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de Winkel J, Maas CCHM, Roozenbeek B, van Klaveren D, Lingsma HF. Pitfalls of single-study external validation illustrated with a model predicting functional outcome after aneurysmal subarachnoid hemorrhage. BMC Med Res Methodol 2024; 24:176. [PMID: 39118007 PMCID: PMC11308226 DOI: 10.1186/s12874-024-02280-9] [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: 08/15/2023] [Accepted: 07/09/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Prediction models are often externally validated with data from a single study or cohort. However, the interpretation of performance estimates obtained with single-study external validation is not as straightforward as assumed. We aimed to illustrate this by conducting a large number of external validations of a prediction model for functional outcome in subarachnoid hemorrhage (SAH) patients. METHODS We used data from the Subarachnoid Hemorrhage International Trialists (SAHIT) data repository (n = 11,931, 14 studies) to refit the SAHIT model for predicting a dichotomous functional outcome (favorable versus unfavorable), with the (extended) Glasgow Outcome Scale or modified Rankin Scale score, at a minimum of three months after discharge. We performed leave-one-cluster-out cross-validation to mimic the process of multiple single-study external validations. Each study represented one cluster. In each of these validations, we assessed discrimination with Harrell's c-statistic and calibration with calibration plots, the intercepts, and the slopes. We used random effects meta-analysis to obtain the (reference) mean performance estimates and between-study heterogeneity (I2-statistic). The influence of case-mix variation on discriminative performance was assessed with the model-based c-statistic and we fitted a "membership model" to obtain a gross estimate of transportability. RESULTS Across 14 single-study external validations, model performance was highly variable. The mean c-statistic was 0.74 (95%CI 0.70-0.78, range 0.52-0.84, I2 = 0.92), the mean intercept was -0.06 (95%CI -0.37-0.24, range -1.40-0.75, I2 = 0.97), and the mean slope was 0.96 (95%CI 0.78-1.13, range 0.53-1.31, I2 = 0.90). The decrease in discriminative performance was attributable to case-mix variation, between-study heterogeneity, or a combination of both. Incidentally, we observed poor generalizability or transportability of the model. CONCLUSIONS We demonstrate two potential pitfalls in the interpretation of model performance with single-study external validation. With single-study external validation. (1) model performance is highly variable and depends on the choice of validation data and (2) no insight is provided into generalizability or transportability of the model that is needed to guide local implementation. As such, a single single-study external validation can easily be misinterpreted and lead to a false appreciation of the clinical prediction model. Cross-validation is better equipped to address these pitfalls.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, 40 Doctor Molewaterplein, P.O. Box 2040, Rotterdam, Zuid-Holland, 3015 GD, The Netherlands.
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Zuid-Holland, The Netherlands.
| | - Carolien C H M Maas
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, 40 Doctor Molewaterplein, P.O. Box 2040, Rotterdam, Zuid-Holland, 3015 GD, The Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
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Pan T, Shi Y, Yu G, Mamtimin A, Zhu W. Intracranial Aneurysms and Lipid Metabolism Disorders: From Molecular Mechanisms to Clinical Implications. Biomolecules 2023; 13:1652. [PMID: 38002334 PMCID: PMC10669412 DOI: 10.3390/biom13111652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 10/23/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
Many vascular diseases are linked to lipid metabolism disorders, which cause lipid accumulation and peroxidation in the vascular wall. These processes lead to degenerative changes in the vessel, such as phenotypic transformation of smooth muscle cells and dysfunction and apoptosis of endothelial cells. In intracranial aneurysms, the coexistence of lipid plaques is often observed, indicating localized lipid metabolism disorders. These disorders may impair the function of the vascular wall or result from it. We summarize the literature on the relationship between lipid metabolism disorders and intracranial aneurysms below.
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Affiliation(s)
- Tonglin Pan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Abdureshid Mamtimin
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200090, China; (T.P.); (Y.S.); (G.Y.); (A.M.)
- Neurosurgical Institute, Fudan University, Shanghai 200032, China
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Wu F, Liu Z, Li G, Zhou L, Huang K, Wu Z, Zhan R, Shen J. Inflammation and Oxidative Stress: Potential Targets for Improving Prognosis After Subarachnoid Hemorrhage. Front Cell Neurosci 2021; 15:739506. [PMID: 34630043 PMCID: PMC8497759 DOI: 10.3389/fncel.2021.739506] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) has a high mortality rate and causes long-term disability in many patients, often associated with cognitive impairment. However, the pathogenesis of delayed brain dysfunction after SAH is not fully understood. A growing body of evidence suggests that neuroinflammation and oxidative stress play a negative role in neurofunctional deficits. Red blood cells and hemoglobin, immune cells, proinflammatory cytokines, and peroxidases are directly or indirectly involved in the regulation of neuroinflammation and oxidative stress in the central nervous system after SAH. This review explores the role of various cellular and acellular components in secondary inflammation and oxidative stress after SAH, and aims to provide new ideas for clinical treatment to improve the prognosis of SAH.
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Affiliation(s)
- Fan Wu
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zongchi Liu
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ganglei Li
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lihui Zhou
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Kaiyuan Huang
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhanxiong Wu
- College of Electronics and Information, Hangzhou Dianzi University, Hangzhou, China
| | - Renya Zhan
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Shen
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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da Costa BBS, Windlin IC, Koterba E, Yamaki VN, Rabelo NN, Solla DJF, Teixeira MJ, Figueiredo EG. Glibenclamide in aneurysmatic subarachnoid hemorrhage (GASH): study protocol for a randomized controlled trial. Trials 2019; 20:413. [PMID: 31288831 PMCID: PMC6617901 DOI: 10.1186/s13063-019-3517-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 06/11/2019] [Indexed: 11/21/2022] Open
Abstract
Background Recent findings on the benefits of glibenclamide as a neuroprotective drug have started a new era for prospective studies on sulfonylureas. The effect of glibenclamide blocking the Sur1-Trpm4 channel was examined in models of subarachnoid hemorrhage and stroke, with findings of significantly reduced tight-junction abnormalities, resulting in less edema formation and considerably reduced transsynaptic apoptosis of hippocampal neurons and significantly ameliorated impairments in spatial learning. Based on these data, we plan a clinical trial to establish evidence of glibenclamide as an adjunct treatment in aneurysmal subarachnoid hemorrhage. Methods An estimated 80 patients meeting the inclusion criteria of radiological confirmatory evidence of an aneurysmal subarachnoid hemorrhage, age 18–70 years, and presentation of less than 96 h from the ictus will be allocated randomly into two groups, one receiving 5 mg daily oral intake of glibenclamide for 21 days and another control group receiving a placebo. The study’s primary outcome is the modified Rankin scale (mRS) after 6 months, as favorable (mRS 0–2) or unfavorable (mRS 3–6). The secondary outcomes will be late cognitive status, assessed after 6 months by psychological tests (the Short Form Health Survey Questionnaire and the Montreal Cognitive Assessment), as well as death at 6 months, delayed cerebral ischemia and occurrence of serious adverse events due to study medication. Discussion There is a growing interest in the scientific community regarding glibenclamide in brain edema and traumatic brain injury, but with very little of this interest targeting spontaneous brain hemorrhage, especially aneurism rupture. Positive outcomes are expected for the treatment patients, especially in language and memory preservation, as has been shown in experimental models. Trial registration ClinicalTrials.gov, NCT03569540. Retrospectively registered on 26 June 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3517-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Edwin Koterba
- Neurosurgery Department, University of São Paulo, São Paulo, SP, Brazil
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Saand AR, Yu F, Chen J, Chou SHY. Systemic inflammation in hemorrhagic strokes - A novel neurological sign and therapeutic target? J Cereb Blood Flow Metab 2019; 39:959-988. [PMID: 30961425 PMCID: PMC6547186 DOI: 10.1177/0271678x19841443] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Growing evidences suggest that stroke is a systemic disease affecting many organ systems beyond the brain. Stroke-related systemic inflammatory response and immune dysregulations may play an important role in brain injury, recovery, and stroke outcome. The two main phenomena in stroke-related peripheral immune dysregulations are systemic inflammation and post-stroke immunosuppression. There is emerging evidence suggesting that the spleen contracts following ischemic stroke, activates peripheral immune response and this may further potentiate brain injury. Whether similar brain-immune crosstalk occurs in hemorrhagic strokes such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not established. In this review, we systematically examined animal and human evidence to date on peripheral immune responses associated with hemorrhagic strokes. Specifically, we reviewed the impact of clinical systemic inflammatory response syndrome (SIRS), inflammation- and immune-associated biomarkers, the brain-spleen interaction, and cellular mediators of peripheral immune responses to ICH and SAH including regulatory T cells (Tregs). While there is growing data suggesting that peripheral immune dysregulation following hemorrhagic strokes may be important in brain injury pathogenesis and outcome, details of this brain-immune system cross-talk remain insufficiently understood. This is an important unmet scientific need that may lead to novel therapeutic strategies in this highly morbid condition.
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Affiliation(s)
- Aisha R Saand
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fang Yu
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jun Chen
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sherry H-Y Chou
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Neurosurgery, School of Medicine, University of Pittsburgh, PA, USA
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Ghali MGZ, Srinivasan VM, Johnson J, Kan P, Britz G. Therapeutically Targeting Platelet-Derived Growth Factor-Mediated Signaling Underlying the Pathogenesis of Subarachnoid Hemorrhage-Related Vasospasm. J Stroke Cerebrovasc Dis 2018; 27:2289-2295. [PMID: 30037648 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/10/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Vasospasm accounts for a large fraction of the morbidity and mortality burden in patients sustaining subarachnoid hemorrhage (SAH). Platelet-derived growth factor (PDGF)-β levels rise following SAH and correlate with incidence and severity of vasospasm. METHODS The literature was reviewed for studies investigating the role of PDGF in the pathogenesis of SAH-related vasospasm and efficacy of pharmacological interventions targeting the PDGF pathway in ameliorating the same and improving clinical outcomes. RESULTS Release of blood under high pressure into the subarachnoid space activates the complement cascade, which results in release of PDGF. Abluminal contact of blood with cerebral vessels increases their contractile response to PDGF-β and thrombin, with the latter upregulating PDGF-β receptors and augmenting effects of PDGF-β. PDGF-β figures prominently in the early and late phases of post-SAH vasospasm. PDGF-β binding to the PDGF receptor-β results in receptor tyrosine kinase domain activation and consequent stimulation of intracellular signaling pathways, including p38 mitogen-activated protein kinase, phosphatidylinositol-3-kinase, Rho-associated protein kinase, and extracellular regulated kinase 1 and 2. Consequent increases in intracellular calcium and increased expression of genes mediating cellular growth and proliferation mediate PDGF-induced augmentation of vascular smooth muscle cell contractility, hypertrophy, and proliferation. CONCLUSION Treatments with statins, serine protease inhibitors, and small molecular pathway inhibitors have demonstrated varying degrees of efficacy in prevention of cerebral vasospasm, which is improved with earlier institution.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas.
| | | | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
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Effect of High-Dose Simvastatin on Cerebral Blood Flow and Static Autoregulation in Subarachnoid Hemorrhage. Neurocrit Care 2017; 25:56-63. [PMID: 26721259 DOI: 10.1007/s12028-015-0233-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Statins may promote vasodilation following subarachnoid hemorrhage (SAH) and improve the response to blood pressure elevation. We sought to determine whether simvastatin increases cerebral blood flow (CBF) and alters the response to induced hypertension after SAH. METHODS Statin-naïve patients admitted <72 h after WFNS ≥2 aneurysmal SAH were randomly assigned to 80 mg simvastatin/day or placebo for 21 days. Regional CBF was measured with quantitative (15)O PET on SAH day 7-10 before and after raising mean arterial pressure (MAP) 20-25 %. Autoregulatory index (AI) was calculated as the ratio of % change in resistance (MAP/CBF) to % change in MAP. Angiography was performed within 24 h of PET. Results are presented as simvastatin vs. placebo. RESULTS Thirteen patients received simvastatin and 12 placebo. Clinical characteristics were similar. Moderate or severe angiographic vasospasm occurred in 42 vs. 45 % and delayed cerebral ischemia in 14 vs. 55 % (p = 0.074). During PET studies, MAP (110 ± 10 vs. 111 ± 12), global CBF (41 ± 12 vs. 43 ± 13), and CVR (2.95 ± 1.0 vs. 2.81 ± 1.0) did not differ at baseline. When MAP was raised to 135 ± 7 mm Hg vs. 137 ± 15, global CBF did not change. Global AI did not differ (107 ± 59 vs. 0. 89 ± 52 %, p = 0.68). CBF did not change in regions with low baseline flow or in regions supplied by vessels with angiographic vasospasm in either group. Six-month modified Rankin Scale scores did not differ. CONCLUSIONS Our data indicate that initiation of therapy with high-dose simvastatin does not alter baseline CBF or response to induced hypertension.
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Cholesterol-Reducing Agents for Treatment of Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2017; 101:476-485. [DOI: 10.1016/j.wneu.2017.01.125] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 11/20/2022]
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Aldakkan A, Mansouri A, Jaja BNR, Alotaibi NM, Macdonald RL. Predictors of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage with Asymptomatic Angiographic Vasospasm on Admission. World Neurosurg 2016; 97:199-204. [PMID: 27717776 DOI: 10.1016/j.wneu.2016.09.096] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/19/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Risk of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) with asymptomatic angiographic vasospasm on admission is unclear in the literature. The goal of this study is to identify predictors of clinical DCI in this group of patients. METHODS An exploratory subgroup analysis was conducted in the SAHIT (Subarachnoid Hemorrhage International Trialists) data repository to identify predictors of clinical DCI in patients with good-grade aSAH (World Federation of Neurological Surgeons grade I and II) with angiographic vasospasm on admission. Predictors considered include age, sex, systolic blood pressure at presentation, World Federation of Neurological Surgeon grade, Fisher grade, aneurysm size and location, treatment modality, hydrocephalus requiring external ventricular drain insertion, and severity of vasospasm. The predictors were ranked based on dominance analysis with R2 as fit statistics and assessed in a set of logistic regression analysis models. RESULTS Four data sets out of 16 studies in the SAHIT database were analyzed, with a total of 4125 patients. One hundred and ninety-one patients (4.6%) had asymptomatic angiographic vasospasm at admission. Of those, 78 patients (40.8%) developed clinical DCI. Univariate analysis showed significant associations between severe vasospasm on admission and development of clinical DCI (odds ratio, 9.5, 95% confidence interval, 2.07-43.50; P = 0.004). None of the studied predictors was associated with the development of clinical DCI on multivariate analysis. CONCLUSIONS Asymptomatic angiographic vasospasm in patients with good-grade aSAH on admission is uncommon. Further studies are needed to identify high-risk patients for the development of DCI in the context of asymptomatic early vasospasm.
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Affiliation(s)
- Abdulrahman Aldakkan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Alireza Mansouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Blessing N R Jaja
- 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
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; 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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Dhandapani S, Aggarwal A, Srinivasan A, Meena R, Gaudihalli S, Singh H, Dhandapani M, Mukherjee KK, Gupta SK. Serum lipid profile spectrum and delayed cerebral ischemia following subarachnoid hemorrhage: Is there a relation? Surg Neurol Int 2015; 6:S543-8. [PMID: 26664869 PMCID: PMC4653325 DOI: 10.4103/2152-7806.168067] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 09/18/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Serum lipid abnormalities are known to be important risk factors for vascular disorders. However, their role in delayed cerebral ischemia (DCI), the major cause of morbidity after subarachnoid hemorrhage (SAH) remains unclear. This study was an attempt to evaluate the spectrum of lipid profile changes in SAH compared to matched controls, and their relation with the occurrence of DCI. METHODS Admission serum lipid profile levels were measured in patients of SAH and prospectively studied in relation to various factors and clinical development of DCI. RESULTS Serum triglyceride (TG) levels were significantly lower among SAH patients compared to matched controls (mean [±standard deviation (SD)] mg/dL: 117.3 [±50.4] vs. 172.8 [±89.1], P = 0.002), probably because of energy consumption due to hypermetabolic response. Patients who developed DCI had significantly higher TG levels compared to those who did not develop DCI (mean [±SD] mg/dL: 142.1 [±56] vs. 111.9 [±54], P = 0.05). DCI was noted in 62% of patients with TG >150 mg/dL, compared to 22% among the rest (P = 0.01). Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and lipoprotein (a) neither showed a significant difference between SAH and controls and nor any significant association with DCI. Multivariate analysis using binary logistic regression adjusting for the effects of age, sex, systemic disease, World Federation of Neurosurgical Societies grade, Fisher grade, and clipping/coiling, revealed higher TG levels to have significant independent association with DCI (P = 0.01). CONCLUSIONS Higher serum TG levels appear to be significantly associated with DCI while other lipid parameters did not show any significant association. This may be due to their association with remnant cholesterol or free fatty acid-induced lipid peroxidation.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anirudh Srinivasan
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Meena
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sachin Gaudihalli
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harnarayan Singh
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Dhandapani
- Department of Neurosurgery, Neuro-nursing Division, National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kanchan K Mukherjee
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil K Gupta
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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A novel trigger for cholesterol-dependent smooth muscle contraction mediated by the sphingosylphosphorylcholine-Rho-kinase pathway in the rat basilar artery: a mechanistic role for lipid rafts. J Cereb Blood Flow Metab 2015; 35:835-42. [PMID: 25605290 PMCID: PMC4420858 DOI: 10.1038/jcbfm.2014.260] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 12/12/2014] [Accepted: 12/13/2014] [Indexed: 02/04/2023]
Abstract
Hyperlipidemia is a risk factor for abnormal cerebrovascular events. Rafts are cholesterol-enriched membrane microdomains that influence signal transduction. We previously showed that Rho-kinase-mediated Ca(2+) sensitization of vascular smooth muscle (VSM) induced by sphingosylphosphorylcholine (SPC) has a pivotal role in cerebral vasospasm. The goals of the study were to show SPC-Rho-kinase-mediated VSM contraction in vivo and to link this effect to cholesterol and rafts. The SPC-induced VSM contraction measured using a cranial window model was reversed by Y-27632, a Rho-kinase inhibitor, in rats fed a control diet. The extent of SPC-induced contraction correlated with serum total cholesterol. Total cholesterol levels in the internal carotid artery (ICA) were significantly higher in rats fed a cholesterol diet compared with a control diet or a β-cyclodextrin diet, which depletes VSM cholesterol. Western blotting and real-time PCR revealed increases in flotillin-1, a raft marker, and flotillin-1 mRNA in the ICA in rats fed a cholesterol diet, but not in rats fed the β-cyclodextrin diet. Depletion of cholesterol decreased rafts in VSM cells, and prevention of an increase in cholesterol by β-cyclodextrin inhibited SPC-induced contraction in a cranial window model. These results indicate that cholesterol potentiates SPC-Rho-kinase-mediated contractions of importance in cerebral vasospasm and are compatible with a role for rafts in this process.
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12
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Boluijt J, Meijers JCM, Rinkel GJE, Vergouwen MDI. Hemostasis and fibrinolysis in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review. J Cereb Blood Flow Metab 2015; 35:724-33. [PMID: 25690473 PMCID: PMC4420861 DOI: 10.1038/jcbfm.2015.13] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/09/2015] [Accepted: 01/12/2015] [Indexed: 11/09/2022]
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with microthrombosis, which can result from activated hemostasis, inhibited fibrinolysis, or both. We systematically searched the PUBMED and EMBASE databases to identify hemostatic or fibrinolytic parameters that can be used for the prediction or diagnosis of DCI, or that inform on the pathogenesis of DCI and may serve as treatment targets. We included 24 studies that fulfilled predefined criteria and described 39 biomarkers. Only one study fulfilled predefined criteria for high quality. Since no parameter on admission was associated with DCI and in none of the included studies blood was drawn at the time of clinical deterioration, none of the studied parameters can presently be used for the prediction or diagnosis of DCI. Regarding the pathogenesis of DCI, it was shown that compared with patients without DCI those with DCI had higher levels of von Willebrand factor and platelet activating factor in plasma 5 to 9 days after aSAH, membrane tissue factor in cerebrospinal fluid 5 to 9 days after aSAH, and D-dimer in plasma 11 to 14 days after aSAH. Confirmation in high-quality studies is needed to investigate whether these parameters can serve as targets for new intervention studies.
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Affiliation(s)
- Jacoline Boluijt
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost C M Meijers
- 1] Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands [2] Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- 1] Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands [2] Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Jaja BNR, Attalla D, Macdonald RL, Schweizer TA, Cusimano MD, Etminan N, Hanggi D, Hasan D, Johnston SC, Le Roux P, Lo B, Louffat-Olivares A, Mayer S, Molyneux A, Noble A, Quinn A, Schenk T, Spears J, Singh J, Todd M, Torner J, Tseng M, van den Bergh W, Vergouwen MDI, Wong GKC. The Subarachnoid Hemorrhage International Trialists (SAHIT) Repository: Advancing Clinical Research in Subarachnoid Hemorrhage. Neurocrit Care 2014; 21:551-9. [DOI: 10.1007/s12028-014-9990-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kirkpatrick PJ, Turner CL, Smith C, Hutchinson PJ, Murray GD. Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial. Lancet Neurol 2014; 13:666-75. [PMID: 24837690 DOI: 10.1016/s1474-4422(14)70084-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The benefit of statins in patients with acute aneurysmal subarachnoid haemorrhage is unclear. We aimed to determine whether simvastatin 40 mg could improve the long-term outcome in patients with this disorder. METHODS In this international, multicentre, randomised, double-blind trial, we enrolled patients aged 18-65 years with confirmatory evidence of an aneurysmal subarachnoid haemorrhage and presenting less than 96 h from ictus from 35 acute neurosurgical centres in nine countries. Patients were randomly allocated (1:1) to receive either simvastatin 40 mg or placebo once a day for up to 21 days. We used a computer-generated randomisation code to randomise patients in every centre by blocks of ten (five simvastatin, five placebo). Participants and investigators were masked to treatment assignment. The primary outcome was the distribution of modified Rankin Scale (mRS) score obtained by questionnaire at 6 months. Analyses were done on the intention-to-treat population. This trial has been completed and is registered with Current Controlled Trials, number ISRCTN75948817. FINDINGS Between Jan 6, 2007, and Feb 1, 2013, apart from the period between May 15, 2009, and Feb 8, 2011, when recruitment was on hold, 803 patients were randomly assigned to receive either simvastatin 40 mg (n=391) or placebo (n=412). All patients were included in the intention-to-treat population. 782 (97%) patients had outcome data recorded at 6 months, of whom 560 (72%) were classed as having a favourable outcome, mRS 0-2 (271 patients in the simvastatin group vs 289 in the placebo group). The primary ordinal analysis of the mRS, adjusted for age and World Federation of Neurological Surgeons grade on admission, gave a common odds ratio (OR) of 0·97, 95% CI 0·75-1·25; p=0·803. At 6 months, we recorded 37 (10%) deaths in the simvastatin group compared with 35 (9%) in the placebo group (log-rank p=0·592). 70 (18%) serious adverse events were reported in the simvastatin group compared with 74 (18%) in the placebo group. No suspected unexpected serious adverse reactions were reported. INTERPRETATION The STASH trial did not detect any benefit in the use of simvastatin for long-term or short-term outcome in patients with aneurysmal subarachnoid haemorrhage. Despite demonstrating no safety concerns, we conclude that patients with subarachnoid haemorrhage should not be treated routinely with simvastatin during the acute stages. FUNDING British Heart Foundation.
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Affiliation(s)
- Peter J Kirkpatrick
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carole L Turner
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Christopher Smith
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Academic Division of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gordon D Murray
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
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Abstract
BACKGROUND Cerebral vasospasm and related delayed ischaemic deficits (DIDs) occur in about 17% to 40% of patients with aneurysmal subarachnoid haemorrhage (SAH) and lead to a poor outcome. Cholesterol-reducing agents might improve unfavourable outcomes. OBJECTIVES To assess the effects of cholesterol-reducing agents for improving outcomes in patients with aneurysmal SAH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5), MEDLINE (1948 to May 2012) and EMBASE (1980 to May 2012). We also searched three Chinese databases: SinoMed, CNKI and VIP (May 2012). In an effort to identify further published, ongoing and unpublished trials we searched relevant clinical trials and research registers (May 2012), contacted pharmaceutical companies and investigators known to be involved in previous trials and screened the reference lists of all relevant articles identified. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared cholesterol-reducing agents with control or placebo treatment in participants with aneurysmal SAH. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, reviewed the relevant trials and extracted data. We did not perform meta-analysis as we only included one RCT in the review. MAIN RESULTS We included one study in which 39 patients received either simvastatin (80 mg daily; n = 19) or placebo (n = 20) for 14 days. The incidence of DIDs (secondary outcome) was 26% (5/19) in the simvastatin group versus 60% (12/20) in the placebo group (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.19 to 1.01, P = 0.05). This means that, in this study, simvastatin had no effect on DIDs. Two patients in the simvastatin group and one patient in the placebo group had elevated levels of aspartate transaminase or alanine transaminase. One patient in the simvastatin group had a raised creatine phosphokinase. There were no results from this trial for the primary outcome of death or dependency at six months. AUTHORS' CONCLUSIONS We cannot draw any conclusions about the effectiveness and safety of lowering cholesterol in aneurysmal SAH because of insufficient reliable evidence from only one small trial. More RCTs are needed.
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Affiliation(s)
- Zhou Liu
- Department of Neurology, Affiliated Hospital of Guangdong Medical College, Zhanjiang, China.
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Barry C, Turner RJ, Corrigan F, Vink R. New therapeutic approaches to subarachnoid hemorrhage. Expert Opin Investig Drugs 2012; 21:845-59. [DOI: 10.1517/13543784.2012.683113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Statins in the management of aneurysmal subarachnoid hemorrhage: an overview of animal research, observational studies, randomized controlled trials and meta-analyses. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 110:193-201. [PMID: 21125471 DOI: 10.1007/978-3-7091-0356-2_36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND the pathophysiology of delayed neurological deficits (DNDs) following aneurysmal subarachnoid hemorrhage (SAH) is complex, and is not limited to arterial narrowing (vasospasm) and classical ischemia. Thus, combined drug approaches, or therapies with multiple effects, may have the greatest potential for benefit. Statins are known to have pleiotropic vascular effects, some of which may interrupt the pathogenesis of DNDs. Based on promising preliminary reports, many clinicians routinely administer statins to prevent DNDs. METHODS a systematic review was performed to identify and summarize all animal research, observational studies, randomized controlled trials (RCTs) and meta-analyses which have evaluated the use of statins in the management of SAH. RESULTS nine animal studies, nine observational (cohort and case-control) studies, six RCTs and three meta-analyses were identified. Animal studies have generally administered statin doses that, when adjusted for body weight, are 10-80 times larger than what is used in humans. Nevertheless, these models have consistently reported statins to reduce vasospasm and to demonstrate additional neuroprotective effects. However, observational studies have not revealed an association between statin-use and reduced DNDs or improved neurological outcomes. Results of RCTs have been inconsistent and limited by small sample size, but together suggest that statins may reduce DNDs, with no clear impact on mortality or neurological recovery. Optimal drug administration strategies (timing of initiation, most effective dose and duration) have not been clarified. CONCLUSIONS the role of statins in the management of patients with SAH remains unclear. Although promising, statins should not, at this time, be considered standard care.
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Abstract
We studied whether endothelial nitric oxide synthase (eNOS) is upregulated and uncoupled in large cerebral arteries after subarachnoid hemorrhage (SAH) and also whether this causes cerebral vasospasm in a mouse model of anterior circulation SAH. Control animals underwent injection of saline instead of blood (n=16 SAH and n=16 controls). There was significant vasospasm of the middle cerebral artery 2 days after SAH (lumen radius/wall thickness ratio 4.3 ± 1.3 for SAH, 23.2 ± 2.1 for saline, P<0.001). Subarachnoid hemorrhage was associated with terminal deoxynucleotidyl transferase dUTP nick-end labeling, cleaved caspase-3, and Fluoro-Jade-positive neurons in the cortex and with CA1 and dentate regions in the hippocampus. There were multiple fibrinogen-positive microthromboemboli in the cortex and hippocampus after SAH. Transgenic mice expressing lacZ under control of the eNOS promoter had increased X-gal staining in large arteries after SAH, and this was confirmed by the increased eNOS protein on western blotting. Evidence that eNOS was uncoupled was found in that nitric oxide availability was decreased, and superoxide and peroxynitrite concentrations were increased in the brains of mice with SAH. This study suggests that artery constriction by SAH upregulates eNOS but that it is uncoupled and produces peroxynitrite that may generate microemboli that travel distally and contribute to brain injury.
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Kiehna EN, Starke RM, Pouratian N, Dumont AS. Standards for reporting randomized controlled trials in neurosurgery. J Neurosurg 2010; 114:280-5. [PMID: 21054137 DOI: 10.3171/2010.8.jns091770] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT The Consolidated Standards for Reporting of Trials (CONSORT) criteria were published in 1996 to standardize the reporting and improve the quality of clinical trials. Despite having been endorsed by major medical journals and shown to improve the quality of reported trials, neurosurgical journals have yet to formally adopt these reporting criteria. The purpose of this study is to evaluate the quality and reporting of randomized controlled trials (RCTs) in neurosurgery and the factors that may affect the quality of reported trials. METHODS The authors evaluated all neurosurgical RCTs published in 2006 and 2007 in the principal neurosurgical journals (Journal of Neurosurgery; Neurosurgery; Surgical Neurology; Journal of Neurology, Neurosurgery, and Psychiatry; and Acta Neurochirurgica) and in 3 leading general medical journals (Journal of the American Medical Association, Lancet, and the New England Journal of Medicine). Randomized controlled trials that addressed operative decision making or the treatment of neurosurgical patients were included in this analysis. The RCT quality was evaluated using the Jadad score and the CONSORT checklist. RESULTS In 2006 and 2007, 27 RCTs relevant to intracranial neurosurgery were reported. Of these trials, only 59% had a Jadad score ≥ 3. The 3 major medical journals all endorsed the CONSORT guidelines, while none of the neurosurgical journals have adopted these guidelines. Randomized controlled trials published in the 3 major medical journals had a significantly higher mean CONSORT score (mean 41, range 39-44) compared with those published in neurosurgical journals (mean 26.4, range 17-38; p < 0.0001). Jadad scores were also significantly higher for the major medical journals (mean 3.42, range 2-5) than neurosurgical journals (mean 2.45, range 1-5; p = 0.05). CONCLUSIONS Despite the growing volume of RCTs in neurosurgery, the quality of reporting of these trials remains suboptimal, especially in the neurosurgical journals. Improved awareness of the CONSORT guidelines by journal editors, reviewers, and authors of these papers could improve the methodology and reporting of RCTs in neurosurgery.
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Affiliation(s)
- Erin N Kiehna
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Zaveri A, Cofiel L, Shah J, Pradhan S, Chan E, Dameron O, Pietrobon R, Ang BT. Achieving high research reporting quality through the use of computational ontologies. Neuroinformatics 2010; 8:261-71. [PMID: 20953737 DOI: 10.1007/s12021-010-9079-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Systematic reviews and meta-analyses constitute one of the central pillars of evidence-based medicine. However, clinical trials are poorly reported which delays meta-analyses and consequently the translation of clinical research findings to clinical practice. We propose a Center of Excellence in Research Reporting in Neurosurgery (CERR-N) and the creation of a clinically significant computational ontology to encode Randomized Controlled Trials (RCT) studies in neurosurgery. A 128 element strong computational ontology was derived from the Trial Bank ontology by omitting classes which were not required to perform meta-analysis. Three researchers from our team tagged five randomly selected RCT's each, published in the last 5 years (2004-2008), in the Journal of Neurosurgery (JoN), Neurosurgery Journal (NJ) and Journal of Neurotrauma (JoNT). We evaluated inter and intra observer reliability for the ontology using percent agreement and kappa coefficient. The inter-observer agreement was 76.4%, 75.97% and 74.9% and intra-observer agreement was 89.8%, 80.8% and 86.56% for JoN, NJ and JoNT respectively. The inter-observer kappa coefficient was 0.60, 0.54 and 0.53 and the intra-observer kappa coefficient was 0.79, 0.82 and 0.79 for JoN, NJ and JoNT journals respectively. The high degree of inter and intra-observer agreement confirms tagging consistency in sections of a given scientific manuscript. Standardizing reporting for neurosurgery articles can be reliably achieved through the integration of a computational ontology within the context of a CERR-N. This approach holds potential for the overall improvement in the quality of reporting of RCTs in neurosurgery, ultimately streamlining the translation of clinical research findings to improvement in patient care.
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Tseng MY, Hutchinson PJ, Kirkpatrick PJ. Interaction of neurovascular protection of erythropoietin with age, sepsis, and statin therapy following aneurysmal subarachnoid hemorrhage. J Neurosurg 2010; 112:1235-9. [DOI: 10.3171/2009.10.jns09954] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In a previous randomized controlled trial, the authors demonstrated that acute erythropoietin (EPO) therapy reduced severe vasospasm and delayed ischemic deficits (DIDs) following aneurysmal subarachnoid hemorrhage. In this study, the authors aimed to investigate the potential interaction of neurovascular protection by EPO with age, sepsis, and concurrent statin therapy.
Methods
The clinical events of 80 adults older than 18 years and with < 72 hours of aneurysmal subarachnoid hemorrhage, who were randomized to receive 30,000 U of intravenous EPO-β or placebo every 48 hours for a total of 3 doses, were analyzed by stratification according to age (< or ≥ 60 years), sepsis, or concomitant statin therapy. End points in the trial included cerebral vasospasm and impaired autoregulation on transcranial Doppler ultrasonography, DIDs, and unfavorable outcome at discharge and at 6 months measured with the modified Rankin Scale and Glasgow Outcome Scale. Analyses were performed using the t-test and/or ANOVA for repeated measurements.
Results
Younger patients (< 60 years old) or those without sepsis obtained benefits from EPO by a reduction in vasospasm, impaired autoregulation, and unfavorable outcome at discharge. Compared with nonseptic patients taking EPO, those with sepsis taking EPO had a lower absolute reticulocyte count (nonsepsis vs sepsis, 143.5 vs. 105.8 × 109/L on Day 6; p = 0.01), suggesting sepsis impaired both hematopoiesis and neurovascular protection by EPO. In the EPO group, none of the statin users suffered DIDs (p = 0.078), implying statins may potentiate neuroprotection by EPO.
Conclusions
Erythropoietin-related neurovascular protection appears to be attenuated by old age and sepsis and enhanced by statins, an important finding for designing Phase III trials.
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22
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The role of statins in neurosurgery. Neurosurg Rev 2010; 33:259-70; discussion 270. [DOI: 10.1007/s10143-010-0259-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 01/22/2010] [Accepted: 03/06/2010] [Indexed: 12/20/2022]
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Abstract
Since the introduction of HMG-CoA reductase inhibitors (statins) for lowering lipids, a large amount of data has been published demonstrating their potential benefits in conditions as varied as cancer, osteoporosis, and Alzheimer's dementia. We reviewed the published literature on MEDLINE from articles between 1950 and 2008 on the non-atheroprotective effects of statins and noted consistent benefits of statin use in improving outcomes of ventricular arrhythmias, sudden cardiac death, cardiac transplant rejection, chronic obstructive pulmonary disease, and sepsis. However, for these conditions, the level of evidence was inadequate to recommend statin use. The evidence for improving outcomes in atrial fibrillation, mortality in heart failure, contrast-induced nephropathy, cataract, age-related macular degeneration, sub-arachnoid hemorrhage, osteoporosis, dementia, and cancer incidence was conflicting and inconclusive. Furthermore, we found that most of the literature consists of small observational studies and their conclusions are often not corroborated by results from larger or randomized studies. Pending large, well designed, randomized trials, we conclude that there is no definite evidence for the use of statins in any condition besides hyperlipidemia and atherosclerosis.
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Affiliation(s)
- Abhimanyu Beri
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan, USA.
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24
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Wible EF, Laskowitz DT. Statins in traumatic brain injury. Neurotherapeutics 2010; 7:62-73. [PMID: 20129498 PMCID: PMC5084113 DOI: 10.1016/j.nurt.2009.11.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Revised: 11/17/2009] [Accepted: 11/18/2009] [Indexed: 10/20/2022] Open
Abstract
Traumatic brain injury (TBI) is a common cause of long-term neurological morbidity, with devastating personal and societal consequences. At present, no pharmacological intervention clearly improves outcomes, and therefore a compelling unmet clinical need remains. 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or "statins," offer a potential novel therapeutic strategy for TBI. Statins are well tolerated, easy to administer, and have a long clinical track record in critically ill patients. Their side effects are well defined and easily monitored. Preclinical studies have shown significant benefit of statins in models of TBI and related disease processes, including cerebral ischemia, intracerebral hemorrhage, and subarachnoid hemorrhage. In fact, multiple mechanisms have been defined by which statins may exert benefit after acute brain injury. Statins are currently positioned to be translated into clinical trials in acute brain injury and have the potential to improve outcomes after TBI.
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Affiliation(s)
- Elissa F. Wible
- grid.26009.3d0000000419367961Department of Medicine (Neurology), Duke University School of Medicine, 27710 Durham, North Carolina
| | - Daniel T. Laskowitz
- grid.26009.3d0000000419367961Department of Medicine (Neurology), Duke University School of Medicine, 27710 Durham, North Carolina
- grid.26009.3d0000000419367961Department of Anesthesiology, Duke University School of Medicine, 27710 Durham, North Carolina
- grid.26009.3d0000000419367961Department of Neurobiology, Duke University School of Medicine, 27710 Durham, North Carolina
- grid.189509.c0000000100241216Duke University Medical Center, Box 2900, 27710 Durham, NC
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Rabinstein AA. Vasospasm and statin therapy: yet another cautionary tale. Neurocrit Care 2009; 12:310-2. [PMID: 19707889 DOI: 10.1007/s12028-009-9267-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Alejandro A Rabinstein
- Division of Critical Care Neurology, Department of Neurology, W8B, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Biologic effects of simvastatin in patients with aneurysmal subarachnoid hemorrhage: a double-blind, placebo-controlled randomized trial. J Cereb Blood Flow Metab 2009; 29:1444-53. [PMID: 19458605 DOI: 10.1038/jcbfm.2009.59] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recently, two randomized controlled phase II studies showed that acute initiation of statin treatment directly after aneurysmal subarachnoid hemorrhage (SAH) decreases the incidence of radiologic vasospasm and clinical signs of delayed cerebral ischemia (DCI), and even reduces mortality. It was hypothesized that the beneficial effect resulted from pleiotropic effects of statins. The purpose of this study was to investigate the biologic effects of acute statin treatment in patients with SAH. We performed an exploratory single-center, prospective, randomized, double-blind, placebo-controlled trial. Patients were randomized to simvastatin 80 mg or placebo once daily. A total of 32 patients were included. There were no statistically significant differences in clinical baseline characteristics. With regard to primary outcomes, there were significant differences by treatment group for total cholesterol and low-density lipoprotein (LDL) cholesterol (P<0.0001), but not for parameters of coagulation, fibrinolysis, endothelium function, and inflammation. With regard to secondary outcomes, no differences were observed in the incidence of transcranial Doppler vasospasm, clinical signs of DCI, and poor outcome. We conclude that both the primary and secondary outcome results of this study do not support a beneficial effect of simvastatin in patients with SAH.
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Koskinen LOD, Olivecrona M, Rodling-Wahlström M, Naredi S. Prostacyclin treatment normalises the MCA flow velocity in nimodipine-resistant cerebral vasospasm after aneurysmal subarachnoid haemorrhage: a pilot study. Acta Neurochir (Wien) 2009; 151:595-9; discussion 599. [PMID: 19350202 DOI: 10.1007/s00701-009-0295-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 03/13/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cerebral vasospasm triggered by subarachnoid haemorrhage is one of the major causes of post-haemorrhage morbidity and mortality. Several treatment modalities have been proposed, and none of them are fully effective. METHODS In this study we treated five patients with prostacyclin suffering vasospasm after a ruptured aneurysm not responding to high i.v. doses of nimodipine. All patients were severely ill, unconscious and in need of intensive care. FINDINGS A low dose of prostacyclin i.v. infusion for 72 h reversed the vasospasm as measured by transcranial Doppler technique. The mean MCA blood flow velocity decreased from 199 +/- 31 cm/s to 92 +/- 6 cm/s within 72 h after the start of the prostacyclin infusion. CONCLUSIONS We suggest that low-dose prostacyclin treatment, an old treatment strategy, can be a treatment option in patients with vasospasm not responding to ordinary measures.
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Gajendragadkar PR, Cooper DG, Walsh SR, Tang TY, Boyle JR, Hayes PD. Novel uses for statins in surgical patients. Int J Surg 2009; 7:285-90. [PMID: 19439205 DOI: 10.1016/j.ijsu.2009.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 04/25/2009] [Accepted: 04/27/2009] [Indexed: 01/22/2023]
Abstract
BACKGROUND Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice. METHODS A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed. CONCLUSIONS Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.
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Affiliation(s)
- P R Gajendragadkar
- Department of Vascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Trust, Cambridge, UK
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29
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Kern M, Lam MM, Knuckey NW, Lind CR. Statins may not protect against vasospasm in subarachnoid haemorrhage. J Clin Neurosci 2009; 16:527-30. [DOI: 10.1016/j.jocn.2008.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 08/17/2008] [Indexed: 10/21/2022]
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30
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Current Opinion in Endocrinology, Diabetes & Obesity. Current world literature. Curr Opin Endocrinol Diabetes Obes 2009; 16:189-202. [PMID: 19300094 DOI: 10.1097/med.0b013e328329fcc2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Vetrugno V, Di Bari MA, Nonno R, Puopolo M, D'Agostino C, Pirisinu L, Pocchiari M, Agrimi U. Oral pravastatin prolongs survival time of scrapie-infected mice. J Gen Virol 2009; 90:1775-1780. [PMID: 19282428 DOI: 10.1099/vir.0.009936-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Statins are potent inhibitors of HMG-CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase in the cholesterol-biosynthesis pathway. They are either lipophilic (e.g. simvastatin) or hydrophilic [e.g. pravastatin (PRV)] compounds, considered mainly for long-term treatment of hypercholesterolaemic individuals. Beneficial effects of statins are not related exclusively to their lipid-lowering action; they also possess cholesterol-independent, pleiotropic effects (e.g. anti-inflammatory and antioxidant). Recent studies revealed that simvastatin treatment increased survival significantly in scrapie-infected mice. Although PRV treatment results in measurable drug levels in the mouse brain, the anti-prion effect of this compound has not been investigated. Therefore, we aimed to test the potential therapeutic action of PRV in a murine scrapie model. Our study showed that high-dose and long-term oral PRV treatment prolonged survival times of strain 139A scrapie-infected mice significantly (194 versus 177 days) in the absence of any obvious toxicity, suggesting that protective effects of statins may be independent of absolute solvent or water solubility of the drug.
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Affiliation(s)
- Vito Vetrugno
- Department of Cell Biology and Neurosciences, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Michele Angelo Di Bari
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Romolo Nonno
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Maria Puopolo
- Department of Cell Biology and Neurosciences, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Claudia D'Agostino
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Laura Pirisinu
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Maurizio Pocchiari
- Department of Cell Biology and Neurosciences, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Umberto Agrimi
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
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Tseng MY, Hutchinson PJ, Turner CL, Czosnyka M, Richards HK, Pickard JD, Kirkpatrick PJ. Statin Use Was not Associated with Less Vasospasm or Improved Outcome after Subarachnoid Hemorrhage. Neurosurgery 2008; 63:E1209; author reply E1209. [DOI: 10.1227/01.neu.0000325676.40399.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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In Reply to Dr. Healy. Int J Radiat Oncol Biol Phys 2008. [DOI: 10.1016/j.ijrobp.2008.06.1908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tapia-Perez JH, Sanchez-Aguilar M, Torres-Corzo JG, Gordillo-Moscoso A, Martinez-Perez P, Madeville P, de la Cruz-Mendoza E, Chalita-Williams J. Effect of Rosuvastatin on Amnesia and Disorientation after Traumatic Brain Injury (NCT00329758). J Neurotrauma 2008; 25:1011-7. [PMID: 18690806 DOI: 10.1089/neu.2008.0554] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- J. Humberto Tapia-Perez
- Clinical Epidemiology, Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, México
- Neurosurgery, Hospital Central “Dr. Ignacio Morones Prieto,” San Luis Potosí, SLP, México
| | - Martin Sanchez-Aguilar
- Clinical Epidemiology, Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, México
| | | | - Antonio Gordillo-Moscoso
- Clinical Epidemiology, Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, México
| | - Patricia Martinez-Perez
- Neuropsychology and Rehabilitation, Hospital Central “Dr. Ignacio Morones Prieto,” San Luis Potosí, SLP, México
| | - Peter Madeville
- Clinical Epidemiology, Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, México
| | - Esperanza de la Cruz-Mendoza
- Nuclear Medicine Laboratory, Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, México
| | - Juan Chalita-Williams
- Neurosurgery, Hospital Central “Dr. Ignacio Morones Prieto,” San Luis Potosí, SLP, México
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