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Zaeske C, Zopfs D, Laukamp K, Lennartz S, Kottlors J, Goertz L, Stetefeld H, Hof M, Abdullayev N, Kabbasch C, Schlamann M, Schönfeld M. Immediate angiographic control after intra-arterial nimodipine administration underestimates the vasodilatory effect. Sci Rep 2024; 14:6154. [PMID: 38486099 PMCID: PMC10940303 DOI: 10.1038/s41598-024-56807-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 03/11/2024] [Indexed: 03/18/2024] Open
Abstract
Intra-arterial nimodipine administration is a widely used rescue therapy for cerebral vasospasm. Although it is known that its effect sets in with delay, there is little evidence in current literature. Our aim was to prove that the maximal vasodilatory effect is underestimated in direct angiographic controls. We reviewed all cases of intra-arterial nimodipine treatment for subarachnoid hemorrhage-related cerebral vasospasm between January 2021 and December 2022. Inclusion criteria were availability of digital subtraction angiography runs before and after nimodipine administration and a delayed run for the most affected vessel at the end of the procedure to decide on further escalation of therapy. We evaluated nimodipine dose, timing of administration and vessel diameters. Delayed runs were performed in 32 cases (19 patients) with a mean delay of 37.6 (± 16.6) min after nimodipine administration and a mean total nimodipine dose of 4.7 (± 1.2) mg. Vessel dilation was more pronounced in delayed vs. immediate controls, with greater changes in spastic vessel segments (n = 31: 113.5 (± 78.5%) vs. 32.2% (± 27.9%), p < 0.0001) vs. non-spastic vessel segments (n = 32: 23.1% (± 13.5%) vs. 13.3% (± 10.7%), p < 0.0001). In conclusion intra-arterially administered nimodipine seems to exert a delayed vasodilatory effect, which should be considered before escalation of therapy.
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Affiliation(s)
- Charlotte Zaeske
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany.
| | - David Zopfs
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Kai Laukamp
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Simon Lennartz
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Jonathan Kottlors
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Lukas Goertz
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Marion Hof
- Department of Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Nuran Abdullayev
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Christoph Kabbasch
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Marc Schlamann
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Michael Schönfeld
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
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Anthofer J, Bele S, Wendl C, Kieninger M, Zeman F, Bruendl E, Schmidt NO, Schebesch KM. Continuous intra-arterial nimodipine infusion as rescue treatment of severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2021; 96:163-171. [PMID: 34789415 DOI: 10.1016/j.jocn.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 08/30/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
Severe refractory cerebral vasospasm (CV) is a major cause of disability and death in patients with aneurysmal subarachnoid hemorrhage (SAH). One rescue therapy in selected patients is intra-arterial nimodipine, either given as a single shot or as continuous infusion. To evaluate treatment efficacy, we analyzed outcome factors such as the incidence of craniectomy, ventriculo-peritonial (VP) shunting, and tracheotomy after intra-arterial nimodipine infusion. We retrospectively analyzed the rates of cerebral infarction, decompressive craniectomy, VP shunting, and tracheotomy in patients with severe CV after SAH. Three different patient groups were compared: group 1 had only been treated with oral nimodipine and hypervolemic hypertensive therapy (HHT) (2006-2010), group 2 with a single shot of intra-arterial nimodipine (SSN) in addition to oral conservative treatment (2006-2010), and group 3 with continuous intra-arterial nimodipine (CIAN) (2011-2017). The incidence of cerebral infarction was significantly lower in CIAN group (p = 0.005) than in conservative and SSN group. The indication for consecutive decompressive craniectomy was significantly lower in CIAN group in comparison with the conservative group (p = 0.018). The rates of VP shunting and tracheotomy were significantly higher in the CIAN group than in the conservative group (p = 0.028 for VP, and p = 0.003 for tracheotomy). The significantly lower rate of craniectomy in the CIAN group was most probably attributable to the significantly lower rate of CV-induced infarction. The higher rate of tracheotomy reflects more extensive sedation and the need of longer stays on the intensive care unit. Thus, the effect on long-term neurological outcome and quality of life has to be evaluated separately.
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Affiliation(s)
- Judith Anthofer
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany.
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Christina Wendl
- Department of Neuroradiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Elisabeth Bruendl
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
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Cordes T, Lucas A, Divakaruni AS, Murphy AN, Cabrales P, Metallo CM. Itaconate modulates tricarboxylic acid and redox metabolism to mitigate reperfusion injury. Mol Metab 2020; 32:122-135. [PMID: 32029222 PMCID: PMC6961711 DOI: 10.1016/j.molmet.2019.11.019] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Cerebral ischemia/reperfusion (IR) drives oxidative stress and injurious metabolic processes that lead to redox imbalance, inflammation, and tissue damage. However, the key mediators of reperfusion injury remain unclear, and therefore, there is considerable interest in therapeutically targeting metabolism and the cellular response to oxidative stress. METHODS The objective of this study was to investigate the molecular, metabolic, and physiological impact of itaconate treatment to mitigate reperfusion injuries in in vitro and in vivo model systems. We conducted metabolic flux and bioenergetic studies in response to exogenous itaconate treatment in cultures of primary rat cortical neurons and astrocytes. In addition, we administered itaconate to mouse models of cerebral reperfusion injury with ischemia or traumatic brain injury followed by hemorrhagic shock resuscitation. We quantitatively characterized the metabolite levels, neurological behavior, markers of redox stress, leukocyte adhesion, arterial blood flow, and arteriolar diameter in the brains of the treated/untreated mice. RESULTS We demonstrate that the "immunometabolite" itaconate slowed tricarboxylic acid (TCA) cycle metabolism and buffered redox imbalance via succinate dehydrogenase (SDH) inhibition and induction of anti-oxidative stress response in primary cultures of astrocytes and neurons. The addition of itaconate to reperfusion fluids after mouse cerebral IR injury increased glutathione levels and reduced reactive oxygen/nitrogen species (ROS/RNS) to improve neurological function. Plasma organic acids increased post-reperfusion injury, while administration of itaconate normalized these metabolites. In mouse cranial window models, itaconate significantly improved hemodynamics while reducing leukocyte adhesion. Further, itaconate supplementation increased survival in mice experiencing traumatic brain injury (TBI) and hemorrhagic shock. CONCLUSIONS We hypothesize that itaconate transiently inhibits SDH to gradually "awaken" mitochondrial function upon reperfusion that minimizes ROS and tissue damage. Collectively, our data indicate that itaconate acts as a mitochondrial regulator that controls redox metabolism to improve physiological outcomes associated with IR injury.
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Affiliation(s)
- Thekla Cordes
- Department of Bioengineering, University of California, San Diego, 9500 Gilman Drive, 92093 La Jolla, CA, USA
| | - Alfredo Lucas
- Department of Bioengineering, University of California, San Diego, 9500 Gilman Drive, 92093 La Jolla, CA, USA
| | - Ajit S Divakaruni
- Department of Pharmacology, University of California, San Diego, 9500 Gilman Drive, 92093 La Jolla, CA, USA
| | - Anne N Murphy
- Department of Pharmacology, University of California, San Diego, 9500 Gilman Drive, 92093 La Jolla, CA, USA
| | - Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, 9500 Gilman Drive, 92093 La Jolla, CA, USA
| | - Christian M Metallo
- Department of Bioengineering, University of California, San Diego, 9500 Gilman Drive, 92093 La Jolla, CA, USA.
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Ditz C, Neumann A, Wojak J, Smith E, Gliemroth J, Tronnier V, Küchler J. Repeated Endovascular Treatments in Patients with Recurrent Cerebral Vasospasms After Subarachnoid Hemorrhage: A Worthwhile Strategy? World Neurosurg 2018; 112:e791-e798. [DOI: 10.1016/j.wneu.2018.01.156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 11/29/2022]
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Park ES, Kim DW, Kang SD. Endovascular Treatment of Symptomatic Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Three-year Experience. J Cerebrovasc Endovasc Neurosurg 2017; 19:155-161. [PMID: 29159148 PMCID: PMC5680078 DOI: 10.7461/jcen.2017.19.3.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/28/2017] [Accepted: 09/17/2017] [Indexed: 11/23/2022] Open
Abstract
Objective The cause of severe clinical vasospasm after aneurysmal subarachnoid hemorrhage remains unknown, despite extensive research over the past 30 years. However, the intra-arterial administration of vasodilating agents and balloon angioplasty have been successfully used in severe refractory cerebral vasospasm. Materials and Methods We retrospectively analyzed the data of 233 patients admitted to our institute with aneurysmal subarachnoid hemorrhage (SAH) over the past 3 years. Results Of these, 27 (10.6%) developed severe symptomatic vasospasm, requiring endovascular therapy. Vasospasm occurred at an average of 5.3 days after SAH. A total of 46 endovascular procedures were performed in 27 patients. Endovascular therapy was performed once in 18 (66.7%) patients, 2 times in 4 (14.8%) patients, 3 or more times in 5 (18.5%) patients. Intra-arterial vasodilating agents were used in 44 procedures (27 with nimodipine infusion, 17 with nicardipine infusion). Balloon angioplasty was performed in only 2 (7.4%) patients. The Average nimodipine infusion volume was 2.47 mg, and nicardipine was 3.78 mg. Most patients recovered after the initial emergency room visit. Two patients (7.4%) worsened, but there were no deaths. Conclusion With advances in endovascular techniques, administration of vasodilating agents and balloon angioplasty reduces the morbidity and mortality of vasospasm after aneurysmal SAH.
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Affiliation(s)
- Eun-Sung Park
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
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Hocking KM, Putumbaka G, Wise ES, Cheung-Flynn J, Brophy CM, Komalavilas P. Papaverine Prevents Vasospasm by Regulation of Myosin Light Chain Phosphorylation and Actin Polymerization in Human Saphenous Vein. PLoS One 2016; 11:e0154460. [PMID: 27136356 PMCID: PMC4852981 DOI: 10.1371/journal.pone.0154460] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 04/13/2016] [Indexed: 11/18/2022] Open
Abstract
Objective Papaverine is used to prevent vasospasm in human saphenous veins (HSV) during vein graft preparation prior to implantation as a bypass conduit. Papaverine is a nonspecific inhibitor of phosphodiesterases, leading to increases in both intracellular cGMP and cAMP. We hypothesized that papaverine reduces force by decreasing intracellular calcium concentrations ([Ca2+]i) and myosin light chain phosphorylation, and increasing actin depolymerization via regulation of actin regulatory protein phosphorylation. Approach and Results HSV was equilibrated in a muscle bath, pre-treated with 1 mM papaverine followed by 5 μM norepinephrine, and force along with [Ca2+]i levels were concurrently measured. Filamentous actin (F-actin) level was measured by an in vitro actin assay. Tissue was snap frozen to measure myosin light chain and actin regulatory protein phosphorylation. Pre-treatment with papaverine completely inhibited norepinephrine-induced force generation, blocked increases in [Ca2+]i and led to a decrease in the phosphorylation of myosin light chain. Papaverine pre-treatment also led to increased phosphorylation of the heat shock-related protein 20 (HSPB6) and the vasodilator stimulated phosphoprotein (VASP), as well as decreased filamentous actin (F-actin) levels suggesting depolymerization of actin. Conclusions These results suggest that papaverine-induced force inhibition of HSV involves [Ca2+]i-mediated inhibition of myosin light chain phosphorylation and actin regulatory protein phosphorylation-mediated actin depolymerization. Thus, papaverine induces sustained inhibition of contraction of HSV by the modulation of both myosin cross-bridge formation and actin cytoskeletal dynamics and is a pharmacological alternative to high pressure distention to prevent vasospasm.
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Affiliation(s)
- Kyle M. Hocking
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Gowthami Putumbaka
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Eric S. Wise
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Joyce Cheung-Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Colleen M. Brophy
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, United States of America
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Padmini Komalavilas
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, United States of America
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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Riordan MA, Kyle M, Dedeo C, Villwock MR, Bauer M, Vallano ML, Deshaies EM. Mild exercise reduces cerebral vasospasm after aneurysm subarachnoid hemorrhage: a retrospective clinical study and correlation with laboratory investigation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:55-61. [PMID: 25366600 DOI: 10.1007/978-3-319-04981-6_10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is a leading cause of death and disability and is often complicated by cerebral vasospasm (CV). Conventional management to prevent CV includes bedrest; however, inactivity places the patient at risk for nonneurological complications. We investigated the effect of mild exercise after SAH in clinical and laboratory settings. METHODS Clinical: Data from 80 patients with SAH were analyzed retrospectively. After aneurysms were secured, physical therapy was initiated as tolerated. CV and complications were compared by the timing of active physical therapy. Laboratory: 18 Rodents were divided into three groups: (1) control, (2) SAH without exercise, and (3) SAH plus mild exercise. On day 5, brainstems were removed and analyzed for the injury marker inducible nitric oxide synthase (iNOS). RESULTS Clinical: Mild exercise before day 4 significantly lowered the incidence of symptomatic CV compared with the nonexercised group. There was no difference in the incidence of additional complications based upon exercise. Laboratory: Staining for iNOS was significantly higher in the SAH group than the control group, but there was no difference between exercised and nonexercised SAH groups, confirming that exercise did not promote neuronal injury. CONCLUSION Early mobilization significantly reduced clinical CV. The relationship should be studied further in a prospective trial with defined exercise regimens.
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Affiliation(s)
- Margaret A Riordan
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
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Safain MG, Malek AM. Delayed progressive bilateral supraclinoid internal carotid artery stenosis in a patient with a ruptured basilar artery aneurysm. J Clin Neurosci 2014; 22:368-72. [PMID: 25304439 DOI: 10.1016/j.jocn.2014.06.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 06/09/2014] [Accepted: 06/12/2014] [Indexed: 11/27/2022]
Abstract
Cerebral vasospasm is a common radiographic and clinical diagnosis after subarachnoid hemorrhage. Conventional treatments include medical hypertension, hypervolemia, and modest hemodilution. When medical treatments fail in severe vasospasm cases, intra-arterial vasodilation and balloon angioplasty may be useful. We present a 47-year-old woman with a ruptured basilar artery aneurysm who developed severe bilateral internal carotid artery vasospasm requiring bilateral balloon angioplasty. Prior to discharge, the patient's bilateral stenosis had improved. Three months post-discharge, severe restenosis in her bilateral internal carotid arteries occurred; a rare event. Balloon angioplasty has been demonstrated to histologically tear and stretch collagen fibers in the vessel wall and overexpansion of vessels may lead to a neo-intimal reaction that is similar to the one seen after stent placement in the intracranial circulation. Clinicians should be aware of the possibility of delayed and progressive stenosis in vessels treated with angioplasty. Follow-up vascular imaging is necessary after subarachnoid hemorrhage. Future study is required on the treatment paradigms necessary for this delayed restenosis.
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Affiliation(s)
- Mina G Safain
- Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Proger 7, Boston, MA 02111, USA
| | - Adel M Malek
- Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Proger 7, Boston, MA 02111, USA.
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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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Doukas A, Petridis AK, Barth H, Jansen O, Mehdorn HM. Continuous intra-arterial infusion of nimodipine at the onset of resistant vasospasm in aneurysmal subarachnoidal haemorrhage. Technical report. Neurol Res 2013; 33:290-4. [DOI: 10.1179/016164110x12759951866830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Desgagné-Penix I, Facchini PJ. Systematic silencing of benzylisoquinoline alkaloid biosynthetic genes reveals the major route to papaverine in opium poppy. THE PLANT JOURNAL : FOR CELL AND MOLECULAR BIOLOGY 2012; 72:331-44. [PMID: 22725256 DOI: 10.1111/j.1365-313x.2012.05084.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Papaverine, a major benzylisoquinoline alkaloid in opium poppy (Papaver somniferum), is used as a vasodilator and antispasmodic. Conversion of the initial intermediate (S)-norcoclaurine to papaverine involves 3'-hydroxylation, four O-methylations and dehydrogenation. However, our understanding of papaverine biosynthesis remains controversial more than a century after an initial scheme was proposed. In vitro assays and in vivo labeling studies have been insufficient to establish the sequence of conversions, the potential role of the intermediate (S)-reticuline, and the enzymes involved. We used virus-induced gene silencing in opium poppy to individually suppress the expression of six genes with putative roles in papaverine biosynthesis. Suppression of the gene encoding coclaurine N-methyltransferase dramatically increased papaverine levels at the expense of N-methylated alkaloids, indicating that the main biosynthetic route to papaverine proceeds via N-desmethylated compounds rather than through (S)-reticuline. Suppression of genes encoding (S)-3'-hydroxy-N-methylcoclaurine 4-O-methyltransferase and norreticuline 7-O-methyltransferase, which accept certain N-desmethylated alkaloids, reduced papaverine content. In contrast, suppression of genes encoding N-methylcoclaurine 3'-hydroxylase or reticuline 7-O-methyltransferase, which are specific for N-methylated alkaloids, did not affect papaverine levels. Suppression of norcoclaurine 6-O-methyltransferase transcript levels significantly suppressed total alkaloid accumulation, implicating (S)-coclaurine as a key branch-point intermediate. The differential detection of N-desmethylated compounds in response to suppression of specific genes highlights the primary route to papaverine.
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Affiliation(s)
- Isabel Desgagné-Penix
- Department of Biological Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
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Doukas A, Petridis AK, Barth H, Jansen O, Maslehaty H, Mehdorn HM. Resistant vasospasm in subarachnoid hemorrhage treated with continuous intraarterial nimodipine infusion. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 112:93-6. [PMID: 21691994 DOI: 10.1007/978-3-7091-0661-7_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Cerebral vasospasm complicating aneurysmal subarachnoid hemorrhage is a well-known medical entity. The delayed ischemic neurological deficits (DIND) as a result of vasospasm remain the main cause of morbidity among patients who manage to survive this severe disease pattern. When the traditional treatment options, either medical or interventional, fail to reverse vasospasm, continuous intraarterial infusion of nimodipine through catheters directly into the spastic arteries presents a promising treatment modality. Of 73 patients with aneurysmal subarachnoid hemorrhage between 2008 and 2009, a total of 27 had Hunt and Hess grades of 4 and 5. Fifteen percent of them showed refractory vasospasms and were treated with continuous nimodipine infusion via catheters in both internal carotid arteries. We present the method's indications and possible complications.
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Affiliation(s)
- A Doukas
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Kiel, Germany.
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Angiographic evaluation of the effect of intra-arterial milrinone therapy in patients with vasospasm from aneurysmal subarachnoid hemorrhage. Neuroradiology 2010; 53:123-8. [PMID: 20549498 DOI: 10.1007/s00234-010-0720-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 05/13/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Several methods have been used to treat cerebral vasospasm, which is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). Here, we examined the effectiveness and safety of intra-arterial injection of milrinone for the treatment of vasospasm. METHODS Consecutive patients with angiographically confirmed vasospasm received intra-arterial milrinone between January 2006 and December 2007. The improvement in diameter of vessel (in millimeters) following treatment was assessed by paired t test for statistical significance. The angiographic improvement of supraclinoid internal carotid artery, M1 segment of middle cerebral artery, and A1 and A2 segment of anterior cerebral artery was compared with the modified Rankin score of the patients at discharge. RESULTS A total of 15 milrinone treatments were performed in 14 patients (11 females and 3 males) with mean age of 52.7 years (31-68 years). There was significant angiographic improvement after milrinone therapy (p < 0.0001). CONCLUSION Intra-arterial milrinone was a safe and effective treatment of cerebral vasospasm following aneurysmal SAH.
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Kim JH, Park IS, Park KB, Kang DH, Hwang SH. Intraarterial nimodipine infusion to treat symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2009; 46:239-44. [PMID: 19844625 DOI: 10.3340/jkns.2009.46.3.239] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 08/05/2009] [Accepted: 08/31/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Cerebral vasospasm leading to cerebral ischemic infarction is a major cause of morbidity and mortality in the patients who suffer with aneurysmal subarachnoid hemorrhage. Despite adequate treatment, some patients deteriorate and they develop symptomatic vasospasm. The objective of the present study was to investigate the efficacy and clinical outcome of intraarterial nimodipine infusion on symptomatic vasospasm that is refractory to hemodynamic therapy. METHODS We retrospectively reviewed the procedure reports, the clinical charts and the transcranial doppler, computed tomography and digital subtraction angiography results for the patients who underwent endovascular treatment for symptomatic cerebral vasospasm due to aneurysmal SAH. During the 36 months between Jan. 2005 and Dec. 2007, 19 patients were identified who had undergone a total of 53 procedures. We assessed the difference in the arterial vessel diameter, the blood flow velocity and the clinical outcome before and after these procedures. RESULTS Vascular dilatation was observed in 42 of 53 procedures. The velocities of the affected vessels before and after procedures were available in 33 of 53 procedures. Twenty-nine procedures exhibited a mean decrease of 84.1 cm/s. We observed clinical improvement and an improved level of consciousness with an improved GCS score after 23 procedures. CONCLUSION Based on our results, the use of intraarterial nimodipine is effective and safe in selected cases of vasospasm following aneurysmal SAH. Prospective, randomized studies are needed to confirm these results.
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Affiliation(s)
- Jong Hoon Kim
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
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Eddleman CS, Hurley MC, Naidech AM, Batjer HH, Bendok BR. Endovascular options in the treatment of delayed ischemic neurological deficits due to cerebral vasospasm. Neurosurg Focus 2009; 26:E6. [PMID: 19249962 DOI: 10.3171/2008.11.focus08278] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The second leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (SAH) is delayed cerebral ischemia due to vasospasm. Although up to 70% of patients have been shown to have angiographic evidence of vasospasm, only 20-30% will present with clinical changes, including mental status changes and neurological deficits that necessitate acute management. Endovascular capabilities have progressed to become viable options in the treatment of cerebral vasospasm. The rationale for intraarterial therapy includes the fact that morbidity and mortality rates have not changed in recent years despite optimized noninvasive medical care. In this report, the authors discuss the most common endovascular options-namely intraarterial vasodilators and transluminal balloon angioplasty-from the standpoint of mechanism, efficacy, limitations, and complications as well as the treatment algorithms for cerebral vasospasm used at our institution.
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Affiliation(s)
- Christopher S Eddleman
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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Abstract
PURPOSE OF REVIEW The aim of this article is to summarize recent concepts regarding the intensive care management of patients with subarachnoid haemorrhage, emphasizing the detection and treatment of cerebral vasospasm and the management of systemic complications. RECENT FINDINGS Aneurysmal subarachnoid haemorrhage is a potentially devastating disease that requires complex treatment strategies and extended monitoring. The prognosis of subarachnoid haemorrhage depends on the severity of the initial bleed, the success of the procedure to secure the aneurysm and the occurrence and severity of sequelae, including cerebral vasospasm. Patients with subarachnoid haemorrhage benefit from multidisciplinary neurointensive care where management is targeted at securing the ruptured aneurysm, optimizing cardiovascular variables, detecting and treating cerebral vasospasm and managing systemic complications. SUMMARY The complex treatment strategies applied after subarachnoid haemorrhage call for interdisciplinary collaboration between neurosurgeons, neuroradiologists, neurointensivists and specialist nurses. Specialized neuromonitoring and neuroimaging techniques must also be available. The neurointensive care unit serves as the focal point for these combined efforts.
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Affiliation(s)
- Martin Smith
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London, UK.
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Keyrouz SG, Diringer MN. Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage. Crit Care 2007; 11:220. [PMID: 17705883 PMCID: PMC2206512 DOI: 10.1186/cc5958] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.
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Affiliation(s)
- Salah G Keyrouz
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
| | - Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
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