Nimodipine in aneurysmal subarachnoid hemorrhage: a randomized study of intravenous or peroral administration

Troponin I as a Predictor of Transcranial Doppler Sonography Defined Vasospasm in Intensive Care Unit Patients After Spontaneous Subarachnoid Hemorrhage

OBJECTIVE

Elevation of Troponin I (TnI) in spontaneous subarachnoid hemorrhage (SAH) patients is a well-known phenomenon and associated with cardiopulmonary complications and poor outcome. The present study was conducted to investigate the association of the TnI value on admission, and the occurrence of cerebral vasospam in SAH patients.

PATIENTS AND METHODS

A total of 142 patients with SAH, who were admitted to the neurosurgical intensive care unit (ICU) between December 2014 and January 2021 were evaluated. Blood samples were drawn on admission to determine TnI value. Each patient's demographic, radiological and medical data on admission, the modified Ranking Scale score at discharge as well as continuous measurements of transcranial Doppler sonography were analyzed. A maximum mean flow velocity (MMFV) > 120 cm/sec was defined as any vasospasm. These were stratified into severe vasospasms, which were defined as at least two measurements of MMFVs > 200 cm/sec or an increase of MMFV > 50 cm/sec/24 h over two consecutive days or a new neurological deterioration and mild vasospasm defined as MMFVs > 120 cm/sec in absence of severe vasospasm criteria. The total study population was dichotomized into patients with an initially elevated TnI (>0.05 µg/L) and without elevated TnI (≤0.05 μg/L).

RESULTS

A total of 52 patients (36.6%) had an elevated TnI level upon admission, which was significantly associated with lower GCS score (p < 0.001), higher WFNS score (p < 0.001) and higher Fisher grade (p = 0.01) on admission. In this context a higher rate of ischemic brain lesions (p = 0.02), a higher modified Rankin Scale score (p > 0.001) and increased mortality (p = 0.02) at discharge were observed in this group. In addition, TnI was identified as an independent predictor for the occurrence of any vasospasm and severe vasospasm.

CONCLUSION

An initially elevated TnI level is an independent predictor for the occurrence of any and severe vasospasm in patients with SAH.

Nimodipine prophylaxis in aneurysmal subarachnoid hemorrhage, a question of tradition or evidence: A scoping review

BACKGROUND

The prophylactic use of nimodipine following subarachnoid hemorrhage is a practice established four decades ago when clinical management differed from current and the concept of Delayed Cerebral Ischemia (DCI) was not established. The applicability of the original studies is limited by the fact of not reflecting current practice; by utilising a dichotomised outcome measure such as good neurological outcome versus death and vegetative state; by applying variable dosing regimens and including all causes of poor neurological outcome different than DCI. This study aims to review the available evidence to discuss the ongoing role of nimodipine in contemporaneous clinical practice.

METHODS

PRISMA guidelines based review, evaluated the evidence on the prophylactic use of nimodipine. The following search engines: Medline, Embase, Cochrane, Web of Science and PubMed, identified Randomized Control Trials (RCTs) with neurological benefit as outcome measure and the impact of fixed versus weight-based nimodipine dosing regimens.

RESULTS

Eight RCT were selected. Three of those trials with a total of 349 patients, showed a reduction on death and vegetative state (pooled RR: 0.62; 95 % confidence interval-CI: 0.45, 0.86) related to DCI. Amongst all studies, all cause death (pooled RR = 0.73, [95 % CI: 0.56, 0.97]) favoured a fixed-dose regimen (pooled RR: 0.60; [95 % CI: 0.43, 0.85]).

CONCLUSION

Available evidence demonstrates that nimodipine only reduces the risk for DCI-related death or vegetative state and that fixed-dose regimens favour all cause infarct and death independent of DCI. Contemporaneous studies assessing the benefit of nimodipine beyond death or vegetative states and applying individualized dosing are warranted.

Risks of nimodipine dose reduction during the high-risk period for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Nimodipine dose reduction is recommended in case of high vasopressor demand after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess potential adverse effects of nimodipine reduction during the high-risk period for delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) between days 5 and 10 after hemorrhage. Demographic and clinical data as well as daily nimodipine dose of aSAH patients admitted between 2010 and 2019 were retrospectively analyzed. Univariable and multivariable regression analyses were performed to identify factors associated with DCI, angiographic CVS, DCI-related infarction, and unfavorable outcome. A total of 205 patients were included. Nimodipine dose reduction occurred in 108 (53%) patients ('nimodipine reduction group'), while 97 patients (47%) received the full dose ('no nimodipine reduction group'), Patients in the 'nimodipine reduction group' had significant worse WFNS and Fisher grades and developed significantly more often DCI and angiographic CVS. DCI-related infarction and unfavorable outcome were also significantly increased in the 'nimodipine reduction group.' 'Reduced nimodipine dose' was the only independent predictor for the occurrence of DCI and angiographic CVS in multivariable regression analysis. 'Poor WFNS grade' and 'reduced nimodipine dose' were identified as independent risk factors for DCI-related infarction while 'older age,' 'poor WFNS grade,' and 'reduced nimodipine dose' were associated with unfavorable outcome at 3 months after discharge. Nimodipine dose reduction during the high-risk period of DCI and CVS between days 5 and 10 after hemorrhage might abrogate the positive prognostic effects of nimodipine and should be critically evaluated.

The efficacy of different nimodipine administration route for treating subarachnoid hemorrhage: A network meta-analysis

BACKGROUND

A systematic review and network meta-analysis (NMA) were conducted to explore the optimal administration route of nimodipine for treatment subarachnoid hemorrhage.

METHODS

Electronic databases (Pubmed, Embase, Web of Science and Cochrane databases) were systematically searched to identify randomized controlled trials evaluating different administration route of nimodipine (intravenous and enteral) versus placebo for treatment subarachnoid hemorrhage. Outcomes included case fatality at 3 months, poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), incidence of delayed cerebral ischemia (DCI), delayed ischemic neurological deficit. A random-effect Bayesian NMA was conducted for outcomes of interest, and results were presented as odds ratios (ORs) and 95% credible intervals. The NMA was performed using R Software with a GeMTC package. A Bayesian NMA was performed and relative ranking of agents was assessed using surface under the cumulative ranking (SUCRA) probabilities.

RESULTS

Nine randomized controlled trials met criteria for inclusion and finally included in this NMA. There was no statistically significant between intravenous and enteral in terms of case fatality, the occurrence of DCI, delayed ischemic neurologic deficit and poor outcomes (P > .05). Both intravenous and enteral could reduce case fatality, the occurrence of DCI, delayed ischemic neurologic deficit and poor outcomes (P < .05). The SUCRA shows that enteral ranked first, intravenous ranked second and placebo ranked the last for case fatality, the occurrence of DCI and poor outcomes. The SUCRA shows that intravenous ranked first, enteral ranked second and placebo ranked the last for delayed ischemic neurologic deficit.

CONCLUSIONS

It is possible that both enteral and intravenous nimodipine have comparable effectiveness in preventing poor outcomes, DCI, and delayed ischemic neurological deficits. However, further investigation may be necessary to determine the exact role of intravenous nimodipine in current clinical practice.

Cerebral Perfusion Pressure-Guided Therapy in Patients with Subarachnoid Haemorrhage-A Retrospective Analysis

BACKGROUND

Prevention and treatment of haemodynamic instability and increased intracranial pressure (ICP) in patients with subarachnoid haemorrhage (SAH) is vital. This study aimed to evaluate the effects of protocolised cerebral perfusion pressure (CPP)-guided treatment on morbidity and functional outcome in patients admitted to the intensive care unit (ICU) with SAH.

METHODS

We performed a retrospective study comparing 37 patients who received standard haemodynamic treatment (control group) with 17 individuals (CPP-guided group) who were on the CPP-guided treatment aimed at maintaining CPP > 70 mmHg using both optimisations of ICP and mean arterial pressure (MAP).

RESULTS

MAP, cumulative crystalloid doses and fluid balance were similar in both groups. However, the incidence of delayed cerebral ischaemia was significantly lower in the CPP-guided group (14% vs. 64%, p < 0.01), and functional outcome as assessed by the Glasgow Outcome Scale at 30 days after SAH was improved (29.0% vs. 5.5%, p = 0.03).

CONCLUSIONS

This preliminary analysis showed that implementing a CPP-guided treatment approach aimed at maintaining a CPP > 70 mmHg may reduce the occurrence of delayed cerebral ischaemia and improve functional outcomes in patients with SAH. This observation merits further prospective investigation of the use of CPP-guided treatment in patients with SAH.

Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH.

METHODS

Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3-15), and World Federation of Neurosurgical Societies scale 4 (range 1-5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h.

RESULTS

We analyzed 7,223 CMD samples over a median of 6 days (5-8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region.

CONCLUSIONS

Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.

A Comparison Between Enteral and Intravenous Nimodipine in Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis

Our objective was to compare the effectiveness of intravenous and enteral nimodipine in preventing poor outcome from delayed cerebral ischemia in patients with subarachnoid hemorrhage. We performed a systematic search and a network meta-analysis using the following databases: PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar. Risk of Bias 2 tool was used to assess risk of bias of included studies. A ranking among methods was performed on the basis of the frequentist analog of the surface under the cumulative ranking curve. Published studies that met the following population, intervention, comparison, outcomes and study (PICOS) criteria were included: patients with subarachnoid hemorrhage aged 15 years or older (P); nimodipine, intravenous and oral formulation (I); placebo or no intervention (C); poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), case fatality at 3 months, delayed cerebral ischemia, delayed ischaemic neurologic deficit, and vasospasm measured with transcranial Doppler or digital subtraction angiography (O); and randomized controlled trials (S). No language or publication date restrictions were applied. Ten studies were finally included, with a total of 1527 randomly assigned patients. Oral and intravenous nimodipine were both effective in preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. Neither treatment was effective in improving case fatality. Evolving clinical protocols over a 30-year period and the risk of bias of the included studies may limit the strength of our results. Enteral and intravenous nimodipine may have a similar effectiveness in terms of preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. More research may be needed to fully establish the role of intravenous nimodipine in current clinical practice.

Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials.

METHODS

We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence.

RESULTS

We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia.

CONCLUSIONS

Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.

Safety and Clinical Effects of Switching From Intravenous to Oral Nimodipine Administration in Aneurysmal Subarachnoid Hemorrhage

Objective: Several guidelines recommend oral administration of nimodipine as vasospasm prophylaxis after aneurysmal subarachnoid hemorrhage (SAH). However, in clinical practice, the drug is administered orally and intravenously (i.v.), depending on clinical conditions and local treatment regimens. We have therefore investigated the safety and clinical effects of switching from i.v. to oral nimodipine therapy.

Methods: Patients with aneurysmal SAH between January 2014 and April 2018 and initial i.v. nimodipine therapy, which was subsequently switched to oral administration, were included in this retrospective study. Transcranial Doppler sonography (TCD) of the vessels of the anterior circulation was performed daily. The occurrence of vasospasm and infarction during the overall course of the treatment was recorded. Statistical level of significance was set to p < 0.05.

Results: A total of 133 patients (mean age 55.8 years, 65% female) initially received nimodipine i.v. after aneurysmal SAH, which was subsequently switched to oral administration after a mean of 12 days. There were no significant increases in mean flow velocities on TCD after the switch from i.v. to oral nimodipine administration regarding the anterior cerebral artery. For the middle cerebral artery, an increase from 62.36 to 71.78 cm/sec could only be detected in the subgroup of patients with infarction. There was no clustering of complicating events such as new-onset vasospasm or infarction during or after the switch.

Conclusions: Our results do not point to any safety concerns when switching nimodipine from initial i.v. to oral administration. Switching was neither associated with clinically relevant increases in TCD velocities nor other relevant adverse events.

Alpha power decrease in quantitative EEG detects development of cerebral infarction after subarachnoid hemorrhage early

OBJECTIVE

In subarachnoid hemorrhage (SAH), transcranial Doppler/color-coded-duplex sonography (TCD/TCCS) is used to detect delayed cerebral ischemia (DCI). In previous studies, quantitative electroencephalography (qEEG) also predicted imminent DCI. This study aimed to compare and analyse the ability of qEEG and TCD/TCCS to early identify patients who will develop later manifest cerebral infarction.

METHODS

We analysed cohorts of two previous qEEG studies. Continuous six-channel-EEG with artefact rejection and a detrending procedure was applied. Alpha power decline of ≥ 40% for ≥ 5 hours compared to a 6-hour-baseline was defined as significant EEG event. Median reduction and duration of alpha power decrease in each channel was determined. Vasospasm was diagnosed by TCD/TCCS, identifying the maximum frequency and days of vasospasm in each territory.

RESULTS

34 patients were included (17 male, mean age 56 ± 11 years, Hunt and Hess grade: I-V, cerebral infarction: 9). Maximum frequencies in TCD/TCCS and alpha power reduction in qEEG were correlated (r = 0.43; p = 0.015). Patients with and without infarction significantly differed in qEEG parameters (maximum alpha power decrease: 78% vs 64%, p = 0.019; summed hours of alpha power decline: 236 hours vs 39 hours, p = 0.006) but showed no significant differences in TCD/TCCS parameters.

CONCLUSIONS

There was a moderate correlation of TCD/TCCS frequencies and qEEG alpha power reduction but only qEEG differentiated between patients with and without cerebral infarction.

SIGNIFICANCE

qEEG represents a non-invasive, continuous tool to identify patients at risk of cerebral infarction.

Side effects of continuous intra-arterial infusion of nimodipine for management of resistant cerebral vasospasm in subarachnoid hemorrhage patients: A systematic review

BACKGROUND

Cerebral vasospasm is a common complication of subarachnoid hemorrhage. Nimodipine is the most frequently used drug for cerebral vasospasm management and is the only approved medication that has been demonstrated to reduce ischemic complications, infarct size and improve neurological outcome after aneurismal subarachnoid hemorrhage. The main purpose of this systematic review was to conduct a comprehensive analysis of the main cerebral and extracerebral side effects of continuous intra-arterial infusion of nimodipine in management of delayed cerebral ischemia in subarachnoid hemorrhage patients.

MATERIALS AND METHODS

A protocol with the inclusion and exclusion criteria for matched cases and the method of analysis were established and agreed by all authors. We defined the scope of this review to include articles (prospective and retrospective) reporting the side effects of continuous intra-arterial infusion of nimodipine in human subjects. PRISMA guidelines were used to conduct this systematic review.

RESULTS

A total of 8 articles reporting 136 patients were included in the review and analyzed. The side effects associated with continuous intra-arterial infusion of nimodipine were arterial hypotention, heparin-induced thrombocytopenia, atrial fibrillation or flutter, infections, acute kidney injury, hepatic and gastro-intestinal side effects.

CONCLUSION

The most frequent side effects reported in the articles included in this systematic review associated with the continuous intra-arterial infusion of nimodipine were arterial hypotension and heparin-induced thrombocytopenia. Intracerebral hemorrhage, the elevation of ICP, heart rhythm disorders, infectious complications, and thrombosis of the catheter might be also associated with CIAN. Future prospective studies are warranted to establish the risks and incidence of procedure-related side effects.

Nimodipine Pharmacokinetic Variability in Various Patient Populations

Nimodipine has been shown to improve outcomes following aneurysmal subarachnoid hemorrhage. Guidelines recommend that all patients receive a fixed dose of oral nimodipine for 21 days. However, pharmacokinetic studies have suggested variability of nimodipine pharmacokinetics in subarachnoid hemorrhage and in other patient populations. The clinical relevance of such variability is unknown. Therefore, the objective of the present review is, first, to conduct a literature review and summarize nimodipine pharmacokinetic data and sources of variability in various patient groups. Second, to determine if there is any evidence reporting an association between nimodipine exposure and clinical outcomes in patients with subarachnoid hemorrhage. A systematic literature search was performed in MEDLINE and EMBASE. The following keywords were used: ("nimodipine" OR "nymalize" OR "nimotop") AND ("pharmacokinetic*", OR "PK"). The search results were limited to English language and human studies. A large interpatient variability in nimodipine pharmacokinetics has been reported. Patient-specific factors that had an influence on pharmacokinetic parameters are age, comorbidities, variabilities in metabolism due to genetic polymorphism and co-administered medications, as well as nimodipine administration technique. The association between nimodipine exposure and clinical outcomes remains unclear and data available are too scarce to reach a firm conclusion. Here, we present a narrative review with a systematic literature search discussing nimodipine pharmacokinetic variability in various patient populations. It is not clear if minimal or lack of systemic exposure to nimodipine denies its benefit and contributes to worsening outcomes in patients with subarachnoid hemorrhage. Further studies are needed to determine if such an association exists.

Cerebrospinal Fluid Concentrations of Nimodipine Correlate With Long-term Outcome in Aneurysmal Subarachnoid Hemorrhage: Pilot Study

OBJECTIVES

The aim was to evaluate plasma and cerebrospinal fluid (CSF) nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage and their correlation with clinical outcome.

METHODS

Nimodipine infusion was started at 1 mg/h and increased up to 2 mg/h and continued up to 21 days in surviving patients. Arterial and CSF samples were collected at least after 24 hours of stable nimodipine dosing. Delayed cerebral ischemia and vasospasm were documented by new neurological deficits and neuroimaging. The clinical outcome was assessed at 9 months by the modified Rankin scale.

RESULTS

Twenty-three patients were enrolled. Nimodipine dose was 13 to 38 μg/kg per hour. Nimodipine arterial and CSF concentrations were 24.9 to 71.8 ng/mL and 37 to 530 pg/mL, respectively. Dose did not correlate with arterial or CSF concentrations. Arterial concentrations did not correlate with corresponding CSF concentrations. Doses and arterial concentrations did not correlate with the clinical outcome and were not associated with the occurrence of delayed cerebral ischemia. However, patients with no significant disability after 9 months of hemorrhage showed significantly higher CSF nimodipine concentrations (P = 0.015) and CSF-to-plasma ratios (P = 0.011) compared with patients who showed some degree of disability or who died.

CONCLUSIONS

Cerebrospinal fluid nimodipine concentrations measured during hospital drug infusion showed a correlation with long-term clinical outcome in patients with aneurysmal subarachnoid hemorrhage. These very preliminary data suggest that CSF concentrations monitoring may have some value in managing these patients.

The role of nimodipine and magnesium sulfate in the prevention and treatment of vascular spasm in patients in the acute rupture of cerebral aneurysms

Vascular spasm in patients with hemorrhage from rupture of cerebral aneurysms is the main cause of adverse outcomes of the disease. One way to treat persistent contraction of cerebral arteries is to use nimodipine and magnesium sulfate. This literature review presents studies on the use of nimodipine and magnesium sulfate in the treatment of vascular spasm, and highlights the main links of pathogenesis and drug action mechanisms.

Nimodipine Reappraised: An Old Drug With a Future

Nimodipine is a dihydropyridine calcium channel antagonist that blocks the flux of extracellular calcium through L-type, voltage-gated calcium channels. While nimodipine is FDAapproved for the prevention and treatment of neurological deficits in patients with aneurysmal subarachnoid hemorrhage (aSAH), it affects myriad cell types throughout the body, and thus, likely has more complex mechanisms of action than simple inhibition of cerebral vasoconstriction. Newer understanding of the pathophysiology of delayed ischemic injury after a variety of acute neurologic injuries including aSAH, traumatic brain injury (TBI) and ischemic stroke, coupled with advances in the drug delivery method for nimodipine, have reignited interest in refining its potential therapeutic use. In this context, this review seeks to establish a firm understanding of current data on nimodipine's role in the mechanisms of delayed injury in aSAH, TBI, and ischemic stroke, and assess the extensive clinical data evaluating its use in these conditions. In addition, we will review pivotal trials using locally administered, sustained release nimodipine and discuss why such an approach has evaded demonstration of efficacy, while seemingly having the potential to significantly improve clinical care.

Side Effects of Long-Term Continuous Intra-arterial Nimodipine Infusion in Patients with Severe Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage

BACKGROUND

Long-term continuous intra-arterial nimodipine infusion (CIAN) is a rescue therapy option in cases of severe refractory cerebral vasospasm (CV) following acute non-traumatic subarachnoid hemorrhage (SAH). However, CIAN therapy can be associated with relevant side effects. Available studies focus on intracerebral complications, whereas extracerebral side effects are rarely examined. Aim of the present study was to generate descriptive data on the clinical course during CIAN therapy and expectable extracerebral side effects.

METHODS

All patients treated with CIAN therapy for at least 5 days between May 2011 and December 2015 were included. We retrospectively extracted data from the patient data management system regarding the period between 2 days before the beginning and 5 days after the termination of CIAN therapy to analyze the course of ventilation parameters and pulmonary gas exchange, hemodynamic support, renal and liver function, integrity of the gastrointestinal tract, and the occurrence of infectious complications. In addition, we recorded the mean daily values of intracranial pressure (ICP) and intracerebral problems associated with CIAN therapy.

RESULTS

Data from 28 patients meeting inclusion criteria were analyzed. The mean duration of long-term CIAN therapy was 10.5 ± 4.5 days. Seventeen patients (60.7%) reached a good outcome level (Glasgow Outcome Scale [GOS] 4-5) 6 months after SAH. An impairment of the pulmonary gas exchange occurred only at the very beginning of CIAN therapy. The required vasopressor support with norepinephrine was significantly higher on all days during and the first day after CIAN therapy compared to the situation before starting CIAN therapy. Two patients required short-time resuscitation due to cardiac arrest during CIAN therapy. Acute kidney injury was observed in four patients, and one of them required renal replacement therapy with sustained low-efficiency daily dialysis. During CIAN therapy, 23 patients (82.1%) needed the escalation of a previous antiinfective therapy or the onset of antibiotics which was in line with a significant increase of C-reactive protein and white blood cell count. Obstipation was observed in 22 patients (78.6%). Ten patients (35.7%) even showed insufficient defecation on at least seven consecutive days. Compared to the situation before, ICP was significantly higher during the whole period of CIAN therapy.

CONCLUSIONS

Long-term CIAN therapy is associated with diverse side effects. The leading problems are an impairment of the hemodynamic situation and cardiac problems, an increase in infectious complications, a worsening of the motility of the gastrointestinal tract, and rising ICP values. Teams on neurointensive care units must be aware of these side effects to avoid that the beneficial effects of CIAN therapy on CV reported elsewhere are foiled by the problems this technique can be associated with.

Quantitative EEG After Subarachnoid Hemorrhage Predicts Long-Term Functional Outcome

PURPOSE

Delayed cerebral ischemia is a major complication after subarachnoid hemorrhage. Our previous study showed that alpha power reduction in continuous quantitative EEG predicts delayed cerebral ischemia. In this prospective cohort, we aimed to determine the prognostic value of alpha power in quantitative EEG for the long-term outcome of patients with subarachnoid hemorrhage.

METHODS

Adult patients with nontraumatic subarachnoid hemorrhage were included if admitted early enough for EEG to start within 72 hours after symptom onset. Continuous six-channel EEG was applied. Unselected EEG signals underwent automated artifact rejection, power spectral analysis, and detrending. Alpha power decline of ≥40% for ≥5 hours was defined as critical EEG event based on previous findings. Six-month outcome was obtained using the modified Rankin scale.

RESULTS

Twenty-two patients were included (14 male; mean age, 59 years; Hunt and Hess grade I-IV; duration of EEG monitoring, median 14 days). Poor outcome (modified Rankin scale, 2-5) was noted in 11 of 16 patients (69%) with critical EEG events. All six patients (100%) without EEG events achieved an excellent outcome (modified Rankin scale 0, 1) (P = 0.0062; sensitivity 100%, specificity 54.5%). Vasospasm detected with transcranial Doppler/Duplex sonography appeared 1.5 days after EEG events and showed weaker association with outcome (P = 0.035; sensitivity 100%, specificity 45.5%). There was no significant association between EEG events and ischemic lesions on imaging (P = 0.1). Also, no association between ischemic lesions and outcome was seen (P = 0.64).

CONCLUSIONS

Stable alpha power in quantitative EEG reflects successful therapy and predicts good functional outcome after subarachnoid hemorrhage. Critical alpha power reduction indicates an increased risk of poor functional outcome.

Impact of Early Versus Late Intravenous Followed by Oral Nimodipine Treatment on the Occurrence of Delayed Cerebral Ischemia Among Patients With Aneurysm Subarachnoid Hemorrhage

BACKGROUND

Guidelines for aneurysm subarachnoid hemorrhage (aSAH) management recommend treatment with nimodipine to all patients to reduce delayed cerebral ischemia (DCI) and poor clinical outcome. However, it did not give the most beneficial time to start therapy and route of administration.

OBJECTIVES

To compare the DCI occurrence and clinical outcome among aSAH patients who received nimodipine treatment at different times.

METHODS

A retrospective cohort study was conducted by collecting data from medical chart reviews between August 30, 2010, and October 31, 2015, at Prasart Neurological Institute, Thailand. Patients were classified into 2 groups by time to receive nimodipine: early group and late group (<96 and >96 hours, respectively). All patients received intravenous (IV) followed by oral nimodipine to complete treatment course. Clinical outcome was graded using the Glasgow Outcome Scale at 21 days. The factors related to DCI were analyzed using multivariate logistic regression.

RESULTS

A total of 149 patients were recruited: early (n = 97) and late (n = 52). No difference in baseline characteristics between groups was observed. The occurrence of DCI was not statistically significantly different between groups (early group, 18.60%, vs late group, 20.80%; P = 0.74). The World Federation of Neurosurgical Societies IV to V was associated with DCI occurrence. The proportion of patients with good outcome, poor outcome, or death did not show any difference between groups.

CONCLUSIONS AND RELEVANCE

Receiving IV nimodipine 3 to 7 days following oral therapy after bleeding can be the alternative regimen in patients who did not start nimodipine within 96 hours.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Cerebral vasospasm: current understanding

PURPOSE OF REVIEW

With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm.

RECENT FINDINGS

Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome.

SUMMARY

Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.

Magnetic resonance imaging and brain injury in the chronic phase after aneurysmal subarachnoid hemorrhage: A systematic review

Background Case-fatality rates after aneurysmal subarachnoid hemorrhage have decreased over the past decades. However, many patients who survive an aneurysmal subarachnoid hemorrhage have long-term functional and cognitive impairments. Aims We sought to review all data on conventional brain MRI obtained in the chronic phase after aneurysmal subarachnoid hemorrhage to (1) analyze the proportion of patients with cerebral infarction or brain volume changes; (2) investigate baseline determinants predictive of MRI-detected damage; and (3) assess if brain damage is predictive of patient outcome. Summary of review All original data published between 1 January 2000 and 4 October 2017 was searched using the PUBMED, EMBASE, and Web of Science databases. Based on preset inclusion criteria, 15 from 5200 articles were included with a total of 996 aneurysmal subarachnoid hemorrhage patients. Quality assessment, risk of bias assessment, and level of evidence assessment were performed. The results according to aim, with levels of evidence, were: (1) 25 to 81% of aneurysmal subarachnoid hemorrhage patients show infarcts (strong); there is a higher ratio of cerebrospinal fluid-to-intracranial volume in patients compared to controls (strong); (2) there is a negative relation between age (moderate), DCI (low) and brain volume measurement outcomes; (3) lower brain parenchymal volume (strong) and the presence of infarcts or infarct volumes (moderate) are associated with a worse outcome. Conclusion Patients after aneurysmal subarachnoid hemorrhage may demonstrate brain infarcts and decreased brain parenchyma, which is related to worse outcome. Thereby, both brain infarcts and brain volume measurements could be used as outcome markers in pharmaceutical trials. Systematic Review Registration PROSPERO CRD42016040095.

[Intensive care treatment after aneurysmal subarachnoid hemorrhage]

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease and nearly one third of patients die in the acute phase. Due to the bleeding event, a hyperactive sympathetic nervous system and an uncontrolled inflammatory response have a profound local and systemic impact on other organ functions. Neuroendocrinological disorders and cardiopulmonary morbidity are dominant. Despite a decrease in hospital mortality for high volume centers, a high proportion of survivors suffer from neurological deficits. Knowledge of the pathophysiology of vasospasms in the later stages of the disease has increased. Anti-inflammatory treatment does not improve the outcome. Nimodipine prophylaxis in the first 96 h after SAH seems to be the only intervention which has been proven to be advantageous in studies; however, nearly every second survivor of SAH suffers from some neurological deficits and more than one third of survivors report depressive episodes or symptoms of posttraumatic stress disorder.

Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis

OBJECTIVES

To examine the clinical outcome of aneurysmal subarachnoid haemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS)-targeted treatments in a meta-analysis and to evaluate the efficacy of intra-arterial (IA) approaches in patients with severe/refractory vasospasm.

METHODS

Randomised controlled trials, prospective and retrospective observational studies reporting clinical outcomes of aSAH patients exposed to CVS targeted treatments, published between 2006-2016 were searched using PubMed, EMBASE and the Cochrane Library. The main endpoint was the proportion of unfavourable outcomes, defined as a modified Rankin score of 3-6 at last follow-up.

RESULTS

Sixty-two studies, including 26 randomised controlled trials, were included (8,976 patients). At last follow-up 2,490 of the 8,976 patients had an unfavourable outcome, including death (random-effect weighted-average, 33.7%; 99% confidence interval [CI], 28.1-39.7%; Q value, 806.0; I ² = 92.7%). The RR of unfavourable outcome was lower in patients treated with Cilostazol (RR = 0.46; 95% CI, 0.25-0.85; P = 0.001; Q value, 1.5; I ² = 0); and in refractory CVS patients treated by IA intervention (RR = 0.68; 95% CI, 0.57-0.80; P < 0.0001; number needed to treat with IA intervention, 6.2; 95% CI, 4.3-11.2) when compared with the best available medical treatment.

CONCLUSIONS

Endovascular treatment may improve the outcome of patients with severe-refractory vasospasm. Further studies are needed to confirm this result.

KEY POINTS

• 33.7% of patients with cerebral Vasospasm following aneurysmal subarachnoid-hemorrhage have an unfavorable outcome. • Refractory vasospasm patients treated using endovascular interventions have lower relative risk of unfavourable outcome. • Subarachnoid haemorrhage patients with severe vasospasm may benefit from endovascular interventions. • The relative risk of unfavourable outcome is lower in patients treated with Cilostazol.

Memantine Attenuates Delayed Vasospasm after Experimental Subarachnoid Hemorrhage via Modulating Endothelial Nitric Oxide Synthase

Delayed cerebral vasospasm is an important pathological feature of subarachnoid hemorrhage (SAH). The cause of vasospasm is multifactorial. Impairs nitric oxide availability and endothelial nitric oxide synthase (eNOS) dysfunction has been reported to underlie vasospasm. Memantine, a low-affinity uncompetitive N-methyl-d-aspartate (NMDA) blocker has been proven to reduce early brain injury after SAH. This study investigated the effect of memantine on attenuation of vasospasm and restoring eNOS functionality. Male Sprague-Dawley rats weighing 350–450 g were randomly divided into three weight-matched groups, sham surgery, SAH + vehicle, and SAH + memantine groups. The effects of memantine on SAH were evaluated by assessing the severity of vasospasm and the expression of eNOS. Memantine effectively ameliorated cerebral vasospasm by restoring eNOS functionality. Memantine can prevent vasospasm in experimental SAH. Treatment strategies may help combat SAH-induced vasospasm in the future.

Serum levels of nimodipine in enteral and parenteral administration in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

The aim of this study was to evaluate serum nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage (SAH) after parenteral therapy and a following course of enteral administration.

METHODS

SAH patients were treated with intravenous nimodipine (2 mg/h) during the 1st week after hemorrhage, and on day 8, we switched over to enteral administration (60 mg/4 h), either orally or by gavage. Serum nimodipine concentrations were measured on days 3, 5, 8, 9 and 12. Area under the curve (AUC) was calculated during parenteral and enteral therapy. The data of 15 patients were analyzed retrospectively.

RESULTS

In this study, 157 blood samples were obtained. In seven samples, during the administration by gavage to two patients with high-grade SAH, the serum nimodipine concentrations were negligible. The AUC values during parenteral administration (median 149.3 ng-h/ml) were significantly higher than during oral administration on days 9 (median 92.1 ng-h/ml) and 12 (median 44.1 ng-h/ml) in seven patients (p = 0.030 and p = 0.016, respectively). The AUC values during parenteral administration were significantly higher than during administration by gavage on day 9 in eight patients (median 87.9 and 34 ng-h/ml, respectively, p = 0.001). The AUC values during enteral administration were higher in patients who received nimodine orally than in those who received it by gavage (median 52.3 and 23.1 ng-h/ml, respectively, p = 0.006).

CONCLUSIONS

Enteral administration of nimodipine showed lower bioavailability during the 2nd week after SAH compared to parenteral application during the 1st week. Negligible serum concentrations were even expected when nimodipine was given by gavage in patients with high-grade SAH, thus suggesting that parenteral administration may be the better route in these patients.

Bedside diagnosis of mitochondrial dysfunction in aneurysmal subarachnoid hemorrhage

OBJECTIVES

Aneurysmal subarachnoid hemorrhage (SAH) is frequently associated with delayed neurological deterioration (DND). Several studies have shown that DND is not always related to vasospasm and ischemia. Experimental and clinical studies have recently documented that it is possible to diagnose and separate cerebral ischemia and mitochondrial dysfunction bedside. The study explores whether cerebral biochemical variables in SAH patients most frequently exhibit a pattern indicating ischemia or mitochondrial dysfunction.

METHODS

In 55 patients with severe SAH, intracerebral microdialysis was performed during neurocritical care with bedside analysis and display of glucose, pyruvate, lactate, glutamate, and glycerol. The biochemical patterns observed were compared to those previously described in animal studies of induced mitochondrial dysfunction as well as the pattern obtained in patients with recirculated cerebral infarcts.

RESULTS

In 29 patients, the biochemical pattern indicated mitochondrial dysfunction while 10 patients showed a pattern of cerebral ischemia, six of which also exhibited periods of mitochondrial dysfunction. Mitochondrial dysfunction was observed during 5162 h. An ischemic pattern was obtained during 688 h. Four of the patients (40%) with biochemical signs of ischemia died at the neurosurgical department as compared with three patients (10%) in the group of mitochondrial dysfunction.

CONCLUSIONS

The study documents that mitochondrial dysfunction is a common cause of disturbed cerebral energy metabolism in patients with SAH. Mitochondrial dysfunction may increase tissue sensitivity to secondary adverse events such as vasospasm and decreased cerebral blood flow. The separation of ischemia and mitochondrial dysfunction bedside by utilizing microdialysis offers a possibility to evaluate new therapies.

Preadmission statin use does not improve functional outcomes or prevent delayed ischemic events in patients with spontaneous subarachnoid hemorrhage

STUDY OBJECTIVE

To determine whether preadmission statin use in patients with spontaneous subarachnoid hemorrhage (SAH) is associated with improved functional outcomes and a lower incidence of delayed cerebral ischemic events compared with statin-naive patients with SAH.

DESIGN

Prospective cohort study.

SETTING

Neurosciences intensive care unit of a tertiary care hospital.

PATIENTS

A total of 295 consecutive patients with SAH admitted between March 2006 and May 2013 who had complete medication histories; of these patients, 41 reported taking a statin prior to admission, and 254 were statin naive.

INTERVENTION

All patients received clinical management for SAH according to hospital protocol for standard care that included acute statin therapy with enteral pravastatin 40 mg/day on hospital day 1 for up to 21 days.

MEASUREMENTS AND MAIN RESULTS

Functional outcomes were assessed by using the modified Rankin Scale (mRS) at 14 days, 28 days, and 3 months. Delayed cerebral ischemia was assessed by using clinical evaluation and computed tomography. Patients taking statins prior to admission were more likely to have a history of diabetes mellitus, hypertension, coronary artery disease, and stroke. No significant difference in favorable neurologic outcome (mRS score 0-3) at 3 months was observed between the preadmission statin group compared with the statin-naive group (56.3% vs 72.4%, p=0.095). In multivariate logistic regression analysis, only age, severity of rupture, and coronary artery disease were less likely to predict a favorable neurologic outcome. No significant difference in the development of delayed cerebral ischemic events was observed between groups (p=0.48).

CONCLUSION

Statin use prior to admission did not improve functional outcomes or prevent delayed cerebral ischemic events in patients with SAH. Age, severity of rupture, and coronary artery disease were less likely to predict a favorable neurologic outcome at 3 months after discharge.

Mechanisms, treatment and prevention of cellular injury and death from delayed events after aneurysmal subarachnoid hemorrhage

INTRODUCTION

Subarachnoid hemorrhage (SAH) patients often develop brain injury as a result of a number of delayed complications, resulting in significant morbidity and mortality. Many of these complications arise due to delayed cerebral ischemia, which occurs secondary to the hemorrhage.

AREAS COVERED

The mechanisms of the delayed injury are reviewed, including angiographic vasospasm, cortical spreading ischemia, small arteriolar constriction, microthromboemboli, free radical injury and inflammation. Some current and prospective therapies for SAH are discussed, in the context of these complications. Statins have been particularly promising in experimental studies.

EXPERT OPINION

Multiple mechanisms are involved in the pathogenesis of the delayed insult after SAH. New drugs may need to target multiple pathways to injury. Trials aiming to treat complications after SAH could benefit from taking into account the multifactorial pathogenesis of delayed insults.

Effects of topical administration of nimodipine on cerebral blood flow following subarachnoid hemorrhage in pigs

We sought to explore whether topical administration of nimodipine improves the abnormal cerebral perfusion following subarachnoid hemorrhage (SAH) in pigs. Fourteen pigs were randomly divided into three groups: sham (n=4), SAH (n=5), or SAH + nimodipine (n=5). The SAH model was established by injecting fresh autologous nonheparinized arterial blood into the suprasellae cistern. Nimodipine or saline placebo (0.04 g/mL) were administered to the operative area on the fourth day after the SAH model was established. The cerebral blood flow (CBF) was measured 60 min after topical administration of nimodipine by cranial SPECT/CT scans with 5 mCi 99mTc-ECD injected intravenously. The CCR (corticocebellar ratio) was calculated by dividing the counts/voxel of the whole cerebral hemisphere by the average count/voxel in the cerebellar region of reference and RD (relative dispersion). A predictor for impaired autoregulation of CBF was calculated by dividing standard deviation (SD) of regional perfusion by mean perfusion (RD=SD/Mean). CCR and RD were applied to describe hemisphere CBF and perfusion heterogeneity. Cerebral perfusion significantly decreased in the SAH group (CCR: 1.382±0.192, RD: 0.417±0.015) compared to sham (CCR: 1.988±0.346, RD 0.389±0.015) (p<0.05). Abnormal cerebral perfusion status, however, was not significantly improved in the nimodipine + SAH group (CCR: 1.503±0.107, RD: 0.425±0.018) compared to the SAH group (p>0.05). Topical administration of nimodipine did not significantly improve CBF following SAH. These findings were not consistent with our previous data demonstrating that the topical administration of nimodipine significantly alleviates cerebral vasospasm following SAH detected by TCD. Potential mechanisms governing these disparate outcomes require further investigation.

[Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: prevention, diagnostics and therapy]

Delayed cerebral ischemia (DCI) is the second most important impacting factor for functional outcome after aneurysmal subarachnoid hemorrhage (SAH) following the initial severity of the bleeding. In contrast to the initial SAH severity the presence and consequences of DCI can be managed with prophylactic and therapeutic interventions. The previous notion of treatment of angiographically observed vasospasm has not been shown to be successful.This article covers prevention, monitoring and therapeutic concepts for patients with SAH with emphasis on the efficacy for DCI and current and ongoing research projects.

Slow and continuous delivery of a low dose of nimodipine improves survival and electrocardiogram parameters in rescue therapy of mice with experimental cerebral malaria

BACKGROUND

Human cerebral malaria (HCM) is a life-threatening complication caused by Plasmodium falciparum infection that continues to be a major global health problem despite optimal anti-malarial treatment. In the experimental model of cerebral malaria (ECM) by Plasmodium berghei ANKA, bolus administration of nimodipine at high doses together with artemether, increases survival of mice with ECM. However, the dose and administration route used is associated with cardiovascular side effects such as hypotension and bradycardia in humans and mice, which could preclude its potential use as adjunctive treatment in HCM.

METHODS

In the present study, alternative delivery systems for nimodipine during late-stage ECM in association with artesunate were searched to define optimal protocols to achieve maximum efficacy in increasing survival in rescue therapy while causing the least cardiac side effects. The baseline electrocardiogram (ECG) and arterial pressure characteristics of uninfected control animals and of mice with ECM and its response upon rescue treatment with artesunate associated or not with nimodipine is also analysed.

RESULTS

Nimodipine, given at 0.5 mg/kg/day via a slow and continuous delivery system by osmotic pumps, increases survival of mice with ECM when used as adjunctive treatment to artesunate. Mice with ECM showed hypotension and ECG changes, including bradycardia and increases in PR, QRS, QTc and ST interval duration. ECM mice also show increased QTc dispersion, heart rate variability (HRV), RMSSD, low frequency (LF) and high frequency (HF) bands of the power spectrum. Both sympathetic and parasympathetic inputs to the heart were increased, but there was a predominance of sympathetic tone as demonstrated by an increased LF/HF ratio. Nimodipine potentiated bradycardia when given by bolus injection, but not when via osmotic pumps. In addition, nimodipine shortened PR duration and improved HRV, RMSSD, LF and HF powers in mice with ECM. In addition, nimodipine did not increased hypotension or decreased the speed of arterial pressure recovery when used in rescue therapy with artesunate.

CONCLUSIONS

These data show that slow and continuous delivery of lower doses of nimodipine improves survival of mice with ECM in rescue therapy with artesunate while showing a safer profile in terms of cardiovascular effects.

Off-label use of drugs and devices in the neuroendovascular suite

SUMMARY

The off-label use of drugs and devices in neuroendovascular procedures is common. Neurointerventionalists should be well aware of the level of evidence available in support of the off-label use of drugs and devices in their practice and some of the potential adverse events associated with them. These uses are categorized as I or II if they have been evaluated as primary or ancillary interventions in prospective trials/registries of neuroendovascular procedures and III if they were evaluated in case series. Category IV use is based on evaluation as primary or ancillary interventions in prospective trials/registries of non-neuroendovascular procedures. Physicians are allowed to use off-label drugs and procedures if there is strong evidence that they are beneficial for the patient. The neurointerventional professional societies agree that off-label use of drugs and devices is an important part of the specialty, but practicing providers should base their decisions on sound evidence when using such drugs and devices.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJECTIVE

To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment.

MATERIAL AND METHODS

A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed.

RESULTS

The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm.

CONCLUSIONS

SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Posterior reversible encephalopathy syndrome postautologous peripheral stem cell transplantation for multiple myeloma

This is a case of a 56-year-old lady with recent autologous peripheral stem cell transplantation for multiple myeloma. She was presented with a 48 h history of worsening headache, drowsiness, nausea/vomiting and some peripheral neurological symptoms. She developed status epilepticus, was intubated and transferred to intensive care unit. After full investigation with a CT head, CT cerebral angiogram, MRI brain and cerebral angiogram, she was diagnosed with posterior reversible encephalopathy syndrome (PRES) with the help of expert opinion, based on the clinical and radiological evidence. The MRI showed bilateral occipital signal changes suggestive of PRES. She was managed with nimodipine, phenytoin and clonazepam with good effect. Eventually extubated, she made good progress on the ward with no further seizure episodes. Functionally she did not appear to have any evidence of residual damage from the PRES. This case discusses PRES on a background of a haematological malignancy and its clinical features.

A randomized outcome study of enteral versus intravenous nimodipine in 171 patients after acute aneurysmal subarachnoid hemorrhage

BACKGROUND

Delayed ischemic neurologic deficit (DIND) is a serious complication of acute aneurysmal subarachnoid hemorrhage (aSAH). Although oral nimodipine is accepted as standard care for the prevention of DIND, the intravenous route is preferred by several centers. In the present study we compared the clinical efficacy between enteral and intravenous nimodipine after aSAH.

METHODS

A total of 171 aSAH patients were randomly assigned to either the enteral (84 patients) or the intravenous (87 patients) nimodipine group and were compared regarding the incidence of DIND, number of new ischemic lesions on 12-month brain magnetic resonance image, and clinical outcome 12 months after aSAH as assessed by Glasgow Outcome scale, modified Rankin scale, and Karnofsky scale. Health-related quality of life was also assessed by the 15D questionnaire 12 months after aSAH.

RESULTS

The incidence of DIND did not differ significantly between the groups (20% in the enteral versus 16% in the intravenous group, P=0.61), whereas no differences were observed, neither in the number of new ischemic lesions (34% in both groups, P=0.99), nor in the clinical outcome 12 months after aSAH (P=0.34 for Glasgow Outcome scale, P=0.74 for modified Rankin scale, and P=0.71 for Karnofsky scale). The mean 15D health-related quality of life sums were also similar in the 2 groups (P=0.43).

CONCLUSIONS

Our pilot study suggested no differences in the clinical efficacy of enteral and intravenous nimodipine after aSAH. However, a much larger phase III clinical trial would be needed to show or exclude meaningful clinical differences.

[Protective measures against cerebral ischemia following subarachnoid hemorrhage: Part 1]

BACKGROUND AND OBJECTIVES

Cerebral vasospasm following aneurysmal subarachnoid hemorrhage contributes significantly to morbidity and mortality. Many studies on the various treatments aimed at preventing cerebral vasospasm have been carried out, but evidence of efficacy is limited. Our aim was to review the literature on the various therapies for which there is scientific evidence of protection against cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

METHODS

MEDLINE search (1950 to the october 2009) and review of articles found on the prevention of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. The search was restricted to articles in English, French, and Spanish. The keywords were cerebral vasospasm, subarachnoid hemorrhage, therapy, nimodipine, triple H, clazosentan, statins, and magnesium in addition to the word forms derived from them. We also searched manually for references cited in the selected articles. A title was included if it was a randomized controlled trial, meta-analysis, nonrandomized clinical trial, descriptive study, observational study with statistical analysis, opinion article, or expert review.

RESULTS

Part 1 analyzed treatment with calcium antagonists and triple-H therapy (hypertension, hemodilution, and hypervolemia). Part 2 analyzed new therapies such as clazosentan, magnesium, and statins. A total of 597 titles were located; 283 were initially selected. The 61 articles finally selected for review were of the following types: 2 opinion articles, 21 randomized controlled trials, 22 expert review articles, 3 meta-analyses, 4 nonrandomized clinical trials, 1 descriptive study, and 5 observational studies with statistical analysis. Three studies (2 meta-analyses and 1 randomized controlled trial) demonstrated that nimodipine use confers benefits (reduced morbidity and mortality) for patients with aneurysmatic subarachnoid hemorrhage. Statistically significant clinical benefits could not be demonstrated for the other drugs (clazosentan, statins, and magnesium).

CONCLUSIONS

Insufficient evidence is available to support the use of the triple-H therapy, clazosentan, statins, or magnesium sulfate for the prevention of cerebral vasospasm following subarachnoid hemorrhage. Nimodipine is the only preventative treatment that can be recommended.

Pharmacological treatment of delayed cerebral ischemia and vasospasm in subarachnoid hemorrhage

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.

Advances in treatment of cerebral vasospasm: an update

An update of published clinical advances in the treatment of cerebral vasospasm after subarachnoid haemorrhage was provided. Searching MEDLINE using the search terms "cerebral vasospasm" and "clinical trials" 46 papers were identified that had been published since the International Conference on Cerebral Vasospasm in Istanbul, Turkey in 2006. Of these 26 were either safety studies or case reports leaving 20 papers for consideration. The major topics covered were calcium antagonists, magnesium sulphate, statins, and fasudil hydrochloride. The studies published did not reach an impact justified recommended routine use, but certainly as options. Results of the CONSCIOUS trials on endothelin receptor antagonists are awaited.