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Suzuki R, Takigawa T, Nagaishi M, Hyodo A, Suzuki K. Cytotoxic Lesions of the Corpus Callosum Associated with Aneurysmal Subarachnoid Hemorrhage May Influence Shunt-Dependent Chronic Hydrocephalus. World Neurosurg 2024; 185:e944-e950. [PMID: 38458249 DOI: 10.1016/j.wneu.2024.03.002] [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: 01/22/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Cytotoxic lesions of the corpus callosum (CLOCCs) are occasionally associated with aneurysmal subarachnoid hemorrhage (aSAH). The effects of aSAH on clinical outcomes in such cases are unclear. The present study aimed to investigate the frequency and characteristics of CLOCCs associated with aSAH to ascertain the predictors of shunt-dependent chronic hydrocephalus (SDCH) after aSAH. METHODS We retrospectively investigated cases of aSAH treated by coil embolization. Patients were divided into those with and without CLOCCs. Between-group differences were evaluated, including clinical outcomes and the characteristics of both the patients and the aneurysms. Patients were divided into those with and without SDCH to identify predictive factors of SDCH after aSAH focusing on CLOCCs. RESULTS This single-center study included 196 patients with aSAH. All patients received coil embolization between April 2013 and March 2020. CLOCCs were detected in 38 (19.4%) patients. In the group with CLOCCs, male sex, poor severity grade at onset, acute hydrocephalus, SDCH (all P < 0.01), and Fisher group 3 or 4 (P = 0.04) were significantly more common than in the group without CLOCCs. Diabetes and CLOCCs were significant predictors of SDCH after aSAH in multivariate analysis (diabetes: P < 0.01, odds ratio: 6.73, 95% confidence interval: 1.61-28.09; CLOCCs: P < 0.01, odds ratio: 6.86, 95% confidence interval: 2.87-16.38). CONCLUSIONS CLOCCs and SDCH were common in patients with poor-grade aSAH, and CLOCCs were independent predictors of SDCH after aSAH. Meticulous follow-up is necessary to detect SDCH after aSAH, especially in patients with poor-grade aSAH and CLOCCs.
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Affiliation(s)
- Ryotaro Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan.
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Masaya Nagaishi
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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Colomina MJ, Contreras L, Guilabert P, Koo M, Méndez E, Sabate A. Clinical use of tranexamic acid: evidences and controversies. Braz J Anesthesiol 2021; 72:795-812. [PMID: 34626756 DOI: 10.1016/j.bjane.2021.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022] Open
Abstract
Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.
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Affiliation(s)
- Maria J Colomina
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain.
| | - Laura Contreras
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Patricia Guilabert
- Universitat Autònoma de Barcelona, Vall d'Hebron University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Maylin Koo
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
| | - Esther Méndez
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Antoni Sabate
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
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Lee JJ, Huang M, Guerrero J, Desai VR, Jenson A, Austerman R, Diaz O, Britz GW. Operative Treatment of a Superior Cerebellar Artery Perforator Dissecting Aneurysm. Oper Neurosurg (Hagerstown) 2020; 19:E203-E208. [PMID: 32123901 DOI: 10.1093/ons/opz407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Superior cerebellar artery (SCA) perforator aneurysms are extremely rare, with only one other case published in the literature. There is no conclusive management strategy for these aneurysms, although endovascular treatment, open surgical treatment with clipping, and antifibrinolytic administration with spontaneous thrombosis have all been discussed. CLINICAL PRESENTATION A 61-yr-old male presented with intraventricular hemorrhage (IVH) primarily in the posterior fossa. He was found to have a dissecting left SCA perforator aneurysm lying on the floor of the fourth ventricle. The aneurysm was not amenable to endovascular treatment, and antifibrinolytic therapy failed to spontaneously thrombose the aneurysm. We performed a suboccipital craniotomy and used a supracerebellar transvermian approach to resect the aneurysm. There was total obliteration of the aneurysm on postoperative cerebral angiogram. CONCLUSION SCA perforator aneurysms represent an extremely uncommon subset of intracranial aneurysms. The best therapeutic strategy has yet to be definitively proven. When pursuing surgical treatment, the supracerebellar transvermian navigated approach can be a useful and safe option, as described and illustrated in this video.
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Affiliation(s)
- Jonathan J Lee
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Meng Huang
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Jaime Guerrero
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Virendra R Desai
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Amanda Jenson
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Ryan Austerman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Orlando Diaz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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Affiliation(s)
- Gretchen M Brophy
- Departments of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
| | - Theresa Human
- Department of Clinical Pharmacy, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO, USA
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Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology 2018; 128:657-670. [PMID: 29200009 PMCID: PMC5811331 DOI: 10.1097/aln.0000000000001997] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
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Affiliation(s)
- Jerrold H. Levy
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany
| | - Quintin J. Quinones
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Nigel S. Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC
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Hobbs JC, Welsby IJ, Green CL, Dhakal IB, Wellman SS. Epsilon Aminocaproic Acid to Reduce Blood Loss and Transfusion After Total Hip and Total Knee Arthroplasty. J Arthroplasty 2018; 33:55-60. [PMID: 28939033 DOI: 10.1016/j.arth.2017.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/15/2017] [Accepted: 08/15/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total hip and knee arthroplasty (THA and TKA) are associated with significant blood loss and some patients require postoperative blood transfusion. While tranexamic acid has been studied extensively among this population, we tested the hypothesis that epsilon aminocaproic acid (EACA) can reduce blood loss and transfusion after joint arthroplasty. METHODS In April 2014, our Veterans Affairs Medical Center introduced a protocol to administer EACA during THA and TKA. No antifibrinolytics were used previously. We retrospectively compared blood loss and incidence of transfusion among patients who underwent primary arthroplasty in the year before standardized administration of EACA with patients having the same procedures the following year. Blood loss was measured as delta hemoglobin (preoperative hemoglobin - hemoglobin on postoperative day 1). All patients undergoing primary THA or TKA were included. Patients having revision surgery were excluded. RESULTS We identified 185 primary arthroplasty patients from the year before and 184 from the year after introducing the EACA protocol. There were no changes in surgical technique or attending surgeons during this period. Delta hemoglobin was significantly lower in the EACA group (2.7 ± 0.8 mg/dL) compared to the control group (3.4 ± 1.1 mg/dL) (P < .0001). The incidence of blood transfusion was also significantly lower in the EACA group (2.7%) compared to the control group (25.4%) (P < .0001). There was no difference in venous thromboembolic complications between groups. CONCLUSION We demonstrated reductions in hemoglobin loss and transfusion following introduction of the EACA protocol in patients undergoing primary arthroplasty. EACA offers a lower cost alternative to TXA for reducing blood loss and transfusion in this population.
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Affiliation(s)
- Juliann C Hobbs
- Department of Anesthesiology, Duke University Medical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Cynthia L Green
- Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Ishwori B Dhakal
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
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8
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Qian Z, Feng X, Kang H, Wen X, Xu W, Zhao F, Jiang C, Wu Z, Li Y, Liu A. Ruptured Wide-Necked Aneurysms: Is Stent-Assisted Coiling During Posthemorrhage Days 4–10 Safe and Efficient? World Neurosurg 2017; 101:137-143. [DOI: 10.1016/j.wneu.2016.10.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 11/16/2022]
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Malekpour M, Kulwin C, Bohnstedt BN, Radmand G, Sethia R, Mendenhall SK, Weyhenmeyer J, Hendricks BK, Leipzig T, Payner TD, Shah MV, Scott J, DeNardo A, Sahlein D, Cohen-Gadol AA. Effect of short-term ε-aminocaproic acid treatment on patients undergoing endovascular coil embolization following aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 126:1606-1613. [DOI: 10.3171/2016.4.jns152951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAneurysmal rebleeding before definitive obliteration of the aneurysm is a cause of mortality and morbidity. There are limited data on the role of short-term antifibrinolytic therapy among patients undergoing endovascular intervention.METHODSAll consecutive patients receiving endovascular therapy for their ruptured saccular aneurysm at the authors' institution between 2000 and 2011 were included in this study. These patients underwent endovascular coiling of their aneurysm within 72 hours of admission. In patients receiving ε-aminocaproic acid (EACA), the EACA administration was continued until the time of the endovascular procedure. Complications and clinical outcomes of endovascular treatment after aneurysmal subarachnoid hemorrhage (aSAH) were compared between EACA-treated and untreated patients.RESULTSDuring the 12-year study period, 341 patients underwent endovascular coiling. Short-term EACA treatment was administered in 146 patients and was withheld in the other 195 patients. EACA treatment did not change the risk of preinterventional rebleeding in this study (OR 0.782, 95% CI 0.176–3.480; p = 0.747). Moreover, EACA treatment did not increase the rate of thromboembolic events. On the other hand, patients who received EACA treatment had a significantly longer duration of hospital stay compared with their counterparts who were not treated with EACA (median 19 days, interquartile range [IQR] 12.5–30 days vs median 14 days, IQR 10–23 days; p < 0.001). EACA treatment was associated with increased odds of shunt requirement (OR 2.047, 95% CI 1.043–4.018; p = 0.037) and decreased odds of developing cardiac complications (OR 0.138, 95% CI 0.031–0.604; p = 0.009) and respiratory insufficiency (OR 0.471, 95% CI 0.239–0.926; p = 0.029). Short-term EACA treatment did not affect the Glasgow Outcome Scale score at discharge, 6 months, or 1 year following discharge.CONCLUSIONSIn this study, short-term EACA treatment in patients who suffered from aSAH and received endovascular aneurysm repair did not decrease the risk of preinterventional rebleeding or increase the risk of thrombotic events. EACA did not affect outcome. Randomized clinical trials are required to provide robust clinical recommendation on short-term use of EACA.
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Affiliation(s)
- Mahdi Malekpour
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Charles Kulwin
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Bradley N. Bohnstedt
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Golnar Radmand
- 2Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rishabh Sethia
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Stephen K. Mendenhall
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Jonathan Weyhenmeyer
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Benjamin K. Hendricks
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Thomas Leipzig
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Troy D. Payner
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Mitesh V. Shah
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - John Scott
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Andrew DeNardo
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Daniel Sahlein
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Aaron A. Cohen-Gadol
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
- 3Indiana University Simon Cancer Center, Indianapolis, Indiana; and
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Arantes GC, Pereira RMR, de Melo DB, Alonso N, Duarte MDCMB. Effectiveness of tranexamic acid for reducing intraoperative bleeding in palatoplasties: A randomized clinical trial. J Craniomaxillofac Surg 2016; 45:642-648. [PMID: 28318926 DOI: 10.1016/j.jcms.2016.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/27/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Few data are available regarding blood loss during cleft palate surgery. This study assessed the effect of using tranexamic acid in the reduction of intraoperative bleeding. METHODS A double-blind, randomized clinical trial compared intraoperative bleeding and the incidence of oronasal fistulas after palatoplasties in a control group that was given placebo and an intervention group that was given 10 mg/kg tranexamic acid followed by a continuous infusion of 1 mg/kg/h of the same until the end of surgery. Patients who underwent primary palatoplasty with no known or suspected coagulation disorders at our institution during the study period were included in the study. RESULTS 70 patients were allocated, 66 received the intervention. Blood loss was reduced by 11.9%, without statistical significance. The incidence of fistulas in the intervention and control groups was 12.9% and 18.75%, respectively. The reduction of 5.8% (CI 95%: 12%-23.8%) was not significant. CONCLUSIONS The reduction of intraoperative blood loss was lower than expected and not statistically significant; a larger sample is needed to confirm the observed reduction. The drug did not seem to have negative effects on flap viability.
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Affiliation(s)
- Guilherme C Arantes
- Department of Plastic Surgery of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira), Recife, Pernambuco (PE), Brazil.
| | - Rui Manoel R Pereira
- Plastic Surgery of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira) (Head: Prof. Rui Manoel R. Pereira), Recife, PE, Brazil
| | - Daniela B de Melo
- Department of Plastic Surgery of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira), Recife, PE, Brazil
| | - Nivaldo Alonso
- Postgraduate Program Sensu Stricto of the University of Sao Paulo (Universidade de Sao Paulo - USP), Brazil
| | - Maria do Carmo M B Duarte
- Postgraduate Program Sensu Stricto of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira), Recife, PE, Brazil
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions, and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages, and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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12
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Kla KM, Lee LA. Minimizing Complications in Major Spine Surgery: The Role of the Anesthesiologist. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0168-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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13
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Shigematsu H, Sorimachi T, Osada T, Aoki R, Srivatanakul K, Oda S, Matsumae M. Predictors of early vs. late permanent shunt insertion after aneurysmal subarachnoid hemorrhage. Neurol Res 2016; 38:600-5. [DOI: 10.1080/01616412.2016.1199184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | | | - Takahiro Osada
- Department of Neurosurgery, Tokai University, Kanagawa, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University, Kanagawa, Japan
| | | | - Shinri Oda
- Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
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Pharmacological agents in aneurysmal subarachnoid hemorrhage: successes and failures. Clin Neuropharmacol 2016; 38:104-8. [PMID: 25970278 DOI: 10.1097/wnf.0000000000000085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition with high mortality. Proper management of this complex disease requires early surgical intervention followed by medical therapy. Pharmacological agents that unequivocally improve outcomes in aSAH are scarce. METHODS The authors performed an exhaustive query of several databases including MEDLINE, the CENTRAL Register of Controlled Trials, and the Cochrane Database of Systematic Reviews for specific evidence on key medications that have been used in the treatment of aSAH. RESULTS The bulk of the data available pertained to the following medications: calcium channel blockers, magnesium, statins, antifibrinolytics, aspirin, glucocorticoids, clazosentan, and tirilazad. Except for calcium channel blockers, the authors could not find any hard evidence that any of these agents affected outcome to a tangible degree. Aspirin may have some promise in prevention of aneurysm rupture and incidence of aSAH, but more substantive data are needed to conclusively corroborate this. CONCLUSIONS Investigational efforts to attain outcome-modifying agents have had dubious results, but the inquest for discovery should not discontinue.
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Komanapalli ES, Sherchan P, Rolland W, Khatibi N, Martin RD, Applegate RL, Tang J, Zhang JH. Epsilon Aminocaproic Acid Pretreatment Provides Neuroprotection Following Surgically Induced Brain Injury in a Rat Model. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 121:311-315. [PMID: 26463967 DOI: 10.1007/978-3-319-18497-5_54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Neurosurgical procedures can damage viable brain tissue unintentionally by a wide range of mechanisms. This surgically induced brain injury (SBI) can be a result of direct incision, electrocauterization, or tissue retraction. Plasmin, a serine protease that dissolves fibrin blood clots, has been shown to enhance cerebral edema and hemorrhage accumulation in the brain through disruption of the blood brain barrier. Epsilon aminocaproic acid (EAA), a recognized antifibrinolytic lysine analogue, can reduce the levels of active plasmin and, in doing so, potentially can preserve the neurovascular unit of the brain. We investigated the role of EAA as a pretreatment neuroprotective modality in a SBI rat model, hypothesizing that EAA therapy would protect brain tissue integrity, translating into preserved neurobehavioral function. Male Sprague-Dawley rats were randomly assigned to one of four groups: sham (n = 7), SBI (n = 7), SBI with low-dose EAA, 150 mg/kg (n = 7), and SBI with high-dose EAA, 450 mg/kg (n = 7). SBI was induced by partial right frontal lobe resection through a frontal craniotomy. Postoperative assessment at 24 h included neurobehavioral testing and measurement of brain water content. Results at 24 h showed both low- and high-dose EAA reduced brain water content and improved neurobehavioral function compared with the SBI groups. This suggests that EAA may be a useful pretherapeutic modality for SBI. Further studies are needed to clarify optimal therapeutic dosing and to identify mechanisms of neuroprotection in rat SBI models.
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Affiliation(s)
- Esther S Komanapalli
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Prativa Sherchan
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - William Rolland
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Nikan Khatibi
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Robert D Martin
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Richard L Applegate
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA.
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA.
- Departments of Anesthesiology, Physiology and Neurosurgery, Loma Linda University School of Medicine, 11234 Anderson Street, Room 2562B, Loma Linda, CA, 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA.
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Foreman PM, Chua M, Harrigan MR, Fisher WS, Tubbs RS, Shoja MM, Griessenauer CJ. Antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage increases the risk for deep venous thrombosis: A case–control study. Clin Neurol Neurosurg 2015; 139:66-9. [DOI: 10.1016/j.clineuro.2015.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 08/29/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022]
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Risk Factors for Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature. World Neurosurg 2015; 85:56-76. [PMID: 26342775 DOI: 10.1016/j.wneu.2015.08.052] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/17/2015] [Accepted: 08/18/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the literature on risk factors for cerebral vasospasm (CV), one of the most serious complications following aneurysmal subarachnoid hemorrhage (SAH), with special reference to the definition of CV. METHODS Using standard search engines, including PubMed, the medical literature on risk factors for CV after SAH was reviewed, and the best definition representative of CV was searched. RESULTS Severe SAH evident on computed tomography scan was the only consistent risk factor for CV after SAH. Effects of risk factors on CV, including age, clinical grade, rebleeding, intraventricular or intracerebral hemorrhage on computed tomography scan, acute hydrocephalus, aneurysm site and size, leukocytosis, interleukin-6 level, and cardiac abnormalities, appeared to be associated with the severity of SAH rather than each having a direct effect. Cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram were associated with CV without any relationship to SAH severity. With regard to parameters representative of CV, the grade of angiographic vasospasm (i.e., the degree of arterial narrowing evident on angiography) was the most adequate. Nevertheless, few reports on the risk factors associated with angiographic vasospasm grade have been reported to date. CONCLUSIONS Severe SAH evident on computed tomography scan appears to be a definite risk factor for CV after SAH, followed by cigarette smoking, hypertension, and left ventricular hypertrophy on electrocardiogram. To understand the pathogenesis of CV, further studies on the relationships between risk factors, especially factors not related to the severity of SAH, and angiographic vasospasm grade are necessary.
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Chen L, Jin XG, Zhu JF, Li HJ, Wang YP, Zhou YX, Wang J, Wang WH. Expression of transferrin in hematoma brain tissue at different stages after intra cerebral hemorrhage in rats. ASIAN PAC J TROP MED 2015; 8:574-7. [PMID: 26276291 DOI: 10.1016/j.apjtm.2015.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/20/2015] [Accepted: 06/15/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To explore the expression of transferrin (Tf) and transferrin receptor (TfR) in hematoma brain tissue at different stage after intracerebral hemorrhage (ICH) in rats. METHODS ICH rats model were established by collagenase method, and rats were sacrificed at 24 h, 72 h, 7 d and 14 d after operation. The levels of Tf and TfR in different periods of rats were detected by immunohistochemical method, and correlation between two groups was analyzed. RESULTS Tf, TfR-positive cells at each time after operation in observation group were significantly higher than that in control group (P < 0.05). Tf, TfR-positive cells began to increase from 24 h after the operation and reached the peak 72 h-7 d after surgery, but then gradually decreased. Tf was mainly expressed in nucleus and cytoplasm of neurons and glial cells around the hematoma, but TfR was mainly expressed in nucleus and cytoplasm of neurons and choroid plexus endothelial cells. Correlation analysis showed that the Tf-positive cell was significantly positively correlated with TfR-positive cell expression (r = 0.447, P = 0.022). CONCLUSIONS Tf and TfR were important transporters in brain tissue excessive load iron transport after ICH, and detecting the expression levels of the two indicators can provide a reference for prognosis treatment in ICH.
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Affiliation(s)
- Long Chen
- Department of Neurosurgery, Kunshan Hospital, Nanjing University of Traditional Chinese Medicine, Suzhou 215300, China
| | - Xue-Gang Jin
- Department of Neurosurgery, Kunshan Hospital, Nanjing University of Traditional Chinese Medicine, Suzhou 215300, China
| | - Jian-Fang Zhu
- Department of Neurosurgery, Kunshan Hospital, Nanjing University of Traditional Chinese Medicine, Suzhou 215300, China
| | - Hui-Juan Li
- Department of Endocrinology, Second People's Hospital, Yangzhou University, Suzhou 205331, China
| | - Yan-Ping Wang
- Department of Neurosurgery, Huai'An Hospital, Nanjing Medical University, Huai'An 223300, China
| | - You-Xin Zhou
- Department of Neurosurgery, First People's Hospital, Suzhou University, Suzhou 215006, China
| | - Jian Wang
- Department of Neurosurgery, Kunshan Hospital, Nanjing University of Traditional Chinese Medicine, Suzhou 215300, China
| | - Wen-Hua Wang
- Department of Neurosurgery, Kunshan Hospital, Nanjing University of Traditional Chinese Medicine, Suzhou 215300, China.
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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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Yin C, Huang GF, Ruan J, He ZZ, Sun XC. The APOE promoter polymorphism is associated with rebleeding after spontaneous SAH in a Chinese population. Gene 2015; 563:52-5. [PMID: 25752291 DOI: 10.1016/j.gene.2015.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/09/2015] [Accepted: 03/04/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Cheng Yin
- Department of Neurosurgery, Hospital of the University of Electronic Science and Technology of China, Sichuan Provincial People's Hospital, Chengdu 610072, PR China
| | - Guang-fu Huang
- Department of Neurosurgery, Hospital of the University of Electronic Science and Technology of China, Sichuan Provincial People's Hospital, Chengdu 610072, PR China
| | - Jian Ruan
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Zong-ze He
- Department of Neurosurgery, Hospital of the University of Electronic Science and Technology of China, Sichuan Provincial People's Hospital, Chengdu 610072, PR China
| | - Xiao-chuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China.
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Park J, Woo H, Kang DH, Kim YS, Kim MY, Shin IH, Kwak SG. Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes. J Neurosurg 2014; 122:383-91. [PMID: 25403841 DOI: 10.3171/2014.9.jns131784] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT While the incidence of a recurrent hemorrhage is highest within 24 hours of subarachnoid hemorrhage (SAH) and increases with the severity of the clinical grade, a recurrent hemorrhage can occur anytime after the initial SAH in patients with both good and poor clinical grades. Therefore, the authors adopted a 24-hour-a-day, formal protocol, emergency treatment strategy for patients with ruptured aneurysms to secure the aneurysms as early as possible. The incidences of in-hospital rebleeding and clinical outcomes were investigated and compared with those from previous years when broadly defined early treatment was used (<3 days of SAH). METHODS During an 11-year period, a total of 1224 patients with a ruptured aneurysm were managed using a strategy of broadly defined early treatment between 2001 and 2004 (Period B, n=423), a mixture of early or emergency treatment between 2005 and 2007, and a formal emergency treatment protocol between 2008 and 2011 (Period A, n=442). Propensity score matching was used to adjust the differences in age, sex, modified Fisher grade, World Federation of Neurosurgical Societies (WFNS) clinical grade at admission, size and location of a ruptured aneurysm, treatment modality (clip placement vs coil embolization), and time interval from SAH to admission between the two time periods. The matched cases were allotted to Group A (n=280) in Period A and Group B (n=296) in Period B and then compared. RESULTS During Period A under the formal emergency treatment protocol strategy, the catheter angiogram, endovascular coiling, and surgical clip placement were started at a median time from admission of 2.0 hours, 2.9 hours, and 3.1 hours, respectively. After propensity score matching, Group A showed a significantly reduced incidence of in-hospital rebleeding (2.1% vs 7.4%, p=0.003) and a higher proportion of patients with a favorable clinical outcome (modified Rankin Scale score 0-3) at 1 month (87.9% vs 79.7%, respectively; p=0.008). In particular, the patients with good WFNS grades in Group A experienced significantly less in-hospital rebleeding (1.7% vs 5.7%, respectively; p=0.018) and better clinical outcomes (1-month mRS score of 0-3: 93.8% vs 87.7%, respectively; p=0.021) than the patients with good WFNS grades in Group B. CONCLUSIONS Patients with ruptured aneurysms may benefit from a strategy of emergency application of surgical clip placement or endovascular coiling due to the reduced incidence of recurrent bleeding and improved clinical outcomes.
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Xi G, Strahle J, Hua Y, Keep RF. Progress in translational research on intracerebral hemorrhage: is there an end in sight? Prog Neurobiol 2014; 115:45-63. [PMID: 24139872 PMCID: PMC3961535 DOI: 10.1016/j.pneurobio.2013.09.007] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 02/08/2023]
Abstract
Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.
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Affiliation(s)
- Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
| | - Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
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Affiliation(s)
- Kevin Meier
- Clinical Neurosciences Center; University of Utah Health Care; 175 N. Medical Drive East; SLC; UT; 84132; USA
| | - Robert Hoesch
- Clinical Neurosciences Center; University of Utah Health Care; 175 N. Medical Drive East; SLC; UT; 84132; USA
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Baharoglu MI, Germans MR, Rinkel GJE, Algra A, Vermeulen M, van Gijn J, Roos YBWEM. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2013; 2013:CD001245. [PMID: 23990381 PMCID: PMC8407182 DOI: 10.1002/14651858.cd001245.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to dissolution of the blood clot at the site of aneurysm rupture by natural fibrinolytic activity. This review is an update of a previously published Cochrane review. OBJECTIVES To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1948 to December 2012), and EMBASE (1947 to December 2012). In an effort to identify further published, unpublished, and ongoing studies we searched reference lists and trial registers, performed forward tracking of relevant references and contacted drug companies. SELECTION CRITERIA Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted the data. Three review authors assessed trial quality. For the primary outcome we converted the outcome scales between good and poor outcome for the analysis. We scored death from any cause and rates of rebleeding, cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses. MAIN RESULTS We included 10 trials involving 1904 participants. The risk of bias was low in six studies. Four studies were open label and were rated as high risk of performance bias. One of these studies was also rated as high risk for attrition bias. Four trials reported on poor outcome (death, vegetative state, or severe disability) with a pooled risk ratio (RR) of 1.02 (95% confidence interval (CI) 0.91 to 1.15). All trials reported on death from all causes with a pooled RR of 1.00 (95% CI 0.85 to 1.18). In a trial that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for cerebral ischaemia the RR for poor outcome was 0.85 (95% CI 0.64 to 1.14). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up (RR 0.65, 95% CI 0.44 to 0.97; 78 per 1000 participants), but there was heterogeneity (I² = 62%) between the trials. The pooled RR for reported cerebral ischaemia was 1.41 (95% CI 1.04 to 1.91, 83 per 1000 participants), again with heterogeneity between the trials (I² = 52%). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in five trials (RR 1.11, 95% CI 0.90 to 1.36). AUTHORS' CONCLUSIONS The current evidence does not support the use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage, even in those who have concomitant treatment strategies to prevent cerebral ischaemia. Results on short-term treatment are promising, but not conclusive. Further randomised trials evaluating short-term antifibrinolytic treatment are needed to evaluate its effectiveness.
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Affiliation(s)
- Merih I Baharoglu
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Menno R Germans
- University of AmsterdamDepartment of Neurosurgery, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Ale Algra
- University Medical Center UtrechtJulius Center for Health Sciences and Primary Care/University Department of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Marinus Vermeulen
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Jan van Gijn
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Yvo BWEM Roos
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
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Erşahin M, Özsavcı D, Şener A, Özakpınar ÖB, Toklu HZ, Akakin D, Şener G, Yeğen BÇ. Obestatin alleviates subarachnoid haemorrhage-induced oxidative injury in rats via its anti-apoptotic and antioxidant effects. Brain Inj 2013; 27:1181-9. [PMID: 23895491 DOI: 10.3109/02699052.2013.804199] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Mehmet Erşahin
- School of Medicine, Department of Neurosurgery, Istanbul Medeniyet University
İstanbulTurkey
| | | | - Azize Şener
- School of Pharmacy, Department of Biochemistry
| | | | | | - Dilek Akakin
- School of Medicine, Department of Histology & Embryology
| | | | - Berrak Ç. Yeğen
- School of Medicine, Department of Physiology, Marmara University
IstanbulTurkey
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Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice. Br J Anaesth 2013; 111:549-63. [PMID: 23661406 DOI: 10.1093/bja/aet154] [Citation(s) in RCA: 222] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Antifibrinolytic drugs have become almost ubiquitous in their use during major surgery when bleeding is expected or commonplace. Inhibition of the fibrinolytic pathway after tissue injury has been consistently shown to reduce postoperative or traumatic bleeding. There is also some evidence for a reduction of perioperative blood transfusion. However, evidence of complications associated with exaggerated thrombosis also exists, although this appears to be influenced by the choice of the individual agent and the dose administered. There is controversy over the use of the serine protease inhibitor aprotinin, whose license was recently withdrawn but may shortly become available on the market again. In the UK, tranexamic acid, a tissue plasminogen and plasmin inhibitor, is most commonly used, with evidence for benefit in cardiac, orthopaedic, urological, gynaecological, and obstetric surgery. In the USA, ε-aminocaproic acid, which also inhibits plasmin, is commonly used. We have reviewed the current literature for this increasingly popular class of drugs to support clinical judgement in daily anaesthetic practice.
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Affiliation(s)
- E Ortmann
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridge CB23 3RE, UK
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Yang TC, Chang CH, Liu YT, Chen YL, Tu PH, Chen HC. Predictors of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid haemorrhage. Eur Neurol 2013; 69:296-303. [PMID: 23445755 DOI: 10.1159/000346119] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 11/24/2012] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Chronic hydrocephalus is a common complication that can occur after aneurysmal subarachnoid haemorrhage (SAH). The purpose of this study was to investigate clinical risk factors that could predict the occurrence of shunt-dependent chronic hydrocephalus after aneurysmal SAH. METHODS Eighty-eight consecutive patients who underwent either surgery or transarterial endovascular embolization as a treatment for cerebral aneurysm within 72 h -after experiencing SAH from March 2005 to July 2006 were studied retrospectively to assess the risk factors that might predict shunt-dependent chronic hydrocephalus. Clinical and demographic factors were examined, including age, sex, initial admission mean arterial blood pressure (MABP), blood sugar level at admission, fever frequency, initial external ventricular drainage (EVD), Fisher grade, Hunt and Hess grade, intraventricular haemorrhage (IVH) and treatment methods to define predictors of shunt-dependent hydrocephalus. The length of hospital stay and modified Rankin scale recorded 6 months after SAH were also evaluated; these parameters were compared between the shunt-dependent and non-shunt-dependent groups. RESULTS Of the 88 patients, 22 (25%) underwent shunt placement to treat their chronic hydrocephalus. The average length of hospital stay was 33.9 days for the shunt-treated group and 14 days for the non-shunt-treated group. The non-shunt-treated group scored an average of 1.05 on the modified Rankin scale compared with 2.77 for the shunt-treated group. A univariate analysis revealed that several admission variables were associated with long-term shunt-dependent hydrocephalus: (1) increased age (p = 0.023); (2) initial admission MABP (p = 0.027); (3) a high Fisher grade (p = 0.031); (4) a poor admission Hunt and Hess grade (p = 0.030); (5) the presence of IVH (p = 0.029), and (6) initial EVD (p < 0.0001). The factor most commonly associated with shunt-dependent hydrocephalus over the course of hospital days was fever frequency (p < 0.0001). CONCLUSIONS Chronic hydrocephalus after aneurysmal SAH has a multifactorial aetiology. Understanding the risk factors that predict the occurrence of chronic hydrocephalus may help neurosurgeons to expedite permanent cerebrospinal fluid diversion, which could decrease both the cost and length of hospital stay and prevent further complications.
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Affiliation(s)
- Tao-Chieh Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung, Taiwan, ROC. jade5048 @ yahoo.com.tw
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Larsen CC, Astrup J. Rebleeding After Aneurysmal Subarachnoid Hemorrhage: A Literature Review. World Neurosurg 2013; 79:307-12. [DOI: 10.1016/j.wneu.2012.06.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 04/04/2012] [Accepted: 06/14/2012] [Indexed: 12/25/2022]
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Çinar C, Oran İ, Bozkaya H, Ozgiray E. Endovascular treatment of ruptured blister-like aneurysms with special reference to the flow-diverting strategy. Neuroradiology 2013; 55:441-7. [DOI: 10.1007/s00234-013-1136-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 01/03/2013] [Indexed: 11/24/2022]
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Rebleeding and its prevention after subarachnoid hemorrhage. World Neurosurg 2012; 79:245-6. [PMID: 22858852 DOI: 10.1016/j.wneu.2012.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/26/2012] [Indexed: 11/22/2022]
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Yin C, Ruan J, Jiang L, Zhou S, Sun X. The relationship between rebleeding after spontaneous SAH and APOE polymorphisms in a Chinese population. Int J Neurosci 2012; 122:472-6. [PMID: 22462403 DOI: 10.3109/00207454.2012.678445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Rebleeding leads to lots of patients' disability and mortality after spontaneous subarachnoid hemorrhage (SAH), but the risk factors of rebleeding have not been fully understood. More evidence showed apolipoprotein E (apoE protein, APOE gene) influenced the outcome of spontaneous SAH. In this study, we aimed to investigate the relationship of APOE polymorphisms with rebleeding after spontaneous SAH. A total of 185 patients with spontaneous SAH were involved in the current study. Genomic DNA was extracted from venous blood samples to identify the APOE genotype by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Rebleeding was defined as acute clinical deterioration that was accompanied by computed tomography (CT) evidence of rebleeding in the subarachnoid space. A total of 21 patients occurred rebleeding in 185 patients with spontaneous SAH in the hospital. Data were analyzed by χ(2)-test and logistic regression analyses. The statistical analysis indicated no significant association between APOE genotype and rebleeding in a Chinese population.
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Affiliation(s)
- Cheng Yin
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
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Hui FK, Schuette AJ, Lieber M, Spiotta AM, Moskowitz SI, Barrow DL, Cawley CM. ε-Aminocaproic Acid in Angiographically Negative Subarachnoid Hemorrhage Patients Is Safe: A Retrospective Review of 83 Consecutive Patients. Neurosurgery 2011; 70:702-5; discussion 705-6. [DOI: 10.1227/neu.0b013e3182358cca] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background:
ε-Aminocaproic acid (EACA) has been used to reduce the rate of cerebral aneurysm rerupture before definitive treatment. In centers administering EACA to patients with a subarachnoid hemorrhage (SAH), patients eventually diagnosed with angiographically negative subarachnoid hemorrhage (ANSAH) may also initially receive EACA, perhaps placing them at increased risk for ischemic complications.
Objective:
To evaluate the effect of short-term EACA on outcomes and secondary measures in patients with ANSAH.
Methods:
We conducted a retrospective study of 454 consecutive SAH patients over a 2-year period under a current protocol for EACA use. Patients were excluded if a source for the SAH was discovered, yielding a total of 83 ANSAH patients. The patients were assigned to groups that did or did not receive EACA. The primary end points of the study were ischemic complications, pulmonary emboli, vasospasm, ventriculoperitoneal shunting rates, and outcomes.
Results:
Statistical analysis yielded no significant difference between the 2 arms with respect to any of the end points: vasospasm (P = .65), deep vein thrombosis (P = .51), pulmonary embolism (P = 1.0), stroke (P = 1.0), myocardial infarction (P = 1.0), and ventriculoperitoneal shunt (P = .57). There was no statistically significant outcome difference using the modified Rankin Scale (P = .30).
Conclusion:
Short-term (<72 hour) application of EACA does not result in an increase in adverse events in patients with ANSAH.
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Affiliation(s)
- Ferdinand K. Hui
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Michael Lieber
- Imaging Institute and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alejandro M. Spiotta
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shaye I. Moskowitz
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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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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Nina P, Schisano G. Antifibrinolytic Drugs in Subarachnoid Hemorrhage by Ruptured Aneurysms. Neurosurgery 2011; 68:E1776; author reply E1776-7. [DOI: 10.1227/neu.0b013e31821551c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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