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Sagues E, Gudino A, Dier C, Aamot C, Samaniego EA. Outcomes Measures in Subarachnoid Hemorrhage Research. Transl Stroke Res 2024:10.1007/s12975-024-01284-3. [PMID: 39073651 DOI: 10.1007/s12975-024-01284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/18/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
Despite advancements in acute management, morbidity rates for subarachnoid hemorrhage (SAH) remain high. Therefore, it is imperative to utilize standardized outcome scales in SAH research for evaluating new therapies effectively. This review offers a comprehensive overview of prevalent scales and clinical outcomes used in SAH assessment, accompanied by recommendations for their application and prognostic accuracy. Standardized terminology and diagnostic criteria should be employed when reporting pathophysiological outcomes such as symptomatic vasospasm and delayed cerebral ischemia. Furthermore, integrating clinical severity scales like the World Federation of Neurosurgical Societies scale and modified Fisher score into clinical trials is advised to evaluate their prognostic significance, despite their limited correlation with outcomes. The modified Rankin score is widely used for assessing functional outcomes, while the Glasgow outcome scale-extended version is suitable for broader social and behavioral evaluations. Avoiding score dichotomization is crucial to retain valuable information. Cognitive and behavioral outcomes, though frequently affected in patients with favorable neurological outcomes, are often overlooked during follow-up outpatient visits, despite their significant impact on quality of life. Comprehensive neuropsychological evaluations conducted by trained professionals are recommended for characterizing cognitive function, with the Montreal Cognitive Assessment serving as a viable screening tool. Additionally, integrating psychological inventories like the Beck Depression and Anxiety Inventory, along with quality-of-life scales such as the Stroke-Specific Quality of Life Scale, can effectively assess behavioral and quality of life outcomes in SAH studies.
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Affiliation(s)
- Elena Sagues
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Andres Gudino
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Carlos Dier
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Connor Aamot
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA.
- Department of Radiology, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA.
- Department of Neurosurgery, University of Iowa, 200, Hawkins Drive, Iowa City, IA, USA.
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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Wang K, Chen Y, Xu Y, Yang C, Lai Z, Tan B, Zhu G, Miao H. Perioperative complications of arteriovenous tirofiban administration versus oral dual antiplatelet therapy for stent-assisted embolization treated aneurysmal subarachnoid hemorrhage: A retrospective, controlled cohort analysis. Brain Behav 2024; 14:e3439. [PMID: 38409912 PMCID: PMC10897354 DOI: 10.1002/brb3.3439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Major perioperative complications of stent-assisted embolization treated for aneurysmal subarachnoid hemorrhage patients include the formation of thromboembolic events (TEs) and hemorrhagic events (HEs), for which antiplatelet protocols play a key role. METHODS We conducted a single-center retrospective analysis to compare the differences between arteriovenous tirofiban administration with traditional oral dual antiplatelet therapy (DAPT). A total of 417 consecutive patients were enrolled. General clinical characteristics, as well as the perioperative ischemic and hemorrhagic events, were retracted in digital documents. Logistic regression was conducted to identify both risk and protective factors of perioperative TEs and HEs. RESULTS Perioperative TEs occurred in 21 patients, with an overall perioperative TEs rate of approximately 5.04%; among these patients, the incidence of perioperative TEs in the tirofiban group was less than that in the DAPT group. Additionally, 66 patients developed perioperative HEs, with an incidence of approximately 15.83%; among these patients, the incidence of perioperative HEs was less than that in the DAPT group. No significant differences were seen between the two groups in terms of the mRS score at the time of discharge. CONCLUSION This study indicated that an improved perioperative antiplatelet drug tirofiban was an independent protective factor for perioperative TEs in stent-assisted embolization of ruptured intracranial aneurysms, but it did not impart an elevated risk of perioperative HEs and had no significant effects on the near-term prognosis of the patients.
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Affiliation(s)
- Kaishan Wang
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Yujie Chen
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Yao Xu
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Chen Yang
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Zhaopan Lai
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Binbin Tan
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Gang Zhu
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
| | - Hongping Miao
- Department of Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Clinical Research Center for Neurosurgery, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest HospitalThird Military Medical University (Army Medical University)ChongqingChina
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Wang J, Zou D. Tirofiban-induced thrombocytopenia. Ann Med 2023; 55:2233425. [PMID: 37439782 PMCID: PMC10348023 DOI: 10.1080/07853890.2023.2233425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 06/15/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023] Open
Abstract
Tirofiban is a small non-peptide ligand-mimetic Glycoprotein (GP) IIb/IIIa inhibitor which can reversibly bind to the arginine-glycine-aspartic acid (RGD) recognition site of GP IIb/IIIa to prevent platelet aggregation. It reduces the incidence of thrombotic cardiovascular events in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Although generally considered safe, tirofiban has been reported to be associated with thrombocytopenia in several case reports and clinical trials. The pathogenesis for this adverse reaction is not entirely understood, is thought to be due to immune-mediated reaction. This side effect caused by tirofiban is especially concerning given how frequently it is used in the practice of contemporary cardiovascular care. The present review provides an overview of the pathophysiology, clinical presentation, management, and risk factors associated with tirofiban-induced thrombocytopenia.
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Affiliation(s)
- Jun Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Dongna Zou
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Ohashi SN, DeLong JH, Kozberg MG, Mazur-Hart DJ, van Veluw SJ, Alkayed NJ, Sansing LH. Role of Inflammatory Processes in Hemorrhagic Stroke. Stroke 2023; 54:605-619. [PMID: 36601948 DOI: 10.1161/strokeaha.122.037155] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Hemorrhagic stroke is the deadliest form of stroke and includes the subtypes of intracerebral hemorrhage and subarachnoid hemorrhage. A common cause of hemorrhagic stroke in older individuals is cerebral amyloid angiopathy. Intracerebral hemorrhage and subarachnoid hemorrhage both lead to the rapid collection of blood in the central nervous system and generate inflammatory immune responses that involve both brain resident and infiltrating immune cells. These responses are complex and can contribute to both tissue recovery and tissue injury. Despite the interconnectedness of these major subtypes of hemorrhagic stroke, few reviews have discussed them collectively. The present review provides an update on inflammatory processes that occur in response to intracerebral hemorrhage and subarachnoid hemorrhage, and the role of inflammation in the pathophysiology of cerebral amyloid angiopathy-related hemorrhage. The goal is to highlight inflammatory processes that underlie disease pathology and recovery. We aim to discuss recent advances in our understanding of these conditions and identify gaps in knowledge with the potential to develop effective therapeutic strategies.
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Affiliation(s)
- Sarah N Ohashi
- Department of Neurology (S.N.O., J.H.D., L.H.S.), Yale School of Medicine, New Haven, CT
- Department of Immunobiology (S.N.O., J.H.D., L.H.S.), Yale School of Medicine, New Haven, CT
| | - Jonathan H DeLong
- Department of Neurology (S.N.O., J.H.D., L.H.S.), Yale School of Medicine, New Haven, CT
- Department of Immunobiology (S.N.O., J.H.D., L.H.S.), Yale School of Medicine, New Haven, CT
| | - Mariel G Kozberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital/ Harvard Medical School, Boston (M.G.K., S.J.v.V.)
- MassGeneral Institute for Neurodegenerative Disease, Department of Neurology, Massachusetts General Hospital, Charlestown (M.G.K., S.J.v.V.)
| | - David J Mazur-Hart
- Department of Neurological Surgery (D.J.M.-H.), Oregon Health and Science University (OHSU), Portland
| | - Susanne J van Veluw
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital/ Harvard Medical School, Boston (M.G.K., S.J.v.V.)
- MassGeneral Institute for Neurodegenerative Disease, Department of Neurology, Massachusetts General Hospital, Charlestown (M.G.K., S.J.v.V.)
| | - Nabil J Alkayed
- Department of Anesthesiology & Perioperative Medicine and Knight Cardiovascular Institute (N.J.A.), Oregon Health and Science University (OHSU), Portland
| | - Lauren H Sansing
- Department of Neurology (S.N.O., J.H.D., L.H.S.), Yale School of Medicine, New Haven, CT
- Department of Immunobiology (S.N.O., J.H.D., L.H.S.), Yale School of Medicine, New Haven, CT
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Zeineddine HA, Honarpisheh P, McBride D, Pandit PKT, Dienel A, Hong SH, Grotta J, Blackburn S. Targeting Hemoglobin to Reduce Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Transl Stroke Res 2022; 13:725-735. [PMID: 35157256 PMCID: PMC9375776 DOI: 10.1007/s12975-022-00995-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
Abstract
Delayed cerebral ischemia (DCI) continues to be a sequela of aneurysmal subarachnoid hemorrhage (aSAH) that carries significant morbidity and mortality. Aside from nimodipine, no therapeutic agents are available to reduce the incidence of DCI. Pathophysiologic mechanisms contributing to DCI are poorly understood, but accumulating evidence over the years implicates several factors. Those have included microvessel vasoconstriction, microthrombosis, oxidative tissue damage, and cortical spreading depolarization as well as large vessel vasospasm. Common to these processes is red blood cell leakage into the cerebrospinal fluids (CSF) and subsequent lysis which releases hemoglobin, a central instigator in these events. This has led to the hypothesis that early blood removal may improve clinical outcome and reduce DCI. This paper will provide a narrative review of the evidence of hemoglobin as an instigator of DCI. It will also elaborate on available human data that discuss blood clearance and CSF drainage as a treatment of DCI. Finally, we will address a recent novel device that is currently being tested, the Neurapheresis CSF Management System™. This is an automated dual-lumen lumbar drainage system that has an option to filter CSF and return it to the patient.
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Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Pedram Honarpisheh
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Devin McBride
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Peeyush Kumar Thankamani Pandit
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Ari Dienel
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Sung-Ha Hong
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - James Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA.
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Monsour M, Croci DM, Agazzi S. Microclots in subarachnoid hemorrhage: an underestimated factor in delayed cerebral ischemia? Clin Neurol Neurosurg 2022; 219:107330. [PMID: 35700661 DOI: 10.1016/j.clineuro.2022.107330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 12/01/2022]
Abstract
Subarachnoid hemorrhage has a poor prognosis due to the wide array of associated complications such as vasospasm, early brain injury, cortical spreading depression, oxidative stress, inflammation, and apoptosis. Each of these complications increases the risk of delayed cerebral ischemia (DCI), but recent research has suggested microclots play a substantial role in DCI incidence. This review will focus on the underlying inflammatory and coagulative mechanisms of microthrombosis while also outlining the current literature relating microclot burden to DCI. With a better understanding DCI pathophysiology as it relates to microthrombosis, more effective therapies can be developed in the future to improve clinical outcomes of SAH.
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Affiliation(s)
- Molly Monsour
- University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Davide Marco Croci
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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