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Hirayama Y, Kida H, Inoue T, Sugimoto K, Oka F, Shirao S, Imoto H, Nomura S, Suzuki M. Focal brain cooling suppresses spreading depolarization and reduces endothelial nitric oxide synthase expression in rats. IBRO Neurosci Rep 2024; 16:609-621. [PMID: 38800086 PMCID: PMC11127172 DOI: 10.1016/j.ibneur.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/29/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
This study aimed to investigate the effects of focal brain cooling (FBC) on spreading depolarization (SD), which is associated with several neurological disorders. Although it has been studied from various aspects, no medication has been developed that can effectively control SD. As FBC can reduce neuronal damage and promote functional recovery in pathological conditions such as epilepsy, cerebral ischemia, and traumatic brain injury, it may also potentially suppress the onset and progression of SD. We created an experimental rat model of SD by administering 1 M potassium chloride (KCl) to the cortical surface. Changes in neuronal and vascular modalities were evaluated using multimodal recording, which simultaneously recorded brain temperature (BrT), wide range electrocorticogram, and two-dimensional cerebral blood flow. The rats were divided into two groups (cooling [CL] and non-cooling [NC]). Warm or cold saline was perfused on the surface of one hemisphere to maintain BrT at 37°C or 15°C in the NC and CL groups, respectively. Western blot analysis was performed to determine the effects of FBC on endothelial nitric oxide synthase (eNOS) expression. In the NC group, KCl administration triggered repetitive SDs (mean frequency = 11.57/h). In the CL group, FBC increased the duration of all KCl-induced events and gradually reduced their frequency. Additionally, eNOS expression decreased in the cooled brain regions compared to the non-cooled contralateral hemisphere. The results obtained by multimodal recording suggest that FBC suppresses SD and decreases eNOS expression. This study may contribute to developing new treatments for SD and related neurological disorders.
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Affiliation(s)
- Yuya Hirayama
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Hiroyuki Kida
- Department of Physiology, Graduate School of Medicine, Yamaguchi University, Japan
| | - Takao Inoue
- Organization of Research Initiatives, Yamaguchi University, Japan
| | - Kazutaka Sugimoto
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Fumiaki Oka
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Satoshi Shirao
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Hirochika Imoto
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Sadahiro Nomura
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Graduate School of Medicine, Yamaguchi University, Japan
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Liu Y, Xu M, Zhang P, Feng G. The Effectiveness of Target Temperature Management on Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Ther Hypothermia Temp Manag 2024. [PMID: 38813648 DOI: 10.1089/ther.2024.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
The effectiveness of target temperature management (TTM) in poor-grade aneurysmal subarachnoid hemorrhage (aSAH) remains a topic of debate. In order to assess the clinical efficacy of TTM in patients with poor-grade aSAH, we conducted a systematic review and meta-analysis. This research was registered in PROSPERO (CRD42023445582) and included all relevant publications up until October 2023. We compared the TTM groups with the control groups in terms of unfavorable outcomes (modified Rankin scale [mRS] score > 3), mortality, delayed cerebral ischemia (DCI), cerebral vasospasm (CVS), and specific complications. Subgroup analyses were performed based on country, study type, follow-up time, TTM method, cooling maintenance period, and rewarming rate. Effect sizes were calculated as relative risk (RR) using random-effect or fixed-effect models. The quality of the articles was assessed using the methodological index for non-randomized studies scale. Our analysis included a total of 5 clinical studies (including 1 randomized controlled trial) and 219 patients (85 in the TTM group and 134 in the control group). Most of the studies were of moderate quality. TTM was found to be associated with a statistically significant improvement in mortality (mRS score 6) rates compared with the control group (RR = 0.61, 95% confidence interval [CI]: 0.40-0.94, p = 0.026). However, there was no statistically significant difference in unfavorable outcomes (mRS 4-6) between the TTM and control groups (RR = 0.94, 95% CI: 0.71-1.26, p = 0.702). The incidence of adverse events, including DCI, CVS, pneumonia, cardiac complications, and electrolyte imbalance, did not significantly differ between the two groups. In conclusion, our overall results suggest that TTM does not significantly reduce unfavorable outcomes in poor-grade aSAH patients. However, TTM may decrease mortality rates. Preoperative TTM may cause patients to miss the opportunity for surgery, although it temporarily protects the brain. Furthermore, the incidence of adverse events was similar between the TTM and control groups.
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Affiliation(s)
- Yang Liu
- Department of Neurosurgical Intensive Care Unit, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Mengyuan Xu
- Department of Neurosurgical Intensive Care Unit, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Pengzhao Zhang
- Department of Neurosurgical Intensive Care Unit, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Guang Feng
- Department of Neurosurgical Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, China
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Lee S, Kim M, Kwon MY, Kwon SM, Ko YS, Chung Y, Park W, Park JC, Ahn JS, Jeon H, Im J, Kim JH. The efficacy of therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Acute Crit Care 2024; 39:282-293. [PMID: 38863359 PMCID: PMC11167421 DOI: 10.4266/acc.2024.00612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus. METHODS Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed. RESULTS The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups. CONCLUSIONS TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.
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Affiliation(s)
- Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Yong Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Young San Ko
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Yeongu Chung
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanwool Jeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihyun Im
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
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Liu Y, Li Y, Han B, Mei L, Zhang P, Zhang J, Xu M, Gao M, Feng G. Targeted Temperature Management for Poor Grade Aneurysmal Subarachnoid Hemorrhage: A Pilot Study. World Neurosurg 2024; 183:e846-e859. [PMID: 38237800 DOI: 10.1016/j.wneu.2024.01.041] [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: 12/23/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE We assessed the effectiveness and safety of target temperature management (TTM) in treating patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). The primary objective was to evaluate the neurological outcome at 3 months. Secondary objectives were to assess mortality, delayed cerebral ischemia, cerebral edema, hydrocephalus, midline shift, and laboratory indicators related to TTM. METHODS A single-blind, nonrandomized controlled trial was conducted. After admission, patients with poor-grade aSAH (Hunt-Hess scores IV ∼ V) were assigned to a TTM group or a control group in a 1:1 ratio. TTM with core temperatures ranging from 36°C to 37°C was performed immediately and maintained until microclipping or endovascular embolization. Subsequently, rapid induction to 33°C ∼ 35°C was carried out and maintained for 3 to 5 days. Then, the patients underwent slow rewarming to 36°C ∼ 37°C and maintained at that temperature for a minimum of 48 hours. RESULTS Sixty patients (30 treated with TTM and 30 with standard treatment) were included in the study. At 3 months, a favorable prognosis (modified Rankin scale score 0 to 3) was significantly higher in the TTM group than in the control group (n = 14, 46.7% vs. n = 6, 20.0%, P = 0.028). Adjusted multivariate logistics regression analysis indicated that TTM (odds ratio = 0.20, 95% confidence interval: 0.05-0.77, P = 0.019) reduced the number of unfavorable prognoses 3 months after admission. CONCLUSIONS This study demonstrated the effectiveness and safety of TTM in patients with poor-grade aSAH, and its implementation improved neurological outcomes. Multicenter randomized controlled studies with a large number of patients are needed to confirm these observations.
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Affiliation(s)
- Yang Liu
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yanru Li
- Department of Neurosurgical Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Bingsha Han
- Department of Neurosurgical Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Leikai Mei
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Pengzhao Zhang
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Jiaqi Zhang
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Mengyuan Xu
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Min Gao
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Guang Feng
- Department of Neurosurgical Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China.
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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: 128] [Impact Index Per Article: 128.0] [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.
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Zhou Z, Liu Z, Zhang C, Zhang W, Zhang C, Chen T, Wang Y. Mild hypothermia alleviates early brain injury after subarachnoid hemorrhage via suppressing pyroptosis through AMPK/NLRP3 inflammasome pathway in rats. Brain Res Bull 2023; 193:72-83. [PMID: 36535306 DOI: 10.1016/j.brainresbull.2022.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
As a subtype of stroke, subarachnoid hemorrhage (SAH) has a notoriously high rate of disability and mortality owing to the lack of effective intervention. Early brain injury (EBI) is the main factor responsible for the dismal prognosis of SAH patients. The current study intends to explore the molecular mechanism underlying the effect of MH on EBI after SAH from a novel perspective of pyroptosis, a highly specific inflammatory programmed cell death, in the SAH rat model. Sprague-Dawley (SD) rats were divided into different groups in accordance with various treatments. In the treatment group, the rats underwent mild hypothermia for 4 h after modeling; in the inhibitor group, Compound C (an inhibitor of AMPK) was administered intravenous injections (i.v.) 30 min before modeling. Neurological score, neuronal death, brain water content, inflammatory reaction, and expression levels of pyroptosis-related proteins were evaluated in the rats. Our results indicate that the MH therapy significantly increased the neurological score and assuaged brain edema, neuronal injury, and inflammatory reaction induced by SAH. Meanwhile, MH therapy upregulated the level of AMPK phosphorylation whereas downregulated the protein expressions of NLRP3, ASC, cleaved caspase-1, GSDMD, IL-1β, and IL-18. The reversed effect of MH therapy by Compound C concretely indicated that MH therapy inhibited pyroptosis through an AMPK-dependent pathway. Our study also found that MH therapy potently curbed the increasing trend of brain temperature (BT), rectal temperature (RT), and ICP after SAH. Taken together, our data indicate that the neuroprotective effects of MH therapy were manifested by inhibiting pyroptosis via the AMPK/NLRP3 inflammasome pathway, which may serve as a promising therapy for the intervention of SAH.
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Affiliation(s)
- Zhaopeng Zhou
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Zhuanghua Liu
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Chenxu Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Wang Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Chunlei Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Tao Chen
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China.
| | - Yuhai Wang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, 214044, China.
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Kobata H, Tucker A, Sarapuddin G, Sugie A, Negoro T, Kawakami M, Tada K. Targeted Temperature Management for Severe Subarachnoid Hemorrhage Using Endovascular and Surface Cooling Systems: A Nonrandomized Interventional Study Using Historical Control. Neurosurgery 2022; 91:863-871. [PMID: 36083144 DOI: 10.1227/neu.0000000000002122] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although targeted temperature management (TTM) may mitigate brain injury for severe subarachnoid hemorrhage (SAH), rebound fever correlates with poor outcomes. OBJECTIVE To study the effect of endovascular TTM after rewarming from initial surface cooling during a high-risk period for delayed cerebral ischemia. METHODS We studied patients with World Federation of Neurological Surgeons grade V SAH before and after the introduction of endovascular TTM. Both groups (36 patients each) were treated with TTM at 34 °C with conventional surface cooling immediately after SAH diagnosis, together with emergency aneurysm repair. When rewarmed to 36 °C, around 7 days later, the study group underwent TTM at 36 to 38 °C for 7 days with an endovascular cooling system. The control group was treated with antipyretics. RESULTS Sex, age, Glasgow Coma Scale score, modified Fisher computed tomography classification, aneurysm location, and treatment methods were not different between the study and control groups. Differences were detected in the incidence of fever >38 °C (13 vs 26 patients, P = .0021), duration of fever >38 °C (4.1 vs 18.8 hours, P = .0021), incidence of vasospasm-related cerebral infarction (17% vs 42%, P = .037), and the likelihood of excellent outcomes (0 and 1 on a modified Rankin Scale) at 6 months (42% vs 17%, P = .037). In endovascular TTM, shivering occurred more frequently in patients with better outcomes, requiring aggressive treatment to avoid fever. CONCLUSION Endovascular TTM at 36 to 38 °C after surface cooling was feasible and safely performed in patients with severe SAH. Combined TTM for 2 weeks was associated with a lower incidence of vasospasm-related infarction and may improve outcomes.
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Affiliation(s)
- Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.,Department of Emergency Medicine, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Adam Tucker
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.,Department of Emergency Medicine, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.,Department of Neurosurgery, Japanese Red Cross Kitami Hospital, Kitami, Japan
| | - Gemmalynn Sarapuddin
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.,Department of Emergency Medicine, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.,Neurology Department, Institute of Neurosciences, The Medical City, Pasig, Philippines
| | - Akira Sugie
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.,Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Takayoshi Negoro
- Department of Emergency Medicine, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Makiko Kawakami
- Department of Emergency Medicine, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Kenji Tada
- Department of Emergency Medicine, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
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Beretta S, Versace A, Fiore G, Piola M, Martini B, Bigiogera V, Coppadoro L, Mariani J, Tinti L, Pirovano S, Monza L, Carone D, Riva M, Padovano G, Galbiati G, Santangelo F, Rasponi M, Padelli F, Giachetti I, Aquino D, Diamanti S, Librizzi L, Bruzzone MG, De Curtis M, Giussani C, Sganzerla EP, Ferrarese C. Selective Cerebrospinal Fluid Hypothermia: Bioengineering Development and In Vivo Study of an Intraventricular Cooling Device (V-COOL). Neurotherapeutics 2022; 19:1942-1950. [PMID: 36129603 PMCID: PMC9723013 DOI: 10.1007/s13311-022-01302-y] [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] [Accepted: 09/11/2022] [Indexed: 12/14/2022] Open
Abstract
Hypothermia is a promising therapeutic strategy for severe vasospasm and other types of non-thrombotic cerebral ischemia, but its clinical application is limited by significant systemic side effects. We aimed to develop an intraventricular device for the controlled cooling of the cerebrospinal fluid, to produce a targeted hypothermia in the affected cerebral hemisphere with a minimal effect on systemic temperature. An intraventricular cooling device (acronym: V-COOL) was developed by in silico modelling, in vitro testing, and in vivo proof-of-concept application in healthy Wistar rats (n = 42). Cerebral cortical temperature, rectal temperature, and intracranial pressure were monitored at increasing flow rate (0.2 to 0.8 mL/min) and duration of application (10 to 60 min). Survival, neurological outcome, and MRI volumetric analysis of the ventricular system were assessed during the first 24 h. The V-COOL prototyping was designed to minimize extra-cranial heat transfer and intra-cranial pressure load. In vivo application of the V-COOL device produced a flow rate-dependent decrease in cerebral cortical temperature, without affecting systemic temperature. The target degree of cerebral cooling (- 3.0 °C) was obtained in 4.48 min at the flow rate of 0.4 mL/min, without significant changes in intracranial pressure. Survival and neurological outcome at 24 h showed no significant difference compared to sham-treated rats. MRI study showed a transient dilation of the ventricular system (+ 38%) in a subset of animals. The V-COOL technology provides an effective, rapid, selective, and safe cerebral cooling to a clinically relevant degree of - 3.0 °C.
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Affiliation(s)
- Simone Beretta
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy.
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy.
| | - Alessandro Versace
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Gianfranco Fiore
- Department of Electronic, Information and Bioengineering, Politecnico Di Milano, Milan, Italy
| | - Marco Piola
- Department of Electronic, Information and Bioengineering, Politecnico Di Milano, Milan, Italy
| | - Beatrice Martini
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Vittorio Bigiogera
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Lorenzo Coppadoro
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Jacopo Mariani
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Lorenzo Tinti
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Silvia Pirovano
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Laura Monza
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Davide Carone
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Matteo Riva
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Giada Padovano
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Gilda Galbiati
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Francesco Santangelo
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Marco Rasponi
- Department of Electronic, Information and Bioengineering, Politecnico Di Milano, Milan, Italy
| | - Francesco Padelli
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Isabella Giachetti
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Domenico Aquino
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Susanna Diamanti
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Laura Librizzi
- Department of Diagnostics and Technology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco De Curtis
- Department of Diagnostics and Technology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carlo Giussani
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Erik P Sganzerla
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Carlo Ferrarese
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
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Won SY, Kim MK, Song J, Lim YC. Therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2022; 221:107369. [DOI: 10.1016/j.clineuro.2022.107369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
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10
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Rhim JK, Park JJ, Kim H, Jeon JP. Early and Prolonged Mild Hypothermia in Patients with Poor-Grade Subarachnoid Hemorrhage: A Pilot Study. Ther Hypothermia Temp Manag 2022; 12:229-234. [PMID: 36130134 DOI: 10.1089/ther.2022.0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We assessed the feasibility of therapeutic early and prolonged mild hypothermia (MH) in patients with poor-grade subarachnoid hemorrhage (SAH). A retrospective pilot study was conducted for poor-grade SAH patients at two university hospitals from March 2015 to December 2018 who had received MH immediately after coil embolization and maintained a target temperature of 34-35°C for 5 days. A matched controlled design at a 1:2 ratio was used to compare MH therapy outcomes. The primary goal was to assess the two groups' severe functional outcomes at discharge defined as a modified Rankin Scale score of 4-6. The secondary aim was to assess mortality and severe vasospasm depending upon MH. A binary logistic regression analysis was performed to identify relevant risk factors for the outcomes. A total of 54 patients (18 with MH treatment and 36 without MH treatment) were included. Severe functional outcome was significantly decreased in poor-grade SAH patients with MH (n = 7, 38.9%) than those without MH (n = 25, 69.4%; p = 0.031). In patients treated with MH, mortality and severe vasospasm tended to be less common, although the difference was not statistically significant. A binary logistic regression analysis revealed that early and prolonged MH (odds ratio [OR] = 0.156, 95% confidence intervals [CI]: 0.037-0.644) and severe vasospasm (OR = 5.593, 95% CI: 1.372-22.812) were risk factors for severe functional outcomes. This study shows potential therapeutic effect of early and prolonged MH treatment in poor-grade SAH patients. A randomized controlled study with a large number of patients is warranted in the future.
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Affiliation(s)
- Jong-Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Heungcheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
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11
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Chen J, Tang P, Fu X. Cilostazol administration for subarachnoid hemorrhage: A meta-analysis of randomized controlled trials. J Clin Neurosci 2021; 89:305-310. [PMID: 34119285 DOI: 10.1016/j.jocn.2021.04.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/22/2021] [Accepted: 04/30/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The efficacy of cilostazol administration to treat subarachnoid hemorrhage remains controversial. We conduct a systematic review and meta-analysis to explore the influence of cilostazol administration on treatment efficacy for subarachnoid hemorrhage. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through July 2020 for randomized controlled trials (RCTs) assessing the effect of cilostazol administration in patients with subarachnoid hemorrhage. This meta-analysis is performed using the random-effect model. RESULTS Four RCTs involving 405 patients were included in the meta-analysis. Overall, compared with control group for subarachnoid hemorrhage, cilostazol intervention can significantly reduce symptomatic vasospasm (OR = 0.35; 95% CI = 0.21 to 0.60; P = 0.0001) and cerebral infarction (OR = 0.40; 95% CI = 0.22 to 0.73; P = 0.003), as well as improve no or mild angiographic vasospasm (OR = 2.01; 95% CI = 1.19 to 3.42; P = 0.01) and mRS score ≤ 2 (OR = 2.70; 95% CI = 1.09 to 6.71; P = 0.03), but revealed no obvious influence on severe angiographic vasospasm (OR = 0.53; 95% CI = 0.27 to 1.02; P = 0.06). There were no increase in adverse events (OR = 1.17; 95% CI = 0.54 to 2.52; P = 0.69), hemorrhagic events (OR = 0.62; 95% CI = 0.06 to 6.27; P = 0.69) and cardiac events (OR = 2.14; 95% CI = 0.44 to 10.27; P = 0.34) after the cilostazol intervention than control intervention. CONCLUSIONS Cilostazol treatment may be effective to treat subarachnoid hemorrhage in the terms of symptomatic vasospasm, cerebral infarction, no or mild angiographic vasospasm and mRS score ≤ 2.
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Affiliation(s)
- Jinlong Chen
- Department of Critical Care Medicine, Daye People's Hospital, China.
| | - Pingjin Tang
- Operating Room, Suizhou Hospital, Hubei University of Medicine, China.
| | - Xiaojuan Fu
- Chongqing Medical and Pharmaceutical College, China.
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12
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Qu X, Shang F, Zhao H, Qi M, Cheng W, Xu Y, Jiang L, Chen W, Wang N, Zhang H. Targeted temperature management at 33 degrees Celsius in patients with high-grade aneurysmal subarachnoid hemorrhage: a protocol for a multicenter randomized controlled study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:581. [PMID: 33987279 DOI: 10.21037/atm-20-4719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Studies on the use of therapeutic hypothermia (TH) to improve the outcome of high-grade aneurysmal subarachnoid hemorrhage (aSAH), show promising, though conflicting results because of the lack of high-quality trials. The aim of this study is to evaluate the safety and efficacy of TH (maintaining bladder temperature at 33 °C for ≥72 h) to treat patients with high-grade aSAH (Hunt-Hess grade IV-V). Methods A multicenter, randomized, controlled clinical trial will be conducted for October 2020 to September 2024 involving 10 clinics. Patients who meet the inclusion criteria will be randomized 1:1 to a TH group and a normothermia group. The trial will enroll 96 participants in TH group and normothermia one, respectively. The trial was registered with ClinicalTrials.gov (NCT03442608) on February 22, 2018. Following conventional treatment for aSAH, patients will undergo either TH for at least 72 h or normothermia. The primary endpoint is the Glasgow outcome scale at 6 months after bleeding. The secondary endpoints are: (I) mortality at 6 months after bleeding; (II) intracranial pressure; (III) intensive care unit stay; and (IV) hospital stay. The safety endpoints include neurological, infectious, intestinal, circulatory, coagulation, and bleeding complications, electrolyte disorders, and other complications. Discussion If the study hypothesis is confirmed, TH at 33 °C in patients with high-grade aSAH may become a promising treatment strategy for improving 6-month outcome. Trial registration The trial has been registered at ClinicalTrials.gov (ID: NCT03442608).
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Affiliation(s)
- Xin Qu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Shang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weitao Cheng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yueqiao Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lidan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenjing Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ning Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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13
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Mäder L, Ganai A, Aroyo I, Schill J, Tröscher-Weber R, Huppert P, Kotterer O, Geletneky K, Kollmar R. Targeted Temperature Management for Subarachnoid Hemorrhage: Excellent Outcome After Severe Vasospasm-A Case Series. Ther Hypothermia Temp Manag 2019; 9:216-221. [PMID: 30912704 DOI: 10.1089/ther.2018.0049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Targeted temperature management (TTM) might improve outcome of patients with severe subarachnoid hemorrhage (SAH) in which vasospasm, delayed cerebral ischemia (DCI), and increased intracranial pressure (ICP) are frequent and severe complications. A series of patients (n = 3) with severe aneurysmatic SAH were treated by TTM if they developed ICP crisis and/or severe vasospasm diagnosed by angiography. Once these complications were detected, body core temperature (BCT) was rapidly decreased to 35°C or 33°C, if necessary. BCT induced and maintained by surface cooling remained at the desired level for at least 72 hours. Rewarming was performed by 1°C, only if the target parameters ICP and velocities in the serial Doppler sonography indicating macrovascular vasospasm improved to regular levels. In case of increase of ICP or middle cerebral arteries velocities BCT was decreased again to the last effective level. The patients developed vasospasm between days 6 and 12 after SAH. All aneurysms were treated by coiling. BCT was reduced between days 6 and 12 after SAH. Total duration of BCT <36.5°C was between 5.5 and 8 days. It remained <35°C for 4-6 days, and at 33°C for 3 days on average. ICP could be sufficiently controlled in all patients, because no ICP crisis was observed during TTM and after rewarming. Two patients developed minor DCI. Side effects of prolonged ventilation of 7-18 days included pneumonia for two patients that could be treated sufficiently. Other complications were one case of ventriculitis and two temporary deliriums. Outcome of the patients was good because no focal neurological symptoms could be detected after rehabilitation. TTM represents a promising treatment approach for severe SAH in which standard treatment is often limited and experimental. It deserves further clinical investigation in a larger cohort.
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Affiliation(s)
- Lisa Mäder
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Ajaz Ganai
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Ilia Aroyo
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Josef Schill
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Regina Tröscher-Weber
- Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Peter Huppert
- Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Otto Kotterer
- Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | | | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany.,University Hospital Erlangen, Erlangen, Germany
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14
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McNett M, Moran C, Johnson H. Evidence-Based Review of Clinical Trials in Neurocritical Care. AACN Adv Crit Care 2019; 29:195-203. [PMID: 29875116 DOI: 10.4037/aacnacc2018200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Neurocritical care is a rapidly growing specialty of complex care for the critically ill patient with neurological injury. This rapid growth has led to an increase in the number of important clinical trials to guide clinical practice and evidence-based care of the critically ill patient with neurological injury. Specialty-trained critical care nurses and advanced practice providers are integral members of neurocritical care teams and must remain informed about pivotal trials shaping practice recommendations. This article presents a summary of recent trials that have affected current practice and influenced care recommendations in the neurocritical care setting.
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Affiliation(s)
- Molly McNett
- Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 . Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio
| | - Cristina Moran
- Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 . Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio
| | - Halee Johnson
- Molly McNett is Director, Nursing Research and Evidence-Based Practice, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Dr, Cleveland, OH 44109 . Cristina Moran is Clinical Nurse, Trauma Surgical Intensive Care Unit, MetroHealth Medical Center, Cleveland, Ohio. Halee Johnson is Advanced Practice Registered Nurse, Department of Neurosurgery, The MetroHealth System, Cleveland, Ohio
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15
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Ravishankar N, Nuoman R, Amuluru K, El-Ghanem M, Thulasi V, Dangayach NS, Lee K, Al-Mufti F. Management Strategies for Intracranial Pressure Crises in Subarachnoid Hemorrhage. J Intensive Care Med 2018; 35:211-218. [PMID: 30514150 DOI: 10.1177/0885066618813073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Standard management strategies for lowering intracranial pressure (ICP) in traumatic brain injury has been well-studied, but the use of lesser known interventions for ICP in subarachnoid hemorrhage (SAH) remains elusive. Searches were performed in PubMed and EBSCO Host to identify best available evidence for evaluation and management of medically refractory ICP in SAH. The role of standard management strategies such as head elevation, hyperventilation, mannitol and hypertonic saline as well as lesser known management such as sodium bicarbonate, indomethacin, tromethamine, decompressive craniectomy, decompressive laparotomy, hypothermia, and barbiturate coma are reviewed. We also included dose concentrations, dose frequency, infusion volume, and infusion rate for these lesser known strategies. Nonetheless, there is still a gap in the evidence to recommend optimal dosing, timing and its role in the improvement of outcomes but early diagnosis and appropriate management reduce adverse outcomes.
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Affiliation(s)
- Nidhi Ravishankar
- Department of Neurology, Windsor University School of Medicine, Frankfort, IL, USA
| | - Rolla Nuoman
- Department of Neurointerventional Radiology, University of Pittsburgh, Hamot, Erie, PA, USA.,Department of Neurology, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh, Hamot, Erie, PA, USA.,Department of Neurology, Division of Neuroendovascular Surgery and Neurocritical Care, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Division of Neuroendovascular Surgery and Neurocritical Care, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Venkatraman Thulasi
- Department of Neurology, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiwon Lee
- Department of Neurology, University of Texas Health, Houston, TX, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Division of Neuroendovascular Surgery and Neurocritical Care, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, NJ, USA
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16
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Lundbye J, Lyden PD, Polderman KH, Schwab S. Clinical Studies Targeting Stroke and Ischemic Insults. Ther Hypothermia Temp Manag 2018; 7:12-15. [PMID: 28253089 DOI: 10.1089/ther.2016.29022.jjl] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Justin Lundbye
- 1 Hospital of Central Connecticut , New Britain, Connecticut
| | - Patrick D Lyden
- 2 Department of Neurology, Cedars-Medical Center , Los Angeles, California
| | - Kees H Polderman
- 3 Department of Critical Care, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Stefan Schwab
- 4 Department of Neurology, Friedrich-Alexander University , Erlangen, Germany
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17
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Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
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18
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Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury. Neurocrit Care 2018; 27:276-286. [PMID: 28004327 DOI: 10.1007/s12028-016-0336-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.
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Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
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Affiliation(s)
- Fred Rincon
- Division of Critical Care and Neurotrauma, Department of Neurology, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA; Division of Critical Care and Neurotrauma, Department of Neurological Surgery, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
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20
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Phillips KF, Deshpande LS, DeLorenzo RJ. Hypothermia Reduces Mortality, Prevents the Calcium Plateau, and Is Neuroprotective Following Status Epilepticus in Rats. Front Neurol 2018; 9:438. [PMID: 29942282 PMCID: PMC6005175 DOI: 10.3389/fneur.2018.00438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022] Open
Abstract
Status Epilepticus (SE) is a major neurological emergency and is considered a leading cause of Acquired Epilepsy (AE). We have shown that SE produces neuronal injury and prolonged alterations in hippocampal calcium levels ([Ca2+]i) that may underlie the development of AE. Interventions preventing the SE-induced Ca2+ plateau could therefore prove to be beneficial in lowering the development of AE after SE. Hypothermia is used clinically to prevent neurological complications associated with Traumatic Brain Injury, cardiac arrest, and stroke. Here, we investigated whether hypothermia prevented the development of Ca2+ plateau following SE. SE was induced in hippocampal neuronal cultures (HNC) by exposing them to no added MgCl2 solution for 3 h. To terminate SE, low Mg2+ solution was washed off with 31°C (hypothermic) or 37°C (normothermic) physiological recording solution. [Ca2+]i was estimated with ratiometric Fura-2 imaging. HNCs washed with hypothermic solution exhibited [Ca2+]i ratios, which were significantly lower than ratios obtained from HNCs washed with normothermic solution. For in vivo SE, the rat pilocarpine (PILO) model was used. Moderate hypothermia (30–33°C) in rats was induced at 30-min post-SE using chilled ethanol spray in a cold room. Hypothermia following PILO-SE significantly reduced mortality. Hippocampal neurons isolated from hypothermia-treated PILO SE rats exhibited [Ca2+]i ratios which were significantly lower than ratios obtained from PILO SE rats. Hypothermia also provided significant neuroprotection against SE-induced delayed hippocampal injury as characterized by decreased FluoroJade C labeling in hypothermia-treated PILO SE rats. We previously demonstrated that hypothermia reduced Ca2+ entry via N-methyl-D-aspartate and ryanodine receptors in HNC. Together, our studies indicate that by targeting these two receptor systems hypothermia could interfere with epileptogenesis and prove to be an effective therapeutic intervention for reducing SE-induced AE.
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Affiliation(s)
- Kristin F Phillips
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Laxmikant S Deshpande
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.,Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Robert J DeLorenzo
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.,Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
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21
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Okazaki T, Kuroda Y. Aneurysmal subarachnoid hemorrhage: intensive care for improving neurological outcome. J Intensive Care 2018; 6:28. [PMID: 29760928 PMCID: PMC5941608 DOI: 10.1186/s40560-018-0297-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients. Main body of the abstract Delayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined. Short conclusion Although we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.
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Affiliation(s)
- Tomoya Okazaki
- 1Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
| | - Yasuhiro Kuroda
- 2Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
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22
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What Do We Mean by Poor-Grade Aneurysmal Subarachnoid Hemorrhage and What Can We Do? Neurocrit Care 2018; 25:335-337. [PMID: 27822740 DOI: 10.1007/s12028-016-0347-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Yao Z, You C, He M. Effect and Feasibility of Therapeutic Hypothermia in Patients with Hemorrhagic Stroke: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 111:404-412.e2. [PMID: 29325957 DOI: 10.1016/j.wneu.2018.01.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/31/2017] [Accepted: 01/04/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Therapeutic hypothermia (TH) has shown good results in experimental models of hemorrhagic stroke. The clinical application of TH, however, remains controversial, since reports regarding its therapeutic effect are inconsistent. METHODS We conducted a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-analyses comparing TH with a control group in terms of mortality, poor outcome, delayed cerebral ischemia (DCI), and specific complications. The subgroup analyses were stratified by study type, country, mean age, hemorrhage type, cooling method, treatment duration, rewarming velocity, and follow-up time. RESULTS Nine studies were included, most of which were of moderate quality. The overall effect demonstrated insignificant differences in mortality (risk ratio [RR] 0.78; 95% confidence interval [CI] 0.58-1.06; P = 0.11) and poor outcome rate (RR 0.89; 95% CI 0.70-1.12; P = 0.32) between TH and the control group. However, sensitivity analyses, after we omitted 1 study, achieved a statistically significant difference in poor outcome favoring TH. Moreover, in the subgroup analyses, the results derived from randomized studies revealed that TH significantly reduced poor outcomes (RR 0.40; 95% CI 0.22-0.74; P = 0.003). In addition, TH significantly reduced DCI compared with control (RR 0.61; 95% CI 0.40-0.93; P = 0.02). The incidence of specific complications (rebleeding, pneumonia, sepsis, arrhythmia, and hydrocephalus) between the 2 groups were comparable and did not reach significant difference. CONCLUSIONS The overall effect showed TH did not significantly reduce mortality and poor outcomes but led to a decreased incidence of DCI. Compared with control, TH resulted in comparable incidences of specific complications.
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Affiliation(s)
- Zhong Yao
- Department of Neurosurgery, West China Hospital, Sichuan University, and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Min He
- Department of Neurosurgery, West China Hospital, Sichuan University, and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, China.
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Lilla N, Rinne C, Weiland J, Linsenmann T, Ernestus RI, Westermaier T. Early Transient Mild Hypothermia Attenuates Neurologic Deficits and Brain Damage After Experimental Subarachnoid Hemorrhage in Rats. World Neurosurg 2017; 109:e88-e98. [PMID: 28951276 DOI: 10.1016/j.wneu.2017.09.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Metabolic exhaustion in ischemic tissue is the basis for a detrimental cascade of cell damage. In the acute stage of subarachnoid hemorrhage (SAH), a sequence of global and focal ischemia occurs, threatening brain tissue to undergo ischemic damage. This study was conducted to investigate whether early therapy with moderate hypothermia can offer neuroprotection after experimental SAH. METHODS Twenty male Sprague-Dawley rats were subjected to SAH and treated by active cooling (34°C) or served as controls by continuous maintenance of normothermia (37.0°C). Mean arterial blood pressure, intracranial pressure, and local cerebral blood flow over both hemispheres were continuously measured. Neurologic assessment was performed 24 hours later. Hippocampal damage was assessed by hematoxylin-eosin and caspase-3 staining. RESULTS By a slight increase of mean arterial blood pressure in the cooling phase and a significant reduction of intracranial pressure, hypothermia improved cerebral perfusion pressure in the first 60 minutes after SAH. Accordingly, a trend to increased cerebral blood flow was observed during this period. The rate of injured neurons was significantly reduced in hypothermia-treated animals compared with normothermic controls. CONCLUSIONS The results of this series cannot finally answer whether this form of treatment permanently attenuates or only delays ischemic damage. In the latter case, slowing down metabolic exhaustion by hypothermia may still be a valuable treatment during this state of ischemic brain damage and prolong the therapeutic window for possible causal treatments of the acute perfusion deficit. Therefore, it may be useful as a first-tier therapy in suspected SAH.
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Affiliation(s)
- Nadine Lilla
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Christoph Rinne
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Thomas Linsenmann
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
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Prolonged TTM – enhanced hypocoagulation and bleeding? Resuscitation 2017; 118:A3-A4. [DOI: 10.1016/j.resuscitation.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 11/19/2022]
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Choi W, Kwon SC, Lee WJ, Weon YC, Choi B, Lee H, Park ES, Ahn R. Feasibility and Safety of Mild Therapeutic Hypothermia in Poor-Grade Subarachnoid Hemorrhage: Prospective Pilot Study. J Korean Med Sci 2017; 32:1337-1344. [PMID: 28665071 PMCID: PMC5494334 DOI: 10.3346/jkms.2017.32.8.1337] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/24/2017] [Indexed: 01/10/2023] Open
Abstract
Therapeutic hypothermia (TH) improves the neurological outcome in patients after cardiac arrest and neonatal hypoxic brain injury. We studied the safety and feasibility of mild TH in patients with poor-grade subarachnoid hemorrhage (SAH) after successful treatment. Patients were allocated randomly to either the TH group (34.5°C) or control group after successful clipping or coil embolization. Eleven patients received TH for 48 hours followed by 48 hours of slow rewarming. Vasospasm, delayed cerebral ischemia (DCI), functional outcome, mortality, and safety profiles were compared between groups. We enrolled 22 patients with poor-grade SAH (Hunt & Hess Scale 4, 5 and modified Fisher Scale 3, 4). In the TH group, 10 of 11 (90.9%) patients had a core body temperature of < 36°C for > 95% of the 48-hour treatment period. Fewer patients in the TH than control group (n = 11, each) had symptomatic vasospasms (18.1% vs. 36.4%, respectively) and DCI (36.3% vs. 45.6%, respectively), but these differences were not statistically significant. At 3 months, 54.5% of the TH group had a good-to-moderate functional outcome (0-3 on the modified Rankin Scale [mRS]) compared with 9.0% in the control group (P = 0.089). Mortality at 1 month was 36.3% in the control group compared with 0.0% in the TH group (P = 0.090). Mild TH is feasible and can be safely used in patients with poor-grade SAH. Additionally, it may reduce the risk of vasospasm and DCI, improving the functional outcomes and reducing mortality. A larger randomized controlled trial is warranted.
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Affiliation(s)
- Wookjin Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soon Chan Kwon
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
| | - Won Joo Lee
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young Cheol Weon
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Byungho Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hyeji Lee
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Lundbye J, Lyden PD, Polderman KH, Schwab S. Clinical Studies Targeting Stroke and Ischemic Insults. Ther Hypothermia Temp Manag 2017:ther.2016.29022.jjl.rev. [PMID: 28106522 DOI: 10.1089/ther.2016.29022.jjl.rev] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Justin Lundbye
- 1 The Greater Waterbury Health Network, Waterbury, Connecticut
| | - Patrick D Lyden
- 2 Department of Neurology, Cedars-Medical Center , Los Angeles, California
| | - Kees H Polderman
- 3 Department of Critical Care, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Stefan Schwab
- 4 Department of Neurology, Friedrich-Alexander University , Erlangen, Germany
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28
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Targeted Temperature Management and Acute Brain Injury: An Update from Recent Clinical Trials. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0164-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hennerici MG, Fatar M. Editorial. Cerebrovasc Dis 2016; 42:512-513. [DOI: 10.1159/000452636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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