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Wang J, Wang Q, Fu Y, Lu M, Chen L, Liu Z, Fu X, Du X, Yu B, Lu H, Cui W. Swimming short fibrous nasal drops achieving intraventricular administration. Sci Bull (Beijing) 2024; 69:1249-1262. [PMID: 38522998 DOI: 10.1016/j.scib.2024.03.013] [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: 12/09/2023] [Revised: 02/06/2024] [Accepted: 03/01/2024] [Indexed: 03/26/2024]
Abstract
Adequate drug delivery across the blood-brain barrier (BBB) is a critical factor in treating central nervous system (CNS) disorders. Inspired by swimming fish and the microstructure of the nasal cavity, this study is the first to develop swimming short fibrous nasal drops that can directly target the nasal mucosa and swim in the nasal cavity, which can effectively deliver drugs to the brain. Briefly, swimming short fibrous nasal drops with charged controlled drug release were fabricated by electrospinning, homogenization, the π-π conjugation between indole group of fibers, the benzene ring of leucine-rich repeat kinase 2 (LRRK2) inhibitor along with charge-dipole interaction between positively charged poly-lysine (PLL) and negatively charged surface of fibers; this enabled these fibers to stick to nasal mucosa, prolonged the residence time on mucosa, and prevented rapid mucociliary clearance. In vitro, swimming short fibrous nasal drops were biocompatible and inhibited microglial activation by releasing an LRRK2 inhibitor. In vivo, luciferase-labelled swimming short fibrous nasal drops delivered an LRRK2 inhibitor to the brain through the nasal mucosa, alleviating cognitive dysfunction caused by sepsis-associated encephalopathy by inhibiting microglial inflammation and improving synaptic plasticity. Thus, swimming short fibrous nasal drops is a promising strategy for the treatment of CNS diseases.
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Affiliation(s)
- Juan Wang
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qiuyun Wang
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yifei Fu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - Min Lu
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Liang Chen
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhiheng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - Xiaohan Fu
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiyu Du
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Buwei Yu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Han Lu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Wenguo Cui
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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2
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Caylor MM, Macdonald RL. Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:159-169. [PMID: 37740138 DOI: 10.1007/s12028-023-01847-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/23/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries. METHODS Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan. RESULTS The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad. CONCLUSIONS We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.
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Affiliation(s)
- Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - R Loch Macdonald
- Community Neurosciences Institute, Community Health Partners, 7257 North Fresno Street, Fresno, CA, 93720, USA.
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3
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Nguyenla X, Wehri E, Van Dis E, Biering SB, Yamashiro LH, Zhu C, Stroumza J, Dugast-Darzacq C, Graham TGW, Wang X, Jockusch S, Tao C, Chien M, Xie W, Patel DJ, Meyer C, Garzia A, Tuschl T, Russo JJ, Ju J, Näär AM, Stanley S, Schaletzky J. Discovery of SARS-CoV-2 antiviral synergy between remdesivir and approved drugs in human lung cells. Sci Rep 2022; 12:18506. [PMID: 36323770 PMCID: PMC9628577 DOI: 10.1038/s41598-022-21034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
SARS coronavirus 2 (SARS-CoV-2) has caused an ongoing global pandemic with significant mortality and morbidity. At this time, the only FDA-approved therapeutic for COVID-19 is remdesivir, a broad-spectrum antiviral nucleoside analog. Efficacy is only moderate, and improved treatment strategies are urgently needed. To accomplish this goal, we devised a strategy to identify compounds that act synergistically with remdesivir in preventing SARS-CoV-2 replication. We conducted combinatorial high-throughput screening in the presence of submaximal remdesivir concentrations, using a human lung epithelial cell line infected with a clinical isolate of SARS-CoV-2. This identified 20 approved drugs that act synergistically with remdesivir, many with favorable pharmacokinetic and safety profiles. Strongest effects were observed with established antivirals, Hepatitis C virus nonstructural protein 5A (HCV NS5A) inhibitors velpatasvir and elbasvir. Combination with their partner drugs sofosbuvir and grazoprevir further increased efficacy, increasing remdesivir's apparent potency > 25-fold. We report that HCV NS5A inhibitors act on the SARS-CoV-2 exonuclease proofreader, providing a possible explanation for the synergy observed with nucleoside analog remdesivir. FDA-approved Hepatitis C therapeutics Epclusa® (velpatasvir/sofosbuvir) and Zepatier® (elbasvir/grazoprevir) could be further optimized to achieve potency and pharmacokinetic properties that support clinical evaluation in combination with remdesivir.
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Affiliation(s)
- Xammy Nguyenla
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, 94720, USA
| | - Eddie Wehri
- The Henry Wheeler Center for Emerging and Neglected Diseases, 344 Li Ka Shing, Berkeley, CA, 94720, USA
| | - Erik Van Dis
- Department of Molecular and Cell Biology, Division of Immunology and Pathogenesis, University of California, Berkeley, CA, 94720, USA
| | - Scott B Biering
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, 94720, USA
| | - Livia H Yamashiro
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, 94720, USA
- Department of Molecular and Cell Biology, Division of Immunology and Pathogenesis, University of California, Berkeley, CA, 94720, USA
| | - Chi Zhu
- Department of Nutritional Sciences & Toxicology, University of California, Berkeley, CA, 94720, USA
- Innovative Genomics Institute, University of California, Berkeley, CA, 94720, USA
| | - Julien Stroumza
- The Henry Wheeler Center for Emerging and Neglected Diseases, 344 Li Ka Shing, Berkeley, CA, 94720, USA
| | - Claire Dugast-Darzacq
- Department of Molecular and Cell Biology, Division of Genetics, Genomics and Development, University of California, Berkeley, CA, 94720, USA
| | - Thomas G W Graham
- Department of Molecular and Cell Biology, Division of Genetics, Genomics and Development, University of California, Berkeley, CA, 94720, USA
| | - Xuanting Wang
- Center for Genome Technology and Biomolecular Engineering, Columbia University, New York, NY, 10027, USA
- Department of Chemical Engineering, Columbia University, New York, NY, 10027, USA
| | - Steffen Jockusch
- Center for Genome Technology and Biomolecular Engineering, Columbia University, New York, NY, 10027, USA
- Department of Chemistry, Columbia University, New York, NY, 10027, USA
| | - Chuanjuan Tao
- Center for Genome Technology and Biomolecular Engineering, Columbia University, New York, NY, 10027, USA
- Department of Chemical Engineering, Columbia University, New York, NY, 10027, USA
| | - Minchen Chien
- Center for Genome Technology and Biomolecular Engineering, Columbia University, New York, NY, 10027, USA
- Department of Chemical Engineering, Columbia University, New York, NY, 10027, USA
| | - Wei Xie
- Laboratory of Structural Biology, Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA
| | - Dinshaw J Patel
- Laboratory of Structural Biology, Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA
| | - Cindy Meyer
- Laboratory of RNA Molecular Biology, Rockefeller University, New York, NY, 10065, USA
| | - Aitor Garzia
- Laboratory of RNA Molecular Biology, Rockefeller University, New York, NY, 10065, USA
| | - Thomas Tuschl
- Laboratory of RNA Molecular Biology, Rockefeller University, New York, NY, 10065, USA
| | - James J Russo
- Center for Genome Technology and Biomolecular Engineering, Columbia University, New York, NY, 10027, USA
- Department of Chemical Engineering, Columbia University, New York, NY, 10027, USA
| | - Jingyue Ju
- Center for Genome Technology and Biomolecular Engineering, Columbia University, New York, NY, 10027, USA
- Department of Chemical Engineering, Columbia University, New York, NY, 10027, USA
- Department of Molecular Pharmacology and Therapeutics, Columbia University, New York, NY, 10032, USA
| | - Anders M Näär
- Department of Nutritional Sciences & Toxicology, University of California, Berkeley, CA, 94720, USA
- Innovative Genomics Institute, University of California, Berkeley, CA, 94720, USA
| | - Sarah Stanley
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, 94720, USA.
- Department of Molecular and Cell Biology, Division of Immunology and Pathogenesis, University of California, Berkeley, CA, 94720, USA.
| | - Julia Schaletzky
- The Henry Wheeler Center for Emerging and Neglected Diseases, 344 Li Ka Shing, Berkeley, CA, 94720, USA.
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Döring K, Sperling S, Ninkovic M, Schroeder H, Fischer A, Stadelmann C, Streit F, Binder L, Mielke D, Rohde V, Malinova V. Ultrasound-Induced Release of Nimodipine from Drug-Loaded Block Copolymer Micelles: In Vivo Analysis. Transl Stroke Res 2022; 13:792-800. [PMID: 34988870 PMCID: PMC9391244 DOI: 10.1007/s12975-021-00979-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 12/01/2021] [Accepted: 12/14/2021] [Indexed: 12/03/2022]
Abstract
Nimodipine prevents cerebral vasospasm and improves functional outcome after aneurysmal subarachnoid hemorrhage (aSAH). The beneficial effect is limited by low oral bioavailability of nimodipine, which resulted in an increasing use of nanocarriers with sustained intrathecal drug release in order to overcome this limitation. However, this approach facilitates only a continuous and not an on-demand nimodipine release during the peak time of vasospasm development. In this study, we aimed to assess the concept of controlled drug release from nimodipine-loaded copolymers by ultrasound application in the chicken chorioallantoic membrane (CAM) model. Nimodipine-loaded copolymers were produced with the direct dissolution method. Vasospasm of the CAM vessels was induced by means of ultrasound (Physiomed, continuous wave, 3 MHz, 1.0 W/cm2). The ultrasound-mediated nimodipine release (Physiomed, continuous wave, 1 MHz, 1.7 W/cm2) and its effect on the CAM vessels were evaluated. Measurements of vessel diameter before and after ultrasound-induced nimodipine release were performed using ImageJ. The CAM model could be successfully carried out in all 25 eggs. After vasospasm induction and before drug release, the mean vessel diameter was at 57% (range 44-61%) compared to the baseline diameter (set at 100%). After ultrasound-induced drug release, the mean vessel diameter of spastic vessels increased again to 89% (range 83-91%) of their baseline diameter, which was significant (p = 0.0002). We were able to provide a proof of concept for in vivo vasospasm induction by ultrasound application in the CAM model and subsequent resolution by ultrasound-mediated nimodipine release from nanocarriers. This concept merits further evaluation in a rat SAH model.
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Affiliation(s)
- Katja Döring
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Swetlana Sperling
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Milena Ninkovic
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Henning Schroeder
- Department for Epigenetics and System Medicine in Neurodegenerative Diseases, German Center for Neurodegenerative Diseases, Göttingen, Germany
| | - André Fischer
- Department for Epigenetics and System Medicine in Neurodegenerative Diseases, German Center for Neurodegenerative Diseases, Göttingen, Germany
| | - Christine Stadelmann
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Frank Streit
- Institute for Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - Lutz Binder
- Institute for Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany.
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5
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Walter J, Grutza M, Möhlenbruch M, Vollherbst D, Vogt L, Unterberg A, Zweckberger K. The Local Intraarterial Administration of Nimodipine Might Positively Affect Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage and Delayed Cerebral Ischemia. J Clin Med 2022; 11:jcm11072036. [PMID: 35407643 PMCID: PMC8999377 DOI: 10.3390/jcm11072036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/26/2022] [Accepted: 04/01/2022] [Indexed: 12/10/2022] Open
Abstract
The effect of the intraarterial administration of nimodipine as a rescue measure to treat delayed vasospasm after aSAH remains understudied; therefore, we evaluated its effect on short- and long-term functional and neuropsychological outcomes after aSAH. In this prospective observational study, a total of 107 consecutive patients treated for aSAH of WFNS grades I−V were recruited. At follow-up visits 3-, 12- and 24-months after the hemorrhage, functional outcome was assessed using the Extended Glasgow Outcome (GOSE) and modified Rankin (mRS) scales, while neurocognitive function was evaluated using the screening module of the Neuropsychological Assessment Battery (NAB-S). The outcome of patients, who had received rescue therapy according to the local standard treatment protocol (interventional group, n = 37), and those, who had been treated conservatively (conservative group, n = 70), were compared. Even though significantly more patients in the interventional treatment group suffered from high-grade aSAH (WFNS Grades IV and V, 54.1% vs. 31.4%, p = 0.04) and required continuous drainage of cerebrospinal fluid at discharge (67.7% vs. 37.7%, p = 0.02) compared to the control group, significant differences in functional outcome were present only at discharge and three months after the bleeding (GOSE > 4 in 8.1% vs. 41.4% and 28.6% vs. 72.7%, p < 0.001 and p = 0.01 for the interventional and control group, respectively). Thereafter, group differences were no longer significant. While significantly more patients in the intervention group had severe neuropsychological deficits (76.3% vs. 36.0% and 66.7% vs. 29.2%, p = 0.04 and 0.05, respectively) and were unable to work (5.9% vs. 38.1%, p = 0.03 at twelve months) at three and twelve months after the hemorrhage, no significant differences between the two groups could be detected at long-term follow-up. The presence of moderate neuropsychological impairments did not significantly differ between the groups at any timepoint. In conclusion, despite initially being significantly more impaired, patients treated with intraarterial administration of nimodipine reached the same functional and neuropsychological outcomes at medium- and long-term follow-up as conservatively treated patients suggesting a potential beneficial effect of intraarterial nimodipine treatment for delayed vasospasm after aSAH.
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Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
- Correspondence: ; Tel.: +49-62-213-4356
| | - Martin Grutza
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.M.); (D.V.)
| | - Dominik Vollherbst
- Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.M.); (D.V.)
| | - Lidia Vogt
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
| | - Klaus Zweckberger
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
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6
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Dayyani M, Sadeghirad B, Grotta JC, Zabihyan S, Ahmadvand S, Wang Y, Guyatt GH, Amin-Hanjani S. Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials. Stroke 2022; 53:1993-2005. [PMID: 35354302 DOI: 10.1161/strokeaha.121.035699] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials. METHODS We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence. RESULTS We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia. CONCLUSIONS Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.
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Affiliation(s)
- Mojtaba Dayyani
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, TX (M.D.).,Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.).,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. (B.S.).,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada. (B.S.)
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center (J.C.G.)
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Saba Ahmadvand
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
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7
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Allen JW, Prater A, Kallas O, Abidi SA, Howard BM, Tong F, Agarwal S, Yaghi S, Dehkharghani S. Diagnostic Performance of Computed Tomography Angiography and Computed Tomography Perfusion Tissue Time-to-Maximum in Vasospasm Following Aneurysmal Subarachnoid Hemorrhage. J Am Heart Assoc 2021; 11:e023828. [PMID: 34970916 PMCID: PMC9075209 DOI: 10.1161/jaha.121.023828] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Vasospasm is a treatable cause of deterioration following aneurysmal subarachnoid hemorrhage. Cerebral computed tomography perfusion mean transit times have been proposed as a predictor of vasospasm but suffer from well‐known technical limitations. We evaluated fully automated, thresholded time‐to‐maxima of the tissue residue function (Tmax) for determination of vasospasm following aneurysmal subarachnoid hemorrhage. Methods and Results Retrospective analysis of 540 arterial segments from 36 encounters in 31 consecutive patients with aneurysmal subarachnoid hemorrhage undergoing computed tomography angiography (CTA), computed tomography perfusion, and digital subtraction angiography (DSA) within 24 hours. Tmax at 4, 6, 8, and 10 s was generated using RAPID (iSchemaView Inc., Menlo Park, CA). Dual‐reader CTA and computed tomography perfusion interpretations were compared for patients with and without vasospasm on DSA (DSA+ and DSA−). Logistic regression models were developed using CTA and Tmax as input predictors and DSA vasospasm as outcome in adjusted and unadjusted models. Imaging studies from all 31 subjects (mean age 47.3±11.1, 77% female, 65% with single aneurysm with mean size of 6.0±2.9 mm) were included. Vasospasm was identified in 42 segments on DSA and 59 segments on CTA, with significant associations across individual vessel segments (P<0.001). In adjusted analyses, DSA vasospasm was associated with CTA (odds ratio [OR], 2.43; 95% CI, 0.94–6.32; P=0.068) as well as territory‐specific Tmax>6 seconds delays (OR, 3.57; 95% CI, 1.36–9.35; P=0.009). Sensitivity/specificity for DSA vasospasm was 31%/91% for CTA, 26%/89% for Tmax>6 seconds, and 12%/99% for CTA+Tmax>6 seconds. Conclusions CTA and Tmax offer high specificity for presence of vasospasm; their utility, even in combination, as screening tests is, however, limited by poor sensitivity.
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Affiliation(s)
- Jason W Allen
- Department of Radiology and Imaging Sciences Emory University Atlanta GA.,Department of Neurology Emory University Atlanta GA
| | - Adam Prater
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Omar Kallas
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Syed A Abidi
- Emory School of Medicine Emory University Atlanta GA
| | - Brian M Howard
- Department of Radiology and Imaging Sciences Emory University Atlanta GA.,Department of Neurosurgery Emory University Atlanta GA
| | - Frank Tong
- Department of Radiology and Imaging Sciences Emory University Atlanta GA.,Department of Neurosurgery Emory University Atlanta GA
| | | | - Shadi Yaghi
- Department of Neurology Brown University Providence RI
| | - Seena Dehkharghani
- Department of Neurology New York University New York NY.,Department of Radiology New York University New York NY
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8
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Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:662-681. [PMID: 34940927 DOI: 10.1007/s12028-021-01372-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
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Göttsche J, Schweingruber N, Groth JC, Gerloff C, Westphal M, Czorlich P. Safety and Clinical Effects of Switching From Intravenous to Oral Nimodipine Administration in Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:748413. [PMID: 34867733 PMCID: PMC8636241 DOI: 10.3389/fneur.2021.748413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Several guidelines recommend oral administration of nimodipine as vasospasm prophylaxis after aneurysmal subarachnoid hemorrhage (SAH). However, in clinical practice, the drug is administered orally and intravenously (i.v.), depending on clinical conditions and local treatment regimens. We have therefore investigated the safety and clinical effects of switching from i.v. to oral nimodipine therapy. Methods: Patients with aneurysmal SAH between January 2014 and April 2018 and initial i.v. nimodipine therapy, which was subsequently switched to oral administration, were included in this retrospective study. Transcranial Doppler sonography (TCD) of the vessels of the anterior circulation was performed daily. The occurrence of vasospasm and infarction during the overall course of the treatment was recorded. Statistical level of significance was set to p < 0.05. Results: A total of 133 patients (mean age 55.8 years, 65% female) initially received nimodipine i.v. after aneurysmal SAH, which was subsequently switched to oral administration after a mean of 12 days. There were no significant increases in mean flow velocities on TCD after the switch from i.v. to oral nimodipine administration regarding the anterior cerebral artery. For the middle cerebral artery, an increase from 62.36 to 71.78 cm/sec could only be detected in the subgroup of patients with infarction. There was no clustering of complicating events such as new-onset vasospasm or infarction during or after the switch. Conclusions: Our results do not point to any safety concerns when switching nimodipine from initial i.v. to oral administration. Switching was neither associated with clinically relevant increases in TCD velocities nor other relevant adverse events.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, Hamburg University Medical Center, Hamburg, Germany
| | | | - Christian Gerloff
- Department of Neurology, Hamburg University Medical Center, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
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10
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Maruhashi T, Higashi Y. An overview of pharmacotherapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage. Expert Opin Pharmacother 2021; 22:1601-1614. [PMID: 33823726 DOI: 10.1080/14656566.2021.1912013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Survival from aneurysmal subarachnoid hemorrhage has increased in the past few decades. However, functional outcome after subarachnoid hemorrhage is still suboptimal. Delayed cerebral ischemia (DCI) is one of the major causes of morbidity.Areas covered: Mechanisms underlying vasospasm and DCI after aneurysmal subarachnoid hemorrhage and pharmacological treatment are summarized in this review.Expert opinion: Oral nimodine, an L-type dihydropyridine calcium channel blocker, is the only FDA-approved drug for the prevention and treatment of neurological deficits after aneurysmal subarachnoid hemorrhage. Fasudil, a potent Rho-kinase inhibitor, has also been shown to improve the clinical outcome and has been approved in some countries for use in patients with aneurysmal subarachnoid hemorrhage. Although other drugs, including nicardipine, cilostazol, statins, clazosentan, magnesium and heparin, have been expected to have beneficial effects on DCI, there has been no convincing evidence supporting the routine use of those drugs in patients with aneurysmal subarachnoid hemorrhage in clinical practice. Further elucidation of the mechanisms underlying DCI and the development of effective therapeutic strategies for DCI, including combination therapy, are necessary to further improve the functional outcome and mortality after subarachnoid hemorrhage.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
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11
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Macdonald RL, Hänggi D, Ko NU, Darsaut TE, Carlson AP, Wong GK, Etminan N, Mayer SA, Aldrich EF, Diringer MN, Ng D, Strange P, Bleck T, Grubb R, Suarez JI. NEWTON-2 Cisternal (Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage): A Phase 2, Multicenter, Randomized, Open-Label Safety Study of Intracisternal EG-1962 in Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 88:E13-E26. [PMID: 32985652 DOI: 10.1093/neuros/nyaa430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A sustained release microparticle formulation of nimodipine (EG-1962) was developed for treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To assess safety, tolerability, and pharmacokinetics of intracisternal EG-1962 in an open-label, randomized, phase 2 study of up to 12 subjects. METHODS Subjects were World Federation of Neurological Surgeons grades 1 to 2, modified Fisher grades 2 to 4, and underwent aneurysm clipping within 48 h of aSAH. EG-1962, containing 600 mg nimodipine, was administered into the basal cisterns. Outcome on the extended Glasgow Outcome Scale (eGOS), pharmacokinetics, delayed cerebral ischemia and infarction, rescue therapy, and safety were evaluated. RESULTS The study was halted when a phase 3 study of intraventricular EG-1962 stopped because that study was unlikely to meet its primary endpoint. Six subjects were randomized (5 EG-1962 and 1 oral nimodipine). After 90-d follow-up, favorable outcome on the eGOS occurred in 1 of 5 EG-1962 and in the single oral nimodipine patient. Four EG-1962 and the oral nimodipine subject had angiographic vasospasm. One EG-1962 subject had delayed cerebral ischemia, and all subjects with angiographic vasospasm received rescue therapy except 1 EG-1962 patient. One subject treated with EG-1962 developed right internal carotid and middle cerebral artery narrowing 5 mo after placement of EG-1962, leading to occlusion and cerebral infarction. Pharmacokinetics showed similar plasma concentrations of nimodipine in both groups. CONCLUSION Angiographic vasospasm and unfavorable clinical outcome still occurred after placement of EG-1962. Internal carotid artery narrowing and occlusion after placement of EG-1962 in the basal cisterns has not been reported.
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Affiliation(s)
- R Loch Macdonald
- Department of Neurological Surgery, University of California, San Francisco, Fresno, California.,Edge Therapeutics, Berkeley Heights, New Jersey
| | - Daniel Hänggi
- Department of Neurosurgery, Düsseldorf University Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nerissa U Ko
- Department of Neurology, University of California, San Francisco, California
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - George K Wong
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Nima Etminan
- University Medical Center Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Stephan A Mayer
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan
| | - E Francois Aldrich
- Neurological Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Michael N Diringer
- Neurological Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | | | - Poul Strange
- Integrated Medical Development LLC, Princeton, New Jersey
| | - Thomas Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Robert Grubb
- Neurological Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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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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13
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Juif PE, Dingemanse J, Ufer M. Clinical Pharmacology of Clazosentan, a Selective Endothelin A Receptor Antagonist for the Prevention and Treatment of aSAH-Related Cerebral Vasospasm. Front Pharmacol 2021; 11:628956. [PMID: 33613288 PMCID: PMC7890197 DOI: 10.3389/fphar.2020.628956] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/30/2020] [Indexed: 11/16/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm and is associated with significant morbidity and mortality. It represents a major unmet medical need due to few treatment options with limited efficacy. The role of endothelin-1 (ET-1) and its receptor ETA in the pathogenesis of aSAH-induced vasospasm suggests antagonism of this receptor as promising asset for pharmacological treatment. Clazosentan is a potent ETA receptor antagonist for intravenous use currently under development for the prevention of aSAH-induced cerebral vasospasm. The pharmacokinetics of clazosentan are characterized by an intermediate clearance, a volume of distribution similar to that of the extracellular fluid volume, dose-proportional exposure, an elimination independent of drug-metabolizing enzymes, and a disposition mainly dependent on the hepatic uptake transporter organic anion transport polypeptide 1B1/1B3. In healthy subjects, clazosentan leads to an increase in ET-1 concentration and prevents the cardiac and renal effects mediated by infusion of ET-1. In patients, it significantly reduced the incidence of moderate or severe vasospasm as well as post-aSAH vasospasm-related morbidity and mortality. Clazosentan is well tolerated up to the expected therapeutic dose of 15 mg/h and, in aSAH patients, lung complications, hypotension, and anemia were adverse events more commonly reported following clazosentan than placebo. In summary, clazosentan has a pharmacokinetic, pharmacodynamic, and safety profile suitable to become a valuable asset in the armamentarium of therapeutic modalities to prevent aSAH-induced cerebral vasospasm.
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Affiliation(s)
- Pierre-Eric Juif
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
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14
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Chen S, Xu P, Fang Y, Lenahan C. The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies. Curr Neuropharmacol 2020; 18:1266-1278. [PMID: 32928088 PMCID: PMC7770644 DOI: 10.2174/1570159x18666200914161231] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke associated with high mortality and morbidity. The blood-brain-barrier (BBB) is a structure consisting primarily of cerebral microvascular endothelial cells, end feet of astrocytes, extracellular matrix, and pericytes. Post-SAH pathophysiology included early brain injury and delayed cerebral ischemia. BBB disruption was a critical mechanism of early brain injury and was associated with other pathophysiological events. These pathophysiological events may propel the development of secondary brain injury, known as delayed cerebral ischemia. Imaging advancements to measure BBB after SAH primarily focused on exploring innovative methods to predict clinical outcome, delayed cerebral ischemia, and delayed infarction related to delayed cerebral ischemia in acute periods. These predictions are based on detecting abnormal changes in BBB permeability. The parameters of BBB permeability are described by changes in computed tomography (CT) perfusion and magnetic resonance imaging (MRI). Kep seems to be a stable and sensitive indicator in CT perfusion, whereas Ktrans is a reliable parameter for dynamic contrast-enhanced MRI. Future prediction models that utilize both the volume of BBB disruption and stable parameters of BBB may be a promising direction to develop practical clinical tools. These tools could provide greater accuracy in predicting clinical outcome and risk of deterioration. Therapeutic interventional exploration targeting BBB disruption is also promising, considering the extended duration of post-SAH BBB disruption.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - PengLei Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - YuanJian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA,Center for Neuroscience Research, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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15
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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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16
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Cerebrospinal Fluid Concentrations of Nimodipine Correlate With Long-term Outcome in Aneurysmal Subarachnoid Hemorrhage: Pilot Study. Clin Neuropharmacol 2020; 42:157-162. [PMID: 31306217 DOI: 10.1097/wnf.0000000000000356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim was to evaluate plasma and cerebrospinal fluid (CSF) nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage and their correlation with clinical outcome. METHODS Nimodipine infusion was started at 1 mg/h and increased up to 2 mg/h and continued up to 21 days in surviving patients. Arterial and CSF samples were collected at least after 24 hours of stable nimodipine dosing. Delayed cerebral ischemia and vasospasm were documented by new neurological deficits and neuroimaging. The clinical outcome was assessed at 9 months by the modified Rankin scale. RESULTS Twenty-three patients were enrolled. Nimodipine dose was 13 to 38 μg/kg per hour. Nimodipine arterial and CSF concentrations were 24.9 to 71.8 ng/mL and 37 to 530 pg/mL, respectively. Dose did not correlate with arterial or CSF concentrations. Arterial concentrations did not correlate with corresponding CSF concentrations. Doses and arterial concentrations did not correlate with the clinical outcome and were not associated with the occurrence of delayed cerebral ischemia. However, patients with no significant disability after 9 months of hemorrhage showed significantly higher CSF nimodipine concentrations (P = 0.015) and CSF-to-plasma ratios (P = 0.011) compared with patients who showed some degree of disability or who died. CONCLUSIONS Cerebrospinal fluid nimodipine concentrations measured during hospital drug infusion showed a correlation with long-term clinical outcome in patients with aneurysmal subarachnoid hemorrhage. These very preliminary data suggest that CSF concentrations monitoring may have some value in managing these patients.
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17
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Carlson AP, Hänggi D, Wong GK, Etminan N, Mayer SA, Aldrich F, Diringer MN, Schmutzhard E, Faleck HJ, Ng D, Saville BR, Bleck T, Grubb R, Miller M, Suarez JI, Proskin HM, Macdonald RL. Single-Dose Intraventricular Nimodipine Microparticles Versus Oral Nimodipine for Aneurysmal Subarachnoid Hemorrhage. Stroke 2020; 51:1142-1149. [PMID: 32138631 DOI: 10.1161/strokeaha.119.027396] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- EG-1962 is a sustained release formulation of nimodipine administered via external ventricular drain in patients with aneurysmal subarachnoid hemorrhage. A randomized, open-label, phase 1/2a, dose-escalation study provided impetus for this study to evaluate efficacy and safety of a single intraventricular 600 mg dose of EG-1962 to patients with aneurysmal subarachnoid hemorrhage, compared with standard of care oral nimodipine. Methods- Subjects were World Federation of Neurological Surgeons grades 2-4, modified Fisher grades 2-4 and had an external ventricular drain inserted as part of standard of care. The primary end point was the proportion of subjects with favorable outcome at day 90 after aneurysmal subarachnoid hemorrhage (extended Glasgow outcome scale 6-8). The proportion of subjects with favorable outcome at day 90 on the Montreal cognitive assessment, as well as the incidence of delayed cerebral ischemia and infarction, use of rescue therapy and safety were evaluated. Results- The study was halted by the independent data monitoring board after planned interim analysis of 210 subjects (289 randomized) with day 90 outcome found the study was unlikely to achieve its primary end point. After day 90 follow-up of all subjects, the proportion with favorable outcome on the extended Glasgow outcome scale was 45% (65/144) in the EG-1962 and 42% (62/145) in the placebo group (risk ratio, 1.01 [95% CI, 0.83-1.22], P=0.95). Consistent with its mechanism of action, EG-1962 significantly reduced vasospasm (50% [69/138] EG-1962 versus 63% [91/144], P=0.025) and hypotension (7% [9/138] versus 10% [14/144]). Analysis of prespecified subject strata suggested potential efficacy in World Federation of Neurological Surgeons 3-4 subjects (46% [32/69] EG-1962 versus 32% [24/75] placebo, odds ratio, 1.22 [95% CI, 0.94-1.58], P=0.13). No safety concerns were identified that halted the study or that preclude further development. Conclusions- There was no significant increase in favorable outcome for EG-1962 compared with standard of care in the overall study population. The safety profile was acceptable. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02790632.
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Affiliation(s)
- Andrew P Carlson
- From the Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque (A.P.C.)
| | - Daniel Hänggi
- Department of Neurosurgery, Düsseldorf University Hospital, Heinrich-Heine-Universität, Germany (D.H.)
| | - George K Wong
- Department of Surgery and Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, China (G.K.W.)
| | - Nima Etminan
- Department of Neurosurgery, Ruprecht-Karls-University Heidelberg, Mannheim, Germany (N.E.)
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI (S.A.M.)
| | | | - Michael N Diringer
- Neurological Critical Care, Washington University School of Medicine, St Louis, MO (M.N.D.)
| | - Erich Schmutzhard
- Department of Neurology, Neurointensive Care Unit, Medical University Innsbruck, Austria (E.S.)
| | | | - David Ng
- WuXi Clinical, Austin, TX (D.N.)
| | | | - Thomas Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (T.B.)
| | - Robert Grubb
- Department of Neurological Surgery, Washington University Medical Center, St Louis, MO (R.G.)
| | - Michael Miller
- Integrated Medical Development, Princeton Junction, NJ (M.M.)
| | - Jose I Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD (J.I.S.)
| | - Howard M Proskin
- Howard M. Proskin & Associates, Rochester, New York, NY (H.M.P.)
| | - R Loch Macdonald
- Edge Therapeutics, Berkeley Heights, NJ (H.J.F., R.L.M.).,Division of Neurosurgery, Department of Surgery, University Neurosciences Institute, University of Toronto, Canada (R.L.M.).,Department of Neurosurgery, University of California San Francisco-Fresno (R.L.M.)
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Fowler MJ, Cotter JD, Knight BE, Sevick-Muraca EM, Sandberg DI, Sirianni RW. Intrathecal drug delivery in the era of nanomedicine. Adv Drug Deliv Rev 2020; 165-166:77-95. [PMID: 32142739 DOI: 10.1016/j.addr.2020.02.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/17/2019] [Accepted: 02/28/2020] [Indexed: 12/23/2022]
Abstract
Administration of substances directly into the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord is one approach that can circumvent the blood-brain barrier to enable drug delivery to the central nervous system (CNS). However, molecules that have been administered by intrathecal injection, which includes intraventricular, intracisternal, or lumbar locations, encounter new barriers within the subarachnoid space. These barriers include relatively high rates of turnover as CSF clears and potentially inadequate delivery to tissue or cellular targets. Nanomedicine could offer a solution. In contrast to the fate of freely administered drugs, nanomedicine systems can navigate the subarachnoid space to sustain delivery of therapeutic molecules, genes, and imaging agents within the CNS. Some evidence suggests that certain nanomedicine agents can reach the parenchyma following intrathecal administration. Here, we will address the preclinical and clinical use of intrathecal nanomedicine, including nanoparticles, microparticles, dendrimers, micelles, liposomes, polyplexes, and other colloidalal materials that function to alter the distribution of molecules in tissue. Our review forms a foundational understanding of drug delivery to the CSF that can be built upon to better engineer nanomedicine for intrathecal treatment of disease.
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Affiliation(s)
- M J Fowler
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America
| | - J D Cotter
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America
| | - B E Knight
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America
| | - E M Sevick-Muraca
- Brown Foundation Institute of Molecular Medicine, Center for Molecular Imaging, Houston, TX 77030, United States of America
| | - D I Sandberg
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America; Department of Pediatric Surgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America; Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, United States of America
| | - R W Sirianni
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America.
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19
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Effect of Locally Delivered Nimodipine Microparticles on Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 34:345-349. [PMID: 32103439 DOI: 10.1007/s12028-020-00935-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recurrent spreading depolarizations (SDs) occur in patients after aneurysmal subarachnoid hemorrhage (aSAH), resulting in metabolic stress to brain. These events are closely associated with delayed cerebral ischemia. Preclinical data suggest that the beneficial effect of nimodipine demonstrated in clinical trials may be related to inhibition of SD rather than limitation of large artery vasospasm. METHODS Subjects enrolled in a phase 3 trial of intraventricularly delivered, sustained-release nimodipine (EG-1962) versus standard of care oral nimodipine (NEWTON 2) who required surgical clipping had subdural strip electrodes implanted for monitoring of SD. SD was then scored blinded to NEWTON 2 allocation. RESULTS Five subjects underwent electrocorticography monitoring of SD. Three of five patients had SD. There were fewer SDs, a lower rate of SD, and shorter depression durations in subjects treated with EG-1962 compared to standard of care. Outcomes were worse in the standard of care group, though there were baseline imbalances. CONCLUSIONS These results are consistent with a beneficial effect of locally delivered nimodipine (EG-1962) on SD after aSAH in more severely injured patients who are at risk of delayed cerebral ischemia related to SD. Larger studies are warranted to test this effect.
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20
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Carlson AP, Hänggi D, Macdonald RL, Shuttleworth CW. Nimodipine Reappraised: An Old Drug With a Future. Curr Neuropharmacol 2020; 18:65-82. [PMID: 31560289 PMCID: PMC7327937 DOI: 10.2174/1570159x17666190927113021] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/02/2019] [Accepted: 09/25/2019] [Indexed: 12/21/2022] Open
Abstract
Nimodipine is a dihydropyridine calcium channel antagonist that blocks the flux of extracellular calcium through L-type, voltage-gated calcium channels. While nimodipine is FDAapproved for the prevention and treatment of neurological deficits in patients with aneurysmal subarachnoid hemorrhage (aSAH), it affects myriad cell types throughout the body, and thus, likely has more complex mechanisms of action than simple inhibition of cerebral vasoconstriction. Newer understanding of the pathophysiology of delayed ischemic injury after a variety of acute neurologic injuries including aSAH, traumatic brain injury (TBI) and ischemic stroke, coupled with advances in the drug delivery method for nimodipine, have reignited interest in refining its potential therapeutic use. In this context, this review seeks to establish a firm understanding of current data on nimodipine's role in the mechanisms of delayed injury in aSAH, TBI, and ischemic stroke, and assess the extensive clinical data evaluating its use in these conditions. In addition, we will review pivotal trials using locally administered, sustained release nimodipine and discuss why such an approach has evaded demonstration of efficacy, while seemingly having the potential to significantly improve clinical care.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Daniel Hänggi
- Department of Neurosurgery, University of Dusseldorf Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Robert L. Macdonald
- University of California San Francisco Fresno Department of Neurosurgery and University Neurosciences Institute and Division of Neurosurgery, Department of Surgery, University of Toronto, Canada
| | - Claude W. Shuttleworth
- Department of Neuroscience University of New Mexico School of Medicine, Albuquerque, NM, USA
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21
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Griffiths S, Clark J, Adamides AA, Ziogas J. The role of haptoglobin and hemopexin in the prevention of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a review of current literature. Neurosurg Rev 2019; 43:1273-1288. [PMID: 31493061 DOI: 10.1007/s10143-019-01169-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 01/01/2023]
Abstract
Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major cause of mortality and morbidity. The pathophysiology of DCI after aSAH is thought to involve toxic mediators released from lysis of red blood cells within the subarachnoid space, including free haemoglobin and haem. Haptoglobin and hemopexin are endogenously produced acute phase proteins that are involved in the clearance of these toxic mediators. The aim of this review is to investigate the pathophysiological mechanisms involved in DCI and the role of both endogenous as well as exogenously administered haptoglobin and hemopexin in the prevention of DCI.
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Affiliation(s)
- Sean Griffiths
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia. .,Western Hospital, 160 Gordon St, Footscray, 3011, Australia.
| | - Jeremy Clark
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - Alexios A Adamides
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - James Ziogas
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, 3010, Australia
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22
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Safety and Clinical Efficacy of Yangxue Qingnao Granules in the Treatment of Chronic Cerebral Circulation Insufficiency: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:8484263. [PMID: 31485250 PMCID: PMC6710749 DOI: 10.1155/2019/8484263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 11/18/2022]
Abstract
To evaluate the safety and clinical efficacy of Yangxue Qingnao (YXQN) granules in the treatment of chronic cerebral circulation insufficiency (CCCI), electronic databases—PubMed, Embase, CNKI, VIP, and Wangfang—were searched for randomized controlled trials (RCTs) published up to January 2019. GRADE and RevMan 5.3.0 were used for grading and analysis, respectively. Fifteen trials involving 1211 CCCI patients were included. Subgroup analysis was performed owing to study heterogeneity. Compared to nimodipine plus routine treatment, YXQN granules plus routine treatment were more effective in increasing basilar artery (BA) blood flow velocity (mean difference (MD) = 3.34, 95% confidence interval (CI) = [2.31, 4.37], P < 0.00001), vertebral artery (VA) blood flow velocity (MD = 0.52, 95% CI = [0.27, 0.76], P < 0.0001), and internal carotid artery (ICA) blood flow velocity (MD = 7.46, 95% CI = [2.01, 12.90], P=0.007). In improving the clinical efficacy of traditional Chinese medicine (TCM) for symptoms such as headache, dizziness, and insomnia, YXQN granules plus routine treatment were shown to be superior to the following control treatments: nimodipine plus routine treatment (mean difference (M-H) = 4.21, 95% CI = [2.49, 7.12], P < 0.00001), flunarizine plus routine treatment (mean difference (M-H) = 3.92, 95% CI = [1.36, 11.29], P=0.01), troxerutin plus routine treatment (mean difference (M-H) = 4.79, 95% CI = [2.20, 10.42], P < 0.00001), and routine treatment (mean difference (M-H) = 6.13, 95% CI = [1.48, 25.34], P=0.01). Risk of bias was assessed in 15 trials. One analysis was graded using GRADE and showed poor results. Adverse events were not reported explicitly in all but one trial. Thus, this meta-analysis suggests that YXQN granules may be beneficial for patients with CCCI. However, owing to the poor quality of the clinical trials and small sample sizes, a definite conclusion on the efficacy and safety of YXQN granules cannot be drawn from existing information.
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23
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Shao A, Zhou Y, Yao Y, Zhang W, Zhang J, Deng Y. The role and therapeutic potential of heat shock proteins in haemorrhagic stroke. J Cell Mol Med 2019; 23:5846-5858. [PMID: 31273911 PMCID: PMC6714234 DOI: 10.1111/jcmm.14479] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/26/2022] Open
Abstract
Heat shock proteins (HSPs) are induced after haemorrhagic stroke, which includes subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH). Most of these proteins function as neuroprotective molecules to protect cerebral neurons from haemorrhagic stroke and as markers to indicate cellular stress or damage. The most widely studied HSPs in SAH are HSP70, haeme oxygenase-1 (HO-1), HSP20 and HSP27. The subsequent pathophysiological changes following SAH can be divided into two stages: early brain injury and delayed cerebral ischaemia, both of which determine the outcome for patients. Because the mechanisms of HSPs in SAH are being revealed and experimental models in animals are continually maturing, new agents targeting HSPs with limited side effects have been suggested to provide therapeutic potential. For instance, some pharmaceutical agents can block neuronal apoptosis signals or dilate cerebral vessels by modulating HSPs. HO-1 and HSP70 are also critical topics for ICH research, which can be attributed to their involvement in pathophysiological mechanisms and therapeutic potential. However, the process of HO-1 metabolism can be toxic owing to iron overload and the activation of succedent pathways, for example, the Fenton reaction and oxidative damage; the overall effect of HO-1 in SAH and ICH tends to be protective and harmful, respectively, given the different pathophysiological changes in these two types of haemorrhagic stroke. In the present study, we focus on the current understanding of the role and therapeutic potential of HSPs involved in haemorrhagic stroke. Therefore, HSPs may be potential therapeutic targets, and new agents targeting HSPs are warranted.
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Affiliation(s)
- Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yunxiang Zhou
- Department of Surgical Oncology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yihan Yao
- Department of Surgical Oncology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wenhua Zhang
- Department of Neurology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yongchuan Deng
- Department of Surgical Oncology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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24
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Wu L, Su Z, Zha L, Zhu Z, Liu W, Sun Y, Yu P, Wang Y, Zhang G, Zhang Z. Tetramethylpyrazine Nitrone Reduces Oxidative Stress to Alleviate Cerebral Vasospasm in Experimental Subarachnoid Hemorrhage Models. Neuromolecular Med 2019; 21:262-274. [PMID: 31134485 DOI: 10.1007/s12017-019-08543-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 05/10/2019] [Indexed: 12/13/2022]
Abstract
Cerebral vasospasm is one of the deleterious complications after subarachnoid hemorrhage (SAH), leading to delayed cerebral ischemia and permanent neurological deficits or even death. Free radicals and oxidative stress are considered as crucial causes contributing to cerebral vasospasm and brain damage after SAH. Tetramethylpyrazine nitrone (TBN), a derivative of the clinically used anti-stroke drug tetramethylpyrazine armed with a powerful free radical scavenging nitrone moiety, has been reported to prevent brain damage from ischemic stroke. The present study aimed to investigate the effects of TBN on vasospasm and brain damage after SAH. Two experimental SAH models were used, a rat model by endovascular perforation and a rabbit model by intracisternal injection of autologous blood. The effects of TBN on SAH were evaluated assessing basilar artery spasm, neuronal apoptosis, and neurological deficits. TBN treatment significantly attenuated vasospasm, improved neurological behavior functions and reduced the number of apoptotic neurons in both the SAH rats and rabbits. Mechanistically, TBN suppressed the increase in 3-nitrotyrosine and 8-hydroxy-2-deoxyguanosine immuno-positive cells in the cortex of SAH rat brain. Western blot analyses indicated that TBN effectively reversed the altered expression of Bcl-2, Bax and cytochrome C, and up-regulated nuclear factor erythroid-derived 2-like 2 (Nrf2) and hemeoxygenase-1 (HO-1) protein expressions. In the in vitro studies, TBN inhibited H2O2-induced bEnd.3 cell apoptosis and reduced ROS generation. Additionally, TBN alleviated the contraction of rat basilar artery rings induced by H2O2 ex vivo. In conclusion, TBN ameliorated SAH-induced cerebral vasospasm and neuronal damage. These effects of TBN may be attributed to its anti-oxidative stress effect and up-regulation of Nrf2/HO-1.
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Affiliation(s)
- Liangmiao Wu
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Zhiyang Su
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Ling Zha
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Zeyu Zhu
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Wei Liu
- Foshan Magpie Pharmaceuticals Co., LTD, Foshan, Guangdong Province, China
| | - Yewei Sun
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Pei Yu
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Yuqiang Wang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China
| | - Gaoxiao Zhang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China.
| | - Zaijun Zhang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Huangpu Road, Guangzhou, China.
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25
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Christensen ST, Johansson SE, Radziwon-Balicka A, Warfvinge K, Haanes KA, Edvinsson L. MEK1/2 inhibitor U0126, but not nimodipine, reduces upregulation of cerebrovascular contractile receptors after subarachnoid haemorrhage in rats. PLoS One 2019; 14:e0215398. [PMID: 30978262 PMCID: PMC6461292 DOI: 10.1371/journal.pone.0215398] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/02/2019] [Indexed: 12/19/2022] Open
Abstract
Vascular pathophysiological changes after haemorrhagic stroke, such as phenotypic modulation of the cerebral arteries and cerebral vasospasms, are associated with delayed cerebral ischemia (DCI) and poor outcome. The only currently approved drug treatment shown to reduce the risk of DCI and improve neurologic outcome after aneurysmal subarachnoid haemorrhage (SAH) is nimodipine, a dihydropyridine L-type voltage-gated Ca2+ channel blocker. MEK1/2 mediated transcriptional upregulation of contractile receptors, including endothelin-1 (ET-1) receptors, has previously been shown to be a factor in the pathology of SAH. The aim of the study was to compare intrathecal and subcutaneous treatment regimens of nimodipine and intrathecal treatment regimens of U0126, a MEK1/2 inhibitor, in a single injection experimental rat SAH model with post 48 h endpoints consisting of wire myography of cerebral arteries, flow cytometry of cerebral arterial tissue and behavioural evaluation. Following ET-1 concentration-response curves, U0126 exposed arteries had a significantly lower ET-1max than vehicle arteries. Arteries from both the intrathecal- and subcutaneous nimodipine treated animals had significantly higher ET-1max contractions than the U0126 arteries. Furthermore, Ca2+ concentration response curves (precontracted with ET-1 and in the presence of nimodipine) showed that nimodipine treatment could result in larger nimodipine insensitive contractions compared to U0126. Flow cytometry showed decreased protein expression of the ETB receptor in U0126 treated cerebral vascular smooth muscle cells compared to vehicle. Only U0126 treatment lowered ET-1max contractions and ETB receptor levels, as well as decreased the contractions involving nimodipine-insensitive Ca2+ channels, when compared to both intrathecal and subcutaneous nimodipine treatment. This indicate that targeting gene expression might be a better strategy than blocking specific receptors or ion channels in future treatments of SAH.
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Affiliation(s)
- Simon T. Christensen
- Department of Clinical Experimental Research, Copenhagen University Hospital, Rigshospitalet-Glostrup, Denmark
| | - Sara E. Johansson
- Department of Clinical Experimental Research, Copenhagen University Hospital, Rigshospitalet-Glostrup, Denmark
| | - Aneta Radziwon-Balicka
- Department of Clinical Experimental Research, Copenhagen University Hospital, Rigshospitalet-Glostrup, Denmark
| | - Karin Warfvinge
- Department of Clinical Experimental Research, Copenhagen University Hospital, Rigshospitalet-Glostrup, Denmark
- Department of Clinical Sciences, Division of Experimental Vascular Research, Lund University, Lund, Sweden
| | - Kristian A. Haanes
- Department of Clinical Experimental Research, Copenhagen University Hospital, Rigshospitalet-Glostrup, Denmark
- * E-mail:
| | - Lars Edvinsson
- Department of Clinical Experimental Research, Copenhagen University Hospital, Rigshospitalet-Glostrup, Denmark
- Department of Clinical Sciences, Division of Experimental Vascular Research, Lund University, Lund, Sweden
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26
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Kieninger M, Gruber M, Knott I, Dettmer K, Oefner PJ, Bele S, Wendl C, Tuemmler S, Graf B, Eissnert C. Incidence of Arterial Hypotension in Patients Receiving Peroral or Continuous Intra-arterial Nimodipine After Aneurysmal or Perimesencephalic Subarachnoid Hemorrhage. Neurocrit Care 2019; 31:32-39. [DOI: 10.1007/s12028-019-00676-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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27
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Hänggi D, Etminan N, Mayer SA, Aldrich EF, Diringer MN, Schmutzhard E, Faleck HJ, Ng D, Saville BR, Macdonald RL. Clinical Trial Protocol: Phase 3, Multicenter, Randomized, Double-Blind, Placebo-Controlled, Parallel-Group, Efficacy, and Safety Study Comparing EG-1962 to Standard of Care Oral Nimodipine in Adults with Aneurysmal Subarachnoid Hemorrhage [NEWTON-2 (Nimodipine Microparticles to Enhance Recovery While Reducing TOxicity After SubarachNoid Hemorrhage)]. Neurocrit Care 2019; 30:88-97. [PMID: 30014184 DOI: 10.1007/s12028-018-0575-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Nimodipine is the only drug approved in the treatment of aneurysmal subarachnoid hemorrhage (aSAH) in many countries. EG-1962, a product developed using the Precisa™ platform, is an extended-release microparticle formulation of nimodipine that can be administered intraventricularly or intracisternally. It was developed to test the hypothesis that delivering higher concentrations of extended-release nimodipine directly to the cerebrospinal fluid would provide superior efficacy compared to systemic administration. RESULTS A Phase 1/2a multicenter, controlled, randomized, open-label, dose-escalation study determined the maximum tolerated dose and supported the safety and tolerability of EG-1962 in patients with aSAH. EG-1962, 600 mg, was selected for a pivotal, Phase 3 multicenter, randomized, double-blind, placebo-controlled, parallel-group efficacy, and safety study comparing it to standard of care oral nimodipine in adults with aSAH. Key inclusion criteria are patients with a ruptured saccular aneurysm repaired by clipping or coiling, World Federation of Neurological Surgeons grade 2-4, and modified Fisher score of > 1. Patients must have an external ventricular drain as part of standard of care. Patients are randomized to receive intraventricular investigational product (EG-1962 or NaCl solution) and an oral placebo or oral nimodipine in the approved dose regimen (active control) within 48 h of aSAH. The primary objective is to determine the efficacy of EG-1962 compared to oral nimodipine. CONCLUSIONS The primary endpoint is the proportion of subjects with favorable outcome (6-8) on the Extended Glasgow Outcome Scale assessed 90 days after aSAH. The secondary endpoint is the proportion of subjects with favorable outcome on the Montreal Cognitive Assessment 90 days after aSAH. Data on safety, rescue therapy, delayed cerebral infarction, and health economics will be collected. Trail registration NCT02790632.
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Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, University Medical Center Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Nima Etminan
- Department of Neurosurgery, University Medical Center Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | - E Francois Aldrich
- Neurological Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael N Diringer
- Neurological Critical Care, Washington University School of Medicine, St. Louis, MO, USA
| | - Erich Schmutzhard
- Neurointensive Care Unit, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | | | - David Ng
- ResearchPoint Global, Austin, TX, USA
| | | | - R Loch Macdonald
- Edge Therapeutics, Berkeley Heights, NJ, USA
- Division of Neurosurgery, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, St. Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
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28
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Huang W, Du R. 2016-2017 clinical trials in cerebrovascular neurosurgery. J Clin Neurosci 2019; 60:31-35. [PMID: 30626525 DOI: 10.1016/j.jocn.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/03/2018] [Indexed: 11/25/2022]
Abstract
Several clinical trials in cerebrovascular neurosurgery were published during 2016-2017. The Collaborative Unruptured Endovascular versus Surgery Trial (CURES) found no difference in outcome between clipping versus coiling of unruptured aneurysms after one year. The Flow Diversion in the Treatment of Intracranial Aneurysm Trial (FIAT) was terminated due to safety concerns. Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity after Subarachnoid Hemorrhage Trial (NEWTON) and other trials demonstrated no improvement in outcome for vasospasm. The Duration of Prophylaxis after Subarachnoid Hemorrhage Trial (DOPAST) did not show benefit for extended seizure prophylaxis. Minimally Invasive Surgery plus Alteplase in Intracerebral Hemorrhage Evacuation Trial (MISTIE) reported a new strategy for treating intracerebral hemorrhage. A hemorrage site analysis from the Japan Adult Moyamoya Trial (JAM) was presented. The 10-year results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) and the new Asymptomatic Carotid Trial I (ACT I) were reported. Lastly, findings from six ischemic stroke trials were presented.
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Affiliation(s)
- Wendy Huang
- Department of Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, 14445 Olive View Drive, Sylmar, CA, United States
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, United States.
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29
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Taş YÇ, Solaroğlu İ, Gürsoy-Özdemir Y. Spreading Depolarization Waves in Neurological Diseases: A Short Review about its Pathophysiology and Clinical Relevance. Curr Neuropharmacol 2019; 17:151-164. [PMID: 28925885 PMCID: PMC6343201 DOI: 10.2174/1570159x15666170915160707] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/03/2017] [Accepted: 09/09/2017] [Indexed: 02/05/2023] Open
Abstract
Lesion growth following acutely injured brain tissue after stroke, subarachnoid hemorrhage and traumatic brain injury is an important issue and a new target area for promising therapeutic interventions. Spreading depolarization or peri-lesion depolarization waves were demonstrated as one of the significant contributors of continued lesion growth. In this short review, we discuss the pathophysiology for SD forming events and try to list findings detected in neurological disorders like migraine, stroke, subarachnoid hemorrhage and traumatic brain injury in both human as well as experimental studies. Pharmacological and non-pharmacological treatment strategies are highlighted and future directions and research limitations are discussed.
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Affiliation(s)
| | | | - Yasemin Gürsoy-Özdemir
- Address correspondence to these authors at the Department of Neurosurgery, School of Medicine, Koç University, İstanbul, Turkey; Tel: +90 850 250 8250; E-mails: ,
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30
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Bernhardt J, Zorowitz RD, Becker KJ, Keller E, Saposnik G, Strbian D, Dichgans M, Woo D, Reeves M, Thrift A, Kidwell CS, Olivot JM, Goyal M, Pierot L, Bennett DA, Howard G, Ford GA, Goldstein LB, Planas AM, Yenari MA, Greenberg SM, Pantoni L, Amin-Hanjani S, Tymianski M. Advances in Stroke 2017. Stroke 2018; 49:e174-e199. [DOI: 10.1161/strokeaha.118.021380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Julie Bernhardt
- From the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (J.B.)
| | - Richard D. Zorowitz
- MedStar National Rehabilitation Network and Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC (R.D.Z.)
| | - Kyra J. Becker
- Department of Neurology, University of Washington, Seattle (K.J.B.)
| | - Emanuela Keller
- Division of Internal Medicine, University Hospital of Zurich, Switzerland (E.K.)
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Germany (M.D.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, OH (D.W.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Amanda Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.T.)
| | - Chelsea S. Kidwell
- Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
| | - Jean Marc Olivot
- Acute Stroke Unit, Toulouse Neuroimaging Center and Clinical Investigation Center, Toulouse University Hospital, France (J.M.O.)
| | - Mayank Goyal
- Department of Diagnostic and Interventional Neuroradiology, University of Calgary, AB, Canada (M.G.)
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, CHU Reims, Reims Champagne-Ardenne University, France (L.P.)
| | - Derrick A. Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (D.A.B.)
| | - George Howard
- Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.)
| | - Gary A. Ford
- Oxford Academic Health Science Network, United Kingdom (G.A.F.)
| | | | - Anna M. Planas
- Department of Brain Ischemia and Neurodegeneration, Institute for Biomedical Research of Barcelona (IIBB), Consejo Superior de Investigaciones CIentíficas (CSIC), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (A.M.P.)
| | - Midori A. Yenari
- Department of Neurology, University of California, San Francisco (M.A.Y.)
- San Francisco Veterans Affairs Medical Center, CA (M.A.Y.)
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| | - Leonardo Pantoni
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P.)
| | | | - Michael Tymianski
- Departments of Surgery and Physiology, University of Toronto, ON, Canada (M.T.)
- Department of Surgery, University Health Network (Neurosurgery), Toronto, ON, Canada (M.T.)
- Krembil Research Institute, Toronto Western Hospital, ON, Canada (M.T.)
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31
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Bix GJ, Fraser JF, Mack WJ, Carmichael ST, Perez-Pinzon M, Offner H, Sansing L, Bosetti F, Ayata C, Pennypacker KR. Uncovering the Rosetta Stone: Report from the First Annual Conference on Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical. Transl Stroke Res 2018; 9:258-266. [PMID: 29633156 PMCID: PMC5982459 DOI: 10.1007/s12975-018-0628-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 01/12/2023]
Abstract
The first annual Stroke Translational Research Advancement Workshop (STRAW), entitled “Uncovering the Rosetta Stone: Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical” was held at the University of Kentucky on October 4–5, 2017. This workshop was organized by the Center for Advanced Translational Stroke Science. The workshop consisted of 2 days of activities. These included three presentations establishing the areas of research in stroke therapeutics, discussing the routes for translation from bench to bedside, and identifying successes and failures in the field. On day 2, grant funding opportunities and goals for the National Institute for Neurological Diseases and Stroke were presented. In addition, the meeting also included break-out sessions designed to connect researchers in areas of stroke, and to foster potential collaborations. Finally, the meeting concluded with an open discussion among attendees led by a panel of experts.
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Affiliation(s)
- Gregory J Bix
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA.,Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA.,Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA.,Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - William J Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, California, Los Angeles, USA
| | - S Thomas Carmichael
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles, California, Los Angeles, USA
| | - Miguel Perez-Pinzon
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Halina Offner
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA.,Department of Anesthesiology, Oregon Health & Science University, Portland, Oregon, USA.,Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Lauren Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Francesca Bosetti
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Cenk Ayata
- Department of Neurology, Harvard Medical School, Charlestown, MA, USA.,Department of Radiology, Harvard Medical School, Charlestown, MA, USA
| | - Keith R Pennypacker
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA. .,Department of Neurology, University of Kentucky, Lexington, KY, USA. .,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.
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Tallarico RT, Pizzi MA, Freeman WD. Investigational drugs for vasospasm after subarachnoid hemorrhage. Expert Opin Investig Drugs 2018; 27:313-324. [DOI: 10.1080/13543784.2018.1460353] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Stienen MN, Germans M, Burkhardt JK, Neidert MC, Fung C, Bervini D, Zumofen D, Röthlisberger M, Marbacher S, Maduri R, Robert T, Seule MA, Bijlenga P, Schaller K, Fandino J, Smoll NR, Maldaner N, Finkenstädt S, Esposito G, Schatlo B, Keller E, Bozinov O, Regli L. Predictors of In-Hospital Death After Aneurysmal Subarachnoid Hemorrhage: Analysis of a Nationwide Database (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]). Stroke 2018; 49:333-340. [PMID: 29335333 DOI: 10.1161/strokeaha.117.019328] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/10/2017] [Accepted: 12/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To identify predictors of in-hospital mortality in patients with aneurysmal subarachnoid hemorrhage and to estimate their impact. METHODS Retrospective analysis of prospective data from a nationwide multicenter registry on all aneurysmal subarachnoid hemorrhage cases admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009-2015). Both clinical and radiological independent predictors of in-hospital mortality were identified, and their effect size was determined by calculating adjusted odds ratios (aORs) using multivariate logistic regression. Survival was displayed using Kaplan-Meier curves. RESULTS Data of n=1866 aneurysmal subarachnoid hemorrhage patients in the Swiss SOS database were available. In-hospital mortality was 20% (n=373). In n=197 patients (10.6%), active treatment was discontinued after hospital admission (no aneurysm occlusion attempted), and this cohort was excluded from analysis of the main statistical model. In the remaining n=1669 patients, the rate of in-hospital mortality was 13.9% (n=232). Strong independent predictors of in-hospital mortality were rebleeding (aOR, 7.69; 95% confidence interval, 3.00-19.71; P<0.001), cerebral infarction attributable to delayed cerebral ischemia (aOR, 3.66; 95% confidence interval, 1.94-6.89; P<0.001), intraventricular hemorrhage (aOR, 2.65; 95% confidence interval, 1.38-5.09; P=0.003), and new infarction post-treatment (aOR, 2.57; 95% confidence interval, 1.43-4.62; P=0.002). CONCLUSIONS Several-and among them modifiable-factors seem to be associated with in-hospital mortality after aneurysmal subarachnoid hemorrhage. Our data suggest that strategies aiming to reduce the risk of rebleeding are most promising in patients where active treatment is initially pursued. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT03245866.
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Affiliation(s)
- Martin Nikolaus Stienen
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.).
| | - Menno Germans
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Jan-Karl Burkhardt
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Marian C Neidert
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Christian Fung
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - David Bervini
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Daniel Zumofen
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Michel Röthlisberger
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Serge Marbacher
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Rodolfo Maduri
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Thomas Robert
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Martin A Seule
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Philippe Bijlenga
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Karl Schaller
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Javier Fandino
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Nicolas R Smoll
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Nicolai Maldaner
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Sina Finkenstädt
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Giuseppe Esposito
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Bawarjan Schatlo
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Emanuela Keller
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Oliver Bozinov
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Luca Regli
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
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Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Beyond Vasospasm and Towards a Multifactorial Pathophysiology. Curr Atheroscler Rep 2017; 19:50. [PMID: 29063300 DOI: 10.1007/s11883-017-0690-x] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischemia (DCI) is common after subarachnoid hemorrhage (SAH) and represents a significant cause of poor functional outcome. DCI was mainly thought to be caused by cerebral vasospasm; however, recent clinical trials have been unable to confirm this hypothesis. Studies in humans and animal models have since supported the notion of a multifactorial pathophysiology of DCI. This review summarizes some of the main mechanisms under investigation including cerebral vascular dysregulation, microthrombosis, cortical spreading depolarizations, and neuroinflammation. RECENT FINDINGS Recent guidelines have differentiated between DCI and angiographic vasospasm and have highlighted roles of the microvasculature, coagulation and fibrinolytic systems, cortical spreading depressions, and the contribution of the immune system to DCI. Many therapeutic interventions are underway in both preclinical and clinical studies to target these novel mechanisms as well as studies connecting these mechanisms to one another. Clinical trials to date have been largely unsuccessful at preventing or treating DCI after SAH. The only successful pharmacologic intervention is the calcium channel antagonist, nimodipine. Recent studies have provided evidence that cerebral vasospasm is not the sole contributor to DCI and that additional mechanisms may play equal if not more important roles.
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Zussman B, Weiner GM, Ducruet A. Intraventricular Nimodipine for Aneurysmal Subarachnoid Hemorrhage: Results of the NEWTON Phase 1/2a Study. Neurosurgery 2017; 81:N3-N4. [PMID: 28873993 DOI: 10.1093/neuros/nyx260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benjamin Zussman
- University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Gregory M Weiner
- University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
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Rustemi O. Letter by Rustemi Regarding Article, “Randomized, Open-Label, Phase 1/2a Study to Determine the Maximum Tolerated Dose of Intraventricular Sustained Release Nimodipine for Subarachnoid Hemorrhage (NEWTON [Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage])”. Stroke 2017; 48:e113. [DOI: 10.1161/strokeaha.116.016512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Oriela Rustemi
- Department of Neuroscience and Neurosurgery, San Bortolo Hospital, Vicenza, Italy
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Hänggi D, Macdonald RL. Response by Hänggi and Macdonald to Letter Regarding Article, "Randomized, Open-Label, Phase 1/2a Study to Determine the Maximum Tolerated Dose of Intraventricular Sustained Release Nimodipine for Subarachnoid Hemorrhage (NEWTON [Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage])". Stroke 2017; 48:e114. [PMID: 28283608 DOI: 10.1161/strokeaha.117.016603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Canada
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van Lieshout JH, Dibué-Adjei M, Cornelius JF, Slotty PJ, Schneider T, Restin T, Boogaarts HD, Steiger HJ, Petridis AK, Kamp MA. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2017; 41:917-930. [PMID: 28215029 DOI: 10.1007/s10143-017-0827-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
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Affiliation(s)
- Jasper H van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Toni Schneider
- Institute for Neurophysiology, Medical Faculty, University of Cologne, Robert-Koch-Str. 39, 50931, Köln, Germany
| | - Tanja Restin
- Zurich Centre for Integrative Human Physiology, Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Institute of Anesthesiology, Medical Faculty, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios K Petridis
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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