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Chlorogiannis DD, Aloizou AM, Mavridis T, Sänger JA, Chlorogiannis A, Madouros N, Papanagiotou P. Evolving frontiers: endovascular strategies for the treatment of delayed cerebral ischemia. Rev Neurosci 2024; 35:463-472. [PMID: 38278624 DOI: 10.1515/revneuro-2023-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/21/2023] [Indexed: 01/28/2024]
Abstract
Cerebral vasospasm and delayed cerebral ischemia represent a very challenging aspect of cerebrovascular pathophysiology, most commonly subarachnoid hemorrhage, with significantly high mortality if left untreated. Considerable advances have been made in medical treatment and prompt diagnosis, while newer endovascular modalities have recently been proposed for cases of resistant cerebral vasospasm. However, there is still paucity of data regarding which and whether a single endovascular technique is non inferior to the pharmacological standard of care. In this review, we aim to summarize the current funds of knowledge concerning cerebral vasospasm and the emerging role of the endovascular techniques for its treatment.
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Affiliation(s)
- David-Dimitris Chlorogiannis
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Society of Junior Doctors, 15123 Athens, Greece
| | - Athina-Maria Aloizou
- Department of Neurology, St. Josef-Hospital, Ruhr Universität Bochum, 44791 Bochum, Germany
| | - Theodoros Mavridis
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Department of Neurology, Tallaght University Hospital (TUH)/The Adelaide and Meath Hospital Dublin, Incorporating the National Children's Hospital (AMNCH), Dublin D24 NR0A, Ireland
| | | | - Anargyros Chlorogiannis
- Department of Health Economics, Policy and Management, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Nikolaos Madouros
- Hull University Teaching Hospitals NHS Trust, Hull HU3 2JZ, UK
- Society of Junior Doctors, 15123 Athens, Greece
| | - Panagiotis Papanagiotou
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, 115 28 Athens, Greece
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, 28205 Bremen, Germany
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2
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Sorrentino ZA, Lucke-Wold BP, Laurent D, Quintin SS, Hoh BL. Interventional Treatment of Symptomatic Vasospasm in the Setting of Traumatic Brain Injury: A Systematic Review of Reported Cases. World Neurosurg 2024; 183:45-55. [PMID: 38043741 DOI: 10.1016/j.wneu.2023.11.135] [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: 08/19/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies.
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Affiliation(s)
- Zachary A Sorrentino
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Brandon P Lucke-Wold
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dimitri Laurent
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Stephan S Quintin
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brian L Hoh
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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3
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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: 146] [Impact Index Per Article: 146.0] [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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4
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Kotwal A, Ramalingaiah AH, Shukla D, Radhakrishnan M, Konar SK, Srinivasaiah B, Chakrabarti D, Sundaram M. Role of Nimodipine and Milrinone in Delayed Cerebral Ischemia. World Neurosurg 2022; 166:e285-e293. [PMID: 35843579 DOI: 10.1016/j.wneu.2022.06.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The role of nimodipine and milrinone in the management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) was studied using clinical and TCD (transcranial Doppler) parameters. METHODS In this prospective observational study, patients with DCI after aneurysmal SAH presenting between November 2020 and June 2021 who were treated by either intra-arterial nimodipine (IAN) or intravenous milrinone (IVM) were included after excluding patients in whom both IAN and IVM had been given or mechanical angioplasty was performed. Twelve-hourly TCD was performed during the course of the therapy. Clinical improvement and the development of new brain infarcts were also assessed. A P value <0.05 was considered statistically significant. RESULTS Thirty-four patients fulfilled the inclusion criteria (IVM, 13/34 [38%]; IAN, 21/34 [62%]); patients in the IVM group (vs. IAN group) had poorer median Glasgow Coma Scale score (12 vs. 13), poorer motor response (<M6 response, 5/13 [38%] vs. 5/21 [24%]; P = 0.36) and higher grades (modified Fisher grade ≥3) of SAH (12/13 [92%] vs. 8/21 [86%]; P = 0.56). More patients in the IAN group (vs. IVM group) showed clinical improvement (17/21 [81%] vs. 10/13 [77%]; P = 0.77), development of new infarcts (15/21 [71%] vs. 7/13 [54%]; P = 0.29] and discharged to home (13/21 [62%] vs. 6/13 [46%]; P = 0.36) with less mortality (1/21 [9%] vs. 4/13 [23%]; P = 0.037). On TCD analysis, both IAN and IVM protocols showed similar effects in middle cerebral artery vasospasm; however, IAN proved better over time. In group-effect analysis, the IAN protocol was significantly better in anterior cerebral artery and posterior cerebral artery vasospasm compared with IVM protocol. CONCLUSIONS In this single-center small study, patients in the IAN group had significantly less mortality compared with the IVM group in the management of DCI after aneurysmal SAH.
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Affiliation(s)
- Abhishek Kotwal
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Arvinda Hanumanthapura Ramalingaiah
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India.
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Muthuchellappan Radhakrishnan
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Subhas Kanti Konar
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Bharath Srinivasaiah
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Mouleeswaran Sundaram
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
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5
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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]
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6
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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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7
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Anthofer J, Bele S, Wendl C, Kieninger M, Zeman F, Bruendl E, Schmidt NO, Schebesch KM. Continuous intra-arterial nimodipine infusion as rescue treatment of severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2021; 96:163-171. [PMID: 34789415 DOI: 10.1016/j.jocn.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 08/30/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
Severe refractory cerebral vasospasm (CV) is a major cause of disability and death in patients with aneurysmal subarachnoid hemorrhage (SAH). One rescue therapy in selected patients is intra-arterial nimodipine, either given as a single shot or as continuous infusion. To evaluate treatment efficacy, we analyzed outcome factors such as the incidence of craniectomy, ventriculo-peritonial (VP) shunting, and tracheotomy after intra-arterial nimodipine infusion. We retrospectively analyzed the rates of cerebral infarction, decompressive craniectomy, VP shunting, and tracheotomy in patients with severe CV after SAH. Three different patient groups were compared: group 1 had only been treated with oral nimodipine and hypervolemic hypertensive therapy (HHT) (2006-2010), group 2 with a single shot of intra-arterial nimodipine (SSN) in addition to oral conservative treatment (2006-2010), and group 3 with continuous intra-arterial nimodipine (CIAN) (2011-2017). The incidence of cerebral infarction was significantly lower in CIAN group (p = 0.005) than in conservative and SSN group. The indication for consecutive decompressive craniectomy was significantly lower in CIAN group in comparison with the conservative group (p = 0.018). The rates of VP shunting and tracheotomy were significantly higher in the CIAN group than in the conservative group (p = 0.028 for VP, and p = 0.003 for tracheotomy). The significantly lower rate of craniectomy in the CIAN group was most probably attributable to the significantly lower rate of CV-induced infarction. The higher rate of tracheotomy reflects more extensive sedation and the need of longer stays on the intensive care unit. Thus, the effect on long-term neurological outcome and quality of life has to be evaluated separately.
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Affiliation(s)
- Judith Anthofer
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany.
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Christina Wendl
- Department of Neuroradiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Elisabeth Bruendl
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
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8
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Martini ML, Neifert SN, Shuman WH, Chapman EK, Schüpper AJ, Oermann EK, Mocco J, Todd M, Torner JC, Molyneux A, Mayer S, Roux PL, Vergouwen MDI, Rinkel GJE, Wong GKC, Kirkpatrick P, Quinn A, Hänggi D, Etminan N, van den Bergh WM, Jaja BNR, Cusimano M, Schweizer TA, Suarez JI, Fukuda H, Yamagata S, Lo B, Leonardo de Oliveira Manoel A, Boogaarts HD, Macdonald RL. Rescue therapy for vasospasm following aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis with machine learning. J Neurosurg 2021; 136:134-147. [PMID: 34214980 DOI: 10.3171/2020.12.jns203778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy. METHODS Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. RESULTS The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17). CONCLUSIONS Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.
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Affiliation(s)
- Michael L Martini
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Sean N Neifert
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - William H Shuman
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Emily K Chapman
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | | | - Eric K Oermann
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - J Mocco
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Michael Todd
- 2Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota
| | - James C Torner
- 3Departments of Epidemiology, Surgery, and Neurosurgery, College of Public Health and Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Andrew Molyneux
- 4Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom
| | - Stephan Mayer
- 5Wayne State University School of Medicine, Detroit, Michigan
| | | | - Mervyn D I Vergouwen
- 7Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- 7Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - George K C Wong
- 8Division of Neurosurgery, Prince of Wales Hospital and the Chinese University of Hong Kong, China
| | - Peter Kirkpatrick
- 9University of Cambridge, Nuffield Health Cambridge Hospital, Cambridge, United Kingdom
| | - Audrey Quinn
- 10Department of Anaesthesia, Cheriton House, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Daniel Hänggi
- 11Department of Neurosurgery, Düsseldorf University Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nima Etminan
- 12Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Walter M van den Bergh
- 13Department of Critical Care, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Blessing N R Jaja
- Divisions of14Neurosurgery and.,15Neurology, St. Michael's Hospital, Toronto, Ontario.,16Neuroscience Research Program, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario
| | - Michael Cusimano
- 17Education and Public Health, St. Michael's Hospital, University of Toronto, Keenan Research Centre and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Tom A Schweizer
- 16Neuroscience Research Program, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario
| | - Jose I Suarez
- 18Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hitoshi Fukuda
- 19Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Sen Yamagata
- 19Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Benjamin Lo
- 20Department of Neurosurgery, Lenox Hill Hospital, New York, New York
| | | | - Hieronymus D Boogaarts
- 22Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - R Loch Macdonald
- 23University of California San Francisco, Fresno Campus, University Neurosciences Institutes, Fresno, California
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Mao G, Gigliotti MJ, Esplin N, Sexton K. The clinical impact and safety profile of high-dose intra-arterial verapamil treatment for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 202:106546. [PMID: 33588359 DOI: 10.1016/j.clineuro.2021.106546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cerebral vasospasm (CVS) leads to delayed cerebral ischemia (DCI) and cerebral infarction, a potential cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to evaluate the clinical efficacy and safety profile of high-dose IA verapamil for aSAH in a large series of patients. METHODS Between 2011-2019, a retrospective cohort of 188 consecutive patients presenting with aSAH were reviewed. High-dose IA verapamil (> 20 mg per vascular territory on each side) was intermittently used for appropriate patients to manage symptomatic CVS. Of the 188 patients reviewed, 86 were treated with high-dose IA verapamil. The clinical efficacy and safety profile of our ruptured aneurysm patient cohort were compared to historical literature controls. The primary endpoints studied included radiographic stroke corresponding to cerebral vasospasm, clinical outcome at discharge and subsequent follow-up, and overall functional status as defined by the modified Rankin scale (mRS). The safety profile of high dose IA verapamil was a secondary endpoint. RESULTS IA verapamil was delivered between 2-16 days after ictus (median post-bleed day 6) and 74 % of patients had documented clinical improvement after therapy, with 61.5 % achieving good functional outcomes (mRS < 2). 25.5 % of all patients had evidence of vasospasm-related DCI. 3 patients sustained transient hemodynamic changes after verapamil treatment and 10 patients developed post-procedural seizures successfully managed with intravenous lorazepam. CONCLUSION High-dose IA verapamil treatment is well-tolerated in the high-risk aneurysmal subarachnoid hemorrhage population that experience severe, symptomatic CVS with good functional outcomes at follow-up.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States
| | - Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, United States.
| | - Nathan Esplin
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States
| | - Kevin Sexton
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States
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10
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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11
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Summary of Torsades de Pointes (TdP) Reports Associated with Intravenous Drug Formulations Containing the Preservative Chlorobutanol. Drug Saf 2020; 42:907-913. [PMID: 30888625 DOI: 10.1007/s40264-019-00804-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Drug-induced torsades de pointes (TdP) is a potentially lethal ventricular arrhythmia that is associated with drugs that prolong the QT interval on the electrocardiogram (ECG) due to their interference with the cardiac potassium current, IKR. Intravenous (IV) formulations of methadone have been associated with TdP and contain the preservative chlorobutanol, which, like methadone, blocks IKR. The combinations of chlorobutanol with methadone or terfenadine, another IKR blocker, produce synergistic IKR block. OBJECTIVE The aim of this study was to examine and summarize the evidence available to address the question: what other IV drug formulations contain chlorobutanol and are they associated with TdP? METHODS IV drug products containing the preservative chlorobutanol were identified by searching the websites DailyMed ( https://dailymed.nlm.nih.gov/dailymed/index.cfm ) and Drugs@FDA ( https://www.accessdata.fda.gov/scripts/cder/daf/ ). For each drug identified, PubMed and the FDA's Adverse Event Reporting System (FAERS) were searched for reports of TdP and/or QT prolongation and FAERS data were analyzed for disproportionality of reports. RESULTS The search found nine drugs (methadone, epinephrine, papaverine, oxytocin, vasopressin, testosterone, estradiol, isoniazid, and desmopressin) that contain chlorobutanol 2.5 (n = 1) or 5.0 mg/mL. All nine drugs had reports of QT prolongation or TdP reported in FAERS and all but estradiol, testosterone, desmopressin, and isoniazid had reports of QT prolongation or TdP in PubMed. Two of the nine drugs (epinephrine and methadone) had positive signals (by disproportionality analysis) for TdP in FAERS (EB05 2.88 and 23.81, respectively) and four (methadone, epinephrine, papaverine, and vasopressin) were reported in published articles as the suspect drugs in cases of TdP. CONCLUSION The pharmacologic profile of chlorobutanol (synergistic IKR block) and its association with reports of TdP and QT prolongation suggest the need for a full evaluation of its cardiac safety when used as a preservative in IV drug and vitamin formulations.
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Hayman MW, Paleologos MS, Kam PCA. Interventional Neuroradiological Procedures—A Review for Anaesthetists. Anaesth Intensive Care 2019; 41:184-201. [DOI: 10.1177/0310057x1304100208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M. W. Hayman
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Visiting Specialist Anaesthestist
| | - M. S. Paleologos
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Staff Specialist Anaesthetist, Director of Services
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Nuffield Professor and Head, Departments of Anaesthetics, University of Sydney and Royal Prince Alfred Hospital
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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.
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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
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Zhou X, Alambyan V, Ostergard T, Pace J, Kohen M, Manjila S, Ramos-Estebanez C. Prolonged Intracisternal Papaverine Toxicity: Index Case Description and Proposed Mechanism of Action. World Neurosurg 2017; 109:251-257. [PMID: 29017981 DOI: 10.1016/j.wneu.2017.09.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intracisternal papaverine (iPPV) is a vasodilator used for prophylaxis of intraoperative vasospasm during aneurysmal clipping. Postoperative side effects of iPPV include transient cranial nerve palsies, most commonly mydriasis owing to oculomotor nerve involvement, with rapid resolution. METHODS We critically reviewed current literature on the adverse effects of iPPV in aneurysmal surgery with a focus on oculomotor nerve involvement. We also present the index case of prolonged bilateral mydriasis secondary to iPPV irrigation toxicity and its putative underlying mechanism. RESULTS Papaverine toxicity occurs in the setting of its antimuscarinic action and blood-cerebrospinal fluid and blood-brain barrier compromise owing to acute subarachnoid hemorrhage and direct effect of papaverine. Our patient also experienced severe vasospasm and a minor stroke, both contributing to further blood-brain barrier disruption, and relatively acidic pH of the subarachnoid hemorrhage milieu. CONCLUSIONS We propose that these factors perpetuate phase dynamics of papaverine crystals and facilitate a sustained slow release of papaverine within the cisternal system. Were it indicated, 0.3% iPPV would reasonably diminish the risk for neurotoxicity.
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Affiliation(s)
- Xiaofei Zhou
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Vilakshan Alambyan
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas Ostergard
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Maryo Kohen
- Department of Ophthalmology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sunil Manjila
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ciro Ramos-Estebanez
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
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Venkatraman A, Khawaja AM, Gupta S, Hardas S, Deveikis JP, Harrigan MR, Kumar G. Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis. J Neurointerv Surg 2017; 10:380-387. [DOI: 10.1136/neurintsurg-2017-013128] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveThe efficacy of intra-arterial vasodilators (IADs) for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) remains debatable. The objective of this meta-analysis was to pool estimates of angiographic and neurological response, clinical outcome, and mortality following treatment of vasospasm with IADs.MethodsWe searched PubMed, Embase, Scopus, Clinicaltrials.gov, Cochrane database, and CINAHL in December 2015 and August 2016. Studies reporting angiographic and neurological response, clinical outcome, and mortality following IAD treatment of vasospasm in 10 or more adults with aSAH were included. All established IADs were allowed. Two authors independently selected studies and abstracted the data. Mean weighted probabilities (MWP) were calculated using random effects model.ResultsInclusion criteria were met by 55 studies (n=1571). MWP for immediate angiographic response to IAD treatment was 89% (95% CI 83% to 94%), post-IAD neurological improvement 57% (95% CI 49% to 65%), good outcome 66% (95% CI 60% to 71%), and mortality was 9% (95% CI 7% to 12%). After adjusting for publication bias, MWP for mortality was 5% (95% CI 4% to 7%). When transcranial Doppler (TCD) was used along with clinical deterioration for patient selection, rates of neurological response (64%) and good outcome (72%) were better. IADs were not superior to controls (balloon angioplasty or medical management).ConclusionIAD treatment leads to a robust angiographic response and fair (but lower) rates of neurological response and good clinical outcome. Mortality was lower than the average reported in the literature. Rates of neurological response and good outcome were better when TCD was used for patient selection. Carefully designed studies are needed to compare IADs against medical management and balloon angioplasty.
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Veldeman M, Höllig A, Clusmann H, Stevanovic A, Rossaint R, Coburn M. Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review. Br J Anaesth 2016; 117:17-40. [PMID: 27160932 DOI: 10.1093/bja/aew095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED : The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials. CLINICAL TRIAL REGISTRATION This systematic review was registered in the international prospective register of systematic reviews. PROSPERO CRD42015019817.
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Affiliation(s)
- M Veldeman
- Department of Neurosurgery Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | | | | | - A Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - M Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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Gölitz P, Kaschka I, Lang S, Roessler K, Knossalla F, Doerfler A. Real-Time, In Vivo Monitoring, and Quantitative Assessment of Intra-Arterial Vasospasm Therapy. Neurocrit Care 2015; 25:40-6. [DOI: 10.1007/s12028-015-0231-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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Tormey WP. Newspaper reports from the Coroners Court in Ireland are used to reveal the potential complexity and need for reform in forensic toxicology and medicine services. J Forensic Leg Med 2015; 32:47-52. [DOI: 10.1016/j.jflm.2015.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/21/2015] [Indexed: 10/23/2022]
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Yang L, Wang F, Han H, Yang L, Zhang G, Fan Z. Functionalized graphene oxide as a drug carrier for loading pirfenidone in treatment of subarachnoid hemorrhage. Colloids Surf B Biointerfaces 2015; 129:21-9. [DOI: 10.1016/j.colsurfb.2015.03.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 03/06/2015] [Accepted: 03/08/2015] [Indexed: 10/23/2022]
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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.
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Kiser TH. Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions? Hosp Pharm 2014; 49:923-41. [PMID: 25477565 DOI: 10.1310/hpj4910-923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.
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Affiliation(s)
- Tyree H Kiser
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital, University of Colorado Anschutz Medical Campus , 12850 E. Montview Boulevard, C238, Aurora, CO 80045 ; phone: 303-724-2883 ; fax: 303-724-0979 ; e-mail:
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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: 71] [Impact Index Per Article: 7.1] [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.
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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
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Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy. ACTA ACUST UNITED AC 2014; 52:77-84. [DOI: 10.1016/j.aat.2014.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/08/2014] [Indexed: 11/23/2022]
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Bauer AM, Rasmussen PA. Treatment of intracranial vasospasm following subarachnoid hemorrhage. Front Neurol 2014; 5:72. [PMID: 24904517 PMCID: PMC4032992 DOI: 10.3389/fneur.2014.00072] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/27/2014] [Indexed: 12/03/2022] Open
Abstract
Vasospasm has been a long known source of delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage patients. Delayed ischemic neurologic deficits associated with vasospasm may account for as high as 50% of the deaths in patients who survive the initial period after aneurysm rupture and its treatment. The diagnosis and treatment of vasospasm has still been met with some controversy. It is clear that subarachnoid hemorrhage is best cared for in tertiary care centers with modern resources and access to cerebral angiography. Ultimately, a high degree of suspicion for vasospasm must be kept during ICU care, and any signs or symptoms must be investigated and treated immediately to avoid permanent stroke and neurologic deficit. Treatment for vasospasm can occur through both ICU intervention and endovascular administration of intra-arterial vasodilators and balloon angioplasty. The best outcomes are often attained when these methods are used in conjunction. The following article reviews the literature on cerebral vasospasm and its treatment and provides the authors’ approach to treatment of these patients.
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Affiliation(s)
- Andrew M Bauer
- Cerebrovascular Center, Cleveland Clinic Foundation , Cleveland, OH , USA
| | - Peter A Rasmussen
- Cerebrovascular Center, Cleveland Clinic Foundation , Cleveland, OH , USA
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A novel and diastereoselective construction of H-pyrazolo[3,2-a]isoquinoline fused spirooxindoles via [3+2] cycloaddition. Tetrahedron Lett 2014. [DOI: 10.1016/j.tetlet.2013.11.116] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Effectiveness of papaverine cisternal irrigation for cerebral vasospasm after aneurysmal subarachnoid hemorrhage and measurement of biomarkers. Neurol Sci 2013; 35:715-22. [DOI: 10.1007/s10072-013-1589-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 11/17/2013] [Indexed: 10/26/2022]
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Kiser TH. Pharmacologic Options for Prevention and Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Hosp Pharm 2013; 48:S2-S9. [PMID: 35694374 PMCID: PMC7210716 DOI: 10.1310/hpj48s5-s2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2024]
Abstract
Background Cerebral vasospasm and delayed cerebral ischemia continue to be major contributors to morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Purpose The purpose of this review was to evaluate the pharmacotherapy interventions for the prevention and management of cerebral vasospasm in patients with SAH. Methods A search of MEDLINE (January 1966-April 2012) and EMBASE (January 1974-April 2012) was conducted to retrieve relevant studies of pharmacotherapy options for prevention or treatment of cerebral vasospasm in SAH. Results Triple-H therapy (hypervolemia, hemodilution, hypertension) has been a widely accepted option by many clinicians for the management of cerebral vasospasm and delayed cerebral ischemia. However, implementation of Triple-H therapy varies considerably at individual institutions. Nimodipine and nicardipine have demonstrated the most dependable improvements in patient outcomes to date. High doses of intravenous magnesium have failed to show consistent benefits. Magnesium supplementation to prevent hypomagnesaemia should be employed. Statin therapy should be continued in patients who are taking statins prior to hospital admission. Use of statins in naive patients may be recommended when the results of an ongoing prospective study are available. Of the available locally administered pharmacologic therapies, nicardipine and thrombolytics appear to provide the most intriguing benefit-to-risk ratio. However, the data supporting the use of locally administered therapy are modest at best and require careful consideration prior to application. Conclusions Clinical studies have tested a variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm. Of available therapies, nimodipine has demonstrated consistent benefits and should be employed routinely. Demonstration of reduced cerebral vasospasm and improved neurological outcomes in larger prospective studies are needed for most pharmacologic therapy options prior to recommending their routine use.
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Affiliation(s)
- Tyree H. Kiser
- *Department of Clinical Pharmacy, University of Colorado
School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy
Specialist, University of Colorado Hospital
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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.
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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.
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Zahid M, Iaroshenko VO, Saghyan AS, Fischer C, Langer P. Convenient synthesis of benzo[b]pyrazolo[5,1-f][1,6]naphthyridines by silver triflate catalyzed three-component reaction of 2-alkynyl-3-formylquinolines, tosylhydrazine and carbonyl compounds. Tetrahedron 2013. [DOI: 10.1016/j.tet.2013.02.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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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
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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.
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Rahme R, Jimenez L, Pyne-Geithman GJ, Serrone J, Ringer AJ, Zuccarello M, Abruzzo TA. Endovascular management of posthemorrhagic cerebral vasospasm: indications, technical nuances, and results. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012; 115:107-12. [PMID: 22890655 DOI: 10.1007/978-3-7091-1192-5_23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Posthemorrhagic cerebral vasospasm (PHCV) is a common problem and a significant cause of mortality and permanent disability following aneurysmal subarachnoid hemorrhage. While medical therapy remains the mainstay of prevention against PHCV and the first-line treatment for symptomatic patients, endovascular options should not be delayed in medically refractory cases. Although both transluminal balloon angioplasty (TBA) and intra-arterial vasodilator therapy (IAVT) can be effective in relieving proximal symptomatic PHCV, only IAVT is a viable treatment option for distal vasospasm. The main advantage of TBA is its long-lasting therapeutic effect and the very low rate of retreatment. However, its use has been associated with a significant risk of serious complications, particularly vessel rupture and reperfusion hemorrhage. Conversely, IAVT is generally considered an effective and low-risk procedure, despite the transient nature of its therapeutic effects and the risk of intracranial hypertension associated with its use. Moreover, newer vasodilator agents appear to have a longer duration of action and a much better safety profile than papaverine, which is rarely used in current clinical practice. Although endovascular treatment of PHCV has been reported to be effective in clinical series, whether it ultimately improves patient outcomes has yet to be demonstrated in a randomized controlled trial.
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Affiliation(s)
- Ralph Rahme
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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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.
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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
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Demushkin VP, Zhavoronkova EV, Khaspekov LG. Effects of drotaverine hydrochloride on viability of rat cultured cerebellar granulocytes. Bull Exp Biol Med 2012; 152:444-6. [PMID: 22803107 DOI: 10.1007/s10517-012-1549-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The neurocytotoxic effect of drotaverine hydrochloride was studied in culture of rat cerebellar granulocytes. Incubation of cells with 100 and 250 μM drotaverine reduced neuronal survival to 60 and 4%, respectively.
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Affiliation(s)
- V P Demushkin
- Laboratory of Peptide Chemistry, M. M. Shemyakin and Yu. A. Ovchinnikov Institute of Organic Biochemistry, Russian Academy of Sciences, Moscow, Russia.
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Abstract
This article outlines the roles of the anesthesiologist in the management of patients undergoing invasive endovascular procedures to treat vascular diseases, primarily of the central nervous system. This practice is usually termed interventional neuroradiology or endovascular neurosurgery. The article emphasizes perioperative and anesthetic management strategies to prevent complications and minimize their effects if they occur. Planning the anesthetic and perioperative management is predicated on understanding the goals of the therapeutic intervention and anticipating potential problems.
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Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711-37. [PMID: 22556195 DOI: 10.1161/str.0b013e3182587839] [Citation(s) in RCA: 2261] [Impact Index Per Article: 188.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
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Selective phosphodiesterase inhibitors improve performance on the ED/ID cognitive task in rats. Neuropharmacology 2012; 62:1182-90. [DOI: 10.1016/j.neuropharm.2011.08.008] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 08/03/2011] [Accepted: 08/04/2011] [Indexed: 12/20/2022]
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Kimball MM, Velat GJ, Hoh BL. Critical care guidelines on the endovascular management of cerebral vasospasm. Neurocrit Care 2012; 15:336-41. [PMID: 21761272 DOI: 10.1007/s12028-011-9600-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.
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Affiliation(s)
- Matthew M Kimball
- Department of Neurosurgery, University of Florida, 1600 South West Archer Rd, P.O. Box 100265, Gainesville, FL 32610, USA
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42
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Macdonald RL. Site-Specific, Sustained-Release Drug Delivery for Subarachnoid Hemorrhage. Transl Stroke Res 2012. [DOI: 10.1007/978-1-4419-9530-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pandey P, Steinberg GK, Dodd R, Do HM, Marks MP. A Simplified Method for Administration of Intra-Arterial Nicardipine for Vasospasm With Cervical Catheter Infusion. Oper Neurosurg (Hagerstown) 2011; 71:77-85. [DOI: 10.1227/neu.0b013e3182426257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Nicardipine has previously been used to treat vasospasm through superselective intracranial microcatheter injections.
OBJECTIVE:
To evaluate a simple method of treatment of vasospasm with slow infusion of nicardipine from a cervical catheter.
METHODS:
Twenty-seven patients with symptomatic vasospasm were treated over 4 years with cervical catheter infusions. Nicardipine was infused at 20 mg/h for 30 to 60 minutes. Angioplasty was used in severe cases at the operator's discretion. Outcome at discharge and follow-up was evaluated with Glasgow Outcome Scale.
RESULTS:
Twenty-seven patients (17 women, 12 men) received intra-arterial therapy for vasospasm. Vasospasm treatment was done at a mean post-hemorrhage date of 7.2 days (range, 4-15 days). They underwent 48 sessions of treatment (mean, 1.8 per patient) in 72 separate arterial territories. Twelve patients underwent multiple treatments. The mean dose used per session was 19.2 mg (range, 5-50 mg). Four patients underwent angioplasty for severe vasospasm. Twenty-two patients (81.5%) had clinical improvement after the infusion. Angiographic improvement was seen in 86.1% of the vessels analyzed, which had moderate or severe spasm before infusion. Overall, 17 patients (62.9%) had good outcome (Glasgow Outcome Scale score, 4 and 5) at discharge, 11 had poor outcome, and 1 patient died. Follow-up was available in 19 patients, and 18 were doing well (Glasgow Outcome Scale score, 4 and 5).
CONCLUSION:
Intra-arterial nicardipine is an effective and safe treatment for cerebral vasospasm. In most patients, infusion can be performed from the cervical catheter, with microcatheter infusion and angioplasty reserved for the more severe and resistant cases.
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Affiliation(s)
| | | | - Robert Dodd
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Huy M. Do
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael P. Marks
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
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Cho WS, Kang HS, Kim JE, Kwon OK, Oh CW, Son YJ, Know BJ, Jung C, Hang MH. Intra-arterial nimodipine infusion for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Interv Neuroradiol 2011; 17:169-78. [PMID: 21696654 DOI: 10.1177/159101991101700205] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 01/31/2011] [Indexed: 11/15/2022] Open
Abstract
This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.
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Affiliation(s)
- W-S Cho
- Department of Neurosurgery, Kangwon National University Hospital, School of Medicine, Chuncheon, Gangwon-do, Korea
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Li S, Wu J. Synthesis of H-Pyrazolo[5,1-a]isoquinolines via Copper(II)-Catalyzed Oxidation of an Aliphatic C−H Bond of Tertiary Amine in Air. Org Lett 2011; 13:712-5. [DOI: 10.1021/ol102939r] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Shaoyu Li
- Department of Chemistry, Fudan University, 220 Handan Road, Shanghai 200433, China, and State Key Laboratory of Organometallic Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, 354 Fenglin Road, Shanghai 200032, China
| | - Jie Wu
- Department of Chemistry, Fudan University, 220 Handan Road, Shanghai 200433, China, and State Key Laboratory of Organometallic Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, 354 Fenglin Road, Shanghai 200032, China
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Jun P, Ko NU, English JD, Dowd CF, Halbach VV, Higashida RT, Lawton MT, Hetts SW. Endovascular treatment of medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2010; 31:1911-6. [PMID: 20616179 DOI: 10.3174/ajnr.a2183] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CV following aneurysmal SAH is a significant cause of morbidity and mortality. We review our experiences using PTA and IA verapamil infusion for treating medically refractory cases. MATERIALS AND METHODS We performed a retrospective review of patients with SAH admitted from July 2003 to January 2008. RESULTS Of 546 patients admitted within 72 hours of symptom onset, 231 patients (42%) developed symptomatic CV and 189 patients (35%) required endovascular therapy. A total of 346 endovascular sessions were performed consisting of 1 single angioplasty, 286 IA verapamil infusions, and 59 combined treatments. PTA was performed on 151 vessel segments, and IA verapamil was infused in 720 vessel segments. IA verapamil doses ranged from 2.0 to 30.0 mg per vessel segment and from 3.0 to 55.0 mg per treatment session. Repeat treatments were necessary in 102 patients (54%) for persistent, recurrent, or worsening CV. There were 6 treatment-related complications, of which 2 resulted in clinical worsening. No deaths were attributable to endovascular therapy. At follow-up, 115 patients (61%) had a good outcome and 55 patients (29%) had a poor outcome. Sixteen patients died from causes related to SAH, while 3 died from other medical complications. CONCLUSIONS Endovascular treatments are an integral part of managing patients with medically refractory CV. In our experience, PTA and IA verapamil are safe, with a low complication rate, but further studies are required to determine appropriate patient selection and treatment efficacy.
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Affiliation(s)
- P Jun
- Departments of Radiology, University of California, San Francisco, 94143-0628, USA
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Albanese E, Russo A, Quiroga M, Willis RN, Mericle RA, Ulm AJ. Ultrahigh-dose intraarterial infusion of verapamil through an indwelling microcatheter for medically refractory severe vasospasm: initial experience. J Neurosurg 2010; 113:913-22. [DOI: 10.3171/2009.9.jns0997] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Vasospasm is one of the leading causes of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). Many patients suffer devastating strokes despite the best medical therapy. Endovascular treatment is the last line of defense for cases of medically refractory vasospasm. The authors present a series of patients who were treated with a prolonged intraarterial infusion of verapamil through an in-dwelling microcatheter.
Methods
Over a 1-year period 12 patients with medically refractory vasospasm due to aneurysmal SAH were identified. Data were retrospectively collected, including age, sex, Hunt and Hess grade, Fisher grade, aneurysm location, aneurysm treatment, day of the onset of vasospasm, intracranial pressure, mean arterial pressures, intraarterial treatment of vasospasm, dosages and times of verapamil infusion, presence of a new ischemic area on CT scan, modified Rankin scale score at discharge and at the last clinical follow-up, and discharge status.
Results
Twenty-seven treatments were administered. Between 25 and 360 mg of verapamil was infused per vessel (average dose per vessel 164.6 mg, range of total dose per treatment 70–720 mg). Infusion times ranged from 1 to 20.5 hours (average 7.8 hours). The number of treated vessels ranged from 1 to 7 per patient. The number of treatments per patients ranged from 1 to 4. There was no treatment-related morbidity or death. Blood pressure and intracranial pressure changes were transient and rapidly reversible. Among the 36 treated vessels, prolonged verapamil infusion was completely effective in 32 cases and partially effective in 4. Only 4 vessels required angioplasty for refractory vasospasm after prolonged verapamil infusion. There was no CT scanning evidence of new ischemic events in 9 of the 12 patients treated. At last clinical follow-up 6–12 months after discharge, 8 of 11 patients had a modified Rankin Scale score ≤2.
Conclusions
Prolonged intraarterial infusion of verapamil is a safe and effective treatment for medically refractory severe vasospasm and reduces the need for angioplasty in such cases.
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Affiliation(s)
- Erminia Albanese
- 1Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia
| | - Antonino Russo
- 1Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia
| | - Monica Quiroga
- 1Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia
| | - Rhett N. Willis
- 1Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia
| | - Robert A. Mericle
- 2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Arthur J. Ulm
- 1Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia
- 3Department of Neurosurgery, Louisiana State University, New Orleans, Louisiana
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Rabinstein AA, Lanzino G, Wijdicks EFM. Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage. Lancet Neurol 2010; 9:504-19. [DOI: 10.1016/s1474-4422(10)70087-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Intra-arterial colforsin daropate for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Neuroradiology 2009; 52:837-45. [PMID: 19953235 DOI: 10.1007/s00234-009-0631-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 11/11/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cerebral vasospasm (CV) remains a major cause of mortality and morbidity in patients with subarachnoid hemorrhage (SAH). Here, we examined the effectiveness and safety of intra-arterial injection of colforsin daropate hydrochloride (CDH). METHODS A consecutive series of 29 patients with angiographically confirmed CV received intra-arterial CDH (IAC) therapy. Angiographic changes in spastic vessels and the cerebral circulation time (CCT) were assessed before and after IAC treatment, together with the change in clinical status. RESULTS IAC treatment was performed in 53 procedures in 29 patients. Angiographic improvement was observed following all procedures (100%), and clinical improvement was observed following 36 of 42 procedures (86%) in symptomatic cases. CCT improved significantly. At the 3-month follow-up, 19 patients (66%) showed good recovery or moderate disability on the Glasgow Outcome Scale. Major adverse effects were headache and increased heart rate. CONCLUSIONS IAC treatment was effective and safe for the treatment of CV after SAH.
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Barbarawi M, Smith SF, Jamous MA, Haboub H, Suhair Q, Abdullah S. Therapeutic approaches to cerebral vasospasm complicating ruptured aneurysm. Neurol Int 2009; 1:e13. [PMID: 21577350 PMCID: PMC3093235 DOI: 10.4081/ni.2009.e13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 06/20/2009] [Accepted: 09/23/2009] [Indexed: 12/02/2022] Open
Abstract
Cerebral vasospasm is a serious complication of ruptured aneurysm. In order to avoid short- and long-term effects of cerebral vasospasm, and as there is no single or optimal treatment modality employed, we have instituted a protocol for the prevention and treatment of vasospasm in patients suffering aneurysmal sub-arachnoid hemorrhage (SAH). We then reviewed the effectiveness of this protocol in reducing the mortality and morbidity rate in our institution. In this study we present a retrospective analysis of 52 cases. Between March 2004 and December 2008 52 patients were admitted to our service with aneurysmal SAH. All patients commenced nimodipine, magnesium sulphate (MgSO4) and triple H therapy. Patients with significant reduction in conscious level were intubated, ventilated and sedated. Intracranial pressure (ICP) monitoring was used for intubated patients. Sodium thiopental coma was induced for patients with refractory high ICP; angiography was performed for diagnosis and treatment. Balloon angioplasty was performed if considered necessary. Using this protocol, only 13 patients (25%) developed clinical vasospasm. Ten of them were given barbiturates to induce coma. Three patients underwent transluminal balloon angioplasty. Four out of 52 patients (7.7%) died from severe vasospasm, 3 patients (5.8%) became severely disabled, and 39 patients (75%) were discharged in a condition considered as either normal or near to their pre-hemorrhage status. Our results confirm that the aforementioned protocol for treatment of cerebral vasospasm is effective and can be used safely.
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