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Julian N, Gaugain S, Labeyrie MA, Barthélémy R, Froelich S, Houdart E, Mebazaa A, Chousterman BG. Systemic tolerance of intravenous milrinone administration for cerebral vasospasm secondary to non-traumatic subarachnoid hemorrhage. J Crit Care 2024; 82:154807. [PMID: 38579430 DOI: 10.1016/j.jcrc.2024.154807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/18/2024] [Accepted: 03/27/2024] [Indexed: 04/07/2024]
Abstract
PURPOSE Delayed cerebral ischemia (DCI) is a severe subarachnoid hemorrhage (SAH) complication, closely related to cerebral vasospasm (CVS). CVS treatment frequently comprises intravenous milrinone, an inotropic and vasodilatory drug. Our objective is to describe milrinone's hemodynamic, respiratory and renal effects when administrated as treatment for CVS. METHODS Retrospective single-center observational study of patients receiving intravenous milrinone for CVS with systemic hemodynamics, oxygenation, renal disorders monitoring. We described these parameters' evolution before and after milrinone initiation (day - 1, baseline, day 1 and day 2), studied treatment cessation causes and assessed neurological outcome at 3-6 months. RESULTS Ninety-one patients were included. Milrinone initiation led to cardiac output increase (4.5 L/min [3.4-5.2] at baseline vs 6.6 L/min [5.2-7.7] at day 2, p < 0.001), Mean Arterial Pressure decrease (101 mmHg [94-110] at baseline vs 95 mmHg [85-102] at day 2, p = 0.001) norepinephrine treatment requirement increase (32% of patients before milrinone start vs 58% at day 1, p = 0.002) and slight PaO2/FiO2 ratio deterioration (401 [333-406] at baseline vs 348 [307-357] at day 2, p = 0.016). Milrinone was interrupted in 8% of patients. 55% had a favorable outcome. CONCLUSION Intravenous milrinone for CVS treatment seems associated with significant impact on systemic hemodynamics leading sometimes to treatment discontinuation.
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Affiliation(s)
- Nathan Julian
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France.
| | - Samuel Gaugain
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Marc-Antoine Labeyrie
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France
| | - Romain Barthélémy
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, University of Paris, France
| | - Emmanuel Houdart
- Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France
| | - Alexandre Mebazaa
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Benjamin G Chousterman
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
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Lu Z, Zhu S, Wu Y, Xu X, Li S, Huang Q. Circ_0008571 modulates the phenotype of vascular smooth muscle cells by targeting miR-145-5p in intracranial aneurysms. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167278. [PMID: 38834101 DOI: 10.1016/j.bbadis.2024.167278] [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: 10/30/2023] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND The dysfunction of human vascular smooth cells (hVSMCs) is significantly connected to the development of intracranial aneurysms (IAs). By suppressing the activity of microRNAs (miRNAs), circular RNAs (circRNAs) participate in IA pathogenesis. Nevertheless, the role of hsa_circ_0008571 in IAs remains unclear. METHODS circRNA sequencing was used to identify circRNAs from human IA tissues. To determine the function of circ_0008571, Transwell, wound healing, and cell proliferation assays were conducted. To identify the target of circ_0008571, the analyses of CircInteractome and TargetScan, as well as the luciferase assay were carried out. Furthermore, circ_0008571 knockdown and over-expression were performed to investigate its functions in IA development and the underlying molecular mechanisms. RESULTS Both hsa_circ_0008571 and Integrin beta 8 (ITGB8) were downregulated, while miR-145-5p transcription was elevated in the aneurysm wall of IAs patients compared to superficial temporal artery tissues. In vitro, cell migration and growth were dramatically suppressed after hsa_circ_0008571 overexpression. Mechanistically, has_circ_0008571 could suppress miR-145-5p activity by direct sponging. Moreover, we found that ITGB8 expression and the activation of the TGF-β-mediated signaling pathway were significantly enhanced. CONCLUSION The hsa_circ_0008571-miR-145-5p-ITGB8 axis plays an essential role in IA progression.
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Affiliation(s)
- Zhiwen Lu
- Department of Neurovascular Centre, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Department of Neurosurgery, Naval Medical Center, The PLA Naval Medical University, Shanghai 200052, China
| | - Shijie Zhu
- Department of Neurovascular Centre, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yina Wu
- Department of Neurovascular Centre, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Xiaolong Xu
- Department of Neurovascular Centre, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Siqi Li
- Department of Neurovascular Centre, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Qinghai Huang
- Department of Neurovascular Centre, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
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Szabo V, Baccialone S, Kucharczak F, Dargazanli C, Garnier O, Pavillard F, Molinari N, Costalat V, Perrigault PF, Chalard K. CT perfusion-guided administration of IV milrinone is associated with a reduction in delayed cerebral infarction after subarachnoid hemorrhage. Sci Rep 2024; 14:14856. [PMID: 38937568 PMCID: PMC11211472 DOI: 10.1038/s41598-024-65706-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 06/24/2024] [Indexed: 06/29/2024] Open
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a singular pathological entity necessitating early diagnostic approaches and both prophylactic and curative interventions. This retrospective before-after study investigates the effects of a management strategy integrating perfusion computed tomography (CTP), vigilant clinical monitoring and standardized systemic administration of milrinone on the occurrence of delayed cerebral infarction (DCIn). The "before" period included 277 patients, and the "after" one 453. There was a higher prevalence of Modified Fisher score III/IV and more frequent diagnosis of vasospasm in the "after" period. Conversely, the occurrence of DCIn was reduced with the "after" management strategy (adjusted OR 0.48, 95% CI [0.26; 0.84]). Notably, delayed ischemic neurologic deficits were less prevalent at the time of vasospasm diagnosis (24 vs 11%, p = 0.001 ), suggesting that CTP facilitated early detection. In patients diagnosed with vasospasm, intravenous milrinone was more frequently administered (80 vs 54%, p < 0.001 ) and associated with superior hemodynamics. The present study from a large cohort of aSAH patients suggests, for one part, the interest of CTP in early diagnosis of vasospasm and DCI, and for the other the efficacy of CT perfusion-guided systemic administration of milrinone in both preventing and treating DCIn.
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Affiliation(s)
- Vivien Szabo
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France
| | - Sarah Baccialone
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Florentin Kucharczak
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), Nîmes University Hospital Center, Univ. Montpellier, Nimes, France
- Department of Nuclear Medicine, Gui de Chauliac University Hospital of Montpellier, University of Montpellier, Montpellier, France
| | - Cyril Dargazanli
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Oceane Garnier
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Frederique Pavillard
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Nicolas Molinari
- Epidemiology and Clinical Research Department, University Hospital of Montpellier, Montpellier, France
- IMAG, Univ Montpellier, CNRS, CHU Montpellier, Montpellier, France
| | - Vincent Costalat
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Pierre-Francois Perrigault
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Kevin Chalard
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France.
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France.
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Fu Q, Wang Y, Yan C, Xiang YK. Phosphodiesterase in heart and vessels: from physiology to diseases. Physiol Rev 2024; 104:765-834. [PMID: 37971403 PMCID: PMC11281825 DOI: 10.1152/physrev.00015.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/17/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
Phosphodiesterases (PDEs) are a superfamily of enzymes that hydrolyze cyclic nucleotides, including cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Both cyclic nucleotides are critical secondary messengers in the neurohormonal regulation in the cardiovascular system. PDEs precisely control spatiotemporal subcellular distribution of cyclic nucleotides in a cell- and tissue-specific manner, playing critical roles in physiological responses to hormone stimulation in the heart and vessels. Dysregulation of PDEs has been linked to the development of several cardiovascular diseases, such as hypertension, aneurysm, atherosclerosis, arrhythmia, and heart failure. Targeting these enzymes has been proven effective in treating cardiovascular diseases and is an attractive and promising strategy for the development of new drugs. In this review, we discuss the current understanding of the complex regulation of PDE isoforms in cardiovascular function, highlighting the divergent and even opposing roles of PDE isoforms in different pathogenesis.
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Affiliation(s)
- Qin Fu
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- The Key Laboratory for Drug Target Research and Pharmacodynamic Evaluation of Hubei Province, Wuhan, China
| | - Ying Wang
- Department of Pharmacology, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Chen Yan
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York, United States
| | - Yang K Xiang
- Department of Pharmacology, University of California at Davis, Davis, California, United States
- Department of Veterans Affairs Northern California Healthcare System, Mather, California, United States
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5
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Vandenbulcke A, Messerer M, Garvayo Navarro M, Peters DR, Starnoni D, Giammattei L, Ben-Hamouda N, Puccinelli F, Saliou G, Cossu G, Daniel RT. Cisternal nicardipine for prevention of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a comparative retrospective cohort study. Acta Neurochir (Wien) 2024; 166:133. [PMID: 38472426 DOI: 10.1007/s00701-024-06023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile. METHODS We performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group). RESULTS Seventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group. CONCLUSION Administration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Marta Garvayo Navarro
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - David R Peters
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Lorenzo Giammattei
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland.
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Sorrentino ZA, Lucke-Wold BP, Laurent D, Quintin SS, Hoh BL. Interventional Treatment of Symptomatic Vasospasm in the Setting of Traumatic Brain Injury: A Systematic Review of Reported Cases. World Neurosurg 2024; 183:45-55. [PMID: 38043741 DOI: 10.1016/j.wneu.2023.11.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies.
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Affiliation(s)
- Zachary A Sorrentino
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Brandon P Lucke-Wold
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dimitri Laurent
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Stephan S Quintin
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brian L Hoh
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Robert-Edan V, Lakhal K. Treating Vasospasm with IV Milrinone: Relax (The Vessel) or Don't Do It! Neurocrit Care 2023; 39:547-548. [PMID: 37434104 DOI: 10.1007/s12028-023-01789-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France
| | - Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France.
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Kotwal A, Ramalingaiah AH, Shukla D, Radhakrishnan M, Konar SK, Srinivasaiah B, Chakrabarti D, Sundaram M. Role of Nimodipine and Milrinone in Delayed Cerebral Ischemia. World Neurosurg 2022; 166:e285-e293. [PMID: 35843579 DOI: 10.1016/j.wneu.2022.06.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The role of nimodipine and milrinone in the management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) was studied using clinical and TCD (transcranial Doppler) parameters. METHODS In this prospective observational study, patients with DCI after aneurysmal SAH presenting between November 2020 and June 2021 who were treated by either intra-arterial nimodipine (IAN) or intravenous milrinone (IVM) were included after excluding patients in whom both IAN and IVM had been given or mechanical angioplasty was performed. Twelve-hourly TCD was performed during the course of the therapy. Clinical improvement and the development of new brain infarcts were also assessed. A P value <0.05 was considered statistically significant. RESULTS Thirty-four patients fulfilled the inclusion criteria (IVM, 13/34 [38%]; IAN, 21/34 [62%]); patients in the IVM group (vs. IAN group) had poorer median Glasgow Coma Scale score (12 vs. 13), poorer motor response (<M6 response, 5/13 [38%] vs. 5/21 [24%]; P = 0.36) and higher grades (modified Fisher grade ≥3) of SAH (12/13 [92%] vs. 8/21 [86%]; P = 0.56). More patients in the IAN group (vs. IVM group) showed clinical improvement (17/21 [81%] vs. 10/13 [77%]; P = 0.77), development of new infarcts (15/21 [71%] vs. 7/13 [54%]; P = 0.29] and discharged to home (13/21 [62%] vs. 6/13 [46%]; P = 0.36) with less mortality (1/21 [9%] vs. 4/13 [23%]; P = 0.037). On TCD analysis, both IAN and IVM protocols showed similar effects in middle cerebral artery vasospasm; however, IAN proved better over time. In group-effect analysis, the IAN protocol was significantly better in anterior cerebral artery and posterior cerebral artery vasospasm compared with IVM protocol. CONCLUSIONS In this single-center small study, patients in the IAN group had significantly less mortality compared with the IVM group in the management of DCI after aneurysmal SAH.
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Affiliation(s)
- Abhishek Kotwal
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Arvinda Hanumanthapura Ramalingaiah
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India.
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Muthuchellappan Radhakrishnan
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Subhas Kanti Konar
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Bharath Srinivasaiah
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Mouleeswaran Sundaram
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
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11
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Delora A, Ezzeldin R, Alderazi Y, Le D, Ezzeldin M. A Rare Case of Cerebral Vasospasm Secondary to Primary Intraventricular Hemorrhage With an Immediate Improvement in Neurological Status Following Intra-arterial Therapy. Cureus 2022; 14:e25697. [PMID: 35812538 PMCID: PMC9270074 DOI: 10.7759/cureus.25697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/18/2022] Open
Abstract
Symptomatic vasospasm following aneurysmal subarachnoid hemorrhage (SAH) occurs in roughly 30% of cases. However, vasospasm after primary intraventricular hemorrhage (IVH) is rare and described in only a handful of case reports and small retrospective studies. We present a patient with primary IVH. A conventional cerebral angiogram ruled out vascular anomalies but demonstrated severe diffuse cerebral vasospasm. The patient was treated with intra-arterial vasodilators, resulting in an immediate and profound improvement in the patient’s neurological examination. Several days later, the patient had another decline in neurological status that immediately resolved after treatment with intra-arterial therapy. To our knowledge, this is the first reported case of a profound and immediate improvement in neurological examination following intra-arterial vasodilator administration.
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12
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Baulier C, Lessert M, Chauvet JL, Garel P, Bergis A, Burdeau J, Clavier T. Left Ventricular Outflow Tract Obstruction in Patients Treated With Milrinone for Cerebral Vasospasm: Case Report and Literature Review. JMIRX MED 2022; 3:e31019. [PMID: 37463041 PMCID: PMC10337478 DOI: 10.2196/31019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/05/2021] [Accepted: 01/27/2022] [Indexed: 07/20/2023]
Abstract
Subarachnoid hemorrhage is associated with high morbidity and mortality, and cerebral arterial vasospasm is one of its main complications that determines neurological prognosis. The use of intravenous milrinone is becoming more common in the treatment of vasospasm. This molecule has positive inotropic and vasodilating properties by inhibiting phosphodiesterase-3. Its most described side effects are cardiac arrhythmias and arterial hypotension. In this paper, we raise a new issue concerning milrinone and discuss an undescribed side effect of this treatment, left ventricular outflow tract obstruction (LVOTO). Dynamic LVOTO is a clinical situation favored by hypovolemia, decreased left ventricular afterload, and excessive inotropism that can lead to severe hemodynamic failure and pulmonary edema. To our knowledge, this is the first study describing milrinone-induced LVOTO. This could compromise cerebral perfusion and therefore the neurological prognosis of patients. While it is known that catecholamines may induce LVOTO, milrinone-induced LVOTO appears to be a new pathophysiological entity of which neurosurgical intensivists should be aware.
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Affiliation(s)
- Charles Baulier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Marc Lessert
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | | | - Pauline Garel
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Alexandre Bergis
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Julie Burdeau
- Cardiology Department Rouen University Hospital Rouen France
| | - Thomas Clavier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
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13
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Steiger HJ, Ensner R, Andereggen L, Remonda L, Berberat J, Marbacher S. Hemodynamic response and clinical outcome following intravenous milrinone plus norepinephrine-based hyperdynamic hypertensive therapy in patients suffering secondary cerebral ischemia after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:811-821. [PMID: 35138488 PMCID: PMC8913475 DOI: 10.1007/s00701-022-05145-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/29/2022] [Indexed: 12/12/2022]
Abstract
Purpose Intravenous and intra-arterial milrinone as a rescue measure for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) has been adopted by several groups, but so far, evidence for the clinical benefit is unclear and effect on brain perfusion is unknown. The aim of the actual analysis was to define cerebral hemodynamic effects and outcome of intravenous milrinone plus norepinephrine supplemented by intra-arterial nimodipine as a rescue strategy for DCI following aneurysmal SAH. Methods Of 176 patients with aneurysmal SAH treated at our neurosurgical department between April 2016 and March 2021, 98 suffered from DCI and were submitted to rescue therapy. For the current analysis, characteristics of these patients and clinical response to rescue therapy were correlated with hemodynamic parameters, as assessed by CT angiography (CTA) and perfusion CT. Time to peak (TTP) delay in the ischemic focus and the volume with a TTP delay of more than 4 s (T4 volume) were used as hemodynamic parameters. Results The median delay to neurological deterioration following SAH was 5 days. Perfusion CT at that time showed median T4 volumes of 40 cc and mean focal TTP delays of 2.5 ± 2.1 s in these patients. Following rescue therapy, median T4 volume decreased to 10 cc and mean focal TTP delay to 1.7 ± 1.9 s. Seventeen patients (17% of patients with DCI) underwent additional intra-arterial spasmolysis using nimodipine. Visible resolution of macroscopic vasospasm on CTA was observed in 43% patients with DCI and verified vasospasm on CTA, including those managed with additional intra-arterial spasmolysis. Initial WFNS grade, occurrence of secondary infarction, ischemic volumes and TTP delays at the time of decline, the time to clinical decline, and the necessity for additional intra-arterial spasmolysis were identified as the most important features determining neurological outcome at 6 months. Conclusion The current analysis shows that cerebral perfusion in the setting of secondary cerebral ischemia following SAH is measurably improved by milrinone and norepinephrine–based hyperdynamic therapy. A long-term clinical benefit by the addition of milrinone appears likely. Separation of the direct effect of milrinone from the effect of induced hypertension is not possible based on the present dataset.
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Affiliation(s)
- Hans-Jakob Steiger
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland.
- Klinik Für Neurochirurgie, Neurozentrum, Kantonsspital Aarau, Tellstr. 25, CH-5001, Aarau, Switzerland.
| | - Rolf Ensner
- Surgical Intensive Care Unit, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Jatta Berberat
- Division of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland
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14
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Balança B, Bouchier B, Ritzenthaler T. The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Rev Neurol (Paris) 2021; 178:64-73. [PMID: 34961603 DOI: 10.1016/j.neurol.2021.11.006] [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: 05/02/2021] [Revised: 10/20/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a rare event affecting relatively young patients therefore leading to a high social impact. The management of SAH follows a biphasic course with early brain injuries in the first 72 hours followed by a phase at risk of secondary deterioration due to delayed cerebral ischemia (DCI) in 20 to 30% patients. Cerebral infarction from DCI is the most preventable cause of mortality and morbidity after SAH. DCI prevention, early detection and treatment is therefore advocated. Formerly limited to the occurrence of vasospasm, DCI is now associated with multiple pathophysiological processes involving for instance the macrocirculation, the microcirculation, neurovascular units, and inflammation. Therefore, the therapeutic targets and management strategies are also evolving and are not only focused on proximal vasospasm. In this review, we describe the current knowledge of DCI pathophysiology. We then discuss the diagnosis strategies that may guide physicians at the bedside with a multimodal approach in the unconscious patient. We will present the prevention strategies that have proven efficient as well as future targets and present the therapeutic approach that is currently being developed when a DCI occurs.
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Affiliation(s)
- B Balança
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France; Équipe TIGER, U1028, UMR5292, centre de recherche en neurosciences de Lyon, université de Lyon, 69500 Bron, France.
| | - B Bouchier
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France
| | - T Ritzenthaler
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France; InserMU1044, INSA-Lyon, CNRS UMR5220, Université Lyon 1, hospices civils de Lyon, université de Lyon CREATIS, Bron cedex, France
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15
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Luo Y, Tang H, Zhang Z, Zhao R, Wang C, Hou W, Huang Q, Liu J. Pharmacological inhibition of epidermal growth factor receptor attenuates intracranial aneurysm formation by modulating the phenotype of vascular smooth muscle cells. CNS Neurosci Ther 2021; 28:64-76. [PMID: 34729926 PMCID: PMC8673708 DOI: 10.1111/cns.13735] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 12/15/2022] Open
Abstract
Aim To study the effect of pharmacological inhibition of epidermal growth factor receptor (EGFR) on intracranial aneurysm (IA) initiation. Methods Human IA samples were analyzed for the expression of p‐EGFR and alpha smooth muscle actin (α‐SMA) by immunofluorescence (IF). Rat models of IA were established to evaluate the ability of the EGFR inhibitor, erlotinib, to attenuate the incidence of IA. We analyzed anterior cerebral artery tissues by pathological and proteomic detection for the expression of p‐EGFR and relevant proteins, and vessel casting was used to evaluate the incidence of aneurysms in each group. Rat vascular smooth muscle cells (VSMCs) and endothelial cells were extracted and used to establish an in vitro co‐culture model in a flow chamber with or without erlotinib treatment. We determined p‐EGFR and relevant protein expression in VSMCs by immunoblotting analysis. Results Epidermal growth factor receptor activation was found in human IA vessel walls and rat anterior cerebral artery walls. Treatment with erlotinib markedly attenuated the incidence of IA by inhibiting vascular remodeling and pro‐inflammatory transformation of VSMC in rat IA vessel walls. Activation of EGFR in rat VSMCs and phenotypic modulation of rat VSMCs were correlated with the strength of shear stress in vitro, and treatment with erlotinib reduced phenotypic modulation of rat VSMCs. In vitro experiments also revealed that EGFR activation could be induced by TNF‐α in human brain VSMCs. Conclusions These results suggest that EGFR plays a critical role in the initiation of IA and that the EGFR inhibitor erlotinib protects rats from IA initiation by regulating phenotypic modulation of VSMCs.
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Affiliation(s)
- Yin Luo
- Department of Biomedical Engineering, School of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China.,Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhaolong Zhang
- Department of Neurology, Strategic Support Force Medical Center of PLA, Beijing, China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chuanchuan Wang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wenguang Hou
- Department of Biomedical Engineering, School of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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16
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Lakhal K, Hivert A, Alexandre PL, Fresco M, Robert-Edan V, Rodie-Talbere PA, Ambrosi X, Bourcier R, Rozec B, Cadiet J. Intravenous Milrinone for Cerebral Vasospasm in Subarachnoid Hemorrhage: The MILRISPASM Controlled Before-After Study. Neurocrit Care 2021; 35:669-679. [PMID: 34478028 DOI: 10.1007/s12028-021-01331-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intravenous (IV) milrinone, in combination with induced hypertension, has been proposed as a treatment option for cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, data on its safety and efficacy are scarce. METHODS This was a controlled observational study conducted in an academic hospital with prospectively and retrospectively collected data. Consecutive patients with cerebral vasospasm following aSAH and treated with both IV milrinone (0.5 µg/kg/min-1, as part of a strict protocol) and induced hypertension were compared with a historical control group receiving hypertension alone. Multivariable analyses aimed at minimizing potential biases. We assessed (1) 6-month functional disability (defined as a score between 2 and 6 on the modified Rankin Scale) and vasospasm-related brain infarction, (2) the rate of first-line or rescue endovascular angioplasty for vasospasm, and (3) immediate tolerance to IV milrinone. RESULTS Ninety-four patients were included (41 and 53 in the IV milrinone and the control group, respectively). IV milrinone infusion was independently associated with a lower likelihood of 6-month functional disability (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.10-0.77]) and vasospasm-related brain infarction (aOR = 0.19, 95% CI 0.04-0.94). Endovascular angioplasty was less frequent in the IV milrinone group (6 [15%] vs. 28 [53%] patients, p = 0.0001, aOR = 0.12, 95% CI 0.04-0.38). IV milrinone (median duration of infusion, 5 [2-8] days) was prematurely discontinued owing to poor tolerance in 12 patients, mostly (n = 10) for "non/hardly-attained induced hypertension" (mean arterial blood pressure < 100 mmHg despite 1.5 µg/kg/min-1 of norepinephrine). However, this event was similarly observed in IV milrinone and control patients (n = 10 [24%] vs. n = 11 [21%], respectively, p = 0.68). IV milrinone was associated with a higher incidence of polyuria (IV milrinone patients had creatinine clearance of 191 [153-238] ml/min-1) and hyponatremia or hypokalemia, whereas arrhythmia, myocardial ischemia, and thrombocytopenia were infrequent. CONCLUSIONS Despite its premature discontinuation in 29% of patients as a result of its poor tolerance, IV milrinone was associated with a lower rate of endovascular angioplasty and a positive impact on long-term neurological and radiological outcomes. These preliminary findings encourage the conduction of confirmatory randomized trials.
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Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.
| | - Antoine Hivert
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-Louis Alexandre
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Marion Fresco
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-André Rodie-Talbere
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Xavier Ambrosi
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Julien Cadiet
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
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17
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Bernier TD, Schontz MJ, Izzy S, Chung DY, Nelson SE, Leslie-Mazwi TM, Henderson GV, Dasenbrock H, Patel N, Aziz-Sultan MA, Feske S, Du R, Abulhasan YB, Angle MR. Treatment of Subarachnoid Hemorrhage-associated Delayed Cerebral Ischemia With Milrinone: A Review and Proposal. J Neurosurg Anesthesiol 2021; 33:195-202. [PMID: 33480639 PMCID: PMC8192346 DOI: 10.1097/ana.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022]
Abstract
Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multifactorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single-center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multicenter, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.
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Affiliation(s)
- Thomas D. Bernier
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David Y. Chung
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah E. Nelson
- Departments of Neurology and Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thabele M. Leslie-Mazwi
- Harvard Medical School, Boston, MA, USA
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Galen V. Henderson
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Hormuzdiyar Dasenbrock
- Department of Neurosurgery, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Nirav Patel
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mohammad Ali Aziz-Sultan
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven Feske
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rose Du
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Yasser B. Abulhasan
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait
| | - Mark R. Angle
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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18
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Shoskes A, Mullaguri N, Purohit M, George P, Newey CR. Ipsilateral Reversible Cerebral Vasculopathy Secondary to Carotid Artery Revascularization: A Case Report. Neurohospitalist 2021; 11:165-169. [PMID: 33791063 DOI: 10.1177/1941874420966850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The emergence of neurologic symptoms after carotid revascularization is not uncommon and typically caused by perioperative ischemic stroke or hyperperfusion. Postoperative vasculopathy, including reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication of carotid intervention and may be an under-identified cause of neurologic deficit after revascularization. We report a case of reversible postoperative vasculopathy following carotid revascularization as well as its management. Case Presentation A 74 year old right-handed woman presented to the emergency department with sudden onset left arm weakness and episodic shaking while hypotensive. Computed tomography angiography revealed total occlusion of her right internal carotid artery. Transcranial Doppler monitoring demonstrated active embolic events in her right middle cerebral artery raising concern for continued stump embolization. She underwent carotid revascularization with carotid endarterectomy, mechanical thrombectomy, and carotid angioplasty and initially did well postoperatively. On postoperative day 5, she developed a fixed right gaze and left hemiparesis. Computed tomography revealed new right frontal lobe and basal ganglia infarcts, and angiography showed new right internal carotid, middle cerebral, and anterior cerebral artery vasoconstriction consistent with postoperative vasculopathy. Despite treatment with pressure augmentation and vasodilator therapy, her symptoms persisted resulting in left hemiplegia at discharge. Discussion This case highlights postoperative vasculopathy (including RCVS) as a rare potential complication after carotid revascularization that should be considered in a patient with persistent acute neurologic symptoms. Information regarding incidence and predisposing risk factors is limited. Multiple diagnostic and therapeutic modalities may be necessary in the recognition and treatment of postoperative vasculopathy.
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Affiliation(s)
- Aaron Shoskes
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Naresh Mullaguri
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Meghan Purohit
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Pravin George
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christopher Ryan Newey
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Epilepsy Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Chalard K, Szabo V, Pavillard F, Djanikian F, Dargazanli C, Molinari N, Manna F, Costalat V, Chanques G, Perrigault PF. Long-term outcome in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation. PLoS One 2021; 16:e0247942. [PMID: 33711023 PMCID: PMC7954305 DOI: 10.1371/journal.pone.0247942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients affected with aneurysmal subarachnoid hemorrhage (aSAH) often require intensive care, and then present distinctive outcome from less severe patients. We aimed to specify their long-term outcome and to identify factors associated with poor outcome. METHODS We conducted a retrospective study in a French university hospital intensive care unit. Patients with aSAH requiring mechanical ventilation hospitalized between 2010 and 2015 were included. At least one year after initial bleeding, survival and degree of disability were assessed using the modified Rankin Scale (mRS) via telephone interviews. A multivariable logistic regression analysis was performed to determine independent factors associated with poor outcome defined as mRS≥3. RESULTS Two-hundred thirty-six patients were included. Among them, 7 were lost to follow-up, and 229 were analyzed: 73 patients (32%) had a good outcome (mRS<3), and 156 (68%) had a poor outcome (mRS≥3). The estimated 1-year survival rate was 63%. One-hundred sixty-three patients patients (71%) suffered from early brain injuries (EBI), 33 (14%) from rebleeding, 80 (35%) from vasospasm and 63 (27%) from delayed cerebral ischemia (DCI). Multivariable logistic regression identified independent factors associated with poor outcome including delay between aSAH diagnosis and mRS assessment (OR, 0.96; 95% CI, 0.95-0.98; p<.0001), age (OR per 10 points, 1.57; 95% CI, 1.12-2.19; p = 0.008), WFNS V versus WFNS III (OR, 5.71; 95% CI 1.51-21.61; p = 0.004), subarachnoid rebleeding (OR, 6.47; 95% CI 1.16-36.06; p = 0.033), EBI (OR, 4.52; 95% CI 1.81-11.29; p = 0.001) and DCI (OR, 4.73; 95% CI, 1.66-13.49; p = 0.004). CONCLUSION Among aSAH patients requiring assisted ventilation, two-third of them survived at one year, and one-third showed good long-term outcome. As it appears as an independant factor associated with poor outcome, DCI shoud retain particular attention in future studies beyond angiographic vasospasm.
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Affiliation(s)
- Kevin Chalard
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, Inserm, Montpellier, France
- * E-mail:
| | - Vivien Szabo
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, Inserm, Montpellier, France
| | - Frederique Pavillard
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Flora Djanikian
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Federico Manna
- Epidemiology and Clinical Research Department, University Hospital of Montpellier, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Gerald Chanques
- Department of Critical Care Medicine and Anesthesiology (DAR B), Saint Eloi University Hospital of Montpellier and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Pierre-Francois Perrigault
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
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Intravenous milrinone for treatment of delayed cerebral ischaemia following subarachnoid haemorrhage: a pooled systematic review. Neurosurg Rev 2021; 44:3107-3124. [PMID: 33682040 DOI: 10.1007/s10143-021-01509-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
Small trials have demonstrated promising results utilising intravenous milrinone for the treatment of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Here we summarise and contextualise the literature and discuss the future directions of intravenous milrinone for DCI. A systematic, pooled analysis of literature was performed in accordance with the PRISMA statement. Methodological rigour was analysed using the MINORS criteria. Extracted data included patient population; treatment protocol; and clinical, radiological, and functional outcome. The primary outcome was clinical resolution of DCI. Eight hundred eighteen patients from 10 single-centre, observational studies were identified. Half (n = 5) of the studies were prospective and all were at high risk of bias. Mean age was 52 years, and females (69%) outnumbered males. There was a similar proportion of low-grade (WFNS 1-2) (49.7%) and high-grade (WFNS 3-5) (50.3%) SAH. Intravenous milrinone was administered to 523/818 (63.9%) participants. Clinical resolution of DCI was achieved in 375/424 (88%), with similar rates demonstrated with intravenous (291/330, 88%) and combined intra-arterial-intravenous (84/94, 89%) therapy. Angiographic response was seen in 165/234 (71%) receiving intravenous milrinone. Hypotension (70/303, 23%) and hypokalaemia (31/287, 11%) were common drug effects. Four cases (0.5%) of drug intolerance occurred. Good functional outcome was achieved in 271/364 (74%) patients. Cerebral infarction attributable to DCI occurred in 47/250 (19%), with lower rates in asymptomatic spasm. Intravenous milrinone is a safe and feasible therapy for DCI. A signal for efficacy is demonstrated in small, low-quality trials. Future research should endeavour to establish the optimal protocol and dose, prior to a phase-3 study.
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Chan AY, Choi EH, Yuki I, Suzuki S, Golshani K, Chen JW, Hsu FP. Cerebral vasospasm after subarachnoid hemorrhage: Developing treatments. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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22
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Velayutham SS, Abhishek BR, Jeyaraj KM, Sowmini PR, Kumar MS, Sarvanan SV, Mugundhan K. Thrombolysis in ischemic stroke after bee sting: A rare scenario. Ann Indian Acad Neurol 2021; 24:985-986. [PMID: 35359526 PMCID: PMC8965970 DOI: 10.4103/aian.aian_770_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 11/04/2022] Open
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Duggal S, Khurana P, Ganjoo P, Das N. Anesthetic Challenges in the Management of Intracranial Aneurysm Clipping in a Patient with Hypertrophic Cardiomyopathy. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1716425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractAneurysmal surgeries are high-risk procedures due to potential for occurrence of fatal perioperative complications. This risk is exaggerated in the presence of co-existing hypertrophic cardiomyopathy (HCM). It involves asymmetrical hypertrophy of left ventricle with mitral valve dysfunction, leading to left ventricular outflow tract obstruction. Various perioperative factors may precipitate this obstruction resulting in life-threatening consequences. We report the management of a patient with HCM undergoing anterior communicating artery aneurysm clipping and discuss the anesthetic concerns. Comprehensive approach with careful drug selection, vigilant monitoring, and preparedness for complications enabled patient safety and a good neurological outcome.
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Affiliation(s)
- Sakshi Duggal
- Department of Anaesthesiology and Intensive Care, G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Priyanka Khurana
- Department of Anaesthesiology and Intensive Care, Neuroanaesthesia Unit, G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Pragati Ganjoo
- Department of Anaesthesiology and Intensive Care, G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Nilima Das
- Department of Anaesthesiology and Intensive Care, G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Wendel C, Scheibe R, Wagner S, Tangemann W, Henkes H, Ganslandt O, Schiff JH. Decrease of blood flow velocity in the middle cerebral artery after stellate ganglion block following aneurysmal subarachnoid hemorrhage: a potential vasospasm treatment? J Neurosurg 2020; 133:773-779. [PMID: 31398704 DOI: 10.3171/2019.5.jns182890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral vasospasm (CV) is a delayed, sustained contraction of the cerebral arteries that tends to occur 3-14 days after aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured aneurysm. Vasospasm potentially leads to delayed cerebral ischemia, and despite medical treatment, 1 of 3 patients suffer a persistent neurological deficit. Bedside transcranial Doppler (TCD) ultrasonography is used to indirectly detect CV through recognition of an increase in cerebral blood flow velocity (CBFV). The present study aimed to use TCD ultrasonography to monitor how CBFV changes on both the ipsi- and contralateral sides of the brain in the first 24 hours after patients have received a stellate ganglion block (SGB) to treat CV that persists despite maximum standard therapy. METHODS The data were culled from records of patients treated between 2013 and 2017. Patients were included if an SGB was administered following aSAH, whose CBFV was ≥ 120 cm/sec and who had either a focal neurological deficit or reduced consciousness despite having received medical treatment and blood pressure management. The SGB was performed on the side where the highest CBFV had been recorded with 8-10 ml ropivacaine 0.2%. The patient's CBFV was reassessed after 2 and 24 hours. RESULTS Thirty-seven patients (male/female ratio 18:19), age 17-70 years (mean age 49.9 ± 11.1), who harbored 13 clipped and 22 coiled aneurysms (1 patient received both a coil and a clip, and 3 patients had 3 untreated aneurysms) had at least one SGB. Patients received up to 4 SGBs, and thus the study comprised a total of 76 SGBs.After the first SGB, CBFV decreased in 80.5% of patients after 2 hours, from a mean of 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001), and it further decreased in 63.4% after 24 hours to 137.2 ± 38.2 cm/sec (p = 0.007). A similar significant effect was found for the subsequent SGB. Adding clonidine showed no significant effect on either the onset or the duration of the SGB. Contralateral middle cerebral artery (MCA) blood flow was not reduced by the SGB. CONCLUSIONS To the authors' knowledge, this is the largest study on the effects of administering an SGB to aSAH patients after aneurysm rupture. The data showed a significant reduction in ipsilateral CBFV (MCA 20.5%) after SGB, lasting in about two-thirds of cases for over 24 hours with no major complications resulting from the SGB.
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Affiliation(s)
| | - Ricardo Scheibe
- 2Department of Anesthesiology and Intensive Care Medicine, Klinikum Stuttgart, Germany
- 3Department of Anesthesiology, Kantonsspital Münsterlingen, Switzerland
| | - Sören Wagner
- 2Department of Anesthesiology and Intensive Care Medicine, Klinikum Stuttgart, Germany
| | - Wiebke Tangemann
- 2Department of Anesthesiology and Intensive Care Medicine, Klinikum Stuttgart, Germany
- 4University of Heidelberg
| | - Hans Henkes
- 5Neuroradiological Clinic, Klinikum Stuttgart; and
| | | | - Jan-Henrik Schiff
- 2Department of Anesthesiology and Intensive Care Medicine, Klinikum Stuttgart, Germany
- 6Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Germany
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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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Abulhasan YB, Ortiz Jimenez J, Teitelbaum J, Simoneau G, Angle MR. Milrinone for refractory cerebral vasospasm with delayed cerebral ischemia. J Neurosurg 2020; 134:971-982. [PMID: 32217799 DOI: 10.3171/2020.1.jns193107] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intravenous (IV) milrinone is a promising option for the treatment of cerebral vasospasm with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). However, data remain limited on the efficacy of treating cases that are refractory to standard therapy with IV milrinone. The aim of this study was to determine predictors of refractory vasospasm/DCI despite treatment with IV milrinone, and to analyze the outcome of rescue therapy with intraarterial (IA) milrinone and/or mechanical angioplasty. METHODS The authors conducted a retrospective cohort study of all patients with aSAH admitted between 2010 and 2016 to the Montreal Neurological Institute and Hospital. Patients were stratified into 3 groups: no DCI, standard therapy, and rescue therapy. The primary outcome was frequency of DCI-related cerebral infarction identified on neuroimaging before hospital discharge. Secondary outcomes included functional outcome reported as modified Rankin Scale (mRS) score, and segment reversal of refractory vasospasm. RESULTS The cohort included 322 patients: 212 in the no DCI group, 89 in the standard therapy group, and 21 in the rescue therapy group. Approximately half (52%, 168/322) were admitted with poor-grade aSAH at treatment decision (World Federation of Neurosurgical Societies grade III-V). Among patients with DCI and imaging assessing severity of vasospasm, 62% (68/109) had moderate/severe radiological vasospasm on DCI presentation. Nineteen percent (21/110) of patients had refractory vasospasm/DCI and were treated with rescue therapy. Targeted rescue therapy with IA milrinone reversed 32% (29/91) of the refractory vasospastic vessels, and 76% (16/21) of those patients experienced significant improvement in their neurological status within 24 hours of initiating therapy. Moderate/severe radiological vasospasm independently predicted the need for rescue therapy (OR 27, 95% CI 8.01-112). Of patients with neuroimaging before discharge, 40% (112/277) had developed new cerebral infarcts, and only 21% (23/112) of these were vasospasm-related. Overall, 65% (204/314) of patients had a favorable functional outcome (mRS score 0-2) assessed at a median of 4 months (interquartile range 2-8 months) after aSAH, and there was no difference in functional outcome between the 3 groups (p = 0.512). CONCLUSIONS The aggressive use of milrinone was safe and effective based on this retrospective study cohort and is a promising therapy for the treatment of vasospasm/DCI after aSAH.
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Affiliation(s)
- Yasser B Abulhasan
- 1Neurological Intensive Care Unit and.,2Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait; and
| | - Johanna Ortiz Jimenez
- 3Department of Radiology, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Gabrielle Simoneau
- 4Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Continuous intra-arterial infusion of verapamil for treatment of severe vasospasm after subarachnoid hemorrhage. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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28
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Hawkes MA, Hlavnicka AA, Wainsztein NA. Reversible Cerebral Vasoconstriction Syndrome Responsive to Intravenous Milrinone. Neurocrit Care 2020; 32:348-352. [PMID: 31571175 DOI: 10.1007/s12028-019-00850-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maximiliano A Hawkes
- Department of Internal Medicine, FLENI, Montañeses 2325, Buenos Aires, Argentina.
- Department of Neurology, FLENI, Montañeses 2325, Buenos Aires, Argentina.
| | | | - Nestor A Wainsztein
- Department of Internal Medicine, FLENI, Montañeses 2325, Buenos Aires, Argentina
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29
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Santos-Teles AG, Ramalho C, Ramos JGR, Passos RDH, Gobatto A, Farias S, Batista PBP, Caldas JR. Efficacy and safety of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage: a systematic review. Rev Bras Ter Intensiva 2020; 32:592-602. [PMID: 33470361 PMCID: PMC7853682 DOI: 10.5935/0103-507x.20200097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 03/17/2020] [Indexed: 12/30/2022] Open
Abstract
Objective To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage. Methods The Pubmed®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies. Results Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm. Conclusion The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.
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Affiliation(s)
- Alex Goes Santos-Teles
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil
| | - Clara Ramalho
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | | | - André Gobatto
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | - Suzete Farias
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | - Juliana Ribeiro Caldas
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil.,Universidade de Salvador - Salvador (BA), Brasil
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30
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Which Protocol for Milrinone to Treat Cerebral Vasospasm Associated With Subarachnoid Hemorrhage? J Neurosurg Anesthesiol 2019; 31:323-329. [PMID: 30015694 DOI: 10.1097/ana.0000000000000527] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Milrinone has emerged as an option to treat delayed cerebral ischemia after subarachnoid hemorrhage. However, substantial variation exists in the administration of this drug. We retrospectively assessed the effectiveness of 2 protocols in patients with angiographically proven cerebral vasospasm. METHODS During 2 successive periods, milrinone was administered using either a combination of intra-arterial milrinone infusion followed by intravenous administration until day 14 after initial bleeding (IA+IV protocol), or a continuous intravenous milrinone infusion for at least 7 days (IV protocol). The primary endpoint was the reversion rate of vasospastic arterial segments following the first IA infusion of milrinone (IA+IV protocol) compared with the reversion rate during the first week of IV infusion (IV protocol). RESULTS There were 24 and 77 consecutive patients in IA+IV and IV protocols, respectively. The reversion rate was comparable between the 2 protocols: 71% (95% confidence interval [CI], 59%-83%) in the IA+IV protocol versus 64% (95% CI, 58%-71%) in the IV protocol (P=0.36). Rescue procedures for persistence or recurrence of vasospasm, that is, mechanical angioplasty and/or IA milrinone infusion, were similar between the 2 protocols. Patients with a good neurological outcome at 1 year, that is, modified Rankin Scale scores 0-2, were comparable between the 2 protocols. Side effects of milrinone were uncommon and equally distributed within the 2 protocols. CONCLUSIONS These findings indicate that a continuous IV infusion of milrinone was as efficient as combined IA+IV infusion and suggest that this modality could be considered as a first easy-to-use option to treat patients with CVS.
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31
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Geraghty JR, Davis JL, Testai FD. Neuroinflammation and Microvascular Dysfunction After Experimental Subarachnoid Hemorrhage: Emerging Components of Early Brain Injury Related to Outcome. Neurocrit Care 2019; 31:373-389. [PMID: 31012056 PMCID: PMC6759381 DOI: 10.1007/s12028-019-00710-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage has a high mortality rate and, for those who survive this devastating injury, can lead to lifelong impairment. Clinical trials have demonstrated that cerebral vasospasm of larger extraparenchymal vessels is not the sole contributor to neurological outcome. Recently, the focus of intense investigation has turned to mechanisms of early brain injury that may play a larger role in outcome, including neuroinflammation and microvascular dysfunction. Extravasated blood after aneurysm rupture results in a robust inflammatory response characterized by activation of microglia, upregulation of cellular adhesion molecules, recruitment of peripheral immune cells, as well as impaired neurovascular coupling, disruption of the blood-brain barrier, and imbalances in endogenous vasodilators and vasoconstrictors. Each of these phenomena is either directly or indirectly associated with neuronal death and brain injury. Here, we review recent studies investigating these various mechanisms in experimental models of subarachnoid hemorrhage with special emphasis on neuroinflammation and its effect on microvascular dysfunction. We discuss the various therapeutic targets that have risen from these mechanistic studies and suggest the utility of a multi-targeted approach to preventing delayed injury and improving outcome after subarachnoid hemorrhage.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA.
- Medical Scientist Training Program, University of Illinois at Chicago, Chicago, IL, USA.
| | - Joseph L Davis
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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33
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Subarachnoid Hemorrhage in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Michelozzi C, Cognard C. [The role of interventional neuroradiology in treatment of hemorrhagic stroke]. Presse Med 2019; 48:684-695. [PMID: 31153680 DOI: 10.1016/j.lpm.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/02/2019] [Indexed: 11/15/2022] Open
Abstract
Treatment of hemorrhagic strokes necessitates hospitalization in an accommodated hospital offering the possibility of a multidisciplinary approach. In this setting, over recent years interventional radiology has become increasingly important from the diagnostic as well as the therapeutic standpoint. In the context of subarachnoid hemorrhage by intracranial aneurysm rupture, the NICE (National Institute for Health and Clinical Excellence) and ASA (American Stroke Academy) recommendations suggest that endovascular coiling should be considered as an alternative to surgical clipping (class I, level of evidence B). As stenting is associated with increased morbidity and mortality in the ruptured aneurysms, it should be avoided (class III, level of evidence C). The patient's clinical status on presentation should be taken into account when deciding on therapeutic management and determining prognosis. Long-term clinical outcome depends on several factors: clinical status on arrival, comorbidities, age, occurrence of operative complications and complications of subarachnoid hemorrhage such as hydrocephaly, vasospasm and delayed cerebral ischemia, as well as complications stemming from prolonged bed rest. In the event of vasospasm refractory to maximal medical therapy, endovascular treatment by intra-arterial injection of Nimodipine and angioplasty can be envisioned. In the event of intracerebral hemorrhage (ICH) by rupture cerebral dural arteriovenous fistula, once the diagnosis has been confirmed, and given the exceedingly high risk of rebleeding, first-line treatment will consist in emergency endovascular embolization. In the event of intracerebral hemorrhage (ICH) by arteriovenous rupture, treatment is decided on during a multidisciplinary meeting and either carried out immediately or delayed according to several factors: clinical conditions, age of the patient, angioarchitecture and ICH location.
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Affiliation(s)
- Caterina Michelozzi
- CHU Toulouse, hôpital Pierre Paul Riquet, service de neuroradiologie, 1, place du Dr Baylac, 31059 Toulouse cedex 9, France.
| | - Christophe Cognard
- CHU Toulouse, hôpital Pierre Paul Riquet, service de neuroradiologie, 1, place du Dr Baylac, 31059 Toulouse cedex 9, France
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35
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Ghanem MA, Shabana AM. Effects of Milrinone continuous intravenous infusion on global cerebral oxygenation and cerebral vasospasm after cerebral aneurysm surgical clipping. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Mohamed A. Ghanem
- Anesthesia Department, Faculty of Medicine, Mansoura University, Egypt
| | - Amir M. Shabana
- Anesthesia Department, Faculty of Medicine, Mansoura University, Egypt
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36
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Santos‐Teles AG, Passos RH, Panerai RB, Ramalho C, Farias S, Rosa JG, Gobatto A, Benigno P, Caldas JR. Intravenous administration of Milrinone, as an alternative approach to treat vasospasm in subarachnoid hemorrhage: A case report of transcranial Doppler monitoring. Clin Case Rep 2019; 7:648-652. [PMID: 30997055 PMCID: PMC6452455 DOI: 10.1002/ccr3.2034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 01/03/2023] Open
Abstract
This case illustrates the importance and potential of having TCD monitoring in intensive care. This easy-to-use, safe, low-cost, and bedside tool allows evaluation of the safety and feasibility of an alternative treatment of VSP in SCH and demonstrates the potential to avoid the use of angiography, a high cost, invasive procedure.
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Affiliation(s)
- Alex Goes Santos‐Teles
- Critical Care UnitHospital São RafaelSalvadorBrazil
- Escola Bahiana de Medicina e Saúde PúblicaSalvadorBrazil
| | | | - Ronney B. Panerai
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
- NIHR Leicester Biomedical Research CentreGlenfield HospitalLeicesterUK
| | | | | | - João G Rosa
- Critical Care UnitHospital São RafaelSalvadorBrazil
| | | | | | - Juliana Ribeiro Caldas
- Critical Care UnitHospital São RafaelSalvadorBrazil
- Escola Bahiana de Medicina e Saúde PúblicaSalvadorBrazil
- University of Salvador (UNIFACS)SalvadorBrazil
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Lakhal K, Rodie-Talbere PA, Alexandre PL, Testard N, Rozec B, Daumas-Duport B. Continuous intravenous milrinone for severe reversible cerebral vasoconstriction syndrome (a case report). J Neurol Sci 2019; 397:55-57. [PMID: 30590342 DOI: 10.1016/j.jns.2018.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Karim Lakhal
- Réanimation chirurgicale polyvalente, Service d'anesthésie-réanimation, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Pierre-André Rodie-Talbere
- Réanimation chirurgicale polyvalente, Service d'anesthésie-réanimation, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Pierre-Louis Alexandre
- Service de radiologie, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Nathalie Testard
- Service de neurologie, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Bertrand Rozec
- Réanimation chirurgicale polyvalente, Service d'anesthésie-réanimation, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France; Institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France.
| | - Benjamin Daumas-Duport
- Service de radiologie, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
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Soliman R, Zohry G. [Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. Rev Bras Anestesiol 2018; 69:64-71. [PMID: 30409409 DOI: 10.1016/j.bjan.2018.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/19/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.
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Affiliation(s)
- Rabie Soliman
- Cairo University, Department of Anesthesia, Cairo, Egito.
| | - Gomaa Zohry
- Cairo University, Department of Anesthesia, Cairo, Egito
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Soliman R, Zohry G. [Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2018; 69. [PMID: 30409409 PMCID: PMC9391725 DOI: 10.1016/j.bjane.2018.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.
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Affiliation(s)
- Rabie Soliman
- Cairo University, Department of Anesthesia, Cairo, Egito.
| | - Gomaa Zohry
- Cairo University, Department of Anesthesia, Cairo, Egito
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Hosmann A, Rauscher S, Wang WT, Dodier P, Bavinzski G, Knosp E, Gruber A. Intra-Arterial Papaverine-Hydrochloride and Transluminal Balloon Angioplasty for Neurointerventional Management of Delayed-Onset Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm. World Neurosurg 2018; 119:e301-e312. [PMID: 30053563 DOI: 10.1016/j.wneu.2018.07.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE After subarachnoid hemorrhage, delayed onset vasospasm can result in devastating ischemic stroke. The phenomenon of delayed cerebral ischemia (DCI) is not yet fully understood, and the correlation of angiographic vasospasm and cerebral infarction is still unclear. Therefore, we investigated the effect of endovascular treatment on the angiographic response and occurrence of DCI. METHODS Eighty patients with subarachnoid hemorrhage and serious cerebral vasospasm underwent endovascular treatment using intra-arterial papaverine-hydrochloride (IAP) or transluminal balloon angioplasty (TBA). The angiographic response and infarction rate were classified using the pre- and postinterventional angiographic images and computed tomography scans. RESULTS In 90% of patients, vasospasm could be improved. In most cases (78.8%), IAP was used. Retreatment after IAP was necessary in 32.9% of patients but never after TBA. A total of 233 vascular territories were treated in 128 procedures. Angiographic improvement was observed in 66.5% of territories, which was significantly associated with early intervention (P = 0.02), the use of TBA (P = 0.01), and the dose of papaverine-hydrochloride (P = 0.01). DCI occurred in 47.5% of the patients. Territorial infarction was associated with a poor Hunt and Hess grade (P = 0.03), day of aneurysm treatment (P = 0.01), severe vasospasm before (P = 0.02) and after (P = 0.03) treatment, and number of interventions (P = 0.01). However, the infarction rate was independent of the angiographic response. CONCLUSION The discrepancy of excellent angiographic results and the high incidence of DCI might stem from an inaccurate or a delayed diagnosis of impending ischemia. In view of the limited time window, optimized peri-interventional management and continuous cerebral multimodality neuromonitoring might be crucial for the ideal timing of endovascular procedures to prevent cerebral infarctions.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Steffen Rauscher
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
| | - Andreas Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Kepler Universitätsklinikum, Johannes Kepler University Linz, Linz, Austria
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Katyal N, George P, Nattanamai P, Raber LN, Beary JM, Newey CR. Improvement in Sonographic Vasospasm Following Intravenous Milrinone in a Subarachnoid Hemorrhage Patient with Normal Cardiac Function. Cureus 2018; 10:e2916. [PMID: 30186721 PMCID: PMC6122655 DOI: 10.7759/cureus.2916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cerebral vasospasm and delayed cerebral ischemia are well-known complications of an aneurysmal subarachnoid hemorrhage (aSAH), generally occurring days to weeks after hemorrhagic ictus. Management strategies for these complications are controversial and vary in efficacy. There is a growing interest in supporting the use of intravenous (IV) milrinone to manage vasospasm. A 31-year-old male presented to the hospital after being found down outside his home. Computed tomography (CT) of the head and subsequent CT angiogram revealed a Fisher Grade 4 aneurysmal subarachnoid hemorrhage (aSAH). Six hours after admission, he became hypotensive and his neurological examination declined. A repeat CT head showed a new, left frontoparietal intracerebral hemorrhage (ICH) along with increasing SAH. He was stabilized with vasopressors and underwent emergent decompressive hemicraniectomy with subsequent clipping of the aneurysm. Approximately one week later, transcranial Doppler (TCD) showed increasing mean flow velocities in the bilateral anterior and middle cerebral arteries consistent with cerebral vasospasm. He was treated with intravenous milrinone. Repeat TCD 6.5 hours after the initial TCD showed improved mean flow velocities. His cardiac function by echocardiogram assessment was normal. The decrease in TCD velocity following treatment with milrinone indicates an improvement in the cerebral vasospasm regardless of cardiac output in a patient with subarachnoid hemorrhage. This case suggests that augmenting cardiac output may not be the only mechanism for the therapeutic benefit of milrinone.
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Affiliation(s)
- Nakul Katyal
- Neurology, University of Missouri, Columbia, USA
| | | | | | | | - Jonathan M Beary
- Neurobehavioral Sciences, A. T. Still University, Kirksville, USA
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Al-Mufti F, Amuluru K, Damodara N, El-Ghanem M, Nuoman R, Kamal N, Al-Marsoummi S, Morris NA, Dangayach NS, Mayer SA. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2018; 390:44-51. [DOI: 10.1016/j.jns.2018.02.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 11/27/2022]
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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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Wu EM, El Ahmadieh TY, Kafka B, Davies MT, Aoun SG, White JA. Milrinone-Associated Cardiomyopathy and Arrhythmia in Cerebral Vasospasm. World Neurosurg 2018; 114:252-256. [PMID: 29609088 DOI: 10.1016/j.wneu.2018.03.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Milrinone is an inotropic and vasodilatory drug proven safe for use in treatment of cerebral vasospasm. Despite its reported safety profile, its use is not free of side effects. Milrinone-associated cardiomyopathy and arrhythmia can occur in patients with cerebral vasospasm. CASE DESCRIPTION This is a retrospective chart review of a patient who presented with aneurysmal subarachnoid hemorrhage and developed clinical vasospasm twice over a period of 2 weeks. Sustained intravenous milrinone infusion was used in association with norepinephrine infusion during this period. The patient developed R-on-T triggered torsades de pointes and cardiogenic shock requiring resuscitation. Follow-up echocardiogram showed decreased ejection fraction from 64% to 43% consistent with cardiac remodeling. Systemic complications such as cardiotoxicity and arrhythmias with the use of intravenous milrinone can be seen particularly when used in combination with catecholamines. CONCLUSIONS With increased combined milrinone and catecholamine use for the treatment of cerebral vasospasm, physicians should be aware of the potential cardiac complications of these agents. Close monitoring with daily electrocardiograms may be helpful to detect changes that suggest cardiotoxicity. If changes are noted, an echocardiogram and cardiology consultation may be warranted.
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Affiliation(s)
- Eva M Wu
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Benjamin Kafka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew T Davies
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan A White
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Koyanagi M, Fukuda H, Lo B, Uezato M, Kurosaki Y, Sadamasa N, Handa A, Chin M, Yamagata S. Effect of intrathecal milrinone injection via lumbar catheter on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 128:717-722. [DOI: 10.3171/2016.10.jns162227] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDelayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI.METHODSThe prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables.RESULTSAfter propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups.CONCLUSIONSIn propensity score–matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.
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Affiliation(s)
- Masaomi Koyanagi
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Hitoshi Fukuda
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Benjamin Lo
- 2Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Minami Uezato
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Yoshitaka Kurosaki
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Nobutake Sadamasa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Akira Handa
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Masaki Chin
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
| | - Sen Yamagata
- 1Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan; and
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Abstract
PURPOSE OF REVIEW With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm. RECENT FINDINGS Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome. SUMMARY Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.
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Mogollon JP, Smoll NR, Panwar R. Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology. World Neurosurg 2018; 113:e29-e37. [PMID: 29410100 DOI: 10.1016/j.wneu.2018.01.121] [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: 10/27/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service. METHODS This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital. RESULTS The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period. CONCLUSIONS Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV. STUDY REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616000201471.
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MESH Headings
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Brain Damage, Chronic/epidemiology
- Brain Damage, Chronic/etiology
- Brain Damage, Chronic/prevention & control
- Computed Tomography Angiography
- Embolization, Therapeutic
- Endovascular Procedures/statistics & numerical data
- Female
- Humans
- Incidence
- Intensive Care Units/statistics & numerical data
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Length of Stay/statistics & numerical data
- Ligation
- Male
- Middle Aged
- Radiography, Interventional/statistics & numerical data
- Recurrence
- Severity of Illness Index
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/surgery
- Tertiary Care Centers/statistics & numerical data
- Treatment Outcome
- Vasospasm, Intracranial/epidemiology
- Vasospasm, Intracranial/etiology
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Affiliation(s)
| | - Nicolas Roydon Smoll
- Melbourne School of Population Health, University of Melbourne, Melbourne, Australia
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
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Duman E, Karakoç F, Pinar HU, Dogan R, Fırat A, Yıldırım E. Higher dose intra-arterial milrinone and intra-arterial combined milrinone-nimodipine infusion as a rescue therapy for refractory cerebral vasospasm. Interv Neuroradiol 2017; 23:636-643. [PMID: 28956512 DOI: 10.1177/1591019917732288] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Cerebral vasospasm (CV) is a major cause of delayed morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Various cerebral protectants have been tested in patients with aneurysmal SAH. We aimed to research the success rate of treatment of CV via intra-arterial milrinone injection and aggressive pharmacological therapy for refractory CV. Methods A total of 25 consecutive patients who received intra-arterial milrinone and nimodipine treatment for CV following SAH between 2014 and 2017 were included in the study. Patients who underwent surgical clipping were excluded. Refractory vasospasm was defined as patients with CV refractory to therapies requiring ≥3 endovascular interventions. Overall, six patients had refractory CV. Long-term neurological outcome was assessed 6-18 months after SAH using a modified Rankin score and Barthel index. Results The median modified Rankin scores were 1 (min: 0, max: 3) and Barthel index scores were 85 (min: 70, max: 100) From each vasospastic territory maximal 10-16 mg milrinone was given to patients; a maximum of 24 mg milrinone was given to each patient in a session and a maximum of 42 mg milrinone was given to a patient in a day. Both milrinone and nimodipine were given to three patients. There was a large vessel diameter increase after milrinone and nimodipine injections. No patient died due to CV; only one patient had motor dysfunction on the right lower extremity. Conclusion Higher doses of milrinone can be used effectively to control refractory CV. For exceptional patients with refractory CV, high dose intra-arterial nimodipine and milrinone infusion can be used as a rescue therapy.
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Affiliation(s)
- Enes Duman
- 1 63994 Baskent University School of Medicine , Konya Research Center, Department of Radiology, Konya, Turkey
| | - Fatma Karakoç
- 2 63994 Baskent University School of Medicine , Konya Research Center, Department of Anesthesiology, Konya, Turkey
| | - H Ulas Pinar
- 2 63994 Baskent University School of Medicine , Konya Research Center, Department of Anesthesiology, Konya, Turkey
| | - Rafi Dogan
- 2 63994 Baskent University School of Medicine , Konya Research Center, Department of Anesthesiology, Konya, Turkey
| | - Ali Fırat
- 3 63994 Baskent University School of Medicine , Konya Research Center, Department of Radiology, Istanbul, Turkey
| | - Erkan Yıldırım
- 1 63994 Baskent University School of Medicine , Konya Research Center, Department of Radiology, Konya, Turkey
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Boulouis G, Labeyrie MA, Raymond J, Rodriguez-Régent C, Lukaszewicz AC, Bresson D, Ben Hassen W, Trystram D, Meder JF, Oppenheim C, Naggara O. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Eur Radiol 2016; 27:3333-3342. [PMID: 28004163 DOI: 10.1007/s00330-016-4702-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To examine the clinical outcome of aneurysmal subarachnoid haemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS)-targeted treatments in a meta-analysis and to evaluate the efficacy of intra-arterial (IA) approaches in patients with severe/refractory vasospasm. METHODS Randomised controlled trials, prospective and retrospective observational studies reporting clinical outcomes of aSAH patients exposed to CVS targeted treatments, published between 2006-2016 were searched using PubMed, EMBASE and the Cochrane Library. The main endpoint was the proportion of unfavourable outcomes, defined as a modified Rankin score of 3-6 at last follow-up. RESULTS Sixty-two studies, including 26 randomised controlled trials, were included (8,976 patients). At last follow-up 2,490 of the 8,976 patients had an unfavourable outcome, including death (random-effect weighted-average, 33.7%; 99% confidence interval [CI], 28.1-39.7%; Q value, 806.0; I 2 = 92.7%). The RR of unfavourable outcome was lower in patients treated with Cilostazol (RR = 0.46; 95% CI, 0.25-0.85; P = 0.001; Q value, 1.5; I 2 = 0); and in refractory CVS patients treated by IA intervention (RR = 0.68; 95% CI, 0.57-0.80; P < 0.0001; number needed to treat with IA intervention, 6.2; 95% CI, 4.3-11.2) when compared with the best available medical treatment. CONCLUSIONS Endovascular treatment may improve the outcome of patients with severe-refractory vasospasm. Further studies are needed to confirm this result. KEY POINTS • 33.7% of patients with cerebral Vasospasm following aneurysmal subarachnoid-hemorrhage have an unfavorable outcome. • Refractory vasospasm patients treated using endovascular interventions have lower relative risk of unfavourable outcome. • Subarachnoid haemorrhage patients with severe vasospasm may benefit from endovascular interventions. • The relative risk of unfavourable outcome is lower in patients treated with Cilostazol.
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Affiliation(s)
- Grégoire Boulouis
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France.
- DHU NeuroVasc Paris Sorbonne, Paris, France.
| | - Marc Antoine Labeyrie
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Christine Rodriguez-Régent
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Anne Claire Lukaszewicz
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Damien Bresson
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Wagih Ben Hassen
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Denis Trystram
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Jean Francois Meder
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Catherine Oppenheim
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Olivier Naggara
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
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The Use of Milrinone in Patients with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Systematic Review. Can J Neurol Sci 2016; 44:152-160. [PMID: 27842615 DOI: 10.1017/cjn.2016.316] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a systematic review of the evidence supporting the use of milrinone for the management of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). DESIGN Primary outcomes were functional neurological status and the incidence of cerebral infarction. Search strategies adapted to the different databases were developed by a professional librarian. Medline, EMBASE, the Cochrane Library database, Web of Science, SCOPUS, BIOSIS, Global Health, Health Star, Open SIGLE, Google Scholar and the New York Academy of Medicine Gray Literature were searched as well as clinical trials databases and the proceedings of several scientific meetings. Quality of the evidence for these outcomes across studies was adjudicated using the GRADE Working Group criteria. RESULTS The search resulted in 284 citations after elimination of duplicates. Of those 9 conference proceedings and 15 studies met inclusion criteria and consisted of case reports, case series and two comparative studies: one non-randomized study with physiological outcomes only and a case series with historical controls. There was considerable variation in dosing and in co-interventions and no case control or randomized controlled studies were found. CONCLUSION There is currently only very low quality evidence to support the use of milrinone to improve important outcomes in patients with delayed cerebral ischemia secondary to subarachnoid hemorrhage. Further research is needed to clarify the value and risks of this medication in patients with SAH.
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