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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [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: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Thiery L, Carle X, Testud B, Boulouis G, Habert P, Tradi F, Reyre A, Lehmann P, Dory-Lautrec P, Stellmann JP, Girard N, Brunel H, Hak JF. Distal cerebral vasospasm treatment following aneurysmal subarachnoid hemorrhage using the Comaneci device: technical feasibility and single-center preliminary results. J Neurointerv Surg 2023; 15:325-329. [PMID: 35584908 DOI: 10.1136/neurintsurg-2022-018699] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Balloon-assisted mechanical angioplasty for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) has a number of limitations, including transient occlusion of the spastic blood vessel. Comaneci is an FDA-approved device for temporary coil embolization assistance which has recently also been approved for the treatment of distal symptomatic refractory vasospasm. We aimed to report the feasibility, efficacy and safety of our experience with Comaneci angioplasty for refractory distal vasospasm (up to the second segment of the cerebral arteries) following aSAH. METHODS This is a retrospective analysis of a prospective series of 18 patients included between April 2019 and June 2021 with aSAH and symptomatic vasospasm refractory to medical therapy, who were treated using Comaneci-17-asssisted mechanical distal angioplasty. Immediate angiographic results, procedure-related complications, and clinical outcomes were assessed. Inter-rater reliability of the scores was determined using the intraclass correlation coefficient. RESULTS Comaneci-assisted distal angioplasty was performed in 18 patients, corresponding to 31 target arteries. All distal anterior segments were easily accessible with the Comaneci-17 device. Vasospasm improvement after Comaneci mechanical angioplasty was seen in 22 distal arteries (71%) (weighted Cohen's kappa (κw) 0.73, 95% CI 0.69 to 0.93). Vasospasm recurrence occurred in three patients (16.67%) and delayed cerebral infarction in three patients (16.67%), with a mean±SD delay between onset of symptoms and imaging follow-up (MRI/CT) of 32.61±8.93 days (κw 0.98, 95% CI 0.88 to 1). CONCLUSION This initial experience suggests that distal mechanical angioplasty performed with the Comaneci-17 device for refractory vasospasm following aSAH seems to be safe, with good feasibility and efficacy.
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Affiliation(s)
- Louis Thiery
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Xavier Carle
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Benoit Testud
- Department of Neuroradiology, APHM La Timone, Marseille, France.,CEMEREM, Aix Marseille University, Marseille, France.,CNRS, CRMBM, Aix Marseille University, Marseille, France
| | | | - Paul Habert
- Department of Medical Imaging, APHM La Timone, Marseille, France.,LIIE, Aix Marseille University, Marseille, France.,CERIMED, Aix Marseille University, Marseille, France
| | - Farouk Tradi
- Department of Medical Imaging, APHM La Timone, Marseille, France.,LIIE, Aix Marseille University, Marseille, France.,CERIMED, Aix Marseille University, Marseille, France
| | - Anthony Reyre
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Pierre Lehmann
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | | | - Jan-Patrick Stellmann
- Department of Neuroradiology, APHM La Timone, Marseille, France.,CEMEREM, Aix Marseille University, Marseille, France.,CNRS, CRMBM, Aix Marseille University, Marseille, France
| | - Nadine Girard
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Herve Brunel
- Department of Neuroradiology, APHM La Timone, Marseille, France
| | - Jean-Francois Hak
- Department of Neuroradiology, APHM La Timone, Marseille, France.,LIIE, Aix Marseille University, Marseille, France.,CERIMED, Aix Marseille University, Marseille, France
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Barbosa S, Jorge N, Silva ML, Maia I, Dias C, Pereira E, Paiva JA. Treatment of Cerebral Vasospasm With Continuous Intra-Arterial Nimodipine: A Case Report. Cureus 2022; 14:e30507. [DOI: 10.7759/cureus.30507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
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Mao G, Gigliotti MJ, Esplin N, Sexton K. The clinical impact and safety profile of high-dose intra-arterial verapamil treatment for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 202:106546. [PMID: 33588359 DOI: 10.1016/j.clineuro.2021.106546] [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: 12/31/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cerebral vasospasm (CVS) leads to delayed cerebral ischemia (DCI) and cerebral infarction, a potential cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to evaluate the clinical efficacy and safety profile of high-dose IA verapamil for aSAH in a large series of patients. METHODS Between 2011-2019, a retrospective cohort of 188 consecutive patients presenting with aSAH were reviewed. High-dose IA verapamil (> 20 mg per vascular territory on each side) was intermittently used for appropriate patients to manage symptomatic CVS. Of the 188 patients reviewed, 86 were treated with high-dose IA verapamil. The clinical efficacy and safety profile of our ruptured aneurysm patient cohort were compared to historical literature controls. The primary endpoints studied included radiographic stroke corresponding to cerebral vasospasm, clinical outcome at discharge and subsequent follow-up, and overall functional status as defined by the modified Rankin scale (mRS). The safety profile of high dose IA verapamil was a secondary endpoint. RESULTS IA verapamil was delivered between 2-16 days after ictus (median post-bleed day 6) and 74 % of patients had documented clinical improvement after therapy, with 61.5 % achieving good functional outcomes (mRS < 2). 25.5 % of all patients had evidence of vasospasm-related DCI. 3 patients sustained transient hemodynamic changes after verapamil treatment and 10 patients developed post-procedural seizures successfully managed with intravenous lorazepam. CONCLUSION High-dose IA verapamil treatment is well-tolerated in the high-risk aneurysmal subarachnoid hemorrhage population that experience severe, symptomatic CVS with good functional outcomes at follow-up.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States
| | - Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, United States.
| | - Nathan Esplin
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States
| | - Kevin Sexton
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States
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Peterson CM, Podila SS, Girotra T. Unruptured aneurysmal clipping complicated by delayed and refractory vasospasm: case report. BMC Neurol 2020; 20:344. [PMID: 32919459 PMCID: PMC7488665 DOI: 10.1186/s12883-020-01925-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022] Open
Abstract
Background Delayed symptomatic vasospasm is a rare complication following clipping of an unruptured intracranial saccular aneurysm. There have been ten reported cases of delayed symptomatic vasospasm and only two of these occurred after 2 weeks from initial intervention. Our case is the first to document the refractory nature of such vasospasm despite aggressive first line therapy. Case presentation Here, we present a 67-year-old female who had surgical clipping of a 10x7mm right middle cerebral artery (MCA) bifurcation aneurysm. Her surgery and initial postoperative course were uncomplicated, but she presented with acute left hemiparesis, dysarthria, headache and vomiting on post-op day 29 secondary to vasospasm of M2. She was initially stabilized with intra-arterial verapamil then managed with volume expansion, permissive hypertension, and nimodipine. She developed recurrent vasospasm of M2 the following day and was again treated with intra-arterial verapamil. Magnetic resonance imaging (MRI) brain showed an infarction involving the right basal ganglia, frontal lobe, and parietal lobe and her hospital course was complicated by super-refractory status epilepticus. At her follow up appointment she displayed continued left lower extremity weakness, left visual field defect, and left-sided neglect. Conclusions Overall, cerebral vasospasms associated with unruptured aneurysms remain rare complications and are not often monitored for after initial recovery. Reviewing the documented cases highlights the unpredictability of when these events occur with our current knowledge. Current hypotheses for the mechanisms responsible for delayed and refractory vasospasms include: blood-derived breakdown products, mechanically induced vasospastic responses, and delayed reactions from the trigemino-cerebrovascular system (TCVS). The uncertainly of these events warrants further research and supports a strong argument for monitoring patients with initial surgical clipping up to a month out from their initial procedure.
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Affiliation(s)
- Crina M Peterson
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Sahitya S Podila
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Tarun Girotra
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
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Hofman M, Hajder N, Duda I, Krzych ŁJ. A Questionnaire Survey of Management of Patients with Aneurysmal Subarachnoid Haemorrhage in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4161. [PMID: 32545225 PMCID: PMC7313024 DOI: 10.3390/ijerph17114161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/06/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) remains a potentially devastating threat to the brain with a serious impact on mortality and morbidity. We attempted to investigate correspondence between the current guidelines for aSAH management and real clinical practice in Poland. METHODS A web-based questionnaire was performed between 03.2019 and 06.2019. Centres performing neuro-interventional radiology procedures and neuro-critical care were included (n = 29). One response from each hospital was recorded. RESULTS In three (10.4%) centres, there was no clear protocol for an interventional treatment plan. Endovascular embolisation was predominantly used in 11 (37.9%) hospitals, and microsurgical clipping, in 10 (34.5%). A written protocol for standard anaesthetic management was established only in six (20.7%) centres for coiling and in five (17.2%) for microsurgical clipping. The diagnosis of cerebral vasospasm was based on transcranial Doppler as the first-choice method in seven (24.1%) units. "3-H therapy" was applied by 15 (51.8%) respondents, and "2-H therapy", by four (13.8%) respondents. In only eight (27.6%) centres were all patients with aSAH being admitted to the ICU. CONCLUSION Many discrepancies exist between the available guidelines and clinical practice in aSAH treatment in Poland. Peri-procedural management is poorly standardised. Means must be undertaken to improve patient-oriented treatment and care.
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Affiliation(s)
- Mariusz Hofman
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-007 Katowice, Poland; (N.H.); (I.D.); (Ł.J.K.)
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Verapamil use in interventional neuroradiology: A case series of postoperative pulmonary edema. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Link TW, Santillan A, Patsalides A. Intra-arterial neuroprotective therapy as an adjunct to endovascular intervention in acute ischemic stroke: A review of the literature and future directions. Interv Neuroradiol 2020; 26:405-415. [PMID: 32423272 DOI: 10.1177/1591019920925677] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion has been shown to significantly improve outcomes. However, despite efficient rates of recanalization (60-90%), the rates of functional independence remain suboptimal (14-58%), most likely due to pathways of cell death in the brain that have already committed despite successful reperfusion. Pharmacologic neuroprotection provides a potential means of preventing this inevitable damage through targeting excitotoxicity, reactive oxygen species, cellular apoptosis, and inflammation. Numerous clinical trials using various neuroprotective agents have failed, but the majority of these trials did not include endovascular reperfusion, and thus the drugs were not reaching the therapeutic target. Intra-arterial delivery of neuroprotective agents via the guide catheter already in place for mechanical thrombectomy could provide a way to deliver high doses directly to the affected territory while limiting systemic exposure. Agents that have shown promise via the intra-arterial route in preclinical as well as some clinical models include magnesium sulfate, verapamil, cold saline, stem cells, and various combined approaches. Targeted hypothermia, achieved with intra-carotid infusion of cold saline, may provide an effective means of achieving hypothermia of the ischemic tissue while avoiding the systemic effects that have limited its use previously. Combination therapy of targeted hypothermia and a cocktail of drugs that provide anti-excitotoxic, anti-oxidant, anti-apopototic, and anti-inflammatory effects may provide an ideal approach that deserves further study in clinical trials.
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Affiliation(s)
- Thomas W Link
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, NY, USA
| | - Alejandro Santillan
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, NY, USA
| | - Athos Patsalides
- Department of Neurology, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, NY, USA
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Continuous intra-arterial infusion of verapamil for treatment of severe vasospasm after subarachnoid hemorrhage. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Intra-arterial Administration of Verapamil for the Prevention and Treatment of Cerebral Angiospasm. ACTA NEUROCHIRURGICA SUPPLEMENT 2020; 127:179-183. [DOI: 10.1007/978-3-030-04615-6_28] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ospel JM, Wright CH, Jung R, Vidal LLM, Manjila S, Singh G, Heck DV, Ray A, Blackham KA. Intra-Arterial Verapamil Treatment in Oral Therapy-Refractory Reversible Cerebral Vasoconstriction Syndrome. AJNR Am J Neuroradiol 2019; 41:293-299. [PMID: 31879333 DOI: 10.3174/ajnr.a6378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 11/16/2019] [Indexed: 12/31/2022]
Abstract
Reversible vasoconstriction syndrome is a complex of clinical symptoms and angiographic findings, which, while having a mostly benign clinical course, has clinical and imaging overlap with more serious disorders such as vasculitis and aneurysmal SAH and itself includes a minority of patients with fulminant vasoconstriction resulting in severe intracranial complications. Endovascular options for patients with refractory reversible cerebral vasoconstriction syndrome include intra-arterial vasodilator infusion similar to therapy for patients with vasospasm after SAH. To date, only case reports and 1 small series have discussed the utility of intra-arterial vasodilators for the treatment of reversible cerebral vasoconstriction syndrome. We report an additional series of 11 medically refractory cases of presumed or proved reversible cerebral vasoconstriction syndrome successfully treated with intra-arterial verapamil infusion. Furthermore, we propose that the reversal of vasoconstriction, as seen on angiography, could fulfill a diagnostic criterion.
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Affiliation(s)
- J M Ospel
- From the Department of Radiology (J.M.O., K.A.B.), Section of Neuroradiology and Interventional Neuroradiology, Basel University Hospital, University of Basel, Basel, Switzerland
| | - C H Wright
- Departments of Neurological Surgery (C.H.W.)
| | - R Jung
- Department of Neurology (R.J.), The Sandra and Malcolm Berman Brain & Spine Institute, Sinai Hospital of Baltimore, LIfebridge Health, Baltimore, Maryland
| | - L L M Vidal
- Department of Diagnostic Radiology and Nuclear Medicine (L.L.M.V.), University of Maryland Medical Center, Baltimore, Maryland
| | - S Manjila
- Department of Neurosurgery and Neurosciences (S.M.), McLaren Bay Region Hospital, Bay City, Michigan
| | - G Singh
- Department of Radiology (G.S.), Section of Neuroradiology, Newark Beth Israel Medical Center, Newark, New Jersey
| | - D V Heck
- Forsyth Radiological Associates (D.V.H.), Winston-Salem, North Carolina
| | - A Ray
- Neurosurgery (A.R.), University Hospitals of Cleveland Case Medical Center, Cleveland, Ohio
| | - K A Blackham
- From the Department of Radiology (J.M.O., K.A.B.), Section of Neuroradiology and Interventional Neuroradiology, Basel University Hospital, University of Basel, Basel, Switzerland
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Labeyrie MA, Gaugain S, Boulouis G, Zetchi A, Brami J, Saint-Maurice JP, Civelli V, Froelich S, Houdart E. Distal Balloon Angioplasty of Cerebral Vasospasm Decreases the Risk of Delayed Cerebral Infarction. AJNR Am J Neuroradiol 2019; 40:1342-1348. [PMID: 31320465 DOI: 10.3174/ajnr.a6124] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/05/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Conventional angioplasty of cerebral vasospasm combines proximal balloon angioplasty (up to the first segment of cerebral arteries) with chemical angioplasty for distal arteries. Distal balloon angioplasty (up to the second segment of cerebral arteries) has been used in our center instead of chemical angioplasty since January 2015. We aimed to assess the effect of this new approach in patients with aneurysmal SAH. MATERIALS AND METHODS The occurrence, date, territory, and cause of any cerebral infarction were retrospectively determined and correlated to angioplasty procedures. Delayed cerebral infarction, new angioplasty in the territory of a previous angioplasty, angioplasty complications, 1-month mortality, and 6- to 12-month modified Rankin Scale ≤ 2 were compared between 2 periods (before-versus-after January 2015, from 2012 to 2017) with adjustment for age, sex, World Federation of Neurosurgical Societies score, and the modified Fisher grade. RESULTS Three-hundred-ninety-two patients were analyzed (160 before versus 232 after January 2015). Distal balloon angioplasty was associated with the following: higher rates of angioplasty (43% versus 27%, P < .001) and intravenous milrinone (31% versus 9%, P < .001); lower rates of postangioplasty delayed cerebral infarction (2.2% versus 7.5%, P = .01) and new angioplasty (8% versus 19%, P = .003) independent of the rate of patients treated by angioplasty and milrinone; and the same rates of stroke related to angioplasty (3.6% versus 3.1%, P = .78), delayed cerebral infarction (7.7% versus 12.5%, P = .12), mortality (10% versus 11%, P = .81), and favorable outcome (79% versus 73%, P = .21). CONCLUSIONS Our study suggests that distal balloon angioplasty is safe and decreases the risk of delayed cerebral infarction and the recurrence of vasospasm compared with conventional angioplasty. It fails to show a clinical benefit possibly because of confounding changes in adjuvant therapies of vasospasm during the study period.
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Affiliation(s)
- M-A Labeyrie
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.) .,EA 7334 REMES (M.-A.L., E.H.), L'Université Paris Diderot, Paris, France
| | - S Gaugain
- Emergency Care Unit (S.G.), Hôpital Lariboisière, Paris, France
| | - G Boulouis
- Department of Radiology (G.B.), Centre Hospitalier Sainte-Anne, Paris, France
| | - A Zetchi
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | - J Brami
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | - J-P Saint-Maurice
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | - V Civelli
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.)
| | | | - E Houdart
- From the Departments of Interventional Neuroradiology (M.-A.L., A.Z., J.B., J.-P.S.-M., V.C., E.H.).,EA 7334 REMES (M.-A.L., E.H.), L'Université Paris Diderot, Paris, France
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Neuropharmacology in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Al-Mufti F, Amuluru K, Damodara N, El-Ghanem M, Nuoman R, Kamal N, Al-Marsoummi S, Morris NA, Dangayach NS, Mayer SA. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2018; 390:44-51. [DOI: 10.1016/j.jns.2018.02.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 11/27/2022]
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Abstract
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.
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Mikeladze KG, Okishev DN, Belousova OB, Konovalov AN, Pilipenko YV, Kheireddin AS, Ageev IS, Shekhtman OD, Kurdyumova NV, Tabasaranskiy TF, Okisheva EA, Eliava SS, Yakovlev SB. [Intra-arterial administration of verapamil for prevention and treatment of cerebral angiospasm after SAH due to cerebral aneurysm rupture]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2018; 82:23-31. [PMID: 30137035 DOI: 10.17116/neiro201882423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
AIM The study purpose was to analyze the efficacy of intra-arterial administration of verapamil (IAV) in the treatment of angiospasm in SAH patients and to determine optimal parameters of the procedure. A number of studies demonstrated the efficacy of intra-arterial administration of vasodilators, in particular verapamil, in the treatment of angiospasm after aneurysmal SAH, which served the basis for inclusion of this method in the recommended protocol for treatment of SAH patients [1-7]. MATERIAL AND METHODS We analyzed the efficacy of IAV in 35 patients in the acute period of SAH, with 77.2% of the patients having a Hunt-Hess score of III-V. The inclusion criteria were as follows: IAV within two weeks after SAH; excluded aneurysm; verapamil dose per administration of at least 15 mg; follow-up for at least three months. Efficacy endpoints were as follows: changes in spasm according to angiography and transcranial dopplerography (TCDG); development of ischemic lesions; clinical outcome according to the modified Rankin scale. RESULTS A total of 76 IAV procedures were performed. The verapamil dose per procedure was 36.7±9.7 mg, on average; the number of procedures varied from 1 to 5. One arterial territory was treated in 12 cases, two arterial territories were treated in 48 cases, and three arterial territories were treated in 15 cases. Typical adverse reactions included decreased blood pressure, a reduced heart rate, and elevated ICP. In all cases, TCDG revealed signs of reduced angiospasm - a 20-40% decrease in the LBFV in the M1 MCA. Four (11.4%) patients died; of these, only one died due to angiospasm progression. On examination at 3 months or more after discharge, favorable outcomes were observed in 74.3% of cases. CONCLUSION IAV is associated with a low risk of significant complications. IAV should be performed under control of systemic hemodynamics and ICP. The indications for IAV include signs of moderate worsening or severe angiospasm according to TCDG and/or angiography. The IAV procedure may be performed every day. Further clarification of the IAV procedure and evaluation of clinical outcomes under prospective study conditions are required.
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Affiliation(s)
| | - D N Okishev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | | | - A S Kheireddin
- Burdenko Neurosurgical Institute, Moscow, Russia, Sechenov First Moscow State Medical University, Moscow, Russia
| | - I S Ageev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | | | - E A Okisheva
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Sh Sh Eliava
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - S B Yakovlev
- Burdenko Neurosurgical Institute, Moscow, Russia
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17
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Fraser JF, Maniskas M, Trout A, Lukins D, Parker L, Stafford WL, Alhajeri A, Roberts J, Bix GJ. Intra-arterial verapamil post-thrombectomy is feasible, safe, and neuroprotective in stroke. J Cereb Blood Flow Metab 2017; 37:3531-3543. [PMID: 28429604 PMCID: PMC5669346 DOI: 10.1177/0271678x17705259] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Large vessel ischemic stroke represents the most disabling subtype. While t-PA and endovascular thrombectomy can recanalize the occluded vessel, good clinical outcomes are not uniformly achieved. We propose that supplementing endovascular thrombectomy with superselective intra-arterial (IA) verapamil immediately following recanalization could be safe and effective. Verapamil, a calcium channel blocker, has been shown to be an effective IA adjunct in a pre-clinical mouse focal ischemia model. To demonstrate translational efficacy, mechanism, feasibility, and safety, we conducted a group of translational experiments. We performed in vivo IA dose-response evaluation in our animal stroke model with C57/Bl6 mice. We evaluated neuroprotective mechanism through in vitro primary cortical neuron (PCN) cultures. Finally, we performed a Phase I trial, SAVER-I, to evaluate feasibility and safety of administration in the human condition. IA verapamil has a likely plateau or inverted-U dose-response with a defined toxicity level in mice (LD50 16-17.5 mg/kg). Verapamil significantly prevented PCN death and deleterious ischemic effects. Finally, the SAVER-I clinical trial showed no evidence that IA verapamil increased the risk of intracranial hemorrhage or other adverse effect/procedural complication in human subjects. We conclude that superselective IA verapamil administration immediately following thrombectomy is safe and feasible, and has direct, dose-response-related benefits in ischemia.
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Affiliation(s)
- Justin F Fraser
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,3 Department of Radiology, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Michael Maniskas
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Amanda Trout
- 4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Doug Lukins
- 3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Lindsey Parker
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
| | - W Lane Stafford
- 3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Abdulnasser Alhajeri
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Jill Roberts
- 4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA.,5 Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Gregory J Bix
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA.,5 Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, USA
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18
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Boulouis G, Labeyrie MA, Raymond J, Rodriguez-Régent C, Lukaszewicz AC, Bresson D, Ben Hassen W, Trystram D, Meder JF, Oppenheim C, Naggara O. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Eur Radiol 2016; 27:3333-3342. [PMID: 28004163 DOI: 10.1007/s00330-016-4702-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Grégoire Boulouis
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France.
- DHU NeuroVasc Paris Sorbonne, Paris, France.
| | - Marc Antoine Labeyrie
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Christine Rodriguez-Régent
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Anne Claire Lukaszewicz
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Damien Bresson
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Wagih Ben Hassen
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Denis Trystram
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Jean Francois Meder
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Catherine Oppenheim
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Olivier Naggara
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
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19
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Andereggen L, Beck J, Z'Graggen WJ, Schroth G, Andres RH, Murek M, Haenggi M, Reinert M, Raabe A, Gralla J. Feasibility and Safety of Repeat Instant Endovascular Interventions in Patients with Refractory Cerebral Vasospasms. AJNR Am J Neuroradiol 2016; 38:561-567. [PMID: 27979797 DOI: 10.3174/ajnr.a5024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 10/11/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions. MATERIALS AND METHODS This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions. RESULTS During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions (P = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; P = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; P = .004). CONCLUSIONS Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.
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Affiliation(s)
- L Andereggen
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.).,Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.)
| | - J Beck
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - W J Z'Graggen
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.).,Departments of Neurology (W.J.Z.)
| | - G Schroth
- Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.)
| | - R H Andres
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - M Murek
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - M Haenggi
- Intensive Care Medicine (M.H.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - M Reinert
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - A Raabe
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - J Gralla
- Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.)
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20
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Abstract
For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.
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Affiliation(s)
- Charles L Francoeur
- Critical Care Division, Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Québec, Canada
| | - Stephan A Mayer
- Department of Neurology (Neurocritical Care), Mount Sinai, New York, NY, USA.
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1522, New York, NY, 10029-6574, USA.
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21
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Veldeman M, Höllig A, Clusmann H, Stevanovic A, Rossaint R, Coburn M. Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review. Br J Anaesth 2016; 117:17-40. [PMID: 27160932 DOI: 10.1093/bja/aew095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED : The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials. CLINICAL TRIAL REGISTRATION This systematic review was registered in the international prospective register of systematic reviews. PROSPERO CRD42015019817.
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Affiliation(s)
- M Veldeman
- Department of Neurosurgery Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | | | | | - A Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - M Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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22
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Initial clinical experience with near-infrared spectroscopy in assessing cerebral tissue oxygen saturation in cerebral vasospasm before and after intra-arterial verapamil injection. J Clin Neurosci 2016; 26:63-9. [DOI: 10.1016/j.jocn.2015.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/26/2015] [Indexed: 11/21/2022]
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23
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Hollingworth M, Chen PR, Goddard AJ, Coulthard A, Söderman M, Bulsara KR. Results of an International Survey on the Investigation and Endovascular Management of Cerebral Vasospasm and Delayed Cerebral Ischemia. World Neurosurg 2015; 83:1120-1126.e1. [DOI: 10.1016/j.wneu.2015.01.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/31/2014] [Accepted: 01/19/2015] [Indexed: 11/30/2022]
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24
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Macdonald RL. When in Rome, do as the Romans do? World Neurosurg 2015; 84:638-9. [PMID: 25982685 DOI: 10.1016/j.wneu.2015.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 05/06/2015] [Indexed: 11/26/2022]
Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario, Canada.
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25
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Abstract
Cerebral vasospasm causes delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage. This is a well-established clinical entity with significant associated morbidity and mortality. The underlying patholphysiology is highly complex and poorly understood. Large-vessel vasospasm, autoregulatory dysfunction, inflammation, genetic predispositions, microcirculatory failure, and spreading cortical depolarization are aspects of delayed neurologic deterioration that have been described in the literature. This article presents a perspective on cerebral vasospasm, as guided by the literature to date, specifically examining the mechanism, diagnosis, and treatment of cerebral vasospasm.
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Kiser TH. Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions? Hosp Pharm 2014; 49:923-41. [PMID: 25477565 DOI: 10.1310/hpj4910-923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.
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Affiliation(s)
- Tyree H Kiser
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital, University of Colorado Anschutz Medical Campus , 12850 E. Montview Boulevard, C238, Aurora, CO 80045 ; phone: 303-724-2883 ; fax: 303-724-0979 ; e-mail:
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27
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Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. INTERVENTIONAL NEUROLOGY 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
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Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
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28
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Bauer AM, Rasmussen PA. Treatment of intracranial vasospasm following subarachnoid hemorrhage. Front Neurol 2014; 5:72. [PMID: 24904517 PMCID: PMC4032992 DOI: 10.3389/fneur.2014.00072] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/27/2014] [Indexed: 12/03/2022] Open
Abstract
Vasospasm has been a long known source of delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage patients. Delayed ischemic neurologic deficits associated with vasospasm may account for as high as 50% of the deaths in patients who survive the initial period after aneurysm rupture and its treatment. The diagnosis and treatment of vasospasm has still been met with some controversy. It is clear that subarachnoid hemorrhage is best cared for in tertiary care centers with modern resources and access to cerebral angiography. Ultimately, a high degree of suspicion for vasospasm must be kept during ICU care, and any signs or symptoms must be investigated and treated immediately to avoid permanent stroke and neurologic deficit. Treatment for vasospasm can occur through both ICU intervention and endovascular administration of intra-arterial vasodilators and balloon angioplasty. The best outcomes are often attained when these methods are used in conjunction. The following article reviews the literature on cerebral vasospasm and its treatment and provides the authors’ approach to treatment of these patients.
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Affiliation(s)
- Andrew M Bauer
- Cerebrovascular Center, Cleveland Clinic Foundation , Cleveland, OH , USA
| | - Peter A Rasmussen
- Cerebrovascular Center, Cleveland Clinic Foundation , Cleveland, OH , USA
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Abstract
Subarachnoid haemorrhage (SAH) causes early brain injury (EBI) that is mediated by effects of transient cerebral ischaemia during bleeding plus effects of the subarachnoid blood. Secondary effects of SAH include increased intracranial pressure, destruction of brain tissue by intracerebral haemorrhage, brain shift, and herniation, all of which contribute to pathology. Many patients survive these phenomena, but deteriorate days later from delayed cerebral ischaemia (DCI), which causes poor outcome or death in up to 30% of patients with SAH. DCI is thought to be caused by the combined effects of angiographic vasospasm, arteriolar constriction and thrombosis, cortical spreading ischaemia, and processes triggered by EBI. Treatment for DCI includes prophylactic administration of nimodipine, and current neurointensive care. Prompt recognition of DCI and immediate treatment by means of induced hypertension and balloon or pharmacological angioplasty are considered important by many physicians, although the evidence to support such approaches is limited. This Review summarizes the pathophysiology of DCI after SAH and discusses established treatments for this condition. Novel strategies--including drugs such as statins, sodium nitrite, albumin, dantrolene, cilostazol, and intracranial delivery of nimodipine or magnesium--are also discussed.
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Pandey AS, Elias AE, Chaudhary N, Thompson BG, Gemmete JJ. Endovascular Treatment of Cerebral Vasospasm. Neuroimaging Clin N Am 2013; 23:593-604. [DOI: 10.1016/j.nic.2013.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kiser T. Pharmacologic Options for Prevention and Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Hosp Pharm 2013; 48:S2-S9. [DOI: 10.1310/hpj48s5-s2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Archavlis E, Carvi Y Nievas M. Cerebral vasospasm: a review of current developments in drug therapy and research. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2050-120x-2-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW Cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage remains a considerable challenge in neurocritical care medicine. This review aims to cover the recent novel aspects and results in CVS treatment. RECENT FINDINGS On the basis of the recent literature, treatment focusing on CVS alone is outdated. A considerable amount of evidence suggests CVS not to be the sole cause of delayed cerebral ischemia (DCI) and poor outcome. Early brain injury, cortical spreading depolarization, inflammation and microthrombosis have recently been discussed as additional factors. The results of a well designed phase III trial, using an endothelin-1 antagonist, indicated a decrease in the occurrence of CVS but did not change the clinical outcome significantly. Induced hypertension is currently recommended for treating suspected DCI, whereas hemodilution and hypervolemia are not. Endovascular intervention is only recommended in case of refractory symptomatic CVS. A couple of newer treatment strategies are under evaluation. Phase III trials are underway for magnesium sulfate and statins. Clinical trials aiming specifically at recently discussed factors other than CVS have not been reported. SUMMARY Reviewing the recent literature, there have been some updates on recommendations and newer treatment modalities are under evaluation. However, a novel treatment with convincing evidence has not been reported so far.
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Kimball MM, Velat GJ, Hoh BL. Critical care guidelines on the endovascular management of cerebral vasospasm. Neurocrit Care 2012; 15:336-41. [PMID: 21761272 DOI: 10.1007/s12028-011-9600-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.
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Affiliation(s)
- Matthew M Kimball
- Department of Neurosurgery, University of Florida, 1600 South West Archer Rd, P.O. Box 100265, Gainesville, FL 32610, USA
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French KF, Hoesch RE, Allred J, Wilder M, Smith A, Digre KB, La Barge DV. Repetitive use of intra-arterial verapamil in the treatment of reversible cerebral vasoconstriction syndrome. J Clin Neurosci 2012; 19:174-6. [DOI: 10.1016/j.jocn.2011.06.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/11/2011] [Accepted: 06/13/2011] [Indexed: 11/17/2022]
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Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N. Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic Vasospasm After Subarachnoid Hemorrhage. Neurosurgery 2011; 68:1541-7; discussion 1547. [DOI: 10.1227/neu.0b013e31820edd46] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm (CV) is a potentially disastrous consequence of subarachnoid hemorrhage despite medical treatment. Nimodipine is a potent drug for vessel relaxation, but side effects may preclude a sufficient dose.
OBJECTIVE:
To explore whether continuous local intra-arterial nimodipine administration (CLINA) can reverse vasospasm and prevent delayed ischemic neurological deficit.
METHODS:
Six consecutive subarachnoid hemorrhage patients (5 women; mean age, 47.2 years) with severe CV despite maximum medical therapy underwent CLINA within 2 hours after the onset of clinical symptoms. After anticoagulation, microcatheters were inserted distally in the concerning supra-aortic vessels. Glyceryl trinitrate injection (2 mg) was followed by CLINA (nimodipine 0.4 mg/h for 70-147 hours). Duration of CLINA was determined by neurological status, transcranial Doppler sonography, and partial tissue oxygen pressure values.
RESULTS:
In all patients, neurological deficits improved or partial tissue oxygen pressure values returned to normal and transcranial Doppler sonography confirmed a reduced blood flow velocity within 12 hours. Magnetic resonance imaging showed no ischemic lesion caused by CV. Neurological outcome was good (modified Rankin Scale score, 0–2) in 3 patients, whereas 1 patient had a moderate clinical outcome (modified Rankin Scale score, 3–4) and 2 patients had a poor outcome (modified Rankin Scale score, 5) because of the SAH.
CONCLUSION:
Preliminary data show that CLINA is a straightforward, effective, and safe option for patients with severe CV refractory to medical therapy. Dilation of spastic arteries starts within a few hours and is lasting. Indication for CLINA is peripheral and diffuse CV at any location.
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Affiliation(s)
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen
| | - Zsolt Vajda
- Department of Neuroradiology, Klinikum Stuttgart, Germany
| | - Jan Coburger
- Department of Neurosurgery, Klinikum Stuttgart, Germany
| | - Nikolai Hopf
- Department of Neurosurgery, Klinikum Stuttgart, Germany
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Jun P, Ko NU, English JD, Dowd CF, Halbach VV, Higashida RT, Lawton MT, Hetts SW. Endovascular treatment of medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2010; 31:1911-6. [PMID: 20616179 DOI: 10.3174/ajnr.a2183] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CV following aneurysmal SAH is a significant cause of morbidity and mortality. We review our experiences using PTA and IA verapamil infusion for treating medically refractory cases. MATERIALS AND METHODS We performed a retrospective review of patients with SAH admitted from July 2003 to January 2008. RESULTS Of 546 patients admitted within 72 hours of symptom onset, 231 patients (42%) developed symptomatic CV and 189 patients (35%) required endovascular therapy. A total of 346 endovascular sessions were performed consisting of 1 single angioplasty, 286 IA verapamil infusions, and 59 combined treatments. PTA was performed on 151 vessel segments, and IA verapamil was infused in 720 vessel segments. IA verapamil doses ranged from 2.0 to 30.0 mg per vessel segment and from 3.0 to 55.0 mg per treatment session. Repeat treatments were necessary in 102 patients (54%) for persistent, recurrent, or worsening CV. There were 6 treatment-related complications, of which 2 resulted in clinical worsening. No deaths were attributable to endovascular therapy. At follow-up, 115 patients (61%) had a good outcome and 55 patients (29%) had a poor outcome. Sixteen patients died from causes related to SAH, while 3 died from other medical complications. CONCLUSIONS Endovascular treatments are an integral part of managing patients with medically refractory CV. In our experience, PTA and IA verapamil are safe, with a low complication rate, but further studies are required to determine appropriate patient selection and treatment efficacy.
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Affiliation(s)
- P Jun
- Departments of Radiology, University of California, San Francisco, 94143-0628, USA
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Sehy JV, Holloway WE, Lin SP, Cross DT, Derdeyn CP, Moran CJ. Improvement in angiographic cerebral vasospasm after intra-arterial verapamil administration. AJNR Am J Neuroradiol 2010; 31:1923-8. [PMID: 20705701 DOI: 10.3174/ajnr.a2215] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular options for therapy for patients with vasospasm after SAH include angioplasty and intra-arterial vasodilator infusion. Preliminary studies of the effects of the calcium channel antagonist verapamil on angiographic vasospasm have yielded mixed and/or qualitative results. In this study, improvement in angiographic vasospasm after intra-arterial verapamil administration is demonstrated with quantitative, blinded methods. MATERIALS AND METHODS This retrospective observational case series includes 12 patients with vasospasm after SAH who collectively received 16 treatments with intra-arterial verapamil during a 2-year period at our institution. The exclusion criterion was concurrent treatment with angioplasty. Blinded reviewers quantitatively evaluated angiograms from each patient and/or treatment after presentation with SAH and before and after intra-arterial treatment of vasospasm. RESULTS Patients were treated with intra-arterial verapamil for vasospasm 9 ± 4 days after SAH with a range from 1 to 16 days. For the 34 arterial distributions treated, the segment with the worst angiographic vasospasm from each arterial distribution averaged 51 ± 13% stenosis, which improved to 29 ± 18% stenosis (P < .001). There was no significant difference in treatment effect in proximal arterial segments, which may be amenable to angioplasty, compared with distal segments (P > .05). There was no significant difference in treatment effect in arterial segments previously subjected to angioplasty compared with other segments (P > .05). CONCLUSIONS Intra-arterially administered verapamil improves angiographic vasospasm after SAH when administered at 10 ± 3 mg per arterial distribution. Optimal dose, infusion rate, and retreatment interval remain to be determined. Randomized controlled trials are needed to prove efficacy in the treatment of clinical vasospasm.
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Affiliation(s)
- J V Sehy
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.
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