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Lakhal K, Hivert A, Alexandre PL, Fresco M, Robert-Edan V, Rodie-Talbere PA, Ambrosi X, Bourcier R, Rozec B, Cadiet J. Intravenous Milrinone for Cerebral Vasospasm in Subarachnoid Hemorrhage: The MILRISPASM Controlled Before-After Study. Neurocrit Care 2021; 35:669-679. [PMID: 34478028 DOI: 10.1007/s12028-021-01331-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intravenous (IV) milrinone, in combination with induced hypertension, has been proposed as a treatment option for cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, data on its safety and efficacy are scarce. METHODS This was a controlled observational study conducted in an academic hospital with prospectively and retrospectively collected data. Consecutive patients with cerebral vasospasm following aSAH and treated with both IV milrinone (0.5 µg/kg/min-1, as part of a strict protocol) and induced hypertension were compared with a historical control group receiving hypertension alone. Multivariable analyses aimed at minimizing potential biases. We assessed (1) 6-month functional disability (defined as a score between 2 and 6 on the modified Rankin Scale) and vasospasm-related brain infarction, (2) the rate of first-line or rescue endovascular angioplasty for vasospasm, and (3) immediate tolerance to IV milrinone. RESULTS Ninety-four patients were included (41 and 53 in the IV milrinone and the control group, respectively). IV milrinone infusion was independently associated with a lower likelihood of 6-month functional disability (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.10-0.77]) and vasospasm-related brain infarction (aOR = 0.19, 95% CI 0.04-0.94). Endovascular angioplasty was less frequent in the IV milrinone group (6 [15%] vs. 28 [53%] patients, p = 0.0001, aOR = 0.12, 95% CI 0.04-0.38). IV milrinone (median duration of infusion, 5 [2-8] days) was prematurely discontinued owing to poor tolerance in 12 patients, mostly (n = 10) for "non/hardly-attained induced hypertension" (mean arterial blood pressure < 100 mmHg despite 1.5 µg/kg/min-1 of norepinephrine). However, this event was similarly observed in IV milrinone and control patients (n = 10 [24%] vs. n = 11 [21%], respectively, p = 0.68). IV milrinone was associated with a higher incidence of polyuria (IV milrinone patients had creatinine clearance of 191 [153-238] ml/min-1) and hyponatremia or hypokalemia, whereas arrhythmia, myocardial ischemia, and thrombocytopenia were infrequent. CONCLUSIONS Despite its premature discontinuation in 29% of patients as a result of its poor tolerance, IV milrinone was associated with a lower rate of endovascular angioplasty and a positive impact on long-term neurological and radiological outcomes. These preliminary findings encourage the conduction of confirmatory randomized trials.
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Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.
| | - Antoine Hivert
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-Louis Alexandre
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Marion Fresco
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-André Rodie-Talbere
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Xavier Ambrosi
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Julien Cadiet
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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Santos-Teles AG, Ramalho C, Ramos JGR, Passos RDH, Gobatto A, Farias S, Batista PBP, Caldas JR. Efficacy and safety of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage: a systematic review. Rev Bras Ter Intensiva 2020; 32:592-602. [PMID: 33470361 PMCID: PMC7853682 DOI: 10.5935/0103-507x.20200097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 03/17/2020] [Indexed: 12/30/2022] Open
Abstract
Objective To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage. Methods The Pubmed®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies. Results Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm. Conclusion The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.
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Affiliation(s)
- Alex Goes Santos-Teles
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil
| | - Clara Ramalho
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | | | - André Gobatto
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | - Suzete Farias
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | - Juliana Ribeiro Caldas
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil.,Universidade de Salvador - Salvador (BA), Brasil
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Neuropharmacology in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lakhal K, Rodie-Talbere PA, Alexandre PL, Testard N, Rozec B, Daumas-Duport B. Continuous intravenous milrinone for severe reversible cerebral vasoconstriction syndrome (a case report). J Neurol Sci 2019; 397:55-57. [PMID: 30590342 DOI: 10.1016/j.jns.2018.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Karim Lakhal
- Réanimation chirurgicale polyvalente, Service d'anesthésie-réanimation, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Pierre-André Rodie-Talbere
- Réanimation chirurgicale polyvalente, Service d'anesthésie-réanimation, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Pierre-Louis Alexandre
- Service de radiologie, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Nathalie Testard
- Service de neurologie, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
| | - Bertrand Rozec
- Réanimation chirurgicale polyvalente, Service d'anesthésie-réanimation, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France; Institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France.
| | - Benjamin Daumas-Duport
- Service de radiologie, Hôpital Laënnec, Centre hospitalier universitaire de Nantes, F-44093 Nantes, France.
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Hayman MW, Paleologos MS, Kam PCA. Interventional Neuroradiological Procedures—A Review for Anaesthetists. Anaesth Intensive Care 2019; 41:184-201. [DOI: 10.1177/0310057x1304100208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M. W. Hayman
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Visiting Specialist Anaesthestist
| | - M. S. Paleologos
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Staff Specialist Anaesthetist, Director of Services
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Nuffield Professor and Head, Departments of Anaesthetics, University of Sydney and Royal Prince Alfred Hospital
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Soliman R, Zohry G. [Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. Rev Bras Anestesiol 2018; 69:64-71. [PMID: 30409409 DOI: 10.1016/j.bjan.2018.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/19/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.
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Affiliation(s)
- Rabie Soliman
- Cairo University, Department of Anesthesia, Cairo, Egito.
| | - Gomaa Zohry
- Cairo University, Department of Anesthesia, Cairo, Egito
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Soliman R, Zohry G. [Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2018; 69. [PMID: 30409409 PMCID: PMC9391725 DOI: 10.1016/j.bjane.2018.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.
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Affiliation(s)
- Rabie Soliman
- Cairo University, Department of Anesthesia, Cairo, Egito.
| | - Gomaa Zohry
- Cairo University, Department of Anesthesia, Cairo, Egito
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Mogollon JP, Smoll NR, Panwar R. Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology. World Neurosurg 2018; 113:e29-e37. [PMID: 29410100 DOI: 10.1016/j.wneu.2018.01.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service. METHODS This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital. RESULTS The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period. CONCLUSIONS Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV. STUDY REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616000201471.
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MESH Headings
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Brain Damage, Chronic/epidemiology
- Brain Damage, Chronic/etiology
- Brain Damage, Chronic/prevention & control
- Computed Tomography Angiography
- Embolization, Therapeutic
- Endovascular Procedures/statistics & numerical data
- Female
- Humans
- Incidence
- Intensive Care Units/statistics & numerical data
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Length of Stay/statistics & numerical data
- Ligation
- Male
- Middle Aged
- Radiography, Interventional/statistics & numerical data
- Recurrence
- Severity of Illness Index
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/surgery
- Tertiary Care Centers/statistics & numerical data
- Treatment Outcome
- Vasospasm, Intracranial/epidemiology
- Vasospasm, Intracranial/etiology
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Affiliation(s)
| | - Nicolas Roydon Smoll
- Melbourne School of Population Health, University of Melbourne, Melbourne, Australia
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
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Life-threatening Tachyarrhythmia Following Intra-Arterial Milrinone for Cerebral Vasospasm. J Neurosurg Anesthesiol 2017; 30:281-283. [PMID: 28225470 DOI: 10.1097/ana.0000000000000418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Use of Milrinone in Patients with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Systematic Review. Can J Neurol Sci 2016; 44:152-160. [PMID: 27842615 DOI: 10.1017/cjn.2016.316] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a systematic review of the evidence supporting the use of milrinone for the management of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). DESIGN Primary outcomes were functional neurological status and the incidence of cerebral infarction. Search strategies adapted to the different databases were developed by a professional librarian. Medline, EMBASE, the Cochrane Library database, Web of Science, SCOPUS, BIOSIS, Global Health, Health Star, Open SIGLE, Google Scholar and the New York Academy of Medicine Gray Literature were searched as well as clinical trials databases and the proceedings of several scientific meetings. Quality of the evidence for these outcomes across studies was adjudicated using the GRADE Working Group criteria. RESULTS The search resulted in 284 citations after elimination of duplicates. Of those 9 conference proceedings and 15 studies met inclusion criteria and consisted of case reports, case series and two comparative studies: one non-randomized study with physiological outcomes only and a case series with historical controls. There was considerable variation in dosing and in co-interventions and no case control or randomized controlled studies were found. CONCLUSION There is currently only very low quality evidence to support the use of milrinone to improve important outcomes in patients with delayed cerebral ischemia secondary to subarachnoid hemorrhage. Further research is needed to clarify the value and risks of this medication in patients with SAH.
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High affinity complexes of pannexin channels and L-type calcium channel splice-variants in human lung: Possible role in clevidipine-induced dyspnea relief in acute heart failure. EBioMedicine 2016; 10:291-7. [PMID: 27349457 PMCID: PMC5006577 DOI: 10.1016/j.ebiom.2016.06.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 12/02/2022] Open
Abstract
Clevidipine, a dihydropyridine (DHP) analogue, lowers blood pressure (BP) by inhibiting l-type calcium channels (CaV1.2; gene CACNA1C) predominantly located in vascular smooth muscle (VSM). However, clinical observations suggest that clevidipine acts by a more complex mechanism. Clevidipine more potently reduces pulmonary vascular resistance (PVR) than systemic vascular resistance and its spectrum of effects on PVR are not shared by other DHPs. Clevidipine has potent spasmolytic effects in peripheral arteries at doses that are sub-clinical for BP lowering and, in hypertensive acute heart failure, clevidipine, but not other DHPs, provides dyspnea relief, partially independent of BP reduction. These observations suggest that a molecular variation in CaV1.2 may exist which confers unique pharmacology to different DHPs. We sequenced CACNA1C transcripts from human lungs and measured their affinity for clevidipine. Human lung tissue contains CACNA1C mRNA with many different splice variations. CaV1.2 channels with a specific combination of variable exons showed higher affinity for clevidipine, well below the concentration associated with BP reduction. Co-expression with pannexin 1 further increased the clevidipine affinity for this CaV1.2 splice variant. A high-affinity splice variant of CaV1.2 in combination with pannexin 1 could underlie the selective effects of clevidipine on pulmonary arterial pressure and on dyspnea. Research in Context Clevidipine lowers blood pressure by inhibiting calcium channels in vascular smooth muscle. In patients with acute heart failure, clevidipine was shown to relieve breathing problems. This was only partially related to the blood pressure lowering actions of clevidipine and not conferred by another calcium channel inhibitor. We here found calcium channel variants in human lung that are more selectively inhibited by clevidipine, especially when associated with pannexin channels. This study gives a possible mechanism for clevidipine's relief of breathing problems and supports future clinical trials testing the role of clevidipine in the treatment of acute heart failure. CaV1.2 splice variants are found in human lung that have increased affinity for clevidipine. Co-expression of CaV1.2 splice variant with Pannexin 1 further increases affinity for clevidipine but not for nicardipine. Study supports future clinical trials testing the role of clevidipine in the treatment of acute hypertensive heart failure.
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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14
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Danière F, Gascou G, Menjot de Champfleur N, Machi P, Leboucq N, Riquelme C, Ruiz C, Bonafé A, Costalat V. Complications and follow up of subarachnoid hemorrhages. Diagn Interv Imaging 2015; 96:677-86. [PMID: 26119863 DOI: 10.1016/j.diii.2015.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/18/2015] [Accepted: 05/18/2015] [Indexed: 11/27/2022]
Abstract
Complications of subarachnoid hemorrhage are the major life threatening and functional components of the follow up of a ruptured aneurysm. Knowing how to identify these is a key challenge. They vary in type throughout the postoperative follow up period. The aim of this article is firstly to list the main complications of the acute phase (rebleeding, acute hydrocephalus, acute ischemic injury and non-neurological complications), the subacute phase (vasospasm) and the chronic phase of subarachnoid hemorrhages: (chronic hydrocephalus and cognitive disorders) and to describe their major clinical and radiological features. Secondly, we describe the long-term follow up strategy for patients who have suffered a subarachnoid hemorrhage and have been treated endovascularly or by surgery. This follow up involves a combination of clinical consultations, cerebral MRI and at least one review angiogram.
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Affiliation(s)
- F Danière
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
| | - G Gascou
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - N Menjot de Champfleur
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - P Machi
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - N Leboucq
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - C Riquelme
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - C Ruiz
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - A Bonafé
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - V Costalat
- Department of Neuroradiology, Montpellier University Hospitals, Gui-de-Chauliac Hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
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15
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Sherif C, Wambacher B, Loyoddin M, Karaic R, Krafft P, Valentin A, Tscholakoff D, Kleinpeter G. Repeated combined endovascular therapy with milrinone and nimodipine for the treatment of severe vasospasm: preliminary results. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:203-207. [PMID: 25366625 DOI: 10.1007/978-3-319-04981-6_35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Delayed vasospasm (VSP) following aneurysmal subarachnoid hemorrhage (aSAH) remains a major source of morbidity. Milrinone was recently suggested as an invasive VSP treatment option. It is a phosphodiesterase III inhibitor with vasodilating and additional positive inotrope and anti-inflammatory effects. METHODS In this preliminary series, we included patients with severe VSP and unsuccessful maximum conservative therapy. Inclusion criteria were (1) transcranial Doppler (TCD) mean >180 cm/s; (2) increase of >50 % of TCD mean values within 6 h to values >150 cm/s; and/or (3) neurological deterioration (after exclusion of hemorrhage, hydrocephalus, and other systemic reasons). Patients received endovascular therapy with nimodipine 2 mg followed by milrinone 4-8 mg. Reinterventions were indicated aggressively in cases of persistent neurological deficits or persistent high mean TCD >180 cm/s. RESULTS Of 121 consecutive aSAH patients, 16 (13.2 %) received endovascular VSP therapy. Of these, 11 patients (68.5 %) received ≥ 3 interventions (median 4; maximum 9); 14 (87.5 %) showed postinterventional angiographic improvement of vessel diameters; and 11 (68.5 %) showed improvement of their neurological deficits after a mean follow-up time of 4.5 months. No cardiovascular adverse events attributed to milrinone were observed. CONCLUSIONS Milrinone may be a useful supplementary substance for endovascular VSP therapy. Aggressive reintervention indications did not cause additional adverse events.
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Affiliation(s)
- Camillo Sherif
- Department of Neurosurgery, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030, Vienna, Austria,
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16
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Kiser TH. Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions? Hosp Pharm 2014; 49:923-41. [PMID: 25477565 DOI: 10.1310/hpj4910-923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.
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Affiliation(s)
- Tyree H Kiser
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital, University of Colorado Anschutz Medical Campus , 12850 E. Montview Boulevard, C238, Aurora, CO 80045 ; phone: 303-724-2883 ; fax: 303-724-0979 ; e-mail:
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17
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Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Republished: Society for Neuroscience in Anesthesiology and Critical Care expert consensus statement: Anesthetic management of endovascular treatment for acute ischemic stroke. Stroke 2014; 45:e138-50. [PMID: 25070964 DOI: 10.1161/strokeaha.113.003412] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Literature on the anesthetic management of endovascular treatment of acute ischemic stroke (AIS) is limited. Anesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Thus, the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) created a task force to provide expert consensus recommendations on anesthetic management of endovascular treatment of AIS. The task force conducted a systematic literature review (up to August 2012). Because of the limited number of research articles relating to this subject, the task force solicited opinions from experts in this area. The task force created a draft consensus statement based on the available data. Classes of recommendations and levels of evidence were assigned to articles specifically addressing anesthetic management during endovascular treatment of stroke using the standard American Heart Association evidence rating scheme. The draft consensus statement was reviewed by the Task Force, SNACC Executive Committee and representatives of Society of NeuroInterventional Surgery (SNIS) and Neurocritical Care Society (NCS) reaching consensus on the final document. For this consensus statement the anesthetic management of endovascular treatment of AIS was subdivided into 12 topics. Each topic includes a summary of available data followed by recommendations. This consensus statement is intended for use by individuals involved in the care of patients with acute ischemic stroke, such as anesthesiologists, interventional neuroradiologists, neurologists, neurointensivists and neurosurgeons.
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Affiliation(s)
- Pekka O Talke
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.
| | - Deepak Sharma
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Eric J Heyer
- Departments of Anesthesiology and Neurology, Columbia University, New York, NY
| | - Sergio D Bergese
- Departments of Anesthesiology and Neurological Surgery, The Ohio State University, Columbus (on behalf of Society for Neuroscience in Anesthesiology and Critical Care [SNACC])
| | - Kristine A Blackham
- Department of Radiology, Case Western Reserve University, Cleveland, OH (representing the Society of NeuroInterventional Surgery [SNIS])
| | - Robert D Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery and Radiology, Hopkins University School of Medicine, Baltimore, MD (representing the Neurocritical Care Society [NCS])
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Sanelli PC, Pandya A, Segal AZ, Gupta A, Hurtado-Rua S, Ivanidze J, Kesavabhotla K, Mir D, Mushlin AI, Hunink MGM. Cost-effectiveness of CT angiography and perfusion imaging for delayed cerebral ischemia and vasospasm in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2014; 35:1714-20. [PMID: 24812015 DOI: 10.3174/ajnr.a3947] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective. MATERIALS AND METHODS We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association" (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty. RESULTS The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of 0.27 quality-adjusted life years and cost savings of $7622 over the transcranial Doppler ultrasound strategy. Univariable and multivariable sensitivity analyses indicated that results were robust to plausible input parameter uncertainty. Probabilistic sensitivity analysis results yielded 96.8% of iterations in the right lower quadrant, representing higher benefits and lower costs. CONCLUSIONS Our model results suggest that CTA and CTP are the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.
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Affiliation(s)
- P C Sanelli
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.) Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - A Pandya
- Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - A Z Segal
- Neurology (A.Z.S.), Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - A Gupta
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | | | - J Ivanidze
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - K Kesavabhotla
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - D Mir
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - A I Mushlin
- Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - M G M Hunink
- Departments of Radiology and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, the Netherlands
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Society for Neuroscience in Anesthesiology and Critical Care Expert Consensus Statement. J Neurosurg Anesthesiol 2014; 26:95-108. [DOI: 10.1097/ana.0000000000000042] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Azevedo MF, Faucz FR, Bimpaki E, Horvath A, Levy I, de Alexandre RB, Ahmad F, Manganiello V, Stratakis CA. Clinical and molecular genetics of the phosphodiesterases (PDEs). Endocr Rev 2014; 35:195-233. [PMID: 24311737 PMCID: PMC3963262 DOI: 10.1210/er.2013-1053] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 11/06/2013] [Indexed: 12/31/2022]
Abstract
Cyclic nucleotide phosphodiesterases (PDEs) are enzymes that have the unique function of terminating cyclic nucleotide signaling by catalyzing the hydrolysis of cAMP and GMP. They are critical regulators of the intracellular concentrations of cAMP and cGMP as well as of their signaling pathways and downstream biological effects. PDEs have been exploited pharmacologically for more than half a century, and some of the most successful drugs worldwide today affect PDE function. Recently, mutations in PDE genes have been identified as causative of certain human genetic diseases; even more recently, functional variants of PDE genes have been suggested to play a potential role in predisposition to tumors and/or cancer, especially in cAMP-sensitive tissues. Mouse models have been developed that point to wide developmental effects of PDEs from heart function to reproduction, to tumors, and beyond. This review brings together knowledge from a variety of disciplines (biochemistry and pharmacology, oncology, endocrinology, and reproductive sciences) with emphasis on recent research on PDEs, how PDEs affect cAMP and cGMP signaling in health and disease, and what pharmacological exploitations of PDEs may be useful in modulating cyclic nucleotide signaling in a way that prevents or treats certain human diseases.
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Affiliation(s)
- Monalisa F Azevedo
- Section on Endocrinology Genetics (M.F.A., F.R.F., E.B., A.H., I.L., R.B.d.A., C.A.S.), Program on Developmental Endocrinology Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland 20892; Section of Endocrinology (M.F.A.), University Hospital of Brasilia, Faculty of Medicine, University of Brasilia, Brasilia 70840-901, Brazil; Group for Advanced Molecular Investigation (F.R.F., R.B.d.A.), Graduate Program in Health Science, Medical School, Pontificia Universidade Catolica do Paraná, Curitiba 80215-901, Brazil; Cardiovascular Pulmonary Branch (F.A., V.M.), National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland 20892; and Pediatric Endocrinology Inter-Institute Training Program (C.A.S.), NICHD, NIH, Bethesda, Maryland 20892
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22
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Abstract
BACKGROUND Vasospasm after subarachnoid hemorrhage is a common and potentially life-threatening complication. Treatment of vasospasm may include intraarterial (IA) injections of verapamil into the cerebral vasculature. Clinical experience suggests that the average patient experiences an acute reduction in systemic blood pressure after IA verapamil. Our study objective was to (1) identify the effects of IA injection of verapamil on mean arterial blood pressure (MAP) and heart rate (HR) in patients with cerebral vasospasm and (2) determine the effect of verapamil dose on change in MAP and HR. We hypothesized that (1) selective IA injection of verapamil for treatment of cerebral vasospasm is associated with a reduction in MAP and an increase in HR and (2) the change in MAP and HR are linearly related to the dose of verapamil administered. METHODS We prospectively studied subjects with vasospasm scheduled for cerebral angiography with possible IA injection of verapamil. All subjects were given a general anesthetic. Invasive arterial blood pressure and HR were monitored continuously and recorded at 10-second intervals throughout the procedure. We identified the lowest MAP and highest HR before and after verapamil injection. The association between IA verapamil and change in MAP and HR was determined using repeated-measures multivariate regression analysis, adjusting for potential confounding factors (weight, preoperative vasopressor use, and preinjection MAP). Data are reported as adjusted coefficients and 95% confidence intervals (CI). RESULTS We included 20 subjects who underwent a total of 46 injections of IA verapamil. On the basis of our multivariate model, on average, each 5 mg of IA verapamil was associated with a 3.5 mm Hg reduction in MAP (95% CI -5.0 to -2.0, P < 0.001). HR was not significantly altered by IA verapamil on both unadjusted and adjusted analyses (nonsignificant increase of 0.4 beats per minute for each 5 mg of IA verapamil, 95% CI -1.6 to 2.4, P = 0.70). CONCLUSIONS Under general anesthesia, injection of IA verapamil into cerebral arteries reduces MAP but does not change HR in the average patient. Further research is required to determine the clinical significance of these results.
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Abstract
Hemodynamic augmentation therapy is considered standard treatment to help prevent and treat vasospasm and delayed cerebral ischemia. Standard triple-H therapy combines volume expansion (hypervolemia), blood pressure augmentation (hypertension), and hemodilution. An electronic literature search was conducted of English-language papers published between 2000 and October 2010 that focused on hemodynamic augmentation therapies in patients with subarachnoid hemorrhage. Among the eligible reports identified, 11 addressed volume expansion, 10 blood pressure management, 4 inotropic therapy, and 12 hemodynamic augmentation in patients with unsecured aneurysms. While hypovolemia should be avoided, hypervolemia did not appear to confer additional benefits over normovolemic therapy, with an excess of side effects occurring in patients treated with hypervolemic targets. Overall, hypertension was associated with higher cerebral blood flow, regardless of volume status (normo- or hypervolemia), with neurological symptom reversal seen in two-thirds of treated patients. Limited data were available for evaluating inotropic agents or hemodynamic augmentation in patients with additional unsecured aneurysms. In the context of sparse data, no incremental risk of aneurysmal rupture has been reported with the induction of hemodynamic augmentation.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology and Pain Medicine, University of Washington, Box 359724, Seattle, WA, USA,
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Pandey P, Steinberg GK, Dodd R, Do HM, Marks MP. A Simplified Method for Administration of Intra-Arterial Nicardipine for Vasospasm With Cervical Catheter Infusion. Oper Neurosurg (Hagerstown) 2011; 71:77-85. [DOI: 10.1227/neu.0b013e3182426257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Nicardipine has previously been used to treat vasospasm through superselective intracranial microcatheter injections.
OBJECTIVE:
To evaluate a simple method of treatment of vasospasm with slow infusion of nicardipine from a cervical catheter.
METHODS:
Twenty-seven patients with symptomatic vasospasm were treated over 4 years with cervical catheter infusions. Nicardipine was infused at 20 mg/h for 30 to 60 minutes. Angioplasty was used in severe cases at the operator's discretion. Outcome at discharge and follow-up was evaluated with Glasgow Outcome Scale.
RESULTS:
Twenty-seven patients (17 women, 12 men) received intra-arterial therapy for vasospasm. Vasospasm treatment was done at a mean post-hemorrhage date of 7.2 days (range, 4-15 days). They underwent 48 sessions of treatment (mean, 1.8 per patient) in 72 separate arterial territories. Twelve patients underwent multiple treatments. The mean dose used per session was 19.2 mg (range, 5-50 mg). Four patients underwent angioplasty for severe vasospasm. Twenty-two patients (81.5%) had clinical improvement after the infusion. Angiographic improvement was seen in 86.1% of the vessels analyzed, which had moderate or severe spasm before infusion. Overall, 17 patients (62.9%) had good outcome (Glasgow Outcome Scale score, 4 and 5) at discharge, 11 had poor outcome, and 1 patient died. Follow-up was available in 19 patients, and 18 were doing well (Glasgow Outcome Scale score, 4 and 5).
CONCLUSION:
Intra-arterial nicardipine is an effective and safe treatment for cerebral vasospasm. In most patients, infusion can be performed from the cervical catheter, with microcatheter infusion and angioplasty reserved for the more severe and resistant cases.
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Affiliation(s)
| | | | - Robert Dodd
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Huy M. Do
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael P. Marks
- Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Stanford, California
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Predicting symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage: are we there yet? World Neurosurg 2011; 80:e161-3. [PMID: 22079275 DOI: 10.1016/j.wneu.2010.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 10/29/2010] [Indexed: 11/21/2022]
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26
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Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MDI, Wolf S, Zipfel G. Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15:211-40. [DOI: 10.1007/s12028-011-9605-9] [Citation(s) in RCA: 754] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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27
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Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N. Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic Vasospasm After Subarachnoid Hemorrhage. Neurosurgery 2011; 68:1541-7; discussion 1547. [DOI: 10.1227/neu.0b013e31820edd46] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm (CV) is a potentially disastrous consequence of subarachnoid hemorrhage despite medical treatment. Nimodipine is a potent drug for vessel relaxation, but side effects may preclude a sufficient dose.
OBJECTIVE:
To explore whether continuous local intra-arterial nimodipine administration (CLINA) can reverse vasospasm and prevent delayed ischemic neurological deficit.
METHODS:
Six consecutive subarachnoid hemorrhage patients (5 women; mean age, 47.2 years) with severe CV despite maximum medical therapy underwent CLINA within 2 hours after the onset of clinical symptoms. After anticoagulation, microcatheters were inserted distally in the concerning supra-aortic vessels. Glyceryl trinitrate injection (2 mg) was followed by CLINA (nimodipine 0.4 mg/h for 70-147 hours). Duration of CLINA was determined by neurological status, transcranial Doppler sonography, and partial tissue oxygen pressure values.
RESULTS:
In all patients, neurological deficits improved or partial tissue oxygen pressure values returned to normal and transcranial Doppler sonography confirmed a reduced blood flow velocity within 12 hours. Magnetic resonance imaging showed no ischemic lesion caused by CV. Neurological outcome was good (modified Rankin Scale score, 0–2) in 3 patients, whereas 1 patient had a moderate clinical outcome (modified Rankin Scale score, 3–4) and 2 patients had a poor outcome (modified Rankin Scale score, 5) because of the SAH.
CONCLUSION:
Preliminary data show that CLINA is a straightforward, effective, and safe option for patients with severe CV refractory to medical therapy. Dilation of spastic arteries starts within a few hours and is lasting. Indication for CLINA is peripheral and diffuse CV at any location.
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Affiliation(s)
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen
| | - Zsolt Vajda
- Department of Neuroradiology, Klinikum Stuttgart, Germany
| | - Jan Coburger
- Department of Neurosurgery, Klinikum Stuttgart, Germany
| | - Nikolai Hopf
- Department of Neurosurgery, Klinikum Stuttgart, Germany
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Castanares-Zapatero D, Hantson P. Pharmacological treatment of delayed cerebral ischemia and vasospasm in subarachnoid hemorrhage. Ann Intensive Care 2011; 1:12. [PMID: 21906344 PMCID: PMC3224484 DOI: 10.1186/2110-5820-1-12] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/24/2011] [Indexed: 12/18/2022] Open
Abstract
Subarachnoid hemorrhage after the rupture of a cerebral aneurysm is the cause of 6% to 8% of all cerebrovascular accidents involving 10 of 100,000 people each year. Despite effective treatment of the aneurysm, delayed cerebral ischemia (DCI) is observed in 30% of patients, with a peak on the tenth day, resulting in significant infirmity and mortality. Cerebral vasospasm occurs in more than half of all patients and is recognized as the main cause of delayed cerebral ischemia after subarachnoid hemorrhage. Its treatment comprises hemodynamic management and endovascular procedures. To date, the only drug shown to be efficacious on both the incidence of vasospasm and poor outcome is nimodipine. Given its modest effects, new pharmacological treatments are being developed to prevent and treat DCI. We review the different drugs currently being tested.
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Affiliation(s)
- Diego Castanares-Zapatero
- Université catholique de Louvain (UCL), Cliniques universitaires Saint Luc, Soins intensifs, Avenue Hippocrate, 10, B-1200 Bruxelles, Belgium.
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Hemorragia subaracnoidea aneurismática: Guía de tratamiento del Grupo de Patología Vascular de la Sociedad Española de Neurocirugía. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70007-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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