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Leppert J, Küchler J, Wagner A, Hinselmann N, Ditz C. Prospective Observational Study of Volatile Sedation with Sevoflurane After Aneurysmal Subarachnoid Hemorrhage Using the Sedaconda Anesthetic Conserving Device. Neurocrit Care 2024:10.1007/s12028-024-01959-7. [PMID: 38485879 DOI: 10.1007/s12028-024-01959-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/09/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Volatile sedation is still used with caution in patients with acute brain injury because of safety concerns. We analyzed the effects of sevoflurane sedation on systemic and cerebral parameters measured by multimodal neuromonitoring in patients after aneurysmal subarachnoid hemorrhage (aSAH) with normal baseline intracranial pressure (ICP). METHODS In this prospective observational study, we analyzed a 12-h period before and after the switch from intravenous to volatile sedation with sevoflurane using the Sedaconda Anesthetic Conserving Device with a target Richmond Agitation Sedation Scale score of - 5 to - 4. ICP, cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO2), metabolic values of cerebral microdialysis, systemic cardiopulmonary parameters, and the administered drugs before and after the sedation switch were analyzed. RESULTS We included 19 patients with a median age of 61 years (range 46-78 years), 74% of whom presented with World Federation of Neurosurgical Societies grade 4 or 5 aSAH. We observed no significant changes in the mean ICP (9.3 ± 4.2 vs. 9.7 ± 4.2 mm Hg), PBrO2 (31.0 ± 13.2 vs. 32.2 ± 12.4 mm Hg), cerebral lactate (5.0 ± 2.2 vs. 5.0 ± 1.9 mmol/L), pyruvate (136.6 ± 55.9 vs. 134.1 ± 53.6 µmol/L), and lactate/pyruvate ratio (37.4 ± 8.7 vs. 39.8 ± 9.2) after the sedation switch to sevoflurane. We found a significant decrease in mean arterial pressure (MAP) (88.6 ± 7.6 vs. 86.3 ± 5.8 mm Hg) and CPP (78.8 ± 8.5 vs. 76.6 ± 6.6 mm Hg) after the initiation of sevoflurane, but the decrease was still within the physiological range requiring no additional hemodynamic support. CONCLUSIONS Sevoflurane appears to be a feasible alternative to intravenous sedation in patients with aSAH without intracranial hypertension, as our study did not show negative effects on ICP, cerebral oxygenation, or brain metabolism. Nevertheless, the risk of a decrease of MAP leading to a consecutive CPP decrease should be considered.
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Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Andreas Wagner
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Niclas Hinselmann
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
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Pugazenthi S, Norris AJ, Lauzier DC, Lele AV, Huguenard A, Dhar R, Zipfel GJ, Athiraman U. Conditioning-based therapeutics for aneurysmal subarachnoid hemorrhage - A critical review. J Cereb Blood Flow Metab 2024; 44:317-332. [PMID: 38017387 PMCID: PMC10870969 DOI: 10.1177/0271678x231218908] [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: 08/21/2023] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) carries significant mortality and morbidity, with nearly half of SAH survivors having major cognitive dysfunction that impairs their functional status, emotional health, and quality of life. Apart from the initial hemorrhage severity, secondary brain injury due to early brain injury and delayed cerebral ischemia plays a leading role in patient outcome after SAH. While many strategies to combat secondary brain injury have been developed in preclinical studies and tested in late phase clinical trials, only one (nimodipine) has proven efficacious for improving long-term functional outcome. The causes of these failures are likely multitude, but include use of therapies targeting only one element of what has proven to be multifactorial brain injury process. Conditioning is a therapeutic strategy that leverages endogenous protective mechanisms to exert powerful and remarkably pleiotropic protective effects against injury to all major cell types of the CNS. The aim of this article is to review the current body of evidence for the use of conditioning agents in SAH, summarize the underlying neuroprotective mechanisms, and identify gaps in the current literature to guide future investigation with the long-term goal of identifying a conditioning-based therapeutic that significantly improves functional and cognitive outcomes for SAH patients.
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Affiliation(s)
- Sangami Pugazenthi
- Department of Neurological Surgery, Washington University, St. Louis MO, USA
| | - Aaron J Norris
- Department of Anesthesiology, Washington University, St. Louis MO, USA
| | - David C Lauzier
- Department of Neurological Surgery, University of California, Los Angeles, CA, USA
| | - Abhijit V Lele
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Anna Huguenard
- Department of Neurological Surgery, Washington University, St. Louis MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Gregory J Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology and Neurological Surgery, Washington University, St. Louis, MO, USA
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Sree A, Hrishi AP, Praveen R, Sethuraman M. Periprocedural management of patients presenting for neurointerventional procedures using flow diverters for complex intracranial aneurysms: An anesthetist's perspective - A narrative review. Brain Circ 2024; 10:21-27. [PMID: 38655436 PMCID: PMC11034442 DOI: 10.4103/bc.bc_77_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 04/26/2024] Open
Abstract
Complex intracranial aneurysms pose significant challenges in the realm of neurointervention, necessitating meticulous planning and execution. This article highlights the crucial roles played by anesthetists in these procedures, including patient assessment, anesthesia planning, and continuous monitoring and maintaining hemodynamic stability, which are pivotal in optimizing patient safety. Understanding these complex procedures and their complications will aid the anesthetist in delivering optimal care and in foreseeing and managing the potential associated complications. The anesthetist's responsibility extends beyond the procedure itself to postprocedure care, ensuring a smooth transition to the recovery phase. Successful periprocedural anesthetic management in flow diverter interventions for complex intracranial aneurysms hinges on carefully orchestrating these elements. Moreover, effective communication and collaboration with the interventional neuroradiologist and the procedural team are emphasized, as they contribute significantly to procedural success. This article underscores the essential requirement for a multidisciplinary team approach when managing patients undergoing neurointerventions. In this collaborative framework, the expertise of the anesthetist harmoniously complements the skills and knowledge of other team members, contributing to the overall success and safety of these procedures. By providing a high level of care throughout the periprocedural period, anesthetists play a pivotal role in enhancing patient outcomes and minimizing the risks associated with these intricate procedures. In conclusion, the periprocedural anesthetic management of neurointervention using flow diverters for complex intracranial aneurysms is a multifaceted process that requires expertise, communication, and collaboration.
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Affiliation(s)
- Anjane Sree
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Ajay Prasad Hrishi
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Ranganatha Praveen
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Manikandan Sethuraman
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Liu M, Jayaraman K, Nelson JW, Mehla J, Diwan D, Vellimana AK, Zipfel GJ, Athiraman U. Propofol Affords No Protection against Delayed Cerebral Ischemia in a Mouse Model of Subarachnoid Hemorrhage. Diseases 2023; 11:130. [PMID: 37873774 PMCID: PMC10594442 DOI: 10.3390/diseases11040130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/25/2023] Open
Abstract
Delayed cerebral ischemia (DCI) is an important contributor to poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. We previously showed that volatile anesthetics such as isoflurane, sevoflurane and desflurane provided robust protection against SAH-induced DCI, but the impact of a more commonly used intravenous anesthetic agent, propofol, is not known. The goal of our current study is to examine the neurovascular protective effects of propofol on SAH-induced DCI. Twelve-week-old male wild-type mice were utilized for the study. Mice underwent endovascular perforation SAH or sham surgery followed one hour later by propofol infusion through the internal jugular vein (2 mg/kg/min continuous intravenous infusion). Large artery vasospasm was assessed three days after SAH. Neurological outcome assessment was performed at baseline and then daily until animal sacrifice. Statistical analysis was performed via one-way ANOVA and two-way repeated measures ANOVA followed by the Newman-Keuls multiple comparison test with significance set at p < 0.05. Intravenous propofol did not provide any protection against large artery vasospasm or sensory-motor neurological deficits induced by SAH. Our data show that propofol did not afford significant protection against SAH-induced DCI. These results are consistent with recent clinical studies that suggest that the neurovascular protection afforded by anesthetic conditioning is critically dependent on the class of anesthetic agent.
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Affiliation(s)
- Meizi Liu
- Molecular Cell Biology, Washington University, St. Louis, MO 63110, USA
| | - Keshav Jayaraman
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, USA
| | - James W. Nelson
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, USA
| | - Jogender Mehla
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, USA
| | - Deepti Diwan
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, USA
| | - Ananth K. Vellimana
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, USA
- Department of Radiology, Washington University, St. Louis, MO 63110, USA
- Department of Neurology, Washington University, St. Louis, MO 63110, USA
| | - Gregory J. Zipfel
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, USA
- Department of Neurology, Washington University, St. Louis, MO 63110, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology, Washington University, Campus Box 8054, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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Liu M, Jayaraman K, Norris AJ, Hussein A, Nelson JW, Mehla J, Diwan D, Vellimana A, Abu-Amer Y, Zipfel GJ, Athiraman U. Isoflurane Conditioning-Induced Delayed Cerebral Ischemia Protection in Subarachnoid Hemorrhage-Role of Inducible Nitric Oxide Synthase. J Am Heart Assoc 2023:e029975. [PMID: 37449587 PMCID: PMC10382105 DOI: 10.1161/jaha.123.029975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
Background Recent evidence implicates inflammation as a key driver in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (SAH). Inducible nitric oxide synthase (iNOS) is one of the known major mediators of inflammation. We previously showed that an inhalational anesthetic, isoflurane, provides strong protection against delayed cerebral ischemia after SAH. Our current study aims to define the role of iNOS in isoflurane conditioning-induced protection against delayed cerebral ischemia in a mouse model of SAH. Methods and Results The experiments used 10- to 14-week-old male wild-type (C57BL/6) and iNOS global knockout mice. Anesthetic conditioning was initiated 1 hour after SAH with isoflurane 2% for 1 hour. Isoflurane-induced changes in iNOS expression were measured. N-(3-(aminomethyl) benzyl) acetamidine, a highly selective iNOS inhibitor, was injected intraperitoneally immediately after SAH and then daily. Vasospasm, microvessel thrombosis, and neurological assessment was performed. Data were analyzed by 1-way ANOVA and 2-way repeated measures ANOVA followed by Student Newman Keuls comparison test. Statistical significance was set at P<0.05. Isoflurane conditioning downregulated iNOS expression in naïve and SAH mice. N-(3-(aminomethyl) benzyl) acetamidine attenuated large artery vasospasm and microvessel thrombosis and improved neurological deficits in wild-type animals. iNOS knockout mice were significantly resistant to vasospasm, microvessel thrombosis, and neurological deficits induced by SAH. Combining isoflurane with N-(3-(aminomethyl) benzyl) acetamidine did not offer extra protection, nor did treating iNOS knockout mice with isoflurane. Conclusions Isoflurane conditioning-induced delayed cerebral ischemia protection appears to be mediated by downregulating iNOS. iNOS is a potential therapeutic target to improve outcomes after SAH.
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Affiliation(s)
- Meizi Liu
- Department of Anesthesiology Washington University St. Louis MO USA
| | - Keshav Jayaraman
- Department of Anesthesiology Washington University St. Louis MO USA
| | - Aaron J Norris
- Department of Anesthesiology Washington University St. Louis MO USA
| | - Ahmed Hussein
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - James W Nelson
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - Jogender Mehla
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - Deepti Diwan
- Department of Neurological Surgery Washington University St. Louis MO USA
| | - Ananth Vellimana
- Department of Neurological Surgery Washington University St. Louis MO USA
- Department of Radiology Washington University St. Louis MO USA
- Department of Neurology Washington University St. Louis MO USA
| | - Yousef Abu-Amer
- Department of Orthopedics Washington University St. Louis MO USA
- Department of Cell Biology & Physiology Washington University St. Louis MO USA
| | - Gregory J Zipfel
- Department of Neurological Surgery Washington University St. Louis MO USA
- Department of Neurology Washington University St. Louis MO USA
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Shao E, Hasanaly N, Venkatraghavan L. Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2021. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis review is a synopsis of selected articles from neuroscience, neuroanesthesia, and neurocritical care from 2021 (January–December 2021). The journals reviewed include anesthesia journals, critical care medicine journals, neurology, and neurosurgical journals as well as high-impact medical journals such as the Lancet, Journal of American Medical Association, New England Journal of Medicine, and Stroke. This summary of important articles will serve to update the knowledge of anesthesiologists and other perioperative physicians who provide care to neurosurgical and neurocritical care patients. In addition, some of the important narrative reviews that are of interest to neuroanesthesiologists are also listed.
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Affiliation(s)
- Evan Shao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nahemah Hasanaly
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
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