1
|
Gupta R, Woodward K, Fiorella D, Woo HH, Liebeskind D, Frei D, Siddiqui A, De Leacy R, Hanel R, Elijovich L, Maud A. Primary results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following Aneurysm Subarachnoid Hemorrhage (VITAL) Study. J Neurointerv Surg 2021; 14:815-819. [PMID: 34493577 DOI: 10.1136/neurintsurg-2021-017859] [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: 06/04/2021] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is linked to worse neurological outcomes. The NeVa VS is a novel cerebral dilation device based on predicate stent retrievers. We report the results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following aSAH (VITAL) Study. METHODS This was a single-arm prospective multicenter trial to assess the safety and probable benefit of the NeVa VS device to treat CV. Patients were screened and treated if they had CV >50% on non-invasive imaging confirmed by cerebral angiography. The vessel diameters were measured before and after treatment by an independent core laboratory. The primary endpoint was ≥50% vessel diameter immediately after treatment with the NeVa VS device. RESULTS Thirty patients with a mean age of 52±11 years and mean Hunt-Hess grade of 3.1±0.9 were enrolled. A total of 74 vessels were treated with an average of 1.3 deployments per vessel (95 deployments total). The mean pre-treatment narrowing of the target vessel (n=74) was 65.6% with reduction of the narrowing to 29.4% after treatment. The primary endpoint was achieved in 64 of 74 vessels (86.5%). In three of 95 total deployments (3.2%), thrombus at the site of deployment was observed during the procedure without apparent neurological sequelae. CONCLUSIONS The NeVa VS device appears to be a safe treatment to regain vessel diameter in severely narrowed intracranial arteries secondary to CV associated with aSAH. This treatment offers a new tool that allows for controlled vessel expansion to treat CV.
Collapse
Affiliation(s)
- Rishi Gupta
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Keith Woodward
- Department of Radiology, Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.,Neurosurgery, SUNY Stony Brook, Stony Brook, New York, USA
| | - Henry H Woo
- Neurosurgery, Northwell Health, Manhasset, New York, USA
| | | | - Donald Frei
- Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
| | - Adnan Siddiqui
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | - Ricardo Hanel
- Neurosurgery, Lyerly Neurosurgery Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Lucas Elijovich
- Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Alberto Maud
- Neurology, Texas Tech University Health Sciences Center - El Paso, El Paso, Texas, USA
| | | |
Collapse
|
2
|
The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model. J Trauma Acute Care Surg 2017. [PMID: 28632582 DOI: 10.1097/ta.0000000000001518] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite clinical reports of poor outcomes, the degree to which resuscitative endovascular balloon occlusion of the aorta (REBOA) exacerbates traumatic brain injury (TBI) is not known. We hypothesized that combined effects of increased proximal mean arterial pressure (pMAP), carotid blood flow (Qcarotid), and intracranial pressure (ICP) from REBOA would lead to TBI progression compared with partial aortic occlusion (PAO) or no intervention. METHODS Twenty-one swine underwent a standardized TBI via computer Controlled cortical impact followed by 25% total blood volume rapid hemorrhage. After 30 minutes of hypotension, animals were randomized to 60 minutes of continued hypotension (Control), REBOA, or PAO. REBOA and PAO animals were then weaned from occlusion. All animals were resuscitated with shed blood via a rapid blood infuser. Physiologic parameters were recorded continuously and brain computed tomography obtained at specified intervals. RESULTS There were no differences in baseline physiology or during the initial 30 minutes of hypotension. During the 60-minute intervention period, REBOA resulted in higher maximal pMAP (REBOA, 105.3 ± 8.8; PAO, 92.7 ± 9.2; Control, 48.9 ± 7.7; p = 0.02) and higher Qcarotid (REBOA, 673.1 ± 57.9; PAO, 464.2 ± 53.0; Control, 170.3 ± 29.4; p < 0.01). Increases in ICP were greatest during blood resuscitation, with Control animals demonstrating the largest peak ICP (Control, 12.8 ± 1.2; REBOA, 5.1 ± 0.6; PAO, 9.4 ± 1.1; p < 0.01). There were no differences in the percentage of animals with hemorrhage progression on CT (Control, 14.3%; 95% confidence interval [CI], 3.6-57.9; REBOA, 28.6%; 95% CI, 3.7-71.0; and PAO, 28.6%; 95% CI, 3.7-71.0). CONCLUSION In an animal model of TBI and shock, REBOA increased Qcarotid and pMAP, but did not exacerbate TBI progression. PAO resulted in physiology closer to baseline with smaller increases in ICP and pMAP. Rapid blood resuscitation, not REBOA, resulted in the largest increase in ICP after intervention, which occurred in Control animals. Continued studies of the cerebral hemodynamics of aortic occlusion and blood transfusion are required to determine optimal resuscitation strategies for multi-injured patients.
Collapse
|
3
|
Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg 2016; 80:372-8; discussion 378-80. [PMID: 26670114 DOI: 10.1097/ta.0000000000000940] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combat-injured patients may require rapid and sustained support during transport; however, the prolonged aortic occlusion produced by conventional resuscitative endovascular balloon occlusion of the aorta (REBOA) may lead to substantial morbidity. Partial REBOA (P-REBOA) may permit longer periods of occlusion by allowing some degree of distal perfusion. However, the ability of this procedure to limit exsanguination is unclear. We evaluated the impact of P-REBOA on immediate survival and ongoing hemorrhage in a highly lethal swine liver injury model. METHODS Fifteen Yorkshire-cross swine were anesthetized, instrumented, splenectomized, and subjected to rapid 10% total blood loss followed by 30% liver amputation. Coagulopathy was created through colloid hemodilution. Randomized swine received no intervention (control), P-REBOA, or complete REBOA (C-REBOA). Central mean arterial pressure (cMAP), carotid blood flow, and blood loss were recorded. Balloons remained inflated in the P-REBOA and C-REBOA groups for 90 minutes followed by graded deflation. The study ended at 180 minutes from onset of hemorrhage or death of the animal. Survival analysis was performed, and data were analyzed using repeated-measures analysis of variance with post hoc pairwise comparisons. RESULTS Mean survival times in the control, P-REBOA, and C-REBOA groups were, 25 ± 21, 86 ± 40, and 163 ± 20 minutes, respectively (p < 0.001). Blood loss was greater in the P-REBOA group than the C-REBOA or control groups, but this difference was not significant (4,722 ± 224, 3,834 ± 319, 3,818 ± 37 mL, respectively, p = 0.10). P-REBOA resulted in maintenance of near-baseline carotid blood flow and cMAP, while C-REBOA generated extreme cMAP and prolonged supraphysiologic carotid blood flow. Both experimental groups experienced profound decreases in cMAP following balloon deflation. CONCLUSION In the setting of severe ongoing hemorrhage, P-REBOA increased survival time beyond the golden hour while maintaining cMAP and carotid flow at physiologic levels.
Collapse
|
4
|
Abstract
OPINION STATEMENT New neuroprotective treatments aimed at preventing or minimizing "delayed brain injury" are attractive areas of investigation and hold the potential to have substantial beneficial effects on aneurysmal subarachnoid hemorrhage (aSAH) survivors. The underlying mechanisms for this "delayed brain injury" are multi-factorial and not fully understood. The most ideal treatment strategies would have the potential for a pleotropic effect positively modulating multiple implicated pathophysiological mechanisms at once. My personal management (RFJ) of patients with aneurysmal subarachnoid hemorrhage closely follows those treatment recommendations contained in modern published guidelines. However, over the last 5 years, I have also utilized a novel treatment strategy, originally developed at the University of Maryland, which consists of a 14-day continuous low-dose intravenous heparin infusion (LDIVH) beginning 12 h after securing the ruptured aneurysm. In addition to its well-known anti-coagulant properties, unfractionated heparin has potent anti-inflammatory effects and through multiple mechanisms may favorably modulate the neurotoxic and neuroinflammatory processes prominent in aneurysmal subarachnoid hemorrhage. In my personal series of patients treated with LDIVH, I have found significant preservation of neurocognitive function as measured by the Montreal Cognitive Assessment (MoCA) compared to a control cohort of my patients treated without LDIVH (RFJ unpublished data presented at the 2015 AHA/ASA International Stroke Conference symposium on neuroinflammation in aSAH and in abstract format at the 2015 AANS/CNS Joint Cerebrovascular Section Annual Meeting). It is important for academic physicians involved in the management of these complex patients to continue to explore new treatment options that may be protective against the potentially devastating "delayed brain injury" following cerebral aneurysm rupture. Several of the treatment options included in this review show promise and could be carefully adopted as the level of evidence for each improves. Other proposed neuroprotective treatments like statins and magnesium sulfate were previously thought to be very promising and to varying degrees were adopted at numerous institutions based on somewhat limited human evidence. Recent clinical trials and meta-analysis have shown no benefit for these treatments, and I currently no longer utilize either treatment as prophylaxis in my practice.
Collapse
|
5
|
Winship IR. Cerebral collaterals and collateral therapeutics for acute ischemic stroke. Microcirculation 2015; 22:228-36. [PMID: 25351102 DOI: 10.1111/micc.12177] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/22/2014] [Indexed: 11/29/2022]
Abstract
Cerebral collaterals are vascular redundancies in the cerebral circulation that can partially maintain blood flow to ischemic tissue when primary conduits are blocked. After occlusion of a cerebral artery, anastomoses connecting the distal segments of the MCA with distal branches of the ACA and PCA (known as leptomeningeal or pial collaterals) allow for partially maintained blood flow in the ischemic penumbra and delay or prevent cell death. However, collateral circulation varies dramatically between individuals, and collateral extent is significant predictor of stroke severity and recanalization rate. Collateral therapeutics attempt to harness these vascular redundancies by enhancing blood flow through pial collaterals to reduce ischemia and brain damage after cerebral arterial occlusion. While therapies to enhance collateral flow remain relatively nascent neuroprotective strategies, experimental therapies including inhaled NO, transient suprarenal aortic occlusion, and electrical stimulation of the parasympathetic sphenopalatine ganglion show promise as collateral therapeutics with the potential to improve treatment of acute ischemic stroke.
Collapse
Affiliation(s)
- Ian R Winship
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
6
|
Guluma KZ, Liebeskind DS, Raman R, Rapp KS, Ernstrom KB, Alexandrov AV, Shahripour RB, Barlinn K, Starkman S, Grunberg ID, Hemmen TM, Meyer BC, Alexandrov AW. Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke-The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial. J Stroke Cerebrovasc Dis 2015; 24:2596-604. [PMID: 26347398 DOI: 10.1016/j.jstrokecerebrovasdis.2015.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/28/2015] [Accepted: 07/16/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND External counterpulsation (ECP) increases perfusion to a variety of organs and may be helpful for acute stroke. METHODS We conducted a single-blinded, prospective, randomized controlled feasibility and safety trial of ECP for acute middle cerebral artery (MCA) ischemic stroke. Twenty-three patients presenting within 48 hours of symptom onset were randomized into one of two groups. One group was treated with ECP for 1 hour at a pressure of up to 300 mmHg ("full pressure"). During the procedure, we also determined the highest possible pressure that would augment MCA mean flow velocity (MFV) by 15%. The other group was treated with ECP at 75 mmHg ("sham pressure"). Transcranial Doppler MCA flow velocities and National Institutes of Health Stroke Scale (NIHSS) scores of both groups were checked before, during, and after ECP. Outcomes were assessed at 30 days after randomization. RESULTS Although the procedures were feasible to implement, there was a frequent inability to augment MFV by 15% despite maximal pressures in full-pressure patients. In sham-pressure patients, however, MFV frequently increased as shown by increases in peak systolic velocity and end diastolic velocity. In both groups, starting ECP was often associated with contemporaneous improvements in NIHSS stroke scores. There were no between-group differences in NIHSS, modified Rankin Scale Scores, and Barthel Indices, and no device or treatment-related serious adverse events, deaths, intracerebral hemorrhages, or episodes of acute neuro-worsening. CONCLUSIONS ECP was safe and feasible to use in patients with acute ischemic stroke. It was associated with unexpected effects on flow velocity, and contemporaneous improvements in NIHSS score regardless of pressure used, with a possibility that even very low ECP pressures had an effect. Further study is warranted.
Collapse
Affiliation(s)
- Kama Z Guluma
- Department of Emergency Medicine, University of California, San Diego, California, USA.
| | - David S Liebeskind
- UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, California, USA
| | - Rema Raman
- Family Medicine and Public Health and Neurosciences, University of California, San Diego, La Jolla, California, USA
| | - Karen S Rapp
- UCSD Stroke and Coordinating Center, University of California, San Diego, La Jolla, California, USA
| | - Karin B Ernstrom
- Family Medicine & Public Health, University of California, San Diego, La Jolla, California, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Reza B Shahripour
- Neurosonology, Comprehensive Stroke Center, University of Alabama, Birmingham, Alabama, USA
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Carl Gustav Carus University Hospital Dresden, Dresden, Germany
| | - Sidney Starkman
- UCLA Stroke Center and Departments of Emergency Medicine and Neurology, University of California, Los Angeles, California, USA
| | - Ileana D Grunberg
- UCLA Stroke Network, University of California, Los Angeles, California, USA
| | - Thomas M Hemmen
- Department of Neurosciences, UCSD Stroke Program, University of California, San Diego, La Jolla, California, USA
| | - Brett C Meyer
- Department of Neurosciences, UCSD Stroke Program, University of California, San Diego, La Jolla, California, USA
| | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
7
|
Durrant JC, Hinson HE. Rescue therapy for refractory vasospasm after subarachnoid hemorrhage. Curr Neurol Neurosci Rep 2015; 15:521. [PMID: 25501582 DOI: 10.1007/s11910-014-0521-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia.
Collapse
Affiliation(s)
- Julia C Durrant
- Department of Neurology and Neurocritical Care, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, CR-127, Portland, OR, 97239, USA,
| | | |
Collapse
|
8
|
Yadollahikhales G, Borhani-Haghighi A, Torabi-Nami M, Edgell R, Cruz-Flores S. Flow Augmentation in Acute Ischemic Stroke. Clin Appl Thromb Hemost 2014; 22:42-51. [PMID: 25475112 DOI: 10.1177/1076029614561320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There is an urgent need for additional therapeutic options for acute ischemic stroke considering the major pitfalls of the options available. Herein, we briefly review the role of cerebral blood flow, collaterals, vasoreactivity, and reperfusion injury in acute ischemic stroke. Then, we reviewed pharmacological and interventional measures such as volume expansion and induced hypertension, intra-aortic balloon counterpulsation, partial aortic occlusion, extracranial-intracranial carotid bypass surgery, sphenopalatine ganglion stimulation, and transcranial laser therapy with regard to their effects on flow augmentation and neuroprotection.
Collapse
Affiliation(s)
- Golnaz Yadollahikhales
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Afshin Borhani-Haghighi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran Neurology Department, Namazi hospital, Shiraz, Fars, Iran
| | - Mohammad Torabi-Nami
- Department of Neuroscience, School of Advanced Medical Science and Technologies, Shiraz University of Medical sciences, Shiraz, Fars, Iran
| | - Randall Edgell
- Departments of Neurology and Psychiatry, Saint Louis University, Saint Louis, MO, USA
| | | |
Collapse
|
9
|
Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. INTERVENTIONAL NEUROLOGY 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
Collapse
Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
| |
Collapse
|
10
|
|
11
|
Griessenauer CJ, Foreman P, Deveikis JP, Harrigan MR. Endovascular Tools Available for the Treatment of Cerebrovascular Disease. Neurosurg Clin N Am 2014; 25:387-94. [DOI: 10.1016/j.nec.2014.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
12
|
Pfluecke C, Christoph M, Kolschmann S, Tarnowski D, Forkmann M, Jellinghaus S, Poitz DM, Wunderlich C, Strasser RH, Schoen S, Ibrahim K. Intra-aortic balloon pump (IABP) counterpulsation improves cerebral perfusion in patients with decreased left ventricular function. Perfusion 2014; 29:511-6. [DOI: 10.1177/0267659114525218] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The current goal of treatment after acute ischemic stroke is the increase of cerebral blood flow (CBF) in ischemic brain tissue. Intra-aortic balloon pump (IABP) counterpulsation in the setting of cardiogenic shock is able to reduce left ventricular afterload and increase coronary blood flow. The effects of an IABP on CBF have not been sufficiently examined. We hypothesize that the use of an IABP especially enhances cerebral blood flow in patients with pre-existing heart failure. Methods: In this pilot study, 36 subjects were examined to investigate the effect of an IABP on middle cerebral artery (MCA) transcranial Doppler (TCD) flow velocity change and relative CBF augmentation by determining velocity time integral changes (ΔVTI) in a constant caliber of the MCA compared to a baseline measurement without an IABP. Subjects were divided into two groups according to their left ventricular ejection fraction (LVEF): Group 1 LVEF >30% and Group 2 LVEF ≤30%. Results: Both groups showed an increase in CBF using an IABP. Patients with a LVEF ≤30% showed a significantly higher increase of ΔVTI in the MCA under IABP augmentation compared to patients with a LVEF >30% (20.9% ± 3.9% Group 2 vs.10.5% ± 2.2% Group 1, p<0,05). The mean arterial pressure (MAP) increased only marginally in both groups under IABP augmentation. Conclusions: IABP improves cerebral blood flow, particularly in patients with pre-existing heart failure and highly impaired LVEF. Hence, an IABP might be a treatment option to improve cerebral perfusion in selected patients with cerebral misperfusion and simultaneously existing severe heart failure.
Collapse
Affiliation(s)
- C Pfluecke
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - M Christoph
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - S Kolschmann
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - D Tarnowski
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - M Forkmann
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - S Jellinghaus
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - DM Poitz
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - C Wunderlich
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - RH Strasser
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - S Schoen
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - K Ibrahim
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| |
Collapse
|
13
|
Shigesato S, Shimizu T, Kittaka T, Akimoto H. Intra-aortic balloon occlusion catheter for treating hemorrhagic shock after massive duodenal ulcer bleeding. Am J Emerg Med 2014; 33:473.e1-2. [PMID: 25633531 DOI: 10.1016/j.ajem.2014.01.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 10/25/2022] Open
Abstract
Clamping the descending aorta by emergency thoracotomy is a well-known effective procedure to stop bleeding from lesions under the diaphragm. We successfully treated a case of cardiopulmonary arrest resulting from a massive duodenal ulcer hemorrhage using an intraaortic balloon occlusion (IABO) catheter instead of the conventional technique. Our experience suggests that IABO catheters can be used to treat patients with hemorrhagic shock regardless of the presence of cardiopulmonary arrest. This can be a life-saving procedure, which prevents ischemic brain injury. This article describes the advantages of using IABO catheters and our experience with this case.
Collapse
Affiliation(s)
- Shintaro Shigesato
- Osaka Mishima Emergency Medical Critical Care Center, Takatsuki City, Osaka 569-1124, Japan
| | - Tetsunosuke Shimizu
- Osaka Mishima Emergency Medical Critical Care Center, Takatsuki City, Osaka 569-1124, Japan
| | - Tadahiro Kittaka
- Osaka Mishima Emergency Medical Critical Care Center, Takatsuki City, Osaka 569-1124, Japan
| | - Hiroshi Akimoto
- Osaka Mishima Emergency Medical Critical Care Center, Takatsuki City, Osaka 569-1124, Japan.
| |
Collapse
|
14
|
Ducruet AF, Albuquerque FC, Crowley RW, Williamson R, Forseth J, McDougall CG. Balloon-Pump Counterpulsation for Management of Severe Cardiac Dysfunction After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2013; 80:e347-52. [DOI: 10.1016/j.wneu.2012.05.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 05/23/2012] [Indexed: 10/27/2022]
|
15
|
L L Yeo L, Sharma VK. The quest for arterial recanalization in acute ischemic stroke-the past, present and the future. J Clin Med Res 2013; 5:251-65. [PMID: 23864913 PMCID: PMC3712879 DOI: 10.4021/jocmr1342w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2013] [Indexed: 01/19/2023] Open
Abstract
Ischemic stroke is one of the major causes of mortality and long-term disability. In the recent past, only very few treatment options were available and a considerable proportion of stroke survivors remained permanently disabled. However, over the last 2 decades rapid advances in acute stroke care have resulted in a corresponding improvement in mortality rates and functional outcomes. In this review, we describe the evolution of systemic thrombolytic agents and various interventional devices, their current status as well as some of the future prospects. We reviewed literature pertaining to acute ischemic stroke reperfusion treatment. We explored the current accepted treatment strategies to attain cerebral reperfusion via intravenous modalities and compare and contrast them within the boundaries of their clinical trials. Subsequently we reviewed the trials for interventional devices for acute ischemic stroke, categorizing them into thrombectomy devices, aspiration devices, clot disruption devices and thrombus entrapment devices. Finally we surveyed several of the alternative reperfusion strategies available. We also shed some light on the controversies surrounding the current strategies of treatment of acute ischemic stroke. Acute invasive interventional strategies continue to improve along with the noninvasive modalities. Both approaches appear promising. We conducted a comprehensive chronological review of the existing treatments as well as upcoming remedies for acute ischemic stroke.
Collapse
Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, National University Hospital, Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | |
Collapse
|
16
|
Bulters DO, Birch AA, Hickey E, Tatlow I, Sumner K, Lamb R, Lang D. A randomized controlled trial of prophylactic intra-aortic balloon counterpulsation in high-risk aneurysmal subarachnoid hemorrhage. Stroke 2012; 44:224-6. [PMID: 23086673 DOI: 10.1161/strokeaha.112.673251] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To assess whether prophylactic postoperative intraaortic balloon counterpulsation (IABC) reduces the risk of poor outcome because of vasospasm following aneurysmal subarachnoid haemorrhage relative to conventional hypervolemic therapy (HT). METHODS This was a single-center, parallel group randomized controlled trial. Patients suffering a subarachnoid hemorrhage at high risk of vasospasm were eligible. Patients were randomly allocated to receive prophylactic IABC (n=35) or HT (n=36). The primary end point was Glasgow Outcome and SF-36 scores assessed at 6 months by a blinded and independent observer and analyzed by intention to treat. Secondary analysis of physiological parameters was by treatment performed. RESULTS Twenty-seven patients in each arm had a good outcome (P=0.55). There was no statistical difference in mean SF-36 score (t=0.39, P=0.70). There were no long-term complications secondary to IABC. There were no differences in preload (pulmonary artery wedge pressure, P=0.97) or afterload (mean arterial pressure, P=0.97). IABC was associated with a lower cardiac output (P=0.002) and higher systemic vascular resistance (P=0.005), although for both groups mean cardiac output was >6 L/min. Cerebral blood flow was not different between groups: HT=41.5 (SD 7.2), IABP=44.9 (SD 8.6) mL/100 g/min (P=0.14). CONCLUSIONS In this study, prophylactic IABC did not improve perfusion indices or confer any clinical benefit following subarachnoid haemorrhage in patients with normal cardiac function. The study was small, however, and cannot be extrapolated to patients with cardiac failure and medically refractory symptomatic cerebral vasospasm. Clinical Trial Registration- This trial was not registered because enrolment began prior to July 1, 2005.
Collapse
Affiliation(s)
- Diederik Olivier Bulters
- FRCS(SN), Wessex Neurological Centre, University Hospital Southampton, Southampton S016 6YD, UK.
| | | | | | | | | | | | | |
Collapse
|
17
|
Leker RR, Molina C, Cockroft K, Liebeskind DS, Concha M, Shuaib A, De Deyn PP, Burgin WS, Gupta R, Dillon W, Diener HC. Effects of age on outcome in the SENTIS trial: better outcomes in elderly patients. Cerebrovasc Dis 2012; 34:263-71. [PMID: 23075518 DOI: 10.1159/000342668] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 08/13/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increasing age is associated with poor outcome after stroke. The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke (SENTIS) trial explored the augmentation of collateral circulation to the ischemic penumbra as a novel approach to stroke treatment. The aim of this post hoc analysis was to examine the effect of age on outcomes in the SENTIS trial. METHODS Using data from the randomized controlled SENTIS trial, we explored outcomes of cerebral blood flow augmentation using the NeuroFlo™ device in patients categorized by age strata at 70 and 80 years. We evaluated outcomes of overall serious adverse event (SAE) and intracerebral hemorrhage (ICH) rates, freedom from all-cause and stroke-related mortality, and independent functional outcome as defined by the modified Rankin Scale score (mRS ≤2). RESULTS The SENTIS as-treated cohort included 251 patients ≥70 years and 107 patients ≥80 years. Elderly SENTIS patients included a higher percentage of women and Caucasians than the younger group. Patients in the older group more frequently had vascular risk factors including hypertension, previous stroke, transient ischemic attacks and atrial fibrillation. However, baseline risk-factor profile, stroke severity, and time to randomization did not differ between the treated and nontreated elderly patients. The older patients treated with NeuroFlo had significantly higher chances for survival and for obtaining an independent functional state (mRS ≤2) compared with those who were not treated. Rates of SAEs and ICHs did not differ between the treatment groups. CONCLUSIONS NeuroFlo treatment is safe and results in better outcomes for elderly patients. This may be the result of recruitment and support of already existing collateral systems in these patients.
Collapse
Affiliation(s)
- Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, IL–91120 Jerusalem, Israel.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Hammer MD, Schwamm L, Starkman S, Schellinger PD, Jovin T, Nogueira R, Burgin WS, Sen S, Diener HC, Watson T, Michel P, Shuaib A, Dillon W, Liebeskind DS. Safety and feasibility of NeuroFlo use in eight- to 24-hour ischemic stroke patients. Int J Stroke 2012; 7:655-61. [PMID: 22264202 DOI: 10.1111/j.1747-4949.2011.00719.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute treatment of ischemic stroke patients presenting more than eight-hours after symptom onset remains limited and largely unproven. Partial aortic occlusion using the NeuroFlo catheter can augment cerebral perfusion in animals. We investigated the safety and feasibility of employing this novel catheter to treat ischemic stroke patients eight-hours to 24 h following symptom onset. METHODS A multicenter, single-arm trial enrolled ischemic stroke patients at nine international academic medical centers. Eligibility included age 18-85 years old, National Institutes of Health stroke scale (NIHSS) score between four and 20, within eight-hours to 24 h after symptom onset, and perfusion-diffusion mismatch confirmed by magnetic resonance imaging. The primary outcome was all adverse events occurring from baseline to 30 days posttreatment. Secondary outcomes included stroke severity on neurological indices through 90 days. This study is registered with ClinicalTrials.gov, number NCT00436592. RESULTS A total of 26 patients were enrolled. Of these, 25 received treatment (one excluded due to aortic morphology); five (20%) died. Favorable neurological outcome at 90 days (modified Rankin score 0-2 vs. 3-6) was associated with lower baseline NIHSS (P < 0·001) and with longer duration from symptom discovery to treatment. There were no symptomatic intracranial hemorrhages or parenchymal hematomas. Asymptomatic intracranial hemorrhage was visible on computed tomography in 32% and only on microbleed in another 20%. CONCLUSIONS Partial aortic occlusion using the NeuroFlo catheter, a novel collateral therapeutic strategy, appears safe and feasible in stroke patients eight-hours to 24 h after symptom onset.
Collapse
Affiliation(s)
- M D Hammer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Shuaib A, Bornstein NM, Diener HC, Dillon W, Fisher M, Hammer MD, Molina CA, Rutledge JN, Saver JL, Schellinger PD, Shownkeen H. Partial Aortic Occlusion for Cerebral Perfusion Augmentation. Stroke 2011; 42:1680-90. [DOI: 10.1161/strokeaha.110.609933] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Fewer than 5% of patients with acute ischemic stroke are currently treated, and there is need for additional treatment options. A novel catheter treatment (NeuroFlo) that increases cerebral blood flow was tested to 14 hours.
Methods—
The Safety and Efficacy of NeuroFlo in Acute Ischemic Stroke trial is a randomized trial of the safety and efficacy of NeuroFlo treatment in improving neurological outcome versus standard medical management. The primary safety end point was the incidence of serious adverse events through 90 days. The primary efficacy end point on a modified intent-to-treat population was a global disability end point at 90 days. Secondary end points included mortality, intracranial hemorrhage, modified Rankin scale score outcome of 0 to 2, and modified Rankin scale shift analysis.
Results—
Between October 2005 and January 2010, 515 patients were enrolled at 68 centers in 9 countries. The primary efficacy end point did not reach statistical significance (OR, 1.17; CI, 0.81–1.67;
P
=0.407). The primary safety end point did not show a difference in serious adverse events (
P
=0.923). Ninety-day mortality was 11.3% (26/230) in treatment and 16.3% (42/257) in control (
P
=0.087). Post hoc analyses showed that patients presenting within 5 hours (OR, 3.33; CI, 1.31–8.48), with NIHSS score 8 to 14 (OR, 1.80; CI, 0.99–3.30), or older than age 70 years (OR, 2.02; CI, 1.02–4.03) had better modified Rankin scale score outcomes of 0 to 2; additionally, there were fewer stroke-related deaths in treatment compared to control groups (7.4%=17/230; 14.4%=37/257).
Conclusions—
The trial met its primary safety end point but not its primary efficacy end point. Signals of treatment effect were suggested on all-cause mortality, in patients presenting early, older than age 70 years, or with moderate strokes, but these require confirmation.
Clinical Trial Registration Information—
URL:
http://clinicaltrials.gov
. Unique identifier: NCT00119717.
Collapse
Affiliation(s)
- Ashfaq Shuaib
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Natan M. Bornstein
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Hans-Christoph Diener
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - William Dillon
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Marc Fisher
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Maxim D. Hammer
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Carlos A. Molina
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - J. Neal Rutledge
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Jeffrey L. Saver
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Peter D. Schellinger
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| | - Harish Shownkeen
- From the University of Alberta, Edmonton, Alberta; Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; University Hospital Essen, Essen, Germany; University of California, San Francisco, CA; University of Massachusetts, Worchester, MA; University of Pittsburgh, Pittsburgh, PA; Hospital Vall d'Hebron, Barcelona, Spain; University Medical Center Brackenridge–Seton, Austin, TX; University of California at Los Angeles, Los Angeles, CA; University Clinic at Erlangen, Erlangen, Germany; Central DuPage
| |
Collapse
|
20
|
Hussain MS, Bhagat YA, Liu S, Scozzafava J, Khan KA, Dillon WP, Shuaib A. DWI lesion volume reduction following acute stroke treatment with transient partial aortic obstruction. J Neuroimaging 2011; 20:379-81. [PMID: 19674247 DOI: 10.1111/j.1552-6569.2009.00407.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Diffusion-weighted imaging (DWI) identifies acute cerebral ischemia and DWI lesions are thought to indicate irreversibly damaged areas. However, new evidence suggests that DWI lesions may be reversible, especially with reperfusion. We present a patient who showed substantial reversal of her acute DWI lesion following partial aortic occlusion with Neuroflo™, a novel dual balloon catheter (Neuroflo™, CoAxia, MN). METHODS Case report/literature review. RESULTS A 48-year-old woman presented with left-sided weakness and demonstrated an acute DWI lesion in the right middle cerebral artery territory, with diffusion-perfusion mismatch. She was enrolled into an experimental study in which a dual balloon catheter was inflated in the lower aorta. The patient improved and her postprocedure magnetic resonance image showed a significant reduction in lesion volume on diffusion and perfusion-weighted imaging. At 1 month, a repeat computed tomography scan showed a small infarction in the right insula, lentiform nucleus, and frontal cortex. The patient had recovered with no significant disability at her 3-month follow-up. CONCLUSION Reperfusion can improve DWI lesions. Partial aortic obstruction with a novel dual balloon catheter may be useful to promote reperfusion.
Collapse
Affiliation(s)
- Muhammad S Hussain
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | | | | | | |
Collapse
|
21
|
Goericke SL, Schlamann M, Hagenacker T, Gartzen K, Wanke I, Forsting M. A High CSF Signal on FLAIR: It Is Not Always Blood. Neuroradiol J 2010; 23:389-92. [PMID: 24148624 DOI: 10.1177/197140091002300401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 05/29/2010] [Indexed: 11/15/2022] Open
Abstract
We describe a patient with progressive neurologic deficit due to middle cerebral branch occlusion. Temporary partial balloon occlusion of the abdominal aorta led to an increased signal in the subarachnoid space on fluid-attenuated inversion recovery images with no evidence of subarachnoid hemorrhage. After spontaneous recanalization, the increased signal of the subarachnoid space returned to normal. We assume that signal changes in the subarachnoid space were due to a temporary increase in blood volume in the superficial brain vessels.
Collapse
Affiliation(s)
- S L Goericke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital of Essen; Essen, Germany -
| | | | | | | | | | | |
Collapse
|
22
|
Bedside Use of a Dual Aortic Balloon Occlusion for the Treatment of Cerebral Vasospasm. Neurocrit Care 2010; 13:385-8. [DOI: 10.1007/s12028-010-9442-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
23
|
Tjoumakaris SI, Jabbour PM, Rosenwasser RH. Neuroendovascular management of acute ischemic stroke. Neurosurg Clin N Am 2010; 20:419-29. [PMID: 19853801 DOI: 10.1016/j.nec.2009.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endovascular reperfusion therapy is evolving as a promising treatment in the setting of acute ischemic stroke. Careful patient selection and angiographic evaluation of the location and extent of occlusion are necessary for the successful management of stroke patients. Intra-arterial chemical thrombolysis, with such agents as alteplase and urokinase, has shown favorable results in the early management of cerebrovascular ischemia. Mechanical thrombolysis is becoming an adjunctive or alternative treatment therapy via novel clot dissolution and retrieval techniques. Existing and upcoming trials are investigating the safety and efficacy of neuroendovascular therapy while attempting to expand its indications in acute ischemic stroke.
Collapse
Affiliation(s)
- Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University, Jefferson Hospital for Neuroscience, 909 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA.
| | | | | |
Collapse
|
24
|
Alnaami I, Saqqur M, Chow M. A novel treatment of distal cerebral vasospasm. A case report. Interv Neuroradiol 2009; 15:417-20. [PMID: 20465879 DOI: 10.1177/159101990901500407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 10/04/2009] [Indexed: 11/17/2022] Open
Abstract
SUMMARY A 22-year-old woman had an aneurysmal SAH due to a ruptured anterior communicating artery aneurysm and was treated successfully with endovascular coiling. The patient subsequently developed severe clinical and angiographically distal vasospasm. After failure of both medical treatment and proximal balloon angioplasty, the NeuroFlo device was tried and the patient showed substantial clinical recovery. We demonstrated an excellent outcome using a novel treatment for distal cerebral vasospasm with the NeuroFlo device.
Collapse
Affiliation(s)
- I Alnaami
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Canada -
| | | | | |
Collapse
|
25
|
Noor R, Wang CX, Todd K, Elliott C, Wahr J, Shuaib A. Partial intra-aortic occlusion improves perfusion deficits and infarct size following focal cerebral ischemia. J Neuroimaging 2009; 20:272-6. [PMID: 19888934 DOI: 10.1111/j.1552-6569.2009.00436.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Reperfusion with intravenous tissue plasminogen activator (tPA) has been the goal of therapy for acute ischemic stroke; however, tPA is contraindicated in many patients, has low recanalization rates in major occlusions, and carries a substantial risk of symptomatic intracerebral hemorrhage. In the present study, we hypothesized that partial intra-aortic occlusion of the abdominal aorta would increase salvage of ischemic penumbra and reduce infarct volume after focal embolic stroke in rats. We examined the effects of aortic occlusion on infarct volume, expression and activation of matrix metalloprotease-9, and hemorrhagic transformation with or without treatment with tPA. We then examined the effects of aortic occlusion on perfusion deficits following embolic occlusion. Results showed that partial aortic occlusion significantly reduces brain infarction volume with or without treatment with tPA after focal ischemia, but does not increase risk for hemorrhagic transformation or matrix metalloprotease-9 expression and activation. Partial intra-aortic occlusion also reduces perfusion deficits after focal cerebral ischemia as compared to control. The present study shows that partial intra-aortic occlusion significantly decreases infarction volume and perfusion deficits following ischemic injury in an embolic model of cerebral ischemia. Moreover, combination treatment with tPA and partial intra-aortic occlusion further reduces infarction volume without any increase in hemorrhagic transformation.
Collapse
Affiliation(s)
- Raza Noor
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | | | | | | | | |
Collapse
|
26
|
Augmenting Regional Cerebral Blood Flow Using External-to-Internal Carotid Artery Flow Diversion Method. Ann Biomed Eng 2009; 37:2428-35. [DOI: 10.1007/s10439-009-9782-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2009] [Accepted: 08/18/2009] [Indexed: 12/24/2022]
|
27
|
Harris AD, Kosior RK, Chen HS, Andersen LB, Frayne R. Evolution of hyperacute stroke over 6 hours using serial MR perfusion and diffusion maps. J Magn Reson Imaging 2009; 29:1262-70. [PMID: 19472379 DOI: 10.1002/jmri.21763] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To develop an appropriate method to evaluate the time-course of diffusion and perfusion changes in a clinically relevant animal model of ischemic stroke and to examine lesion progression on MR images. An exploration of acute stroke infarct expansion was performed in this study by using a new methodology for developing time-to-infarct maps based on the time at which each voxel becomes infarcted. This enabled definition of homogeneous regions from the heterogeneous stroke infarct. MATERIALS AND METHODS Time-to-infarct maps were developed based on apparent diffusion coefficient (ADC) changes. These maps were validated and then applied to blood flow and time-to-peak maps to examine perfusion changes. RESULTS ADC stroke infarct showed different evolution patterns depending on the time at which that region of tissue infarcted. Applying the time-to-infarct maps to the perfusion maps showed localized perfusion evolution characteristics. In some regions, perfusion was immediately affected and showed little change over the experiment; however, in some regions perfusion changes were more dynamic. CONCLUSION Results were consistent with the diffusion-perfusion mismatch hypothesis. In addition, characteristics of collateral recruitment were identified, which has interesting stroke pathophysiology and treatment implications.
Collapse
Affiliation(s)
- Ashley D Harris
- Seaman Family MR Research Centre, Foothills Medical Centre, University of Calgary, Alberta, Canada
| | | | | | | | | |
Collapse
|
28
|
Nogueira RG, Schwamm LH, Hirsch JA. Endovascular approaches to acute stroke, part 1: Drugs, devices, and data. AJNR Am J Neuroradiol 2009; 30:649-61. [PMID: 19279271 DOI: 10.3174/ajnr.a1486] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Despite years of research and pioneering clinical work, stroke remains a massive public health concern. Since 1996, we have lived in the era of US Food and Drug Administration-approved intravenous (i.v.) recombinant tissue plasminogen activator (rtPA). This treatment, despite its promise, continues to exhibit its limitations. Endovascular therapy has several theoretic advantages over i.v. rtPA, including site specificity, longer treatment windows, and higher recanalization rates. In this article, we will review the various pharmacologic strategies for acute stroke treatment, providing both a historic context and the state of the art. The drugs will be classified on the basis of their theoretic rationale for therapy. Next, we will review the various devices and strategies for mechanical revascularization with an aim toward comprehensiveness. These range from wire disruption of thrombus to preclinical trials for novel mechanical solutions. This first installment of this 2-part series will end with an analysis of retrograde reperfusion techniques.
Collapse
Affiliation(s)
- R G Nogueira
- Endovascular Neurosurgery/Interventional Neuroradiology Section, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. 02114, USA.
| | | | | |
Collapse
|
29
|
Critical Care Management of Subarachnoid Hemorrhage and Ischemic Stroke. Clin Chest Med 2009; 30:103-22, viii-ix. [DOI: 10.1016/j.ccm.2008.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
30
|
Abstract
Background and Purpose—
External counterpulsation (ECP) improves coronary perfusion, increases left ventricular stroke volume similar to intraaortic balloon counterpulsation, and recruits arterial collaterals within ischemic territories. We sought to determine ECPs effect on middle cerebral artery (MCA) blood flow augmentation in normal controls as a first step to support future clinical trials in acute stroke.
Methods—
Healthy volunteers were recruited and screened for exclusions. Bilateral 2-MHz pulsed wave transcranial Doppler (TCD) probes were mounted by head frame, and baseline M1 MCA TCD measurements were obtained. ECP was then initiated using standard procedures for 30 minutes, and TCD readings were repeated at 5 and 20 minutes. Physiological correlates associated with ECP-TCD waveform morphology were identified, and measurable criteria for TCD assessment of ECP arterial mean flow velocity (MFV) augmentation were constructed.
Results—
Five subjects were enrolled in the study. Preprocedural M1 MCA TCD measurements were within normal limits. Onset of ECP counterpulsation produced an immediate change in TCD waveform configuration with the appearance of a second upstroke at the dicrotic notch, labeled peak diastolic augmented velocity (PDAV). Although end-diastolic velocities did not increase, both R-MCA and L-MCA PDAVs were significantly higher than baseline end-diastolic values (
P
<0.05 Wilcoxon rank-sum test) at 5 and 20 minutes. Augmented MFVs (aMFVs) were also significantly higher than baseline MFV in the R-MCA and L-MCA at both 5 and 20 minutes (
P
<0.05).
Conclusions—
ECP induces marked changes in cerebral arterial waveforms and augmented peak diastolic and mean MCA flow velocities on TCD in 5 healthy subjects.
Collapse
|
31
|
Abstract
Stroke is the third leading cause of death in the United States and the leading cause of adult disability, consistently ranking in the top 10 of leading diagnostic categories encountered by practitioners in emergency and critical care settings. Despite its prevalence and clinical significance, only tissue plasminogen activator for ischemic stroke has been shown to reduce 3-month mortality and disability in phase III clinical trials, whereas for hemorrhagic stroke, no medicinal treatment has yet to demonstrate a similar reduction in mortality or disability. This article describes challenges inherent in the design and conduct of hyperacute stroke trials. Sample heterogeneity associated with pathophysiologic stroke mechanisms, the neurovascular territory implicated, systemic and intracranial hemodynamics, risk factor profiles, and patient access to requisite healthcare services are reviewed as contributors challenging enrollment into well-designed studies. Current controversies associated with designation of endpoints are presented and strategies to enhance trial design, and subsequent enrollment, are discussed. Recommendations are made for future clinical research into phenomena associated with hyperacute stroke.
Collapse
|
32
|
Zaharchuk G, Martin AJ, Dillon WP. Noninvasive imaging of quantitative cerebral blood flow changes during 100% oxygen inhalation using arterial spin-labeling MR imaging. AJNR Am J Neuroradiol 2008; 29:663-7. [PMID: 18397966 DOI: 10.3174/ajnr.a0896] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Tracer studies have demonstrated that 100% oxygen inhalation causes a small cerebral blood flow (CBF) decrease. This study was performed to determine whether arterial spin-labeling (ASL), a noninvasive MR imaging technique, could image these changes with clinically reasonable imaging durations. MATERIALS AND METHODS Continuous ASL imaging was performed in 7 healthy subjects before, during, and after 100% oxygen inhalation. ASL difference signal intensity (DeltaM, control - label), CBF, and CBF percentage change were measured. A test-retest paradigm was used to calculate the variability of the initial and final room air CBF measurements. RESULTS During oxygen inhalation, DeltaM decreased significantly in all regions (eg, global DeltaM decreased by 23 +/- 11%, P < .01, all values mean +/- SD). Accounting for the reduced T1 of hyperoxygenated blood, we found a smaller CBF decrease, which did not reach significance in any of the regions. Global CBF dropped from 50 +/- 10 mL per 100 g/minute to 47 +/- 10 mL per 100 g/minute following 100% oxygen inhalation, a decrease of 5 +/- 14% (P > .17). The root-mean-square variability of the initial and final room air CBF measurements was 7-8 mL per 100 g/minute. CONCLUSIONS The DeltaM signal intensity decreased significantly with oxygen inhalation; however, after accounting for changes in blood T1 with oxygen, CBF decreases were small. Such measurements support the use of hyperoxia as an MR imaging contrast agent and may be helpful to interpret hyperoxia-based stroke trials.
Collapse
Affiliation(s)
- G Zaharchuk
- Department of Radiology, Stanford University, Stanford, CA 94305-5487, USA.
| | | | | |
Collapse
|
33
|
|
34
|
Tavernier B, Decamps F, Vega E, Poidevin P, Verdin M, Riegel B. Traitements systémiques du vasospasme. ACTA ACUST UNITED AC 2007; 26:980-4. [DOI: 10.1016/j.annfar.2007.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
35
|
Barbry T, Le Guen M, De Castro V, Coriat P, Riou B, Vivien B. Minimum alveolar concentration of halogenated volatile anaesthetics in left ventricular hypertrophy and congestive heart failure in rats. Br J Anaesth 2007; 99:787-93. [PMID: 17959588 DOI: 10.1093/bja/aem292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although many physiological and pathological conditions affect minimal alveolar concentration (MAC), there are no reliable data on the MAC for halogenated anaesthetics during left ventricular hypertrophy (LVH) and congestive heart failure (CHF). The aim of this experimental study was to determine the MAC values of halothane, isoflurane, and sevoflurane in rats, at early and later stages of cardiomyopathic hypertrophy. METHODS LVH was induced by ascending aortic stenosis in 3-4-week-old rats. LVH and CHF in each animal were assessed weekly by echocardiography. MAC of halothane, isoflurane, and sevoflurane was determined using the tail-clamp technique in spontaneously breathing rats from each group. Response vs no-response data were analysed using logistic regression analysis. Data are medians (95% confidence interval). RESULTS The MAC of halothane [1.30% (1.26-1.34)], isoflurane [1.52% (1.48-1.57)], and sevoflurane [2.93% (2.78-3.07)] in rats with LVH was not different from sham-operated rats [respectively, 1.23% (1.20-1.26), 1.52% (1.47-1.56), and 2.90% (2.79-3.00)]. Conversely, the MAC of halothane [1.44 (1.39-1.50)] and isoflurane [1.74 (1.69-1.78)], but not sevoflurane [2.99 (2.93-3.06)], was significantly increased in rats with CHF. CONCLUSIONS MAC values for halothane, isoflurane, and sevoflurane were unchanged in rats with pressure-induced overload LVH. Conversely, the MAC for halothane and isoflurane, but not sevoflurane, was significantly increased in rats with CHF.
Collapse
Affiliation(s)
- T Barbry
- Laboratoire d'Anesthésiologie (EA 3975), Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
| | | | | | | | | | | |
Collapse
|
36
|
Affiliation(s)
- David Pelz
- University of Western Ontario, London, Ontario, Canada.
| | | | | | | | | |
Collapse
|