| | | | | | | | | |
Collapse
|
39
|
Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. INTERVENTIONAL NEUROLOGY 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
Collapse
Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
| |
Collapse
|
40
|
Chalouhi N, Tjoumakaris S, Thakkar V, Theofanis T, Hammer C, Hasan D, Starke RM, Wu C, Gonzalez LF, Rosenwasser R, Jabbour P. Endovascular management of cerebral vasospasm following aneurysm rupture: outcomes and predictors in 116 patients. Clin Neurol Neurosurg 2014; 118:26-31. [PMID: 24529225 DOI: 10.1016/j.clineuro.2013.12.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 11/11/2013] [Accepted: 12/25/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To retrospectively assess the safety and efficacy of endovascular treatment of cerebral vasospasm with different modalities and assess predictors of outcome. METHODS Endovascular treatment was indicated in the event of neurological deterioration refractory to medical therapy. Data were collected for 116 patients treated at our institution. RESULTS Vasospasm was treated with balloon angioplasty in 52.6%, intra-arterial nicardipine infusion in 19.8%, or both in 27.6%. Angiographic vasospasm was reversed in all but 4 (96.6%) patients. The complication rate was 0.9%. Twenty patients (17.2%) had incipient pre-procedure hypodensities; 3 (15%) hypodensities were reversed and neurological improvement occurred in 60% of these patients. Retreatment was required in 22 (19%) patients. Higher Hunt and Hess grades and treatment with nicardipine alone predicted retreatment. Neurological improvement was noted in 82%. Male gender, pre-procedure hypodensities, and posterior communicating artery aneurysm location negatively predicted neurological recovery. Favorable outcomes were noted in 73%. Higher Hunt and Hess grades, pre-procedure hypodensities, posterior circulation aneurysms, and no neurological recovery predicted poor outcome. CONCLUSION Endovascular therapy for vasospasm has an excellent safety-efficacy profile. Balloon angioplasty and nicardipine are equally effective but effects of nicardipine are less durable. Patients with incipient pre-procedure hypodensities benefit from endovascular intervention and should probably not be excluded from treatment.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Vismay Thakkar
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Christine Hammer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, USA
| | - Robert M Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Chengyuan Wu
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA.
| |
Collapse
|
41
|
Heit JJ, Choudhri O, Marks MP, Dodd RL, Do HM. Cerebral angioplasty using the Scepter XC dual lumen balloon for the treatment of vasospasm following intracranial aneurysm rupture. J Neurointerv Surg 2014; 7:56-61. [DOI: 10.1136/neurintsurg-2013-011043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
42
|
Chun-jing H, Shan O, Guo-dong L, Hao-xiong N, Yi-ran L, Ya-ping F. Effect of cervical sympathetic block on cerebral vasospasm after subarachnoid hemorrhage in rabbits. Acta Cir Bras 2013; 28:89-93. [PMID: 23370920 DOI: 10.1590/s0102-86502013000200001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 12/12/2012] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Cerebral vasospasm (CVS) is a major complication after subarachnoid hemorrhage (SAH) induced by the rupture of intracranial aneurysms. The aim of the present study was to investigate the effect and mechanism of cervical sympathetic block on cerebral vasospasm of the rabbits after SAH. METHODS After successful modeling of cervical sympathetic block, 18 healthy male white rabbits were randomly divided into three groups (n=6), ie, sham operation group (Group A), SAH group (Group B) and SAH with cervical sympathetic block group (Group C). Models of delayed CVS were established by puncturing cisterna magna twice with an injection of autologous arterial blood in Groups B and C. A sham injection of blood through cisterna magna was made in Group A. 0.5 ml saline was injected each time through a catheter for cervical sympathetic block after the first injection of blood three times a day for 3 d in Group B (bilateral alternating). 0.5 ml of 0.25% bupivacaine was injected each time through a catheter for cervical sympathetic block after the first injection of blood three times a day for 7 d in Group B. 2 ml venous blood and cerebrospinal fluid were obtained before (T1), 30 min (T2) and 7 d (T3) after the first injection of blood, respectively, and conserved in a low temperature refrigerator. Basilar artery value at T1, T2 and T3 was measured via cerebral angiography. The degree of damage to nervous system at T1 and T3 was recorded. RESULTS There was no significant difference in diameter of basilar artery at T1 among three groups. The diameters of basilar artery at T2 and T3 of Groups B and C were all smaller than that in Group A, which was smaller than Group C, with a significant difference. There was no significant difference in NO and NOS in plasma and cerebrospinal fluid among three groups. The NO and NOS contents at T2 and T3 of Groups B and C were all lower than Group A; Group C was higher than Group B, with a significant difference. The nerve function at T3 of Groups B and C were all lower than Group A and that of Group C higher than Group B, with a significant difference. CONCLUSION Cervical sympathetic block can relieve cerebral vasospasm after subarachnoid hemorrhage and increase NO content and NOS activity in plasma and cerebrospinal fluid to promote neural functional recovery.
Collapse
Affiliation(s)
- He Chun-jing
- Department of Anesthesiology, People's Hospital of Guizhou Province, China
| | | | | | | | | | | |
Collapse
|
43
|
Pandey AS, Elias AE, Chaudhary N, Thompson BG, Gemmete JJ. Endovascular Treatment of Cerebral Vasospasm. Neuroimaging Clin N Am 2013; 23:593-604. [DOI: 10.1016/j.nic.2013.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
44
|
Santillan A, Knopman J, Zink W, Patsalides A, Gobin YP. Transluminal balloon angioplasty for symptomatic distal vasospasm refractory to medical therapy in patients with aneurysmal subarachnoid hemorrhage. Neurosurgery 2013; 69:95-101; discussion 102. [PMID: 21368694 DOI: 10.1227/neu.0b013e31821424f9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cerebral vasospasm (VSP) is a major cause of morbidity and mortality associated with subarachnoid hemorrhage. The current endovascular paradigm for VSP refractory to medical therapy is to perform angioplasty for proximal vessel VSP and vasodilator infusion for distal vessel VSP. OBJECTIVE To report our experience with a large series of balloon angioplasty for distal VSP refractory to medical therapy in patients with aneurysmal subarachnoid hemorrhage. METHODS This was a retrospective series of 32 patients with subarachnoid hemorrhage and symptomatic VSP refractory to medical therapy who were treated with balloon angioplasty for distal vessel VSP. Immediate angiographic results, procedure-related complications, and clinical outcomes were assessed. RESULTS From September 2001 to January 2010, 32 patients with symptomatic VSP refractory to medical therapy underwent angioplasty for distal arterial VSP. There were 26 women (81.3%); patients were 29 to 67 years of age. A total of 175 vessels were angioplastied (95 proximal and 80 distal). The only complication was rupture of an incompletely clipped aneurysm that was treated by immediate coiling and did not result in any clinical worsening. Repeated treatment was needed for 6 arteries (6 of 80, 7.5%). There were no procedure-related symptomatic complications. Good outcomes (modified Rankin Scale score ≤ 2) were observed in 23 of 28 patients (82.1%) with follow-up. CONCLUSION Balloon angioplasty for distal VSP is safe and effective and decreases the need for repeated intraarterial treatments seen with infusion of vasodilator.
Collapse
Affiliation(s)
- Alejandro Santillan
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York 10065, USA.
| | | | | | | | | |
Collapse
|
45
|
Abdihalim MM, Hassan AE, Qureshi AI. Off-label use of drugs and devices in the neuroendovascular suite. AJNR Am J Neuroradiol 2013; 34:2054-63. [PMID: 23518356 DOI: 10.3174/ajnr.a3447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARY The off-label use of drugs and devices in neuroendovascular procedures is common. Neurointerventionalists should be well aware of the level of evidence available in support of the off-label use of drugs and devices in their practice and some of the potential adverse events associated with them. These uses are categorized as I or II if they have been evaluated as primary or ancillary interventions in prospective trials/registries of neuroendovascular procedures and III if they were evaluated in case series. Category IV use is based on evaluation as primary or ancillary interventions in prospective trials/registries of non-neuroendovascular procedures. Physicians are allowed to use off-label drugs and procedures if there is strong evidence that they are beneficial for the patient. The neurointerventional professional societies agree that off-label use of drugs and devices is an important part of the specialty, but practicing providers should base their decisions on sound evidence when using such drugs and devices.
Collapse
|
46
|
Serrone J, Jimenez L, Andaluz N, Abruzzo TA, Zuccarello M, Ringer AJ. Management of vasospasm in ruptured unsecured intracranial vascular lesions: review of 10 cases. J Neurointerv Surg 2013; 6:108-14. [DOI: 10.1136/neurintsurg-2012-010591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Joseph Serrone
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cerebrovascular Center at UC Neuroscience Institute, Cincinnati, Ohio, USA
| | | | | | | | | | | |
Collapse
|
47
|
Vasospasm after aneurysmal subarachnoid hemorrhage: recent advances in endovascular management. Curr Opin Crit Care 2013; 16:110-6. [PMID: 20098322 DOI: 10.1097/mcc.0b013e3283372ef2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In a rapidly advancing specialty, it is essential to review the recent studies of alternative new treatments and present their efficacy, safety and outcome. We discuss the recent advances in the endovascular treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage in the past few years with special focus on the literature regarding this subject in the last 18-24 months. RECENT FINDINGS The recent findings are as follows: effect of papaverine on brain oxygen; recent evaluation concerning nimodipine use; combined intraarterial and intravenous use of milrinone; illustration of the numerous recent studies on nicardipine; the safety and efficacy of high-dose intraarterial verapamil; outcome and adverse effects of intraarterial fasudil; transluminal balloon angioplasty; and recent evaluation of its efficacy and evaluation of its prophylactic use. SUMMARY Endovascular treatment, including intraarterial vasodilators and transluminal balloon angioplasty, has a very important place in the management of symptomatic vasospasm related to aneurysmal subarachnoid hemorrhage. The efficacy of intraarterial vasodilators has been proven. Numerous studies and analysis of different treatments of cerebrovascular vasospasm took place in the past period. This allowed more understanding and evaluation of their outcome, safety and efficacy helping physicians to choose better treatments to adopt. It emphasizes also the aspects that need more study and research.
Collapse
|
48
|
Senbokuya N, Kinouchi H, Kanemaru K, Ohashi Y, Fukamachi A, Yagi S, Shimizu T, Furuya K, Uchida M, Takeuchi N, Nakano S, Koizumi H, Kobayashi C, Fukasawa I, Takahashi T, Kuroda K, Nishiyama Y, Yoshioka H, Horikoshi T. Effects of cilostazol on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a multicenter prospective, randomized, open-label blinded end point trial. J Neurosurg 2013; 118:121-30. [DOI: 10.3171/2012.9.jns12492] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of subsequent morbidity and mortality. Cilostazol, a selective inhibitor of phosphodiesterase 3, may attenuate cerebral vasospasm because of its antiplatelet and vasodilatory effects. A multicenter prospective randomized trial was conducted to investigate the effect of cilostazol on cerebral vasospasm.
Methods
Patients admitted with SAH caused by a ruptured anterior circulation aneurysm who were in Hunt and Kosnik Grades I to IV and were treated by clipping within 72 hours of SAH onset were enrolled at 7 neurosurgical sites in Japan. These patients were assigned to one of 2 groups: the usual therapy group (control group) or the add-on 100 mg cilostazol twice daily group (cilostazol group). The group assignments were done by a computer-generated randomization sequence. The primary study end point was the onset of symptomatic vasospasm. Secondary end points were the onset of angiographic vasospasm and new cerebral infarctions related to cerebral vasospasm, clinical outcome as assessed by the modified Rankin scale, and length of hospitalization. All end points were assessed for the intention-to-treat population.
Results
Between November 2009 and December 2010, 114 patients with SAH were treated by clipping within 72 hours from the onset of SAH and were screened. Five patients were excluded because no consent was given. Thus, 109 patients were randomly assigned to the cilostazol group (n = 54) or the control group (n = 55). Symptomatic vasospasm occurred in 13% (n = 7) of the cilostazol group and in 40% (n = 22) of the control group (p = 0.0021, Fisher exact test). The incidence of angiographic vasospasm was significantly lower in the cilostazol group than in the control group (50% vs 77%; p = 0.0055, Fisher exact test). Multiple logistic analyses demonstrated that nonuse of cilostazol is an independent factor for symptomatic and angiographic vasospasm. The incidence of new cerebral infarctions was also significantly lower in the cilostazol group than in the control group (11% vs 29%; p = 0.0304, Fisher exact test). Clinical outcomes at 1, 3, and 6 months after SAH in the cilostazol group were better than those in the control group, although a significant difference was not shown. There was also no significant difference in the length of hospitalization between the groups. No severe adverse event occurred during the study period.
Conclusions
Oral administration of cilostazol is effective in preventing cerebral vasospasm with a low risk of severe adverse events. Clinical trial registration no. UMIN000004347, University Hospital Medical Information Network Clinical Trials Registry.
Collapse
Affiliation(s)
- Nobuo Senbokuya
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Hiroyuki Kinouchi
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Kazuya Kanemaru
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Yasuhiro Ohashi
- 2Department of Neurosurgery and Radiology, Nasu Neurosurgical Center, Nasushiobara, Tochigi
| | - Akira Fukamachi
- 2Department of Neurosurgery and Radiology, Nasu Neurosurgical Center, Nasushiobara, Tochigi
| | - Shinichi Yagi
- 3Department of Neurosurgery, Kanto Neurosurgical Hospital, Kumagaya, Saitama
| | - Tsuneo Shimizu
- 3Department of Neurosurgery, Kanto Neurosurgical Hospital, Kumagaya, Saitama
| | - Koro Furuya
- 4Department of Neurosurgery, Suwa Central Hospital, Chino, Nagano; and
| | - Mikito Uchida
- 4Department of Neurosurgery, Suwa Central Hospital, Chino, Nagano; and
| | - Nobuyasu Takeuchi
- 5Department of Neurosurgery, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi
| | - Shin Nakano
- 5Department of Neurosurgery, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi
| | - Hidehito Koizumi
- 5Department of Neurosurgery, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi
| | | | - Isao Fukasawa
- 6Department of Neurosurgery, Kofu Johnan Hospital, Kofu, Yamanashi
| | - Teruo Takahashi
- 7Department of Neurosurgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Katsuhiro Kuroda
- 7Department of Neurosurgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Yoshihisa Nishiyama
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Hideyuki Yoshioka
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Toru Horikoshi
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| |
Collapse
|
49
|
Aburto-Murrieta Y, Marquez-Romero JM, Bonifacio-Delgadillo D, López I, Hernández-Curiel B. Endovascular Treatment. Vasc Endovascular Surg 2012; 46:460-5. [DOI: 10.1177/1538574412454585] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cerebral vasospasm (CV) accounts significant morbimortality after aneurysmal subarachnoid hemorrhage. The objective of this study was to compare the clinical outcome of patients with CV treated by 2 endovascular procedures: intra-arterial nimodipine angioplasty (IANA) and balloon angioplasty (BA). Between 2008 and June 2011, we performed 22 IANA and 8 BA in 30 patients. The mean age was 44 years and 60% was female. In 17 patients, the treatment was clipping, whereas 13 underwent coil treatment. The CV was severe in 63%, moderate in 30%, and mild in 7%. Good outcome between 2 groups was similar ( P = .36). The clinical outcome according to the subgroups of CV severity and modality treatment was equivalent ( P = .22). Mortality at 3 months was 16% and 20% at 1 year. We did not find differences in the clinical outcome despite the fact that both techniques produce adequate angiographic resolution of CV.
Collapse
Affiliation(s)
- Yolanda Aburto-Murrieta
- Departamento de Terapia Endovascular, Instituto Nacional de Neurología y Neurología, Insurgentes Sur, Mexico
| | - Juan M. Marquez-Romero
- Departamento de Terapia Endovascular, Instituto Nacional de Neurología y Neurología, Insurgentes Sur, Mexico
| | - Dulce Bonifacio-Delgadillo
- Departamento de Terapia Endovascular, Instituto Nacional de Neurología y Neurología, Insurgentes Sur, Mexico
| | - Iván López
- Departamento de Terapia Endovascular, Instituto Nacional de Neurología y Neurología, Insurgentes Sur, Mexico
| | - B. Hernández-Curiel
- Departamento de Terapia Endovascular, Instituto Nacional de Neurología y Neurología, Insurgentes Sur, Mexico
| |
Collapse
|
50
|
Miley JT, Tariq N, Souslian FG, Qureshi N, Suri MFK, Tummala RP, Vazquez G, Qureshi AI. Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage. Neurosurgery 2012; 69:ons161-8; discussion ons168. [PMID: 21712743 DOI: 10.1227/neu.0b013e31822a8976] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage. OBJECTIVE To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm. METHODS Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons. RESULTS A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01). CONCLUSION No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.
Collapse
Affiliation(s)
- Jefferson T Miley
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
| | | | | | | | | | | | | | | |
Collapse
|