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Windlin IC, da Costa BBS, Mota Telles JP, Oliveira LB, Koterba E, Yamaki VN, Rabelo NN, Solla DJF, Teixeira MJ, Figueiredo EG. The Effects of Glibenclamide on Cognitive Performance, Quality of Life, and Emotional Aspects Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Controlled Trial. World Neurosurg 2024:S1878-8750(24)01585-7. [PMID: 39278541 DOI: 10.1016/j.wneu.2024.09.048] [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: 09/03/2024] [Accepted: 09/07/2024] [Indexed: 09/18/2024]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with a high incidence of long-term cognitive impairment, decreased quality of life (QoL), and psychiatric disorders. The effects of glibenclamide on such outcomes in the setting of aSAH are unknown. OBJECTIVE To assess the impact of glibenclamide in patients with aSAH on cognitive performance, QoL, and emotional aspects. METHODS Patients identified with aSAH were randomly allocated to receive 5 mg of glibenclamide for 21 days or placebo, starting within 96 hours of the ictus. After 6 months, patients were evaluated with Montreal Cognitive Assessment test (cognitive performance), Medical Outcomes Short-form Health Survey (QoL), and Hospital Anxiety and Depression Scale and Screen for Post-traumatic Stress Symptoms (emotional aspects). RESULTS The mean Montreal Cognitive Assessment score was 22.5 ± 6.2. No statistically significant difference was found between groups, with a mean score of 21.7 ± 6.4 in the Glibenclamide group and 23.4 ± 6.2 in the placebo group (P = 0.392). A score <23 was observed in 16 patients (35.6%) and its frequency was similar between groups (P = 0.900). The most frequently impaired domains were Attention (N = 21/45; 46.7%) and Visuospatial (18/45; 40.0%). Impairment of each domain was similar between groups (P > 0.05). In each domain, the mean score was similar between groups (P > 0.05). The Hospital Anxiety and Depression Scale scores did not differ between groups (P > 0.05). The mean Screen for Post-traumatic Stress Symptoms score as well as the mean scores of its domains were similar between groups (P > 0.05). CONCLUSIONS Glibenclamide did not improve cognitive performance, QoL, and emotional aspects after 6 months of follow-up of aSAH survivors.
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Affiliation(s)
- Isabela Costola Windlin
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil
| | | | - João Paulo Mota Telles
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil
| | - Leonardo B Oliveira
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil; Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, Brazil
| | - Edwin Koterba
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil
| | - Vitor Nagai Yamaki
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil
| | - Nicollas Nunes Rabelo
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil
| | | | - Manoel Jacobsen Teixeira
- Department of Neurology, Hospital das Clínicas FMUSP, University of São Paulo, São Paulo, Brazil
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Lin Q, Zhou D, Ma J, Zhao J, Chen G, Wu L, Li T, Zhao S, Wen H, Yu H, Zhang S, Gao K, Yang R, Shi G. Efficacy and Safety of Early Treatment with Glibenclamide in Patients with Aneurysmal Subarachnoid Hemorrhage: A Randomized Controlled Trial. Neurocrit Care 2024:10.1007/s12028-024-01999-z. [PMID: 39117964 DOI: 10.1007/s12028-024-01999-z] [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: 12/30/2023] [Accepted: 04/10/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND This study aims to investigate the efficacy and safety of glibenclamide treatment in patients with acute aneurysmal subarachnoid hemorrhage (aSAH). METHODS The randomized controlled trial was conducted from October 2021 to May 2023 at two university-affiliated hospitals in Beijing, China. The study included patients with aSAH within 48 h of onset, of whom were divided into the intervention group and the control group according to the random number table method. Patients in the intervention group received glibenclamide tablet 3.75 mg/day for 7 days. The primary end points were the levels of serum neuron-specific enolase (NSE) and soluble protein 100B (S100B) between the two groups. Secondary end points included evaluating changes in the midline shift and the gray matter-white matter ratio, as well as assessing the modified Rankin Scale scores during follow-up. The trial was registered at ClinicalTrials.gov (identifier NCT05137678). RESULTS A total of 111 study participants completed the study. The median age was 55 years, and 52% were women. The mean admission Glasgow Coma Scale was 10, and 58% of the Hunt-Hess grades were no less than grade III. The baseline characteristics of the two groups were similar. On days 3 and 7, there were no statistically significant differences observed in serum NSE and S100B levels between the two groups (P > 0.05). The computer tomography (CT) values of gray matter and white matter in the basal ganglia were low on admission, indicating early brain edema. However, there were no significant differences found in midline shift and gray matter-white matter ratio (P > 0.05) between the two groups. More than half of the patients had a beneficial outcome (modified Rankin Scale scores 0-2), and there were no statistically significant differences between the two groups. The incidence of hypoglycemia in the two groups were 4% and 9%, respectively (P = 0.439). CONCLUSIONS Treating patients with early aSAH with oral glibenclamide did not decrease levels of serum NSE and S100B and did not improve the poor 90-day neurological outcome. In the intervention group, there was a visible decreasing trend in cases of delayed cerebral ischemia, but no statistically significant difference was observed. The incidence of hypoglycemia did not differ significantly between the two groups.
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Affiliation(s)
- Qing Lin
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Dawei Zhou
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jiawei Ma
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, China
| | - Jingwei Zhao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, China
| | - Guangqiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, China
| | - Lei Wu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shangfeng Zhao
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Honglin Wen
- Clinical Laboratory Center, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Huixian Yu
- Department of Rehabilitation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shaolan Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, China
| | - Kai Gao
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Rongli Yang
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, China.
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Costa BBSD, Windlin IC, Koterba E, Yamaki VN, Rabelo NN, Solla DJF, Samaia da Silva Coelho AC, Telles JPM, Teixeira MJ, Figueiredo EG. Glibenclamide in aneurysmal subarachnoid hemorrhage: a randomized controlled clinical trial. J Neurosurg 2022; 137:121-128. [PMID: 34798604 DOI: 10.3171/2021.7.jns21846] [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: 03/30/2021] [Accepted: 07/26/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Glibenclamide has been shown to improve outcomes in cerebral ischemia, traumatic brain injury, and subarachnoid hemorrhage (SAH). The authors sought to evaluate glibenclamide's impact on mortality and functional outcomes of patients with aneurysmal SAH (aSAH). METHODS Patients with radiologically confirmed aSAH, aged 18 to 70 years, who presented to the hospital within 96 hours of ictus were randomly allocated to receive 5 mg of oral glibenclamide for 21 days or placebo, in a modified intention-to-treat analysis. Outcomes were mortality and functional status at discharge and 6 months, evaluated using the modified Rankin Scale (mRS). RESULTS A total of 78 patients were randomized and allocated to glibenclamide (n = 38) or placebo (n = 40). Baseline characteristics were similar between groups. The mean patient age was 53.1 years, and the majority of patients were female (75.6%). The median Hunt and Hess, World Federation of Neurosurgical Societies (WFNS), and modified Fisher scale (mFS) scores were 3 (IQR 2-4), 3 (IQR 3-4), and 3 (IQR 1-4), respectively. Glibenclamide did not improve the functional outcome (mRS) after 6 months (ordinal analysis, unadjusted common OR 0.66 [95% CI 0.29-1.48], adjusted common OR 1.25 [95% CI 0.46-3.37]). Similar results were found for analyses considering the dichotomized 6-month mRS score (favorable score 0-2), as well as for the secondary outcomes of discharge mRS score (either ordinal or dichotomized), mortality, and delayed cerebral ischemia. Hypoglycemia was more frequently observed in the glibenclamide group (5.3%). CONCLUSIONS In this study, glibenclamide was not associated with better functional outcomes after aSAH. Mortality and delayed cerebral ischemia rates were also similar compared with placebo.
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Marazzi TBM, Mendes PV. Updates on aneurysmal subarachnoid hemorrhage: is there anything really new? ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:80-87. [PMID: 35976291 PMCID: PMC9491434 DOI: 10.1590/0004-282x-anp-2022-s101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe disease, with systemic involvement and complex diagnosis and treatment. Since the current guidelines were published by the AHA/ASA, Neurocritical Care Society and the European Stroke Organization in 2012-2013,there has been an evolution in the comprehension of SAH-associated brain injury and its multiple underlying mechanisms. As a result, several clinical and translational trials were developed or are underway. Objective: The aim of this article is to review some updates in the diagnosis and treatment of neurological complications of SAH. Methods: A review of PubMed (May, 2010 to February, 2022) was performed. Data was summarized. Results: Content of five meta-analyses, nine review articles and 23 new clinical trials, including pilots, were summarized. Conclusions:Advances in the comprehension of pathophysiology and improvements in critical care have been reflected in the reduction of mortality in SAH. However, despite the number of publications, the only treatments shown to be effective in adequate, well-controlled clinical trials are nimodipine and repair of the ruptured aneurysm. Thus, doubts about the optimal management of SAH still persist.
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Affiliation(s)
| | - Pedro Vitale Mendes
- Universidade de São Paulo, Departamento de Emergências Clínicas, São Paulo SP, Brazil
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Jha RM, Rani A, Desai SM, Raikwar S, Mihaljevic S, Munoz-Casabella A, Kochanek PM, Catapano J, Winkler E, Citerio G, Hemphill JC, Kimberly WT, Narayan R, Sahuquillo J, Sheth KN, Simard JM. Sulfonylurea Receptor 1 in Central Nervous System Injury: An Updated Review. Int J Mol Sci 2021; 22:11899. [PMID: 34769328 PMCID: PMC8584331 DOI: 10.3390/ijms222111899] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/17/2022] Open
Abstract
Sulfonylurea receptor 1 (SUR1) is a member of the adenosine triphosphate (ATP)-binding cassette (ABC) protein superfamily, encoded by Abcc8, and is recognized as a key mediator of central nervous system (CNS) cellular swelling via the transient receptor potential melastatin 4 (TRPM4) channel. Discovered approximately 20 years ago, this channel is normally absent in the CNS but is transcriptionally upregulated after CNS injury. A comprehensive review on the pathophysiology and role of SUR1 in the CNS was published in 2012. Since then, the breadth and depth of understanding of the involvement of this channel in secondary injury has undergone exponential growth: SUR1-TRPM4 inhibition has been shown to decrease cerebral edema and hemorrhage progression in multiple preclinical models as well as in early clinical studies across a range of CNS diseases including ischemic stroke, traumatic brain injury, cardiac arrest, subarachnoid hemorrhage, spinal cord injury, intracerebral hemorrhage, multiple sclerosis, encephalitis, neuromalignancies, pain, liver failure, status epilepticus, retinopathies and HIV-associated neurocognitive disorder. Given these substantial developments, combined with the timeliness of ongoing clinical trials of SUR1 inhibition, now, another decade later, we review advances pertaining to SUR1-TRPM4 pathobiology in this spectrum of CNS disease-providing an overview of the journey from patch-clamp experiments to phase III trials.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Anupama Rani
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
| | - Sudhanshu Raikwar
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Sandra Mihaljevic
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Amanda Munoz-Casabella
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joshua Catapano
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Ethan Winkler
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy;
- Neurointensive Care Unit, Department of Neuroscience, San Gerardo Hospital, ASST—Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94143, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Raj Narayan
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY 11549, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain;
- Neurotraumatology and Neurosurgery Research Unit, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Department of Neurosurgery, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, School of Medicine, Yale University, New Haven, CT 06510, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Zhou X, Li Y, Lenahan C, Ou Y, Wang M, He Y. Glymphatic System in the Central Nervous System, a Novel Therapeutic Direction Against Brain Edema After Stroke. Front Aging Neurosci 2021; 13:698036. [PMID: 34421575 PMCID: PMC8372556 DOI: 10.3389/fnagi.2021.698036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Stroke is the destruction of brain function and structure, and is caused by either cerebrovascular obstruction or rupture. It is a disease associated with high mortality and disability worldwide. Brain edema after stroke is an important factor affecting neurologic function recovery. The glymphatic system is a recently discovered cerebrospinal fluid (CSF) transport system. Through the perivascular space and aquaporin 4 (AQP4) on astrocytes, it promotes the exchange of CSF and interstitial fluid (ISF), clears brain metabolic waste, and maintains the stability of the internal environment within the brain. Excessive accumulation of fluid in the brain tissue causes cerebral edema, but the glymphatic system plays an important role in the process of both intake and removal of fluid within the brain. The changes in the glymphatic system after stroke may be an important contributor to brain edema. Understanding and targeting the molecular mechanisms and the role of the glymphatic system in the formation and regression of brain edema after stroke could promote the exclusion of fluids in the brain tissue and promote the recovery of neurological function in stroke patients. In this review, we will discuss the physiology of the glymphatic system, as well as the related mechanisms and therapeutic targets involved in the formation of brain edema after stroke, which could provide a new direction for research against brain edema after stroke.
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Affiliation(s)
- Xiangyue Zhou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Youwei Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, United States
| | - Yibo Ou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Minghuan Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue He
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Zhou D, Wei D, Xing W, Li T, Huang Y. Effects of craniotomy clipping and interventional embolization on treatment efficacy, cognitive function and recovery of patients complicated with subarachnoid hemorrhage. Am J Transl Res 2021; 13:5117-5126. [PMID: 34150100 PMCID: PMC8205842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/15/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This research was designed to investigate the effects of craniotomy clipping and interventional embolization (IE) on the treatment efficacy, cognitive function and recovery of patients with subarachnoid hemorrhage (SAH). METHODS A total of 148 patients with aneurysmal subarachnoid hemorrhage (ASAH) who underwent surgery in our hospital from December 2017 to August 2019 were included. They were divided into the clipping group (CG) (68 cases) and intervention group (IG) (80 cases) according to different surgical methods. The former received craniotomy clipping, and the latter underwent IE. The postoperative clinical indexes of patients were observed. The immune function (IgG, IgM, IgA) and inflammatory indexes (TNF-α, IL-8, HS-CRP) were detected before and after operation. The improvement of cognitive function, neurological function and sleep quality before and after operation was evaluated. Three months after operation, the treatment efficacy was evaluated and the postoperative complications were recorded. RESULTS The time of operation and hospitalization of patients in the IG were dramatically less than those in the CG (P < 0.05). The levels of IgG, IgM and IgA in the IG were higher than those in the CG after operation, while those of TNF-α, IL-8 and hs-CRP in the IG were lower than those in the CG. The MOCA scores of patients in the IG were obviously higher than those in the CG (P < 0.05), and the NIHSS and PSQI scores of patients in the IG were markedly lower than those in the CG. The total effective rate of patients in the IG was remarkably higher than that in the CG (P < 0.05), while the total incidence of postoperative complications in the IG was markedly lower than that in the CG. CONCLUSION IE is effective in the treatment of SAH patients, reducing the damage of immune, cognitive and nerve functions, with a high efficacy.
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Affiliation(s)
- Dezhong Zhou
- Brain Center, Sanya People's Hospital Sanya 572000, Hainan Province, China
| | - Didai Wei
- Brain Center, Sanya People's Hospital Sanya 572000, Hainan Province, China
| | - Weizhou Xing
- Brain Center, Sanya People's Hospital Sanya 572000, Hainan Province, China
| | - Tinglong Li
- Brain Center, Sanya People's Hospital Sanya 572000, Hainan Province, China
| | - Yun Huang
- Brain Center, Sanya People's Hospital Sanya 572000, Hainan Province, China
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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9
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Griepp DW, Lee J, Moawad CM, Davati C, Runnels J, Fiani B. BIIB093 (intravenous glibenclamide) for the prevention of severe cerebral edema. Surg Neurol Int 2021; 12:80. [PMID: 33767884 PMCID: PMC7982107 DOI: 10.25259/sni_933_2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/09/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Vasogenic edema in the setting of acute ischemic stroke can be attributed to the opening of transient receptor potential 4 channels, which are expressed in the setting of injury and regulated by sulfonylurea receptor 1 (SUR1) proteins. Glibenclamide, also known as glyburide, RP-1127, Cirara, and BIIB093, is a second-generation sulfonylurea that binds SUR1 at potassium channels and may significantly reduce cerebral edema following stroke, as evidenced by recent clinical trials. This review provides a comprehensive analysis of clinical considerations of glibenclamide use and current patient outcomes when administered in the setting of acute ischemic stroke to reduce severe edema. Methods: National databases (MEDLINE, EMBASE, Cochrane, and Google scholar databases) were searched to identify studies that reported on the clinical outcomes of glibenclamide administered immediately following acute ischemic stroke. Results: The pharmacological mechanism of glibenclamide was reviewed in depth as well as the known indications and contraindications to receiving treatment. Eight studies were identified as having meaningful clinical outcome data, finding statistically significant differences in glibenclamide treatment groups ranging from matrix metalloproteinase-9 serum levels, midline shift, modified Rankin Scores, National Institute of Health Stroke Score, and mortality endpoints. Conclusion: Studies analyzing the GAMES-Pilot and GAMES-PR trials suggest that glibenclamide has a moderate, however, measurable effect on intermediate biomarkers and clinical endpoints. Meaningful conclusions are limited by the small sample size of patients studied.
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Affiliation(s)
- Daniel W Griepp
- College of Osteopathic Medicine, New York Institute of Technology, Glen Head, New York, United States
| | - Jason Lee
- College of Osteopathic Medicine, New York Institute of Technology, Glen Head, New York, United States
| | - Christina M Moawad
- Department of Biomedical Engineering, Carle Illinois College of Medicine, University of Illinois at Urbana Champaign, Champaign, Illinois, United States
| | - Cyrus Davati
- College of Osteopathic Medicine, New York Institute of Technology, Glen Head, New York, United States
| | - Juliana Runnels
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, United States
| | - Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
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Raper DMS, Winkler EA, Rutledge WC, Cooke DL, Abla AA. An Update on Medications for Brain Arteriovenous Malformations. Neurosurgery 2021; 87:871-878. [PMID: 32433738 DOI: 10.1093/neuros/nyaa192] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/17/2020] [Indexed: 02/07/2023] Open
Abstract
Despite a variety of treatment options for brain arteriovenous malformations (bAVMs), many lesions remain challenging to treat and present significant ongoing risk for hemorrhage. In Vitro investigations have recently led to a greater understanding of the formation, growth, and rupture of bAVMs. This has, in turn, led to the development of therapeutic targets for medications for bAVMs, some of which have begun testing in clinical trials in humans. These include bevacizumab, targeting the vascular endothelial growth factor driven angiogenic pathway; thalidomide or lenalidomide, targeting blood-brain barrier impairment; and doxycycline, targeting matrix metalloproteinase overexpression. A variety of other medications appear promising but either requires adaptation from other disease states or development from early bench studies into the clinical realm. This review aims to provide an overview of the current state of development of medications targeting bAVMs and to highlight their likely applications in the future.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Engineering, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Zeyu Zhang, Yuanjian Fang, Cameron Lenahan, Sheng Chen. The role of immune inflammation in aneurysmal subarachnoid hemorrhage. Exp Neurol 2020; 336:113535. [PMID: 33249033 DOI: 10.1016/j.expneurol.2020.113535] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease, which mainly caused by the rupture of an intracranial aneurysm. Clinical trials have demonstrated that cerebral vasospasm (CVS) is not the sole contributor to delayed cerebral ischemia (DCI) and poor outcomes in patients with aSAH. Currently, accumulating evidence suggests that early brain injury (EBI), which occurs within 72 h after the onset of aSAH, lays the foundation for subsequent pathophysiological changes and poor outcomes of patients. The pathological mechanisms of EBI mainly include increased intracranial pressure, oxidative stress, neuroinflammation, blood-brain barrier (BBB) disruption, cerebral edema and cell death. Among them, the brain immune inflammatory responses involve a variety of immune cells and active substances, which play an important role in EBI after aSAH and may be related to DCI and long-term outcomes. Thus, attention should be paid to strategies targeting cerebral immune inflammatory responses. In this review, we discuss the role of immune inflammatory responses in the occurrence and development of aSAH, as well as some inflammatory biomarkers related to CVS, DCI, and aSAH outcomes. In addition, we also summarize the potential therapeutic drugs that target cerebral immune inflammatory responses for patients with aSAH in current research.
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Affiliation(s)
- Zeyu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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