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Miller M, Thappa P, Bhagat H, Veldeman M, Rahmani R. Prevention of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage-Summary of Existing Clinical Evidence. Transl Stroke Res 2024:10.1007/s12975-024-01292-3. [PMID: 39212835 DOI: 10.1007/s12975-024-01292-3] [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: 04/24/2024] [Revised: 07/18/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, cerebrospinal fluid (CSF) diversion, hemodynamic, endovascular, and medical management. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintaining euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension. Nimodipine remains the medical therapy with the most support for prevention.
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Affiliation(s)
- Margaux Miller
- Barrow Neurological Institute, 2910 N 3rd Avenue, Phoenix, AZ, 85013, USA
| | - Priya Thappa
- All India Institute of Medical Sciences, Nagpur, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Chandigarh, India
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Redi Rahmani
- Barrow Neurological Institute, 2910 N 3rd Avenue, Phoenix, AZ, 85013, USA.
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Lee KS, Chari A, Motiwala M, Khan NR, Arthur AS, Lawton MT. Effectiveness of Cerebrospinal Fluid Lumbar Drainage Among Patients with Aneurysmal Subarachnoid Hemorrhage: An Updated Systematic Review and Meta-Analysis. World Neurosurg 2024; 183:246-253.e12. [PMID: 38246528 DOI: 10.1016/j.wneu.2024.01.062] [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: 11/26/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH. METHODS Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality. RESULTS A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99). CONCLUSIONS For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, King's College Hospital, London, United Kingdom; Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Aswin Chari
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mustafa Motiwala
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Lee KS, Lee C, Dhillon PS, Kirollos R, Nga VDW, Yeo TT, Henkes H, Arthur AS, Yeo LLL, Bhogal P. Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: an updated meta-analysis. Neurosurg Rev 2023; 46:221. [PMID: 37665377 PMCID: PMC10477151 DOI: 10.1007/s10143-023-02120-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023]
Abstract
Antiplatelet therapy (AT) may serve to reduce the effects of aneurysmal subarachnoid hemorrhage (aSAH)-induced pro-coagulant state in the cerebral circulation. Several studies, however, have delivered conflicting conclusions on the efficacy of AT post aSAH. Systematic searches of Medline, Embase, and Cochrane Central were undertaken on 27th March 2023. The primary outcome was delayed cerebral ischaemia (DCI). Secondary outcomes were symptomatic and angiographic vasospasm, good functional outcome (modified Rankin Scale [mRS] with scores 0-2), hemorrhagic events, and in-hospital mortality. Twenty-two studies reporting 4378 patients with aSAH were included in the meta-analysis. AT was associated with lower rates of DCI (RR=0.62, 95% CI: 0.43; 0.89), symptomatic vasospasm (RR=0.63, 95% CI: 0.46; 0.86), and moderate/severe angiographic vasospasm (RR=0.74, 95% CI: 0.65; 0.84), with no effect on hemorrhagic complications (RR=1.36, 95% CI: 0.77; 2.41). When analyzing only post-ictal use of AT, AT additionally favored rates of good functional outcomes (RR=1.18, 95% CI: 1.10; 1.26) and in-hospital mortality (RR=0.56, 95% CI: 0.39; 0.80). In the subgroup treated with cilostazol, AT was associated with lower rates of DCI (RR=0.40, 95% CI: 0.32), symptomatic vasospasm (RR=0.47, 95% CI: 0.33; 0.65), moderate/severe angiographic vasospasm (RR=0.75, 95% CI: 0.57; 0.98) and good functional outcome (RR=1.24, 95% CI: 1.08; 1.43). In the surgically treated aSAH subgroup, AT favored rates of symptomatic vasospasm (RR=0.55, 95% CI: 0.30; 0.98), moderate/severe angiographic vasospasm (RR=0.70, 95% CI: 0.54; 0.90) and good functional outcome (RR=1.23, 95% CI: 1.09; 1.41). In the endovascularly treated aSAH subgroup, AT was associated with lower rates of in-hospital mortality (RR=0.60, 95% CI: 0.41; 0.88). In aSAH patients, post-ictal AT is associated with benefits in terms of rates of DCI, vasospasm, good functional outcomes, and in-hospital mortality without an increased risk of hemorrhagic events.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
| | - Cheyenne Lee
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
| | - Permesh S Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ramez Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Vincent D W Nga
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, London, UK
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Zhao L, Lin P, Zhang Y, Huang XY, Li HY, Xia MK, Huang X, Li Z, Zhou LX, Tang XP. Effect of antiplatelet treatment on aneurysmal subarachnoid hemorrhage patients after endovascular treatment: a systematic review with meta-analysis. Neurosurg Rev 2022; 45:3523-3536. [PMID: 36178562 DOI: 10.1007/s10143-022-01877-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/11/2022] [Accepted: 09/24/2022] [Indexed: 10/14/2022]
Abstract
Antiplatelet treatment (APT) has been reported to be used in some patients with aneurysmal subarachnoid hemorrhage (aSAH) after endovascular treatment, but there is controversy among different studies regarding its clinical effects. This study intends to conduct a meta-analysis to evaluate the impact of APT on aSAH patients after endovascular treatment. The PubMed, EMBASE, and Cochrane Library databases were systematically searched up to January 2022 for eligible English publications. Quality assessment was conducted for the included studies. Publication bias and heterogeneity were assessed by Egger's test and the I2 statistic, respectively. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by meta-analysis. Robustness was checked by subgroup and sensitivity analyses. In total, 597 and 522 patients with and without APT, respectively, in 5 retrospective studies were retained for the meta-analysis. Pooled analyses showed that the APT group had a lower mortality (41/499 [8%] versus 56/402 [14%]; OR = 0.533; 95% CI, 0.347-0.820; P = 0.004) and a higher proportion of favorable clinical outcomes (400/532 [75%] versus 266/421 [63%]; OR = 1.801; 95% CI, 1.359-2.414; P = 0.000) than the control group. There was no significant difference in the incidence of hemorrhagic complications (39/564 [7%] versus 26/503 [5%]; OR = 1.386; 95% CI, 0.825-2.329; P = 0.218) between groups. Although the incidence of delayed cerebral ischemia (DCI) was significantly lower in the APT group (65/512 [13%] versus 105/447 [23%]; OR = 0.325; 95% CI, 0.107-0.988; P = 0.048), it showed substantial heterogeneity (I2 = 64.7%). Subsequent sensitivity analysis suggested that the meta-analysis was robust. Subgroup analyses revealed that long-term (> 2 weeks) APT (60/479 [13%] versus 103/428 [24%]; OR = 0.212; 95% CI, 0.056-0.806; P = 0.023) significantly reduced the DCI rate and that different grouping methods in the included studies may be a source of heterogeneity. In the absence of randomized controlled trials, a meta-analysis of retrospective studies suggested that APT was associated with reduced mortality and better functional outcomes in aSAH patients after endovascular treatment without an increased incidence of hemorrhagic complications. Long-term APT was also associated with a decrease in the incidence of DCI. Well-designed randomized controlled trials are warranted and updated meta-analyses are needed to verify our findings.
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Affiliation(s)
- Long Zhao
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ping Lin
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Yi Zhang
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Xing-Yuan Huang
- College of Mental Health, North Sichuan Medical College, Nanchong, 637000, China
| | - Hang-Yang Li
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Ming-Kai Xia
- College of Medical Imaging, North Sichuan Medical College, Nanchong, 637000, China
| | - Xi Huang
- College of Medical Imaging, North Sichuan Medical College, Nanchong, 637000, China
| | - Zheng Li
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Liang-Xue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Xiao-Ping Tang
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China.
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China.
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Snyder MH, Ironside N, Kumar JS, Doan KT, Kellogg RT, Provencio JJ, Starke RM, Park MS, Ding D, Chen CJ. Antiplatelet therapy and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg 2022; 137:95-107. [PMID: 34740185 DOI: 10.3171/2021.7.jns211239] [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: 05/17/2021] [Accepted: 07/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a potentially preventable cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The authors performed a meta-analysis to assess the effect of antiplatelet therapy (APT) on DCI in patients with aSAH. METHODS A systematic review of the PubMed and MEDLINE databases was performed. Study inclusion criteria were 1) ≥ 5 aSAH patients; 2) direct comparison between aSAH management with APT and without APT; and 3) reporting of DCI, angiographic, or symptomatic vasospasm rates for patients treated with versus without APT. The primary efficacy outcome was DCI. The outcomes of the APT versus no-APT cohorts were compared. Bias was assessed using the Downs and Black checklist. RESULTS The overall cohort comprised 2039 patients from 15 studies. DCI occurred less commonly in the APT compared with the no-APT cohort (pooled = 15.9% vs 28.6%; OR 0.47, p < 0.01). Angiographic (pooled = 51.6% vs 68.7%; OR 0.46, p < 0.01) and symptomatic (pooled = 23.6% vs 37.7%; OR 0.51, p = 0.01) vasospasm rates were lower in the APT cohort. In-hospital mortality (pooled = 1.7% vs 4.1%; OR 0.53, p = 0.01) and functional dependence (pooled = 21.0% vs 35.7%; OR 0.53, p < 0.01) rates were also lower in the APT cohort. Bleeding event rates were comparable between the two cohorts. Subgroup analysis of cilostazol monotherapy compared with no APT demonstrated a lower DCI rate in the cilostazol cohort (pooled = 10.6% vs 28.1%; OR 0.31, p < 0.01). Subgroup analysis of surgically treated aneurysms demonstrated a lower DCI rate for the APT cohort (pooled = 18.4% vs 33.9%; OR 0.43, p = 0.02). CONCLUSIONS APT is associated with improved outcomes in aSAH without an increased risk of bleeding events, particularly in patients who underwent surgical aneurysm repair and those treated with cilostazol. Although study heterogeneity is the most significant limitation of the analysis, the findings suggest that APT is worth exploring in patients with aSAH, particularly in a randomized controlled trial setting.
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Affiliation(s)
- M Harrison Snyder
- 1Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Natasha Ironside
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jeyan S Kumar
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kevin T Doan
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan T Kellogg
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - J Javier Provencio
- 3Department of Neurology, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M Starke
- 4Department of Neurosurgery, University of Miami, Miami, Florida
| | - Min S Park
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 5Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky; and
| | - Ching-Jen Chen
- 6Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Naraoka M, Matsuda N, Shimamura N, Ohkuma H. Role of microcirculatory impairment in delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2022; 42:186-196. [PMID: 34496662 PMCID: PMC8721782 DOI: 10.1177/0271678x211045446] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early brain injury (EBI) is considered an important cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). As a factor in EBI, microcirculatory dysfunction has become a focus of interest, but whether microcirculatory dysfunction is more important than angiographic vasospasm (aVS) remains unclear. Using data from 128 cases, we measured the time to peak (TTP) in several regions of interest on digital subtraction angiography. The intracerebral circulation time (iCCT) was obtained between the TTP in the ultra-early phase (the baseline iCCT) and in the subacute phase and/or at delayed cerebral ischemia (DCI) onset (the follow-up iCCT). In addition, the difference in the iCCT was calculated by subtracting the baseline iCCT from the follow-up iCCT. Univariate analysis showed that DCI was significantly increased in those patients with a prolonged baseline iCCT, prolonged follow-up iCCT, increased differences in the iCCT, and with severe aVS. Poor outcome was significantly increased in patients with prolonged follow-up iCCT and increased differences in the iCCT. Multivariate analysis revealed that increased differences in the iCCT were a significant risk factor that increased DCI and poor outcome. The results suggest that the increasing microcirculatory dysfunction over time, not aVS, causes DCI and poor outcome after aneurysmal aSAH.
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Affiliation(s)
- Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Naoya Matsuda
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine & Hospital, Hirosaki, Japan
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Dienel A, Kumar T P, Blackburn SL, McBride DW. Role of platelets in the pathogenesis of delayed injury after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2021; 41:2820-2830. [PMID: 34112003 PMCID: PMC8756481 DOI: 10.1177/0271678x211020865] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) patients develop delayed cerebral ischemia and delayed deficits (DCI) within 2 weeks of aneurysm rupture at a rate of approximately 30%. DCI is a major contributor to morbidity and mortality after SAH. The cause of DCI is multi-factorial with contributions from microthrombi, blood vessel constriction, inflammation, and cortical spreading depolarizations. Platelets play central roles in hemostasis, inflammation, and vascular function. Within this review, we examine the potential roles of platelets in microthrombi formation, large artery vasospasm, microvessel constriction, inflammation, and cortical spreading depolarization. Evidence from experimental and clinical studies is provided to support the role(s) of platelets in each pathophysiology which contributes to DCI. The review concludes with a suggestion for future therapeutic targets to prevent DCI after aSAH.
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Affiliation(s)
- Ari Dienel
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peeyush Kumar T
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Spiros L Blackburn
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Devin W McBride
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Hvas CL, Hvas AM. Hemostasis and Fibrinolysis following Aneurysmal Subarachnoid Hemorrhage: A Systematic Review on Additional Knowledge from Dynamic Assays and Potential Treatment Targets. Semin Thromb Hemost 2021; 48:356-381. [PMID: 34261149 DOI: 10.1055/s-0041-1730346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mortality after aneurysmal subarachnoid hemorrhage (aSAH) is augmented by rebleeding and delayed cerebral ischemia (DCI). A range of assays evaluating the dynamic process of blood coagulation, from activation of clotting factors to fibrinolysis, has emerged and a comprehensive review of hemostasis and fibrinolysis following aSAH may reveal targets of treatment. We conducted a systematic review of existing literature assessing coagulation and fibrinolysis following aSAH, but prior to treatment. PubMed, Embase, and Web of Science were searched on November 18, 2020, without time boundaries. In total, 45 original studies were eventually incorporated into this systematic review, divided into studies presenting data only from conventional or quantitative assays (n = 22) and studies employing dynamic assays (n = 23). Data from conventional or quantitative assays indicated increased platelet activation, whereas dynamic assays detected platelet dysfunction possibly related to an increased risk of rebleeding. Secondary hemostasis was activated in conventional, quantitative, and dynamic assays and this was related to poor neurological outcome and mortality. Studies systematically investigating fibrinolysis were sparse. Measurements from conventional or quantitative assays, as well as dynamic fibrinolysis assays, revealed conflicting results with normal or increased lysis and changes were not associated with outcome. In conclusion, dynamic assays were able to detect reduced platelet function, not revealed by conventional or quantitative assays. Activation of secondary hemostasis was found in both dynamic and nondynamic assays, while changes in fibrinolysis were not convincingly demonstrable in either dynamic or conventional or quantitative assays. Hence, from a mechanistic point of view, desmopressin to prevent rebleeding and heparin to prevent DCI may hold potential as therapeutic options. As changes in fibrinolysis were not convincingly demonstrated and not related to outcome, the use of tranexamic acid prior to aneurysm closure is not supported by this review.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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9
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Shimamura N, Naraoka M, Katagai T, Fujiwara N, Katayama K, Sasaki T, Kinoshita S, Yanagiya K, Ohkuma H. Follow-Up DSA at Day 9 ± 2 after Subarachnoid Hemorrhage Predicts Long-Term Recurrence of Ruptured Cerebral Aneurysm after Coiling. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:793-799. [PMID: 37502000 PMCID: PMC10370934 DOI: 10.5797/jnet.oa.2020-0212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/20/2021] [Indexed: 07/29/2023]
Abstract
Objective The recurrence rate of coiled ruptured cerebral aneurysms is greater than that of clipped aneurysms. The aim of this study is to determine the factors that relate to the recurrence of embolized, ruptured cerebral aneurysms, and the evidence thereto. Methods From April 2007 through July 2017, we treated 134 ruptured cerebral aneurysm cases by coiling. DSA and/or MRI were done in 98 saccular aneurysm cases one year after the coiling. Recurrence was defined as enlargement of the aneurysm neck or contrast opacification along the aneurysm wall. A chi-square test and a logistic regression analysis were done to analyze the relationship between aneurysm recurrence and clinical factors. Results The median follow-up period was 58 months (interquartile range [IQR]: 33-107). Ten cases (10.2%) were subjected to aneurysm recurrence. Internal carotid artery (ICA) aneurysms proximal to the posterior communicating artery, incomplete obliteration of an aneurysm at initial embolization and postoperative DSA during day 9 ± 2, and increased contrast medium in the aneurysm at postoperative DSA during day 9 ± 2 were all statistically related to the recurrence of the aneurysm. Logistic regression analysis showed that the increased contrast medium in the aneurysm at day 9 ± 2 was statistically related to aneurysm recurrence (p <0.0001). Recurrence or retreatment of the aneurysm did not influence the outcome. Conclusion Complete obliteration of the aneurysm at the first session is important. Recurrence of an embolized ruptured aneurysm can be estimated by postoperative DSA at day 9 ± 2 days.
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Affiliation(s)
- Norihito Shimamura
- Department of Neuroendovascular Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takeshi Katagai
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Nozomi Fujiwara
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kosuke Katayama
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takao Sasaki
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Shouhei Kinoshita
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Keita Yanagiya
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Effects of post-interventional antiplatelet therapy on angiographic vasospasm, delayed cerebral ischemia, and clinical outcome after aneurysmal subarachnoid hemorrhage: a single-center experience. Neurosurg Rev 2021; 44:2899-2912. [PMID: 33492514 PMCID: PMC8490212 DOI: 10.1007/s10143-021-01477-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/22/2020] [Accepted: 01/08/2021] [Indexed: 02/08/2023]
Abstract
Platelet activation has been postulated to be involved in the pathogenesis of delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to investigate potentially beneficial effects of antiplatelet therapy (APT) on angiographic CVS, DCI-related infarction and functional outcome in endovascularly treated aSAH patients. Retrospective single-center analysis of aSAH patients treated by endovascular aneurysm obliteration. Based on the post-interventional medical regime, patients were assigned to either an APT group or a control group not receiving APT. A subgroup analysis separately investigated those APT patients with aspirin monotherapy (MAPT) and those receiving dual treatment (aspirin plus clopidogrel, DAPT). Clinical and radiological characteristics were compared between groups. Possible predictors for angiographic CVS, DCI-related infarction, and an unfavorable functional outcome (modified Rankin scale ≥ 3) were analyzed. Of 160 patients, 85 (53%) had received APT (n = 29 MAPT, n = 56 DAPT). APT was independently associated with a lower incidence of an unfavorable functional outcome (OR 0.40 [0.19-0.87], P = 0.021) after 3 months. APT did not reduce the incidence of angiographic CVS or DCI-related infarction. The pattern of angiographic CVS or DCI-related infarction as well as the rate of intracranial hemorrhage did not differ between groups. However, the lesion volume of DCI-related infarctions was significantly reduced in the DAPT subgroup (P = 0.011). Post-interventional APT in endovascularly treated aSAH patients is associated with better functional outcome at 3 months. The beneficial effect of APT might be mediated by reduction of the size of DCI-related infarctions.
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11
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Wallace AN, Kayan Y, Almandoz JED, Mulder M, Milner AA, Scholz JM, Stiernagle K, Contestabile E, Tipps ME. Dual antiplatelet therapy does not improve outcomes after aneurysmal subarachnoid hemorrhage compared with aspirin monotherapy. Clin Neurol Neurosurg 2020; 195:106038. [PMID: 32650208 DOI: 10.1016/j.clineuro.2020.106038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathophysiology of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) may include platelet activation and microthrombi formation. Antiplatelet therapy may reduce the incidence of DCI and improve clinical outcomes after aSAH. This study compared outcomes among aSAH patients receiving aspirin monotherapy versus dual antiplatelet therapy (DAPT). METHODS Aneurysmal subarachnoid hemorrhage patients treated at a single institution between November 2011 and December 2017 were divided according to whether they received aspirin monotherapy or DAPT after endovascular treatment. Baseline characteristics and outcomes of the groups were compared, including incidences of delayed cerebral ischemia, bleeding complications, symptomatic vasospasm, in-hospital mortality, and functional status 6 months after discharge. RESULTS During the study period, 142 patients met study inclusion criteria, of which 123 were treated with aspirin monotherapy (87 %) and 19 were treated with DAPT (13 %). There was no statistically significant difference between the aspirin monotherapy and DAPT groups with respect to incidences of delayed cerebral ischemia (4.9 vs 10.5 %; p = 0.32), symptomatic vasospasm (13.0 vs 15.8 %; p = 0.74), or good clinical outcome at 6-month follow up (73.3 vs 66.7 %; p = 0.56). The DAPT group experienced a higher incidence of in-hospital mortality (21 vs 5.7 %; p = 0.02), but DAPT did not remain independently predictive of this outcome on regression analysis. There was a trend toward a higher bleeding complication rate in the DAPT group (0.8 vs 5.3 %; p = 0.13). CONCLUSIONS DAPT does not reduce the incidence of DCI or improve outcomes in aSAH patients, and may increase the risk of clinically significant bleeding complications.
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Affiliation(s)
- Adam N Wallace
- Division of Neurointerventional Surgery, Ascension Columbia St. Mary's Hospital, Milwaukee, WI, USA; University of Iowa, Department of Radiology, Iowa City, IA, USA.
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Maximilian Mulder
- Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Anna A Milner
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Jill M Scholz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Kayla Stiernagle
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Emma Contestabile
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Megan E Tipps
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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12
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Increased Mean Platelet Volume is Associated with Poor Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 137:e118-e125. [DOI: 10.1016/j.wneu.2020.01.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 12/26/2022]
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13
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Darkwah Oppong M, Gembruch O, Pierscianek D, Köhrmann M, Kleinschnitz C, Deuschl C, Mönninghoff C, Kaier K, Forsting M, Sure U, Jabbarli R. Post-treatment Antiplatelet Therapy Reduces Risk for Delayed Cerebral Ischemia due to Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 85:827-833. [PMID: 30544176 DOI: 10.1093/neuros/nyy550] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/24/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) has a strong impact on outcome of patients with aneurysmal subarachnoid hemorrhage (SAH). Positive effect of antiplatelet therapy on DCI rates has been supposed upon smaller SAH series. OBJECTIVE To analyze the benefit/risk profile of antiplatelet use in SAH patients. METHODS This retrospective case-control study was based on institutional observational cohort with 994 SAH patients treated between January 2003 and June 2016. The individuals with postcoiling antiplatelet therapy (aspirin with/without clopidogrel) were compared to a control group without antiplatelet therapy. Occurrence of DCI, major/minor bleeding events in the follow-up computed tomography scans, and favorable outcome at 6 mo after SAH (modified Rankin scale < 3) were compared in both groups. RESULTS Of 580 patients in the final analysis, 329 patients received post-treatment antiplatelet medication. There were no significant differences between the compared groups with regard to basic outcome confounders. Aspirin use was independently associated with reduced DCI risk (P < .001, adjusted odds ratio = 0.41, 95% confidence interval 0.24-0.65) and favorable outcome (P = .02, adjusted odds ratio = 1.78, 95% confidence interval 1.06-2.98). Regarding bleeding complications, aspirin was associated only with minor bleeding events (P = .02 vs P = .51 for major bleeding events). CONCLUSION Regular administration of aspirin might have a positive impact on DCI risk and outcome of SAH patients, without increasing the risk for clinically relevant bleeding events. In our SAH cohort, dual antiplatelet therapy showed no additional benefit on DCI risk, but increased the likelihood of major bleeding events.
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Affiliation(s)
- Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | | | | | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Christoph Mönninghoff
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
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14
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Pharmacologic Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Crit Care Nurs Q 2020; 43:138-156. [DOI: 10.1097/cnq.0000000000000299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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15
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Use of Preprocedural, Multiple Antiplatelet Medications for Coil Embolization of Ruptured Cerebral Aneurysm in the Acute Stage Improved Clinical Outcome and Reduced Thromboembolic Complications without Hemorrhagic Complications. World Neurosurg 2020; 133:e751-e756. [DOI: 10.1016/j.wneu.2019.09.149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/21/2022]
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16
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van Dijk BJ, Meijers JCM, Kloek AT, Knaup VL, Rinkel GJE, Morgan BP, van der Kamp MJ, Osuka K, Aronica E, Ruigrok YM, van de Beek D, Brouwer M, Pekna M, Hol EM, Vergouwen MDI. Complement C5 Contributes to Brain Injury After Subarachnoid Hemorrhage. Transl Stroke Res 2019; 11:678-688. [PMID: 31811640 PMCID: PMC7340633 DOI: 10.1007/s12975-019-00757-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/29/2019] [Accepted: 11/19/2019] [Indexed: 12/13/2022]
Abstract
Previous studies showed that complement activation is associated with poor functional outcome after aneurysmal subarachnoid hemorrhage (SAH). We investigated whether complement activation is underlying brain injury after aneurysmal SAH (n = 7) and if it is an appropriate treatment target. We investigated complement expression in brain tissue of aneurysmal SAH patients (n = 930) and studied the role of common genetic variants in C3 and C5 genes in outcome. We analyzed plasma levels (n = 229) to identify the functionality of a single nucleotide polymorphism (SNP) associated with outcome. The time course of C5a levels was measured in plasma (n = 31) and CSF (n = 10). In an SAH mouse model, we studied the extent of microglia activation and cell death in wild-type mice, mice lacking the C5a receptor, and in mice treated with C5-specific antibodies (n = 15 per group). Brain sections from aneurysmal SAH patients showed increased presence of complement components C1q and C3/C3b/iC3B compared to controls. The complement component 5 (C5) SNP correlated with C5a plasma levels and poor disease outcome. Serial measurements in CSF revealed that C5a was > 1400-fold increased 1 day after aneurysmal SAH and then gradually decreased. C5a in plasma was 2-fold increased at days 3–10 after aneurysmal SAH. In the SAH mouse model, we observed a ≈ 40% reduction in both microglia activation and cell death in mice lacking the C5a receptor, and in mice treated with C5-specific antibodies. These data show that C5 contributes to brain injury after experimental SAH, and support further study of C5-specific antibodies as novel treatment option to reduce brain injury and improve prognosis after aneurysmal SAH.
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Affiliation(s)
- Bart J van Dijk
- UMC Utrecht Brain Center, Department of Translational Neurosciences, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Joost C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, Amsterdam, The Netherlands
| | - Anne T Kloek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Veronique L Knaup
- Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Gabriel J E Rinkel
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - B Paul Morgan
- Systems Immunity Research Institute, Cardiff University, Heath Park, Cardiff, UK
| | - Marije J van der Kamp
- UMC Utrecht Brain Center, Department of Translational Neurosciences, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Koji Osuka
- Department of Neurological Surgery, Aichi Medical University, 1-1 Karimatayazako, Aichi, Japan
| | - Eleonora Aronica
- Department of Neuropathology, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ynte M Ruigrok
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Matthijs Brouwer
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marcela Pekna
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Medicinaregatan 9A, Gothenburg, Sweden
| | - Elly M Hol
- UMC Utrecht Brain Center, Department of Translational Neurosciences, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands.,Netherlands Institute for Neuroscience, Institute of the Royal Netherlands Academy of Arts and Sciences, Meibergdreef 47, Amsterdam, The Netherlands
| | - Mervyn D I Vergouwen
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands.
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17
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Lauridsen SV, Hvas CL, Sandgaard E, Gyldenholm T, Mikkelsen R, Obbekjær T, Sunde N, Tønnesen EK, Hvas AM. Thromboelastometry Shows Early Hypercoagulation in Patients with Spontaneous Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e140-e149. [DOI: 10.1016/j.wneu.2019.06.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/14/2022]
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18
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Endothelial Cell Dysfunction and Injury in Subarachnoid Hemorrhage. Mol Neurobiol 2018; 56:1992-2006. [DOI: 10.1007/s12035-018-1213-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/27/2018] [Indexed: 01/15/2023]
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19
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Perez P, Lukaszewicz AC, Lenck S, Nizard R, Drouet L, Payen D. Platelet activation and aggregation after aneurysmal subarachnoid hemorrhage. BMC Neurol 2018; 18:57. [PMID: 29704896 PMCID: PMC5924502 DOI: 10.1186/s12883-018-1062-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 04/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Endovascular techniques have proven beneficial in the treatment of aneurysmal subarachnoid hemorrhage (aSAH), but with high risk of arterial clotting, emboli and dissection. Platelet activation and alterations in hemostasis may contribute to these complications. We investigated platelet activation and aggregation pathways in aSAH patients who underwent endovascular treatment. Methods Two blood samples were taken, in the early days after bleeding and during the period at risk of vasospasm. We studied platelet activation through the expression of GpIIbIIIa and P-selectin as well as aggregation rate in the presence of agonists. Platelets from aSAH patients were compared with those from orthopedic postoperative patients (POSTOP). Results Platelets in aSAH were initially spontaneously activated and remained so over time. aSAH platelets were further activated with rapid aggregation in the presence of agonists, particularly ADP, with behavior comparable to POSTOP platelets. Conclusions aSAH platelets showed prolonged increases in activation and aggregation. Therapies targeting the ADP pathway might reduce the risk of clotting and ischemic events in this context among patients requiring multiple endovascular procedures. Trial registration Not applicable. Electronic supplementary material The online version of this article (10.1186/s12883-018-1062-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pauline Perez
- Anesthesiology and Critical Care Department, Lariboisière Hospital, Paris, France
| | - Anne-Claire Lukaszewicz
- Anesthesiology and Critical Care Department, Lariboisière Hospital, Paris, France. .,Inserm U1160, Lariboisière Hospital, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France.
| | - Stephanie Lenck
- Department of Neuroradiology, Lariboisière Hospital, Paris, France
| | - Rémy Nizard
- Department of Orthopedic Surgery and Traumatology, Lariboisière Hospital, Paris, France
| | - Ludovic Drouet
- Angio-Hematology Department (L.D.), Lariboisière Hospital, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Didier Payen
- Anesthesiology and Critical Care Department, Lariboisière Hospital, Paris, France.,Inserm U1160, Lariboisière Hospital, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
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20
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Ray B, Pandav VM, Mathews EA, Thompson DM, Ford L, Yearout LK, Bohnstedt BN, Chaudhary S, Dale GL, Prodan CI. Coated-Platelet Trends Predict Short-Term Clinical OutcomeAfter Subarachnoid Hemorrhage. Transl Stroke Res 2017; 9:459-470. [DOI: 10.1007/s12975-017-0594-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022]
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21
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Nagahama Y, Allan L, Nakagawa D, Zanaty M, Starke RM, Chalouhi N, Jabbour P, Brown RD, Derdeyn CP, Leira EC, Broderick J, Chimowitz M, Torner JC, Hasan D. Dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage: association with reduced risk of clinical vasospasm and delayed cerebral ischemia. J Neurosurg 2017; 129:702-710. [PMID: 29099296 DOI: 10.3171/2017.5.jns17831] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical vasospasm and delayed cerebral ischemia (DCI) are devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Several theories involving platelet activation have been postulated as potential explanations of the development of clinical vasospasm and DCI. However, the effects of dual antiplatelet therapy (DAPT; aspirin and clopidogrel) on clinical vasospasm and DCI have not been previously investigated. The objective of this study was to evaluate the effects of DAPT on clinical vasospasm and DCI in aSAH patients. METHODS Analysis of patients treated for aSAH during the period from July 2009 to April 2014 was performed in a single-institution retrospective study. Patients were divided into 2 groups: patients who underwent stent-assisted coiling or placement of flow diverters requiring DAPT (DAPT group) and patients who underwent coiling only without DAPT (control group). The frequency of symptomatic clinical vasospasm and DCI and of hemorrhagic complications was compared between the 2 groups, utilizing univariate and multivariate logistic regression. RESULTS Of 312 aSAH patients considered for this study, 161 met the criteria for inclusion and were included in the analysis (85 patients in the DAPT group and 76 patients in the control group). The risks of clinical vasospasm (OR 0.244, CI 95% 0.097-0.615, p = 0.003) and DCI (OR 0.056, CI 95% 0.01-0.318, p = 0.001) were significantly lower in patients receiving DAPT. The rates of hemorrhagic complications associated with placement of external ventricular drains and ventriculoperitoneal shunts were similar in both groups (4% vs 2%, p = 0.9). CONCLUSIONS The use of DAPT was associated with a lower risk of clinical vasospasm and DCI in patients treated for aSAH, without an increased risk of hemorrhagic complications.
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Affiliation(s)
| | - Lauren Allan
- 2Department of General Surgery, Mercy Medical Center, Des Moines, Iowa
| | | | | | | | - Nohra Chalouhi
- 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert D Brown
- 6Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - Enrique C Leira
- 8Department of Neurology, University of Iowa College of Medicine.,9Department of Epidemiology, University of Iowa, Iowa City
| | - Joseph Broderick
- 10Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio; and
| | - Marc Chimowitz
- 11Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - James C Torner
- 9Department of Epidemiology, University of Iowa, Iowa City
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22
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Ding YS, Sun B, Jiang JX, Zhang Q, Lu J, Gao GZ. Increased serum concentrations of signal peptide-Cub-Egf domain-containing protein-1 in patients with aneurysmal subarachnoid hemorrhage. Clin Chim Acta 2016; 459:117-122. [DOI: 10.1016/j.cca.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/26/2016] [Accepted: 06/02/2016] [Indexed: 02/07/2023]
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23
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Ramchand P, Nyirjesy S, Frangos S, Doerfler S, Nawalinski K, Quattrone F, Ju C, Patel H, Driscoll N, Maloney-Wilensky E, Stein SC, Levine JM, Kasner SE, Kumar MA. Thromboelastography Parameter Predicts Outcome After Subarachnoid Hemorrhage: An Exploratory Analysis. World Neurosurg 2016; 96:215-221. [PMID: 27072337 DOI: 10.1016/j.wneu.2016.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Hypercoagulability after subarachnoid hemorrhage (SAH) is well described and may be platelet mediated. Thromboelastography (TEG) provides a global assessment of coagulation. We sought to determine whether the maximum amplitude (MA) parameter of TEG, a measure of platelet strength and function, is associated with outcome after SAH. METHODS One hundred ten TEG analyses were performed for patients with moderate-to-severe SAH and compared with 6 healthy age- and sex-matched controls. TEG indices included MA, G value (G), alpha angle, and thrombus generation and were correlated to functional outcomes and laboratory tests including complete blood count, erythrocyte sedimentation rate, high sensitivity C-reactive protein, fibrinogen, and d-dimer, obtained on post-bleed days (PBDs) 1, 3, 5, 7, and 10. RESULTS MA was significantly elevated compared with controls on PBD 3 (70.0 mm ± 4.5 mm vs. 64.1 mm ± 6.5 mm; P = 0.02), PBD 5 (72.6 mm ± 5.3 mm vs. 64.1 mm ± 6.5 mm; P = 0.003), PBD 7 (73.0 mm ± 5.4 mm vs. 64.1 mm ± 6.5 mm; P = 0.003), and PBD 10 (73.4 mm ± 6.0 mm vs. 64.1 mm ± 6.5 mm; P = 0.005). G was significantly elevated compared with controls on PBD 3 (P = 0.03), PBD 5 (P = 0.01), PBD 7 (P = 0.01), and PBD 10 (P = 0.02). The only biomarker associated with poor outcome was CRP. Multivariate logistic regression demonstrated an association between elevated MA and outcome (odds ratio 39.1, P = 0.006) independent of CRP, age, Hunt Hess grade, and transfusion. CONCLUSIONS TEG indices are associated with poor outcome after SAH and may identify a platelet-mediated hypercoagulable state. The association between MA and outcome was stronger than that between traditional biomarkers and was independent of age and Hunt Hess grade.
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Affiliation(s)
- Preethi Ramchand
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah Nyirjesy
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Suzanne Frangos
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelsey Nawalinski
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis Quattrone
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Connie Ju
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hiren Patel
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicki Driscoll
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Levine
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Monisha A Kumar
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Budohoski KP, Guilfoyle M, Helmy A, Huuskonen T, Czosnyka M, Kirollos R, Menon DK, Pickard JD, Kirkpatrick PJ. The pathophysiology and treatment of delayed cerebral ischaemia following subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2014; 85:1343-53. [PMID: 24847164 DOI: 10.1136/jnnp-2014-307711] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cerebral vasospasm has traditionally been regarded as an important cause of delayed cerebral ischaemia (DCI) which occurs after aneurysmal subarachnoid haemorrhage, and often leads to cerebral infarction and poor neurological outcome. However, data from recent studies argue against a pure focus on vasospasm as the cause of delayed ischaemic complications. Findings that marked reduction in the incidence of vasospasm does not translate to a reduction in DCI, or better outcomes has intensified research into other possible mechanisms which may promote ischaemic complications. Early brain injury and cell death, blood-brain barrier disruption and initiation of an inflammatory cascade, microvascular spasm, microthrombosis, cortical spreading depolarisations and failure of cerebral autoregulation, have all been implicated in the pathophysiology of DCI. This review summarises the current knowledge about the mechanisms underlying the development of DCI. Furthermore, it aims to describe and categorise the known pharmacological treatment options with respect to the presumed mechanism of action and its role in DCI.
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Affiliation(s)
- Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Mathew Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Terhi Huuskonen
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK Department of Neurosurgery, Kuopio Neurocenter, Kuopio University Hospital, Kuopio, Finland
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ramez Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Department of Anaesthesiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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The role of arterioles and the microcirculation in the development of vasospasm after aneurysmal SAH. BIOMED RESEARCH INTERNATIONAL 2014; 2014:253746. [PMID: 24900959 PMCID: PMC4037567 DOI: 10.1155/2014/253746] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/19/2014] [Accepted: 04/20/2014] [Indexed: 12/13/2022]
Abstract
Cerebral vasospasm of the major cerebral arteries, which is characterized by angiographic narrowing of those vessels, had been recognized as a main contributor to delayed cerebral ischemia (DCI) in subarachnoid hemorrhage (SAH) patients. However, the CONSCIOUS-1 trial revealed that clazosentan could not improve mortality or clinical outcome in spite of successful reduction of relative risk in angiographic vasospasm. This result indicates that the pathophysiology underlying DCI is multifactorial and that other pathophysiological factors, which are independent of angiographic vasospasm, can contribute to the outcome. Recent studies have focused on microcirculatory disturbance, such as microthrombosis and arteriolar constriction, as a factor affecting cerebral ischemia after SAH. Reports detecting microthrombosis and arteriolar constriction will be reviewed, and the role of the microcirculation on cerebral ischemia during vasospasm after SAH will be discussed.
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Naranjo D, Arkuszewski M, Rudzinski W, Melhem ER, Krejza J. Brain ischemia in patients with intracranial hemorrhage: pathophysiological reasoning for aggressive diagnostic management. Neuroradiol J 2013; 26:610-28. [PMID: 24355179 PMCID: PMC4202872 DOI: 10.1177/197140091302600603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/15/2013] [Indexed: 11/15/2022] Open
Abstract
Patients with intracranial hemorrhage have to be managed aggressively to avoid or minimize secondary brain damage due to ischemia, which contributes to high morbidity and mortality. The risk of brain ischemia, however, is not the same in every patient. The risk of complications associated with an aggressive prophylactic therapy in patients with a low risk of brain ischemia can outweigh the benefits of therapy. Accurate and timely identification of patients at highest risk is a diagnostic challenge. Despite the availability of many diagnostic tools, stroke is common in this population, mostly because the pathogenesis of stroke is frequently multifactorial whereas diagnosticians tend to focus on one or two risk factors. The pathophysiological mechanisms of brain ischemia in patients with intracranial hemorrhage are not yet fully elucidated and there are several important areas of ongoing research. Therefore, this review describes physiological and pathophysiological aspects associated with the development of brain ischemia such as the mechanism of oxygen and carbon dioxide effects on the cerebrovascular system, neurovascular coupling and respiratory and cardiovascular factors influencing cerebral hemodynamics. Consequently, we review investigations of cerebral blood flow disturbances relevant to various hemodynamic states associated with high intracranial pressure, cerebral embolism, and cerebral vasospasm along with current treatment options.
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Affiliation(s)
- Daniel Naranjo
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Michal Arkuszewski
- Department of Neurology, Medical University of Silesia, Central University Hospital; Katowice, Poland
| | - Wojciech Rudzinski
- Department of Cardiology, Robert Packer Hospital; Sayre, Pennsylvania USA
| | - Elias R. Melhem
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Jaroslaw Krejza
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
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Aggarwal A, Salunke P, Singh H, Gupta SK, Chhabra R, Singla N, Sachdeva AK. Vasospasm following aneurysmal subarachnoid hemorrhage: Thrombocytopenia a marker. J Neurosci Rural Pract 2013; 4:257-61. [PMID: 24250155 PMCID: PMC3821408 DOI: 10.4103/0976-3147.118762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Symptomatic vasospasm (SV) is often seen after aneurysmal subarachnoid hemorrhage (aSAH). The pathophysiology suggests that platelets initiate the process and are consumed. This is likely to result in thrombocytopenia. The objective of this study was to find out if thrombocytopenia preceded or followed SV and to analyze the relationship between the two. Materials and Methods: The platelet counts of 74 patients were studied on day 1, 3, 5, 7, 9, 11, and 14 following aSAH. Clinical symptoms and raised velocities on transcranial Doppler were studied on the same days to determine SV. The relationship of platelet counts and SV were analyzed. Results: Thirty-nine (52.7%) patients developed SV. Platelet counts dropped on postictal day (PID) 3-7 and SV was commonly seen on PID 5-9. The median platelet counts were significantly lower in patients with SV when compared to those without SV. Platelet count <150,000/mm3 on PID 1 and 7 had statistically significant association (P < 0.001) with SV. The odds ratio was 5.1, 6.9, and 5.1 on PID 5, 7, and 9, respectively, for patients with relative thrombocytopenia (P < 0.001). Conclusions: There is a strong correlation between thrombocytopenia and SV. A platelet count < 150,000/mm3 on PID 1 and 7 predicts presence of SV. The relative risk of developing SV is >5 times for a patient with relative thrombocytopenia especially on PID 5-9. Additionally, it appears that thrombocytopenia precedes vasospasm and may be an independent predictor. However, this requires further studies for validation.
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Grinberg L, Fedosov DA, Karniadakis GE. Parallel multiscale simulations of a brain aneurysm. JOURNAL OF COMPUTATIONAL PHYSICS 2013; 244:131-147. [PMID: 23734066 PMCID: PMC3668797 DOI: 10.1016/j.jcp.2012.08.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Cardiovascular pathologies, such as a brain aneurysm, are affected by the global blood circulation as well as by the local microrheology. Hence, developing computational models for such cases requires the coupling of disparate spatial and temporal scales often governed by diverse mathematical descriptions, e.g., by partial differential equations (continuum) and ordinary differential equations for discrete particles (atomistic). However, interfacing atomistic-based with continuum-based domain discretizations is a challenging problem that requires both mathematical and computational advances. We present here a hybrid methodology that enabled us to perform the first multi-scale simulations of platelet depositions on the wall of a brain aneurysm. The large scale flow features in the intracranial network are accurately resolved by using the high-order spectral element Navier-Stokes solver εκαr . The blood rheology inside the aneurysm is modeled using a coarse-grained stochastic molecular dynamics approach (the dissipative particle dynamics method) implemented in the parallel code LAMMPS. The continuum and atomistic domains overlap with interface conditions provided by effective forces computed adaptively to ensure continuity of states across the interface boundary. A two-way interaction is allowed with the time-evolving boundary of the (deposited) platelet clusters tracked by an immersed boundary method. The corresponding heterogeneous solvers ( εκαr and LAMMPS) are linked together by a computational multilevel message passing interface that facilitates modularity and high parallel efficiency. Results of multiscale simulations of clot formation inside the aneurysm in a patient-specific arterial tree are presented. We also discuss the computational challenges involved and present scalability results of our coupled solver on up to 300K computer processors. Validation of such coupled atomistic-continuum models is a main open issue that has to be addressed in future work.
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Affiliation(s)
- Leopold Grinberg
- Division of Applied Mathematics, Brown University, Providence, RI, 02912, USA
| | - Dmitry A. Fedosov
- Institute of Complex Systems and Institute for Advanced Simulation, Forschungszentrum Jülich, Jülich, 52425, Germany
| | - George Em Karniadakis
- Division of Applied Mathematics, Brown University, Providence, RI, 02912, USA
- Corresponding author: (George Em Karniadakis)
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Ducruet AF, Gigante PR, Hickman ZL, Zacharia BE, Arias EJ, Grobelny BT, Gorski JW, Mayer SA, Connolly ES. Genetic determinants of cerebral vasospasm, delayed cerebral ischemia, and outcome after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2010; 30:676-88. [PMID: 20068580 PMCID: PMC2949164 DOI: 10.1038/jcbfm.2009.278] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Despite extensive effort to elucidate the cellular and molecular bases for delayed cerebral injury after aneurysmal subarachnoid hemorrhage (aSAH), the pathophysiology of these events remains poorly understood. Recently, much work has focused on evaluating the genetic underpinnings of various diseases in an effort to delineate the contribution of specific molecular pathways as well as to uncover novel mechanisms. The majority of subarachnoid hemorrhage genetic research has focused on gene expression and linkage studies of these markers as they relate to the development of intracranial aneurysms and their subsequent rupture. Far less work has centered on the genetic determinants of cerebral vasospasm, the predisposition to delayed cerebral injury, and the determinants of ensuing functional outcome after aSAH. The suspected genes are diverse and encompass multiple functional systems including fibrinolysis, inflammation, vascular reactivity, and neuronal repair. To this end, we present a systematic review of 21 studies suggesting a genetic basis for clinical outcome after aSAH, with a special emphasis on the pathogenesis of cerebral vasospasm and delayed cerebral ischemia. In addition, we highlight potential pitfalls in the interpretation of genetic association studies, and call for uniformity of design of larger multicenter studies in the future.
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Affiliation(s)
- Andrew F Ducruet
- Department of Neurological Surgery, Columbia University, 630 West 168th Street, Room no. 5-454, New York, NY 10032, USA.
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Vergouwen MDI, Vermeulen M, Coert BA, Stroes ESG, Roos YBWEM. Microthrombosis after aneurysmal subarachnoid hemorrhage: an additional explanation for delayed cerebral ischemia. J Cereb Blood Flow Metab 2008; 28:1761-70. [PMID: 18628782 DOI: 10.1038/jcbfm.2008.74] [Citation(s) in RCA: 240] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with aneurysmal subarachnoid hemorrhage (SAH) who experience delayed cerebral ischemia (DCI) have an increased risk of poor outcome. Delayed cerebral ischemia is considered to be caused by vasospasm. However, not all patients with DCI have vasospasm. Inversely, not all patients with vasospasm develop clinical symptoms and signs of DCI. In the past, treatments aiming at vasospasm were not successful in preventing ischemia. The purpose of this review is to give an overview of clinical data showing that DCI cannot always be attributed to vasospasm, and to present an in-depth analysis of clinical and autopsy studies on the role of microthrombosis in the pathogenesis of DCI. Clinical studies show that DCI is associated with an activation of the coagulation cascade within a few days after SAH, preceding the time window during which vasospasm occurs. Furthermore, impaired fibrinolytic activity, and inflammatory and endothelium-related processes, lead to the formation of microthrombi, which ultimately result in DCI. The presence of microthrombi is confirmed by autopsy studies. Insight in the pathophysiology of DCI is crucial for the development of effective therapies against this complication. Because multiple pathways are involved, future research should focus on drugs with pleiotropic effects.
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Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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31
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Abstract
Treating patients with aneurysmal subarachnoid haemorrhage is taking care of acutely ill patients, and should be performed in centres where a multidisciplinary team is available 24 hours a day 7 days a week, and where enough patients are managed to maintain and improve standards of care. There is no medical management that improves outcome by reducing the risk of rebleeding, therefore occlusion of the aneurysm, nowadays preferably by means of coiling, remains an important goal in treating patients with aneurysms. Because the poor outcome after subarachnoid haemorrhage is caused to a large extent by complications other than rebleeding, proper medical management to prevent and treat these complications is therefore essential. On basis of the available evidence, oral (not intravenous) nimodipine should be standard care in patients with subarachnoid haemorrhage. It is rational to refrain from treating hypertension unless cardiac failure develops and to aim for normovolaemia, even in case of hyponatraemia. There is no evidence for prophylactic hypervolaemia, and the strategy of hypervolaemia and hypertension in patients with secondary cerebral ischaemia is based on case reports and uncontrolled observational series of patients. Magnesium sulphate and statins are promising therapies, and large trials on effectiveness in improving clinical outcome are underway. There is no evidence for prophylactic use of anti epileptic drugs, and routine use of corticosteroids should be avoided.
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32
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Dorhout Mees S, van den Bergh WM, Algra A, Rinkel GJE. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2007; 2007:CD006184. [PMID: 17943892 PMCID: PMC8919458 DOI: 10.1002/14651858.cd006184.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Secondary ischaemia is a frequent cause of poor outcome in patients with aneurysmal subarachnoid haemorrhage (SAH). Besides vasospasm, platelet aggregation seems to play a role in the pathogenesis of secondary ischaemia. Experimental studies have suggested that antiplatelet agents can prevent secondary ischaemia. OBJECTIVES To determine whether antiplatelet agents change outcome in patients with aneurysmal SAH. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched August 2006), MEDLINE (1966 to August 2006) and EMBASE databases (1980 to August 2006). We also searched reference lists of identified trials. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing any antiplatelet agent with control in patients with aneurysmal SAH. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data and assessed trial quality. Relative risks (RR) were calculated with regard to poor outcome, case fatality, secondary ischaemia, haemorrhagic intracranial complications and aneurysmal rebleeding according to the intention-to-treat principle. In case of a statistically significant primary analysis, a worst case analysis was performed. MAIN RESULTS Seven RCTs were included in the review, totalling 1385 patients. Four of these trials met the criteria for good quality studies. For any antiplatelet agent there were reductions of a poor outcome (RR 0.79, 95% confidence interval (CI) 0.62 to 1.01) and secondary brain ischaemia (RR 0.79, 95% CI 0.56 to 1.22) and more intracranial haemorrhagic complications (RR 1.36, 95% CI 0.59 to 3.12), but none of these differences were statistically significant. There was no effect on case fatality (RR 1.01, 95% CI 0.74 to 1.37) or aneurysmal rebleeding (RR 0.98, 95% CI 0.78 to 1.38). For individual antiplatelet agents, only ticlopidine was associated with statistically significant fewer occurrences of a poor outcome (RR 0.37, 95% CI 95% CI 0.14 to 0.98) but this estimate was based on only one small RCT. AUTHORS' CONCLUSIONS This review shows a trend towards better outcome in patients treated with antiplatelet agents, possibly due to a reduction in secondary ischaemia. However, results were not statistically significant, thus no definite conclusions can be drawn. Also, antiplatelet agents could increase the risk of haemorrhagic complications. On the basis of the current evidence treatment with antiplatelet agents in order to prevent secondary ischaemia or poor outcome cannot be recommended.
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Affiliation(s)
- Sanne Dorhout Mees
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Walter M van den Bergh
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Ale Algra
- University Medical Center UtrechtJulius Centre for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is analogous to a pathophysiological watershed, disrupting brain integrity and function and precipitating an array of systemic derangements including cardiovascular, respiratory, endocrine, hematological, and immune dysfunction. Extracerebral organ dysfunction is closely linked to the magnitude of the primary neurological insult, suggesting neurogenic, neuroendocrine and neuroimmunomodulatory mechanisms. Systemic organ involvement is associated with increased mortality and neurological impairment, even after adjustment for other outcome predictors such as the severity of the initial neurological injury. This may be a reflection of secondary brain injury precipitated by hypoxemia, circulatory failure, fever, or hyperglycemia, all of which have been linked to adverse clinical outcomes. Interventions to avert or reverse these and other perturbations need to be tested in clinical trials as they represent opportunities to improve survival and neurological recovery in patients with SAH.
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Affiliation(s)
- Robert D Stevens
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Topcuoglu MA, Singhal AB. Effects of common medications on cerebral vasospasm after subarachnoid haemorrhage. Expert Opin Drug Saf 2006; 5:57-65. [PMID: 16370956 DOI: 10.1517/14740338.5.1.57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cerebral vasospasm is a common and serious complication of aneurysmal subarachnoid haemorrhage (SAH). At present, no consistently effective preventative and therapeutic measures are available, perhaps because of incomplete understanding of the pathogenesis of vasospasm. Experimental studies provide evidence that the incidence and severity of vasospasm after SAH can be modulated by drugs that affect neurotransmitter levels, intracellular signalling mechanisms, vascular smooth muscle function, inflammation and cellular proliferation, and the concentration of 'spasmogenic' factors. Preliminary clinical studies indicate that some illicit drugs and common prescription medications can have similar effects in humans. Recognition of these pharmacological effects is important because medications that can worsen or alleviate vasospasm are frequently administered to SAH patients to treat coincident medical problems.
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Naval NS, Stevens RD, Mirski MA, Bhardwaj A. Controversies in the management of aneurysmal subarachnoid hemorrhage*. Crit Care Med 2006; 34:511-24. [PMID: 16424735 DOI: 10.1097/01.ccm.0000198331.45998.85] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management. OBJECTIVE To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation. DATA SOURCE Search of MEDLINE and Cochrane databases and manual review of article bibliographies. DATA SYNTHESIS AND CONCLUSIONS Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.
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Affiliation(s)
- Neeraj S Naval
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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36
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Ilveskero S, Juvela S, Siironen J, Lassila R. D-dimer Predicts Outcome after Aneurysmal Subarachnoid Hemorrhage: No Effect of Thromboprophylaxis on Coagulation Activity. Neurosurgery 2005; 57:16-24; discussion 16-24. [PMID: 15987536 DOI: 10.1227/01.neu.0000163085.48999.d6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2004] [Accepted: 01/13/2005] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Approximately one-third of all patients with acute nontraumatic subarachnoid hemorrhage (SAH) experience complications owing to delayed ischemic deficit. We reported recently that enoxaparin 40 mg once daily for 10 days seems safe and demonstrates thromboprophylactic efficacy, but it failed to improve outcome in a randomized SAH trial. In the present study, we assessed hemostatic variables associated with clinical status and outcome of SAH. We also monitored the effect of enoxaparin on activation of coagulation and fibrinolysis after closure of the ruptured aneurysm. METHODS Blood samples to measure activation of coagulation and fibrinolysis were collected from 42 patients participating in the enoxaparin trial for acute aneurysmal SAH at four time points: 1) at hospital admission; 2) 12 to 24 hours after aneurysm surgery but before initiation of enoxaparin therapy; 3) 3 hours after the first dose; and 4) at the conclusion of treatment. RESULTS At admission, several variables of coagulation and fibrinolysis were elevated and correlated well with clinical status. Specifically, D-dimer levels at all four time points correlated with patients' long-term outcomes. A single dose of enoxaparin suppressed early coagulation activity, but thrombin generation was not inhibited during thromboprophylaxis. However, PAI-1 activity was suppressed. CONCLUSION D-dimer offers a useful laboratory tool for assessing early and late clinical severity of SAH. A thromboprophylactic dose of enoxaparin inhibited PAI-1 activity but failed to down-regulate coagulation activity and D-dimer. These findings are compatible with the lack of efficacy of enoxaparin in reducing ischemic deficit after SAH.
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Affiliation(s)
- Sorella Ilveskero
- Wihuri Research Institute, Department of Hematology, Helsinki University Central Hospital, Helsinki, Finland
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37
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Toussaint LG, Friedman JA, Wijdicks EFM, Piepgras DG, Pichelmann MA, McIver JI, McClelland RL, Nichols DA, Meyer FB, Atkinson JLD. Influence of aspirin on outcome following aneurysmal subarachnoid hemorrhage. J Neurosurg 2005; 101:921-5. [PMID: 15597751 DOI: 10.3171/jns.2004.101.6.0921] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Previous studies have indicated an increased incidence of death in patients with subarachnoid hemorrhage (SAH) who are currently receiving anticoagulation therapy. The significance of previous aspirin use in patients with SAH is unknown. The authors analyzed the effects of prior aspirin use on clinical course and outcomes following aneurysmal SAH. METHODS The medical records of 305 patients with angiogram-confirmed aneurysmal SAH who consecutively presented to our institution between 1990 and 1997 within 7 days of ictus were analyzed. Twenty-nine (9.5%) of these patients had a history of regular aspirin use before onset of the SAH. The Glasgow Outcome Scale (GOS) was used to measure patient outcome at the longest available follow up. Aspirin users were older on average than nonusers (59 years of age compared with 53 years; p = 0.018). The mean admission Hunt and Hess grades of patients with and without aspirin use were similar (2 compared with 2.3; p = 0.51). Two trends, which did not reach statistical significance, were observed. 1) The rebleeding rate in aspirin users was 14.3%, compared with a 4.7% rebleeding rate in nonusers (p = 0.06). 2) Permanent disability from vasospasm was less common among aspirin users (23% compared with 50%; p = 0.069). Outcomes did not differ between aspirin users and nonusers (mean GOS Score 3.83 compared with GOS Score 3.86, respectively; p = 0.82). CONCLUSIONS Despite trends indicating increased rebleeding rates and a lower incidence of permanent disability due to delayed ischemic neurological deficits, there was no significant effect of previous aspirin use on overall outcome following aneurysmal SAH. Based on these preliminary data, the presence of an intracranial aneurysm is not a strict contraindication to aspirin use.
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Affiliation(s)
- L Gerard Toussaint
- Department of Neurologic Surgery, Mayo Graduate School of Medicine, Rochester, Minnesota 55905, USA.
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Pyne GJ, Cadoux-Hudson TAD, Clark JF. Platelets play an essential role in the aetiology of cerebral vasospasm after subarachnoid haemorrhage. Med Hypotheses 2003; 60:525-30. [PMID: 12615514 DOI: 10.1016/s0306-9877(02)00452-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Platelets have long been implicated in the aetiology of cerebral vasospasm (CV) after subarachnoid haemorrhage (SAH). It was noticed that vasospastic CSF (CSF(V)) could be formed in vitro by the mixing of control blood (with platelets) and non-SAH CSF. We also propose a hypothesis for the aetiology of CV after SAH based on this and previous research. This study also aims to determine which blood fraction is responsible for the stimulation of O(2) consumption and vasospasm of blood vessels. Control blood was separated into various fractions and mixed with non-SAH CSF. The activity of the resulting mixture and the blood fraction alone were assessed. Only the fractions containing platelets mixed with CSF showed vasoactivity. These data suggest that platelets plus some component in the CSF produce vasoactive factors with actions similar to CSF(V). This study may help to elucidate the aetiology of CV after SAH.
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Affiliation(s)
- Gail J Pyne
- MRC Collaborative Centre, Mill Hill, London, UK
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Abe Y, Kasuya H, Suzuki S, Yamanishi Y, Hori T. Effect of a platelet-activating factor antagonist, E5880, on cerebrovasospasm following subarachnoid hemorrhage in a canine double-hemorrhage model. Eur J Pharmacol 2002; 455:127-33. [PMID: 12445578 DOI: 10.1016/s0014-2999(02)02586-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We investigated the effects of a platelet-activating factor (PAF) antagonist, E5880 (1-ethyl-2-[N-(2-methoxy)benzoyl-N-[(2)-2-methoxy-3-(4-octadecycarbamoylox)piperidinocarbonyloxy-propyloxy]carbonyl]aminomethyl-pyridiniumchloride), on subarachnoid hemorrhage-induced prolongation of cerebral circulation time and decrease in the basilar artery diameter in a canine double-hemorrhage model. Animals were assigned to three groups, control (saline), E5880 1.2 mg/kg and E5880 2.4 mg/kg. For measurement of cerebral circulation time, regions of interest were chosen at the basilar artery and the straight sinus in order to obtain time-density curves. Cerebral circulation time was defined as the difference between the arterial and venous peaks. Cerebral circulation time and basilar artery diameter were assessed by intra-arterial digital subtraction angiography (IA-DSA) on Days 0, 2 and 7. The prolongation of cerebral circulation time following subarachnoid hemorrhage was significantly inhibited by intravenous administration of 2.4 mg/kg of E5880. Basilar artery constriction was also reduced by E5880. Thus, E5880 had preventive effects on the prolongation of cerebral circulation time and the vasoconstriction of basilar artery in this model. These results suggest that E5880 may have a preventive effect on neurological symptoms aggravated by cerebrovascular lesions following subarachnoid hemorrhage.
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Affiliation(s)
- Yoshihisa Abe
- Developmental Pharmacology Research Section, Drug Safety and Disposition Research Laboratories, Eisai Company, Limited, Tsukuba City, Ibaraki, 300-2635, Japan.
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Romano JG, Forteza AM, Concha M, Koch S, Heros RC, Morcos JJ, Babikian VL. Detection of microemboli by transcranial Doppler ultrasonography in aneurysmal subarachnoid hemorrhage. Neurosurgery 2002; 50:1026-30; discussion 1030-1. [PMID: 11950405 DOI: 10.1097/00006123-200205000-00016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2001] [Accepted: 01/08/2002] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine the frequency and characteristics of microembolic signals (MES) in subarachnoid hemorrhage (SAH). METHODS Twenty-three patients with aneurysmal SAH were monitored with transcranial Doppler ultrasonography for the presence of MES and vasospasm. Each middle cerebral artery was monitored for 30 minutes three times each week. Patients were excluded if they had traumatic SAH or cardiac or arterial sources of emboli. Monitoring was initiated 6.3 days (1-16 d) after SAH and lasted 6.6 days (1-13 d). Eleven individuals without SAH or other cerebrovascular diseases who were treated in the same unit served as control subjects. Each patient underwent monitoring of both middle cerebral arteries a mean of three times; therefore, 46 vessels were studied (a total of 138 observations). Control subjects underwent assessment of each middle cerebral artery once, for a total of 22 control vessels. RESULTS MES were detected for 16 of 23 patients (70%) and 44 of 138 patient vessels (32%) monitored, compared with 2 of 11 control subjects (18%) and 2 of 22 control vessels (9%) (P < 0.05). MES were observed for 83% of patients with clinical vasospasm and 54% of those without clinical vasospasm. Ultrasonographic vasospasm was observed for 71 of 138 vessels monitored; MES were observed for 28% of vessels with vasospasm and 36% of those without vasospasm. Aneurysms proximal to the monitored artery were identified in 38 of 138 vessels, of which 34% exhibited MES, which is similar to the frequency for vessels without proximal aneurysms (31%). Coiled, clipped, and unsecured aneurysms exhibited similar frequencies of MES. CONCLUSION MES were common in SAH, occurring in 70% of cases of SAH and one-third of all vessels monitored. Although MES were more frequent among patients with clinical vasospasm, this difference did not reach statistical significance. We were unable to demonstrate a relationship between ultrasonographic vasospasm and MES, and the presence of a proximal secured or unsecured aneurysm did not alter the chance of detection of MES. Further studies are required to determine the origin and clinical relevance of MES in SAH.
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Affiliation(s)
- Jose G Romano
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA.
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Romano JG, Forteza AM, Concha M, Koch S, Heros RC, Morcos JJ, Babikian VL. Detection of Microemboli by Transcranial Doppler Ultrasonography in Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2002. [DOI: 10.1227/00006123-200205000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.
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Affiliation(s)
- J van Gijn
- Department of Neurology, University Medical Centre, Utrecht, The Netherlands.
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Ohkuma H, Itoh K, Shibata S, Suzuki S. Morphological changes of intraparenchymal arterioles after experimental subarachnoid hemorrhage in dogs. Neurosurgery 1997; 41:230-5; discussion 235-6. [PMID: 9218311 DOI: 10.1097/00006123-199707000-00036] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Morphological and microcirculatory changes in intraparenchymal vessels after subarachnoid hemorrhage (SAH) have not yet been fully clarified. We conducted this experimental study to investigate the serial morphological changes of intraparenchymal arterioles after SAH. METHODS SAH was produced by injecting autologous arterial blood into the cisterna magna twice at 48-hour intervals in 30 dogs. The dogs were killed 3, 7, or 14 days after SAH, and then perfusion-fixed specimens of both anterior sylvian giri were obtained by using two methods. Microvascular corrosion casts produced by arterial injection of polyester resin were examined using scanning electron microscopy, and the widths of 40 arterioles of each animal were measured. Sectioned slices from the brain surface to 500 microns deep were examined by light microscopy, and external diameter, internal diameters, and wall thickness of the arterioles at depths of 50, 200, and 500 microns from the brain surface were morphometrically evaluated in 40 arterioles of each animal. In control animals receiving cisternal injections of mock cerebrospinal fluid (n = 10) and in healthy control animals (n = 10), the same examination and evaluation were performed. RESULTS Corrosion casts of arterioles showed tapered narrowing with folding after SAH, and the width of the arterioles significantly decreased 3 and 7 days after SAH (P < 0.01). Morphometric examination by light microscopy showed a significant decrease of internal diameter of arterioles associated with a significant increase of wall thickness at any depth from the brain surface 3 and 7 days after SAH (P < 0.05 or P < 0.01). These findings improved 14 days after SAH. Control animals receiving cisternal injections of mock cerebrospinal fluid showed no significant differences compared with healthy control animals. CONCLUSION These results suggest that constriction of intraparenchymal arterioles occurs after SAH and may contribute to delayed cerebral ischemia.
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Affiliation(s)
- H Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine, Japan
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Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Serial changes of hemostasis in aneurysmal subarachnoid hemorrhage with special reference to delayed ischemic neurological deficits. J Neurosurg 1997; 86:594-602. [PMID: 9120621 DOI: 10.3171/jns.1997.86.4.0594] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study was undertaken to elucidate comprehensively the serial changes occurring in hemostatic systems after aneurysmal subarachnoid hemorrhage (SAH) and thereby to ascertain whether the examination of the integrity of these systems is helpful in predicting delayed ischemic neurological deficits (DINDs). The authors examined 117 patients admitted to the hospital within 24 hours after onset of SAH. Blood samples were collected from each patient on Days 0 (at admission), 3, 6, 14, and 30. A number of hemostatic parameters were examined in these samples, and the relationships between their changes and DINDs were assessed. Eighteen (15.4%) of the patients exhibited DINDs, and their frequency increased as the severity of subarachnoid clotting increased. Also, the frequency of DINDs was significantly higher in the patients with hydrocephalus on initial computerized tomography (CT) scans than in those without hydrocephalus. Regarding the hemostatic parameters at admission, there was no significant difference between the patients with and without DINDs. On Day 3, however, the fibrinogen and D-dimer levels were higher in the patients with than in those without DINDs. The fibrinogen and thrombin-antithrombin complex levels on Day 6 and the D-dimer level on Day 14 in the patients with DINDs were higher than the corresponding levels in those without DINDs. Multivariate analyses revealed that the following variables (in order of importance) were independent predictors of DINDs: the levels of D-dimer on Day 3, fibrinogen on Day 6, and the presence of hydrocephalus on admission. These data indicate that the levels of hemostatic parameters in concert with the CT findings may enable us to predict the appearance of DINDs.
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Affiliation(s)
- Y Fujii
- Department of Neurosurgery, Niigata University, Japan
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Gaetani P, Tancioni F, Grignani G, Tartara F, Merlo EM, Brocchieri A, Rodriguez y Baena R. Platelet derived growth factor and subarachnoid haemorrhage: a study on cisternal cerebrospinal fluid. Acta Neurochir (Wien) 1997; 139:319-24. [PMID: 9202771 DOI: 10.1007/bf01808827] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Platelet derived growth factor (PDGF) was identified as a powerful mitogenic growth factor which is released from activated platelets and has a marked activity as vasoconstrictor agent. In the present study we have measured cisternal cerebrospinal fluid (CSF) levels of PDGF in 72 patients operated on for intracranial aneurysm in order to verify whether it might be related to the clinical aspects of SAH with special regard to symptomatic vasospasm. CSF samples were obtained at surgery by cisternal puncture of the subarachnoid cistern the nearest to the aneurysm before aneurysm isolation and exclusion. The specimen were frozen in liquid nitrogen and stored at -80 degrees C until analysis. PDGF was measured using a commercially available reagent. Values are expressed as pg/ml of CSF. In 18 cases no radiological and clinical signs of SAH were detected and the mean cisternal CSF level of PDGF was 885.0 +/- 104.5 pg/ml; 20 patients were operated on between day 1 and 3 from the last SAH episode: mean cisternal CSF level of PDGF was 1917.5 +/- 459.4 pg/ml. In 34 patients treated with delayed surgery protocol, mean cisternal CSF level of PDGF was 995.3 +/- 73.8 pg/ml. Statistical analysis showed significant differences between groups (P: 0.011). In the subgroup of patients operated on within day 3 after SAH, 6 presented vasospasm and had mean cisternal CSF PDGF level which was significantly higher (P < 0.01) than in 14 patients without vasospasm. In the delayed "surgical" patients there was no significant difference in cisternal CSF levels of PDGF considering the occurrence of vasospasm. The results of the present study suggest that (a) after SAH there is a significant release of PDGF early after SAH and (b) higher levels of PDGF found in cisternal CSF of patients operated on within 72 hours after SAH may be predictive of symptomatic vasospasm.
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Affiliation(s)
- P Gaetani
- Department of Surgery, Neurosurgery, IRCCS Policlinico S. Matteo, Italy
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Hirashima Y, Endo S, Kato R, Takaku A. Prevention of cerebrovasospasm following subarachnoid hemorrhage in rabbits by the platelet-activating factor antagonist, E5880. J Neurosurg 1996; 84:826-30. [PMID: 8622157 DOI: 10.3171/jns.1996.84.5.0826] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Recently, an important role of platelet-activating factor (PAF), an inflammation mediator, has been demonstrated in the genesis of cerebral vasospasm following subarachnoid hemorrhage (SAH). In the current study, the authors examined whether intravenous administration of the novel PAF antagonist, E5880, can prevent vasospasm following SAH in rabbits. A vasospasm model was produced in three groups of rabbits using two subarachnoid injections of autologous arterial blood, followed by intravenous administration of distilled water (control), a low dose of E5880 (0.1 mg/kg in distilled water), or a high dose of E5880 (0.5 mg/kg in distilled water). Neurological deterioration was largely prevented in the rabbits that received E5880. Basilar artery constriction was also reduced by both doses of E5880. Histological examination at autopsy predominantly showed ischemic changes in the brain. Animals in each E5880-treated group exhibited ischemic changes less frequently than those in the control group. Plasma thromboxane B2 concentrations were reduced in rabbits treated with E5880. Platelet-activating factor was immunolocalized in the intima and media of the basilar artery in the control group. The PAF immunoreactivity demonstrated in the basilar artery was decreased in the E5880 groups in a dose-dependent manner. Thus, this study provides evidence that PAF may play a role in the pathogenesis of vasospasm after SAH and that intravenous administration of E5880 is a promising approach in preventing vasospasm.
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Affiliation(s)
- Y Hirashima
- Department of Neurosurgery, Toyama Medical and Pharmaceutical University, Toyama-shi, Japan
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Hirashima Y, Kurimoto M, Tsukamoto E, Endo S, Takaku A. Anti-phospholipid antibodies and cerebral vasospasm following subarachnoid haemorrhage. Acta Neurochir (Wien) 1995; 135:191-7. [PMID: 8748813 DOI: 10.1007/bf02187767] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Delayed ischaemic deficits due to cerebral vasospasm contribute to the high morbidity and mortality rates associated with subarachnoid haemorrhage. We evaluated the usefulness of measuring anti-phospholipid antibodies (aPLs) for prediction of the occurrence of symptomatic vasospasm and the outcome after subarachnoid haemorrhage. 32 consecutive patients with subarachnoid haemorrhage due to ruptured cerebral aneurysms were studied. They were admitted and operated on within 72 hours after the onset of subarachnoid haemorrhage. aPLs such as lupus anticoagulants, anti-cardiolipin IgG and anti-cardiolipin IgM were measured repeatedly after admission. Furthermore, platelet count, platelet aggregability and plasma platelet factor 4 were also measured. Eleven among the 32 patients (34.4%) showed positive in the examination for aPLs. Although aPLs could not predict symptomatic vasospasm, once symptomatic vasospasm occurred, patients with aPLs frequently demonstrated cerebral infarction and therefore their outcome was worse. aPLs were associated with a severe initial clinical grade and SAH grade on CT scan. Therefore it may explain the association of aPLs with worse outcome. aPLs were detected between 1 and 7 days. Four of 6 patients (67%) with aPLs became negative between 7 and 13 days after subarachnoid haemorrhage. The mechanism of transient aPLs is unclear but it is more likely to occur in the severer grade patients. The reduction in platelet count, the increased platelet aggregability, and the increased plasma platelet factor 4 concentration were also observed in aPLs-positive patients with symptomatic vasospasm.
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Affiliation(s)
- Y Hirashima
- Department of Neurosurgery, Toyama Medical and Pharmaceutical University, Japan
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Wang DZ, Futrell N, Taylon C, Millikan C. Anticoagulation for prevention of cerebral infarcts following subarachnoid hemorrhage. SURGICAL NEUROLOGY 1995; 44:270-4. [PMID: 8545780 DOI: 10.1016/0090-3019(95)00142-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Late neurologic deterioration following subarachnoid hemorrhage is often due to vasospasm and rebleeding. Although the sudden onset of a focal neurologic deficit can actually be the result of thromboembolism, anticoagulation has rarely been used in such cases. METHODS We report a case of a 55-year-old woman who developed recurrent transient focal neurologic deficits 13 days after having a subarachnoid hemorrhage, with multiple cerebral infarcts by CT. Two cerebral angiograms showed no aneurysm. Her symptoms and clinical temporal profile were consistent with thromboembolic phenomenon. We elected to treat her with systemic anticoagulation. RESULTS The patient had no recurrent events after systemic anticoagulation, but had episodic sensory changes and a new infarct on MRI once the anticoagulation was discontinued. CONCLUSIONS Anticoagulant was safely administered after subarachnoid hemorrhage (SAH) in this patient and may have been effective in preventing further cerebral ischemic infarction following her SAH. Our patient's clinical profile of sudden (rather than gradual) onset of a transient focal neurologic deficit and resolution of blood on CT indicates one setting in which the use of heparin may be considered.
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Affiliation(s)
- D Z Wang
- Department of Neurology, Medical College of Ohio, Toledo 43614, USA
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Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Hemostasis in spontaneous subarachnoid hemorrhage. Neurosurgery 1995; 37:226-34. [PMID: 7477773 DOI: 10.1227/00006123-199508000-00006] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
To comprehensively examine changes in the hemostatic systems early after spontaneous subarachnoid hemorrhage (SAH) and to assess the relationships between those changes and neurological findings, computed tomographic findings, and clinical outcomes, we reviewed 167 patients who were admitted within 24 hours of the onset of SAH. Blood was taken from all of the patients at admission for detailed examinations of the hemostatic systems. The following results were obtained: 1) the levels of the thrombin-antithrombin complex (elevation indicating the activation fo the blood coagulation system), plasmin-antiplasmin complex, and D-dimer (elevation indicating the activation of the fibrinolytic system) significantly increased with the neurological severity, amount of subarachnoid clot, and severity of clinical outcome; 2) the levels of the thrombin-antithrombin complexes and plasmin-antiplasmin complexes were significantly higher in patients with intracerebral or intraventricular hematomas than in patients without those hematomas; 3) in each of almost all the neurological and computed tomographic grades, the levels of the thrombin-antithrombin complexes were significantly higher in the patients with poor outcomes than in those with good outcomes; 4) the poor outcome rate significantly increased with neurological severity and the amount of subarachnoid clot. These data suggest that the activation of the blood coagulation system as well as of the fibrinolytic system occurred early in the course of SAH and that these systems were activated to a greater extent with the severity of neurological grades, computed tomographic findings, and clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- Y Fujii
- Department of Neurosurgery, Kuwana Hospital, Niigata, Japan
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