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Vadokas G, Koehler S, Weiland J, Lilla N, Stetter C, Westermaier T. Early Antiinflammatory Therapy Attenuates Brain Damage After Sah in Rats. Transl Neurosci 2019; 10:104-111. [PMID: 31098320 PMCID: PMC6487785 DOI: 10.1515/tnsci-2019-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early inflammatory processes may play an important role in the development of early brain injury (EBI) after subarachnoid hemorrhage (SAH). Experimental studies suggest that anti-inflammatory and membrane-stabilizing drugs might have beneficial effects, although the underlying mechanisms are not fully understood. The aim of this study was to investigate the effect of early treatment with methylprednisolone and minocycline on cerebral perfusion and EBI after experimental SAH. METHODS Male Sprague-Dawley rats were subjected to SAH using the endovascular filament model. 30 minutes after SAH, they were randomly assigned to receive an intravenous injection of methylprednisolone (16mg/kg body weight, n=10), minocycline (45mg/kg body weight, n=10) or saline (n=11). Mean arterial blood pressure (MABP), intracranial pressure (ICP) and local cerebral blood flow (LCBF) over both hemispheres were recorded continuously for three hours following SAH. Neurological assessment was performed after 24 hours. Hippocampal damage was analyzed by immunohistochemical staining (caspase 3). RESULTS Treatment with methylprednisolone or minocycline did not result in a significant improvement of MABP, ICP or LCBF. Animals of both treatment groups showed a non-significant trend to better neurological recovery compared to animals of the control group. Mortality was reduced and hippocampal damage significantly attenuated in both methylprednisolone and minocycline treated animals. CONCLUSION The results of this study suggest that inflammatory processes may play an important role in the pathophysiology of EBI after SAH. Early treatment with the anti-inflammatory drugs methylprednisolone or minocycline in the acute phase of SAH has the potential to reduce brain damage and exert a neuroprotective effect.
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Affiliation(s)
- Georg Vadokas
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
- Department of Urology, Canisius Wilhelmina Hospital Nijmegen, Weg door Jonkerbos 100, 6532 SZ Nijmegen, Netherlands
| | - Stefan Koehler
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
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Young AMH, Karri SK, Helmy A, Budohoski KP, Kirollos RW, Bulters DO, Kirkpatrick PJ, Ogilvy CS, Trivedi RA. Pharmacologic Management of Subarachnoid Hemorrhage. World Neurosurg 2015; 84:28-35. [PMID: 25701766 DOI: 10.1016/j.wneu.2015.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 01/31/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
Abstract
Subarachnoid hemorrhage (SAH) remains a condition with suboptimal functional outcomes, especially in the young population. Pharmacotherapy has an accepted role in several aspects of the disease and an emerging role in several others. No preventive pharmacologic interventions for SAH currently exist. Antiplatelet medications as well as anticoagulation have been used to prevent thromboembolic events after endovascular coiling. However, the main focus of pharmacologic treatment of SAH is the prevention of delayed cerebral ischemia (DCI). Currently the only evidence-based medical intervention is nimodipine. Other calcium channel blockers have been evaluated without convincing efficacy. Anti-inflammatory drugs such as statins have demonstrated early potential; however, they failed to provide significant evidence for the use in preventing DCI. Similar findings have been reported for magnesium, which showed potential in experimental studies and a phase 2 trial. Clazosentane, a potent endothelin receptor antagonist, did not translate to improve functional outcomes. Various other neuroprotective agents have been used to prevent DCI; however, the results have been, at best inconclusive. The prevention of DCI and improvement in functional outcome remain the goals of pharmacotherapy after the culprit lesion has been treated in aneurysmal SAH. Therefore, further research to elucidate the exact mechanisms by which DCI is propagated is clearly needed. In this article, we review the current pharmacologic approaches that have been evaluated in SAH and highlight the areas in which further research is needed.
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Affiliation(s)
- Adam M H Young
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Surya K Karri
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ramez W Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Diederik O Bulters
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Christopher S Ogilvy
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rikin A Trivedi
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Inflammation, vasospasm, and brain injury after subarachnoid hemorrhage. BIOMED RESEARCH INTERNATIONAL 2014; 2014:384342. [PMID: 25105123 PMCID: PMC4106062 DOI: 10.1155/2014/384342] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/14/2014] [Accepted: 05/26/2014] [Indexed: 12/15/2022]
Abstract
Subarachnoid hemorrhage (SAH) can lead to devastating neurological outcomes, and there are few pharmacologic treatments available for treating this condition. Both animal and human studies provide evidence of inflammation being a driving force behind the pathology of SAH, leading to both direct brain injury and vasospasm, which in turn leads to ischemic brain injury. Several inflammatory mediators that are elevated after SAH have been studied in detail. While there is promising data indicating that blocking these factors might benefit patients after SAH, there has been little success in clinical trials. One of the key factors that complicates clinical trials of SAH is the variability of the initial injury and subsequent inflammatory response. It is likely that both genetic and environmental factors contribute to the variability of patients' post-SAH inflammatory response and that this confounds trials of anti-inflammatory therapies. Additionally, systemic inflammation from other conditions that affect patients with SAH could contribute to brain injury and vasospasm after SAH. Continuing work on biomarkers of inflammation after SAH may lead to development of patient-specific anti-inflammatory therapies to improve outcome after SAH.
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4
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Hwang SH, Park YS, Kwon JT, Nam TK, Hwang SN, Kang H. Significance of C-reactive protein and transcranial Doppler in cerebral vasospasm following aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2013; 54:289-95. [PMID: 24294451 PMCID: PMC3841270 DOI: 10.3340/jkns.2013.54.4.289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/17/2013] [Accepted: 09/30/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. C-reactive protein (CRP) constitutes a highly sensitive inflammatory marker. Elevation of serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between CRP levels in the serum and transcranial Doppler (TCD) and the development of vasospasm in patients with aSAH. Methods A total of 61 adult patients in whom aSAH was diagnosed were included in the study from November 2008 to May 2011. The patients' demographics, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum CRP measurements were obtained on days 1, 3, 5, 7, 9, 11 and 13 and TCD was measured on days 3, 5, 7, 9, 11 and 13. All patients underwent either surgical or endovascular treatment within 24 hours of their hemorrhagic attacks. Results Serum CRP levels peaked on the 3rd postoperative day. There were significant differences between the vasospasm group and the non-vasospasm group on the 1st, 3rd and 5th day. There were significant differences between the vasospasm group and the non-vasospasm group on the 3rd day in the mean middle cerebral artery velocities on TCD. Conclusion Patients with high levels of CRP on the 1st postoperative day and high velocity of mean TCD on the 3rd postoperative day may require closer observation to monitor for the development of vasospasm.
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Affiliation(s)
- Sung-Hwan Hwang
- Department of Neurosurgery, Chung-Ang University College of Medicine, Seoul, Korea
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5
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Abstract
OPINION STATEMENT Aneurysmal subarachnoid hemorrhage (SAH) induces a potent inflammatory cascade that contributes to endothelial dysfunction, imbalance of vasoactive substances (excess endothelin, depletion of nitric oxide), and arterial vasospasm. This process results in delayed cerebral ischemia, a major cause of neurologic disability in those surviving the initial hemorrhage. The only therapy shown to be effective in improving neurologic outcomes after SAH is a calcium-channel antagonist, nimodipine (although it achieved this result without reducing vasospasm). A number of novel therapies have been explored to inhibit the development of vasospasm and reduce the burden of ischemia and cerebral infarction. Statins are promising candidates, as they block multiple aspects of the inflammatory pathway that contributes to ischemic brain injury. Early clinical trials have produced conflicting results, however, and the adoption of statins in clinical practice should await the results of larger, more definitive studies. Though endothelin-receptor antagonists showed promise in significantly reducing vasospasm in preliminary trials, their failure to improve clinical outcomes in phase 3 studies has been disappointing, highlighting the complex link between vasospasm and ischemia. Future directions in the quest to improve outcomes of patients with SAH may need to approach ischemia as a multifactorial process with inflammatory, vasoactive, and ionic/metabolic components.
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Pradilla G, Garzon-Muvdi T, Ruzevick JJ, Bender M, Edwards L, Momin EN, Thompson RC, Tamargo RJ. Systemic L-Citrulline Prevents Cerebral Vasospasm in Haptoglobin 2-2 Transgenic Mice After Subarachnoid Hemorrhage. Neurosurgery 2012; 70:747-56; discussion 756-7. [DOI: 10.1227/neu.0b013e3182363c2f] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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7
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Pradilla G, Chaichana KL, Hoang S, Huang J, Tamargo RJ. Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:365-79. [PMID: 20380976 DOI: 10.1016/j.nec.2009.10.008] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Morbidity and mortality of patients with aneurysmal subarachnoid hemorrhage (aSAH) is significantly related to the development of chronic cerebral vasospasm. Despite extensive clinical and experimental research, the pathophysiology of the events that result in delayed arterial spasm is not fully understood. A review of the published literature on cerebral vasospasm that included but was not limited to all PubMed citations from 1951 to the present was performed. The findings suggest that leukocyte-endothelial cell interactions play a significant role in the pathophysiology of cerebral vasospasm and explain the clinical variability and time course of the disease. Experimental therapeutic targeting of the inflammatory response when timed correctly can prevent vasospasm, and supplementation of endothelial relaxation by nitric oxide-related therapies and other approaches could result in reversal of the arterial narrowing and improved outcomes in patients with aSAH.
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Affiliation(s)
- Gustavo Pradilla
- Division of Cerebrovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Meyer Building 8-181, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Chaichana KL, Pradilla G, Huang J, Tamargo RJ. Role of inflammation (leukocyte-endothelial cell interactions) in vasospasm after subarachnoid hemorrhage. World Neurosurg 2009; 73:22-41. [PMID: 20452866 DOI: 10.1016/j.surneu.2009.05.027] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2008] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed vasospasm is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). This phenomenon was first described more than 50 years ago, but only recently has the role of inflammation in this condition become better understood. METHODS The literature was reviewed for studies on delayed vasospasm and inflammation. RESULTS There is increasing evidence that inflammation and, more specifically, leukocyte-endothelial cell interactions play a critical role in the pathogenesis of vasospasm after aSAH, as well as in other conditions including meningitis and traumatic brain injury. Although earlier clinical observations and indirect experimental evidence suggested an association between inflammation and chronic vasospasm, recently direct molecular evidence demonstrates the central role of leukocyte-endothelial cell interactions in the development of chronic vasospasm. This evidence shows in both clinical and experimental studies that cell adhesion molecules (CAMs) are up-regulated in the perivasospasm period. Moreover, the use of monoclonal antibodies against these CAMs, as well as drugs that decrease the expression of CAMs, decreases vasospasm in experimental studies. It also appears that certain individuals are genetically predisposed to a severe inflammatory response after aSAH based on their haptoglobin genotype, which in turn predisposes them to develop clinically symptomatic vasospasm. CONCLUSION Based on this evidence, leukocyte-endothelial cell interactions appear to be the root cause of chronic vasospasm. This hypothesis predicts many surprising features of vasospasm and explains apparently unrelated phenomena observed in aSAH patients. Therapies aimed at preventing inflammation may prevent and/or reverse arterial narrowing in patients with aSAH and result in improved outcomes.
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Affiliation(s)
- Kaisorn L Chaichana
- Division of Cerebrovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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9
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McGirt MJ, Garces Ambrossi GL, Huang J, Tamargo RJ. Simvastatin for the prevention of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a single-institution prospective cohort study. J Neurosurg 2009; 110:968-74. [PMID: 19199459 DOI: 10.3171/2008.10.jns08901] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vasospasm is the major cause of disability and death after aneurysmal subarachnoid hemorrhage (aSAH). Although the results of 2 randomized clinical trials demonstrated that statin decreases the incidence of symptomatic cerebral vasospasm after aSAH, retrospective studies have failed to confirm this. The authors conducted a prospective observational study to determine whether a standardized regimen of simvastatin would reduce the incidence of cerebral vasospasm and improve neurological outcomes in patients with aSAH. METHODS Since 1991, all patients with aSAH admitted to the authors' institution have been prospectively followed up with standardized outcomes recording. Starting in September 2005, all patients admitted with aSAH were given enteral simvastatin (80 mg/day for 14 days) in addition to the standard care. The incidence of symptomatic cerebral vasospasm, length of hospitalization, in-hospital mortality rate, and discharge Glasgow Outcome Scale scores in these 170 patients were compared to data obtained in 170 consecutive patients who underwent treatment in our unit prior to the introduction of statin therapy. RESULTS The 5-year study period included 340 consecutively treated patients (170 who received statins and 170 who did not). Patients who received simvastatin therapy were more frequently male (29 vs 20%) and had a smaller median aneurysm diameter (6 vs 7 mm). Baseline characteristics were otherwise similar between the cohorts. There were no differences in the incidence of symptomatic vasospasm (25.3 vs 30.5%; p = 0.277), in-hospital mortality rate (18 vs 15%; p = 0.468), length of hospitalization (21 +/- 15 vs 19 +/- 12 days; p = 0.281), or poor outcome at discharge (Glasgow Outcome Scale Scores 1-2: 21.7 vs 18.2%; p = 0.416) between the simvastatin and nonstatin cohorts. There were no statin-related complications. CONCLUSIONS The uniform introduction of simvastatin did not reduce the incidence of symptomatic cerebral vasospasm, death, or poor outcome in patients with aSAH. Simvastatin was well tolerated, but its benefit may be less than has been previously reported.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurosurgery, Johns Hopkins University Hospital, Baltimore, Maryland, USA
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10
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Bowman G, Bonneau RH, Chinchilli VM, Tracey KJ, Cockroft KM. A novel inhibitor of inflammatory cytokine production (CNI-1493) reduces rodent post-hemorrhagic vasospasm. Neurocrit Care 2007; 5:222-9. [PMID: 17290094 DOI: 10.1385/ncc:5:3:222] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a devastating complication, yet despite multiple lines of investigation an effective treatment remains lacking. Cytokine-mediated inflammation has been implicated as a causative factor in the development of posthemorrhagic vasospasm. In previous experiments using the rat femoral artery model of vasospasm, we demonstrated that elevated levels of the proinflammatory cytokine interleukin (IL)-6 are present after hemorrhage and that a polyclonal antibody against IL-6 is capable of attenuating experimental vasospasm. METHODS In the present study, we tested the ability of a novel selective proinflammatory cytokine inhibitor (CNI-1493) to protect against the occurrence of experimental vasospasm in the same rat femoral artery model. CNI-1493 was administered by injection directly into the blood-filled femoral pouches of animals at the time of their initial surgery (hemorrhage). Control animals received an equal volume of vehicle alone. Animals were killed at 8 days posthemorrhage and degree of vasospasm was assessed by image analysis of artery cross-sectional area. In a separate series of experiments, enzyme-linked immunosorbent assay (ELISA) was used to assess levels of the proinflammatory cytokine IL-6 and the prototypical antiinflammatory cytokine transforming growth factor (TGF)-beta1 after treatment with CNI-1493. RESULTS Pretreatment with CNI-1493 provided dose-dependent attenuation of posthemorrhagic vasospasm, with the highest dose (200 microg in 8 microL dH2O) causing complete reversal of vasospasm (vessel cross-sectional area ratio 1.06 +/- 0.04 versus 0.87 +/- 0.06, p < 0.05, one-way analysis of variance). Assessment of cytokine levels by ELISA confirmed the selectivity of CNI-1493 by demonstrating significant reductions in IL-6 levels, but no suppression of TGF-beta1 levels. CONCLUSIONS These findings support the conclusion that inflammatory cytokines, in particular IL-6, play an important role in development of vasospasm in the rat femoral artery model. Furthermore, these results suggest that the inhibition of inflammatory cytokines may be an appropriate strategy for the treatment of vasospasm after SAH.
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Affiliation(s)
- George Bowman
- Cerebrovascular Surgery Laboratory, Department of Neurosurgery, Pennsylvania State University College of Medicine - M.S. Hershey Medical Center, Hershey, PA 17033, USA
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11
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Gallia GL, Tamargo RJ. Leukocyte-endothelial cell interactions in chronic vasospasm after subarachnoid hemorrhage. Neurol Res 2007; 28:750-8. [PMID: 17164038 DOI: 10.1179/016164106x152025] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Leukocyte-endothelial cell interactions appear to be the root cause of chronic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). Early clinical observations and indirect experimental evidence suggested an association between inflammation and chronic vasospasm. Early clinical observations in patients with post-hemorrhagic vasospasm included pyrexia, leukocytosis and the presence of circulating immune complexes. Inflammatory infiltrates and increased levels of immunoglobulins and complement fractions within spastic cerebral arteries also provided early evidence for an inflammatory mechanism underlying chronic vasospasm. Early indirect experimental evidence included the ability to reproduce chronic vasospasm with the introduction of inflammatory agents into the subarachnoid space and the inhibition of vasospasm with anti-inflammatory agents. Currently, however, there is an increasing body of direct molecular evidence that demonstrates the pivotal role of leukocyte-endothelial cell interactions in the development of chronic vasospasm. Cell adhesion molecules such as intercellular adhesion molecule-1 (ICAM-1), lymphocyte function-associated antigen-1 (LFA-1), macrophage antigen-1 (Mac-1) and endothelial (E)-selectin mediate interactions between circulating leukocytes and cerebral endothelium. Following aSAH, ICAM-1 is up-regulated in cerebral endothelial cells and along with other cell adhesion molecules, can be detected in the serum and cerebrospinal fluid (CSF) of patients with post-hemorrhagic vasospasm. Monoclonal antibody blocking experiments have demonstrated that the prevention of leukocyte extravasation into the subarachnoid space prevents chronic vasospasm. Similarly, drugs like ibuprofen, which prevent ICAM-1 up-regulation and transendothelial cell migration of leukocytes, prevent vasospasm. In this review, we highlight early observations that suggested an association between inflammation and post-hemorrhagic vasospasm, detail the role of leukocyte-endothelial cell interactions in the development of chronic vasospasm and discuss therapeutic implications of an inflammatory etiology of post-hemorrhagic cerebral vasospasm.
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Affiliation(s)
- Gary L Gallia
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bulsara KR, Coates JR, Agrawal VK, Eifler DM, Wagner-Mann CC, Durham HE, Fine DM, Toft K. Effect of combined simvastatin and cyclosporine compared with simvastatin alone on cerebral vasospasm after subarachnoid hemorrhage in a canine model. Neurosurg Focus 2006; 21:E11. [PMID: 17029335 DOI: 10.3171/foc.2006.21.3.11] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to determine whether the combination of cyclosporine and simvastatin could ameliorate cerebral vasospasm after subarachnoid hemorrhage (SAH) in a canine model to a greater extent than simvastatin alone.
Methods
Animals were assigned to one of three groups: control (five dogs), simvastatin alone (four), or simvastatin and cyclosporine (four). A double SAH model was used. Baseline basilar artery (BA) angiograms were obtained. These were repeated at Days 3, 7, and 10. Measurement of the BA diameter was performed.
Decreased BA diameter was seen on Day 3 in the control and simvastatin/cyclosporine group. A return to baseline diameters was seen by Day 7. An increase from baseline diameter was seen in the simvastatin group at Day 10.
Conclusions
Cyclosporine may interfere with the vasodilatory effects of simvastatin. Vasodilation greater than baseline is seen at Day 10 in the simvastatin group. The combination of simvastatin and cyclosporine does not ameliorate cerebral vasospasm in a canine model to a greater extent than simvastatin alone.
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Affiliation(s)
- Ketan R Bulsara
- Division of Neurosurgery and Department of Radiology, University of Missouri-Columbia, Columbia, Missouri, USA.
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Feigin VL, Anderson N, Rinkel GJE, Algra A, van Gijn J, Bennett DA. Corticosteroids for aneurysmal subarachnoid haemorrhage and primary intracerebral haemorrhage. Cochrane Database Syst Rev 2005:CD004583. [PMID: 16034939 DOI: 10.1002/14651858.cd004583.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Corticosteroids, particularly dexamethasone, are commonly used for treatments in patients with subarachnoid haemorrhage (SAH) and primary intracerebral haemorrhage (PICH) despite the lack of evidence. OBJECTIVES This review aimed: (1) to determine whether corticosteroid therapy reduces the proportion of patients who die or have a poor outcome at one to six months after the onset of SAH or PICH; (2) to determine whether corticosteroid therapy reduces the frequency of delayed cerebral ischaemia (DCI) in patients with SAH; (3) to determine the frequency of adverse effects of corticosteroid therapy in patients with SAH or PICH within six months of the onset of the event. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched November 2003). In addition, we searched MEDLINE (1966 to March 2004) and EMBASE (1980 to March 2004), and searched reference lists of relevant studies identified. We also made an attempt to identify any relevant ongoing and published or unpublished studies by contacting trialists and pharmaceutical companies. SELECTION CRITERIA We sought to identify all randomised or quasi-randomised clinical trials of corticosteroid therapy, in patients with SAH or PICH, that have a placebo or standard strategy arm as control. Patients of any age and either gender with clinically (bed-side) diagnosed PICH and cerebrospinal fluid documented SAH were included in the analysis. The data were analysed both separately and combined for computed tomography (CT)/magnetic resonance imaging (MRI)/autopsy/angiography verified patients. DATA COLLECTION AND ANALYSIS Data extracted from eligible clinical trials included: (1) death and poor outcome (death, severe disability, or vegetative state) within the first one to six months of the event onset (primary outcomes); (2) development of delayed cerebral ischaemia (as defined by the trialists) in patients with SAH; and (3) adverse effects of the treatment during the scheduled treatment or follow-up period (secondary outcomes). A pooled estimate of the effect size was computed, and the test for heterogeneity between trial results was carried out using The Cochrane Collaboration's Review Manager software, RevMan 4.2. Intention-to-treat analysis was carried out whenever possible. MAIN RESULTS Eight trials that fulfilled the eligibility criteria were identified, with a total of 256 randomised patients in three SAH trials, and 206 patients in five PICH trials. The studies differed substantially with regard to the study populations and drugs, and methodological quality. The number of patients allocated to either hydrocortisone or fludrocortisone acetate treatment in patients with SAH, or to dexamethasone treatment in patients with PICH, was too small to make any definitive conclusions (confidence intervals were wide for any of the outcome estimates). AUTHORS' CONCLUSIONS Overall, there is no evidence of a beneficial or adverse effect of corticosteroids in patients with either SAH or PICH. Confidence intervals are wide and include clinically significant effects in both directions.
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Affiliation(s)
- V L Feigin
- Clinical Trials Research Unit, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Abstract
BACKGROUND The pivotal role of inflammation and edema across the spectrum of central nervous system injury has driven extensive investigation into the therapeutic potential of glucocorticoids. OBJECTIVE To review the experimental and clinical data relating to the efficacy and adverse effects of glucocorticoids in conditions encountered in critical neurologic and neurosurgical illness. DATA SOURCE Search of MEDLINE and Cochrane databases, manual review of article bibliographies. DATA SYNTHESIS AND CONCLUSIONS The efficacy of glucocorticoids is well established in ameliorating edema associated with brain tumors and in improving outcome in subsets of patients with bacterial meningitis. Despite frequently encouraging experimental results, clinical trials of glucocorticoids in ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and traumatic brain injury have not shown a definite therapeutic effect. The evidence supporting glucocorticoid therapy for spinal cord injury is controversial; however methylprednisolone continues to be widely employed in this setting.
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Affiliation(s)
- Joao A Gomes
- Neurosciences Critical Care Division, Department of Anesthesia and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Pradilla G, Thai QA, Legnani FG, Clatterbuck RE, Gailloud P, Murphy KP, Tamargo RJ. Local Delivery of Ibuprofen via Controlled-release Polymers Prevents Angiographic Vasospasm in a Monkey Model of Subarachnoid Hemorrhage. Oper Neurosurg (Hagerstown) 2005; 57:184-90; discussion 184-90. [PMID: 15987587 DOI: 10.1227/01.neu.0000163604.52273.28] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 02/07/2005] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Adhesion and migration of leukocytes into the periadventitial space play a role in the pathophysiology of vasospasm after subarachnoid hemorrhage (SAH). Intercellular adhesion molecule-1 is a determinant cell adhesion molecule involved in this process. Ibuprofen has been shown to inhibit intercellular adhesion molecule-1 upregulation and prevent vasospasm in animal models of SAH. In this study, we report the toxicity and efficacy of locally delivered ibuprofen incorporated into controlled-release polymers to prevent vasospasm in a monkey model of SAH.
METHODS:
Ibuprofen was incorporated into ethylene-vinyl acetate (EVAc) polymers at 45% loading (wt:wt). For the toxicity study, cynomolgus monkeys (n = 5) underwent surgical implantation of either blank/EVAc polymers (n = 3) or 45% ibuprofen/EVAc polymers (n = 2) in the subarachnoid space, were followed up for 13 weeks, and were killed for histopathological analysis. For the efficacy study, cynomolgus monkeys (n = 14) underwent cerebral angiography 7 days before and 7 days after surgery and SAH and were randomized to receive either a 45% ibuprofen/EVAc polymer (n = 7; mean dose of ibuprofen, 6 mg/kg) or blank EVAc polymers (n = 7) in the subarachnoid space. Angiographic vasospasm was determined by digital image analysis. Student's t test was used for analysis.
RESULTS:
Animals implanted with ibuprofen polymers showed no signs of local or systemic toxicity. Animals treated with ibuprofen polymers had 91 ± 9% lumen patency of the middle cerebral artery, compared with 53 ± 11% of animals treated with blank/EVAc polymers (P < 0.001).
CONCLUSION:
Ibuprofen polymers are safe and prevent angiographic vasospasm after SAH in the monkey model. These findings support the role of cell adhesion molecules and inflammation in the pathophysiology of vasospasm.
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Affiliation(s)
- Gustavo Pradilla
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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16
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Gomis P, Tran-Dinh YR, Sercombe C, Sercombe R. Dexamethasone preventing contractile and cytoskeletal protein changes in the rabbit basilar artery after subarachnoid hemorrhage. J Neurosurg 2005; 102:715-20. [PMID: 15871515 DOI: 10.3171/jns.2005.102.4.0715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this project was to study the perturbations of four smooth-muscle proteins and an extracellular protein, type I collagen, after subarachnoid hemorrhage (SAH) and to examine the possible preventive effects of dexamethasone. METHODS Using a one-hemorrhage rabbit model, the authors first examined the effects of SAH on the expression of alpha-actin, h-caldesmon, vimentin, smoothelin-B, and type I collagen; second, they studied whether post-SAH systemic administration of dexamethasone (three daily injections) corrected the induced alterations. Measurements were obtained at Day 7 post-SAH. The proteins were studied by performing immunohistochemical staining and using a laser-scanning confocal microscope. Compared with control (sham-injured) arteries, the density of the media of arteries subjected to SAH was reduced for alpha-actin (-11%, p = 0.01) and h-caldesmon (-15%, p = 0.06) but increased for vimentin (+15%, p = 0.04) and smoothelin-B (+53%, p = 0.04). Among animals in which SAH was induced, arteries in those treated with dexamethasone demonstrated higher values of density for alpha-actin (+13%, p = 0.05) and h-caldesmon (+20%, p = 0.01), lower values for vimentin (-55%, p = 0.05), and nonsignificantly different values for smoothelin-B. The density of type I collagen in the adventitia decreased significantly after SAH (-45%, p = 0.01), but dexamethasone treatment had no effect on this decrease. CONCLUSIONS The SAH-induced alterations in the density of three of four smooth-muscle proteins were prevented by dexamethasone treatment; two of these proteins--alpha-actin and h-caldesmon--are directly related to contraction. This drug may potentially be useful to prevent certain morphological and functional changes in cerebral arteries after SAH.
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Affiliation(s)
- Philippe Gomis
- Laboratoire de Recherches Cérébrovasculaires Centre National de la Recherche Scientifique, Unité Propre de Recherche 646 Paris, France.
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Pradilla G, Thai QA, Legnani FG, Hsu W, Kretzer RM, Wang PP, Tamargo RJ. Delayed Intracranial Delivery of a Nitric Oxide Donor from a Controlled-release Polymer Prevents Experimental Cerebral Vasospasm in Rabbits. Neurosurgery 2004; 55:1393-9; discussion 1399-1400. [PMID: 15574221 DOI: 10.1227/01.neu.0000143615.26102.1a] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2004] [Accepted: 08/19/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Decreased local availability of nitric oxide (NO) may mediate chronic vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Previous reports have shown that early treatment with NO prevents vasospasm in animals. We evaluated the efficacy of controlled-release polymers that contain the NO donor diethylenetriamine (DETA-NO) for the delayed treatment of vasospasm in a rabbit model of SAH. METHODS DETA-NO 20% (wt/wt) was incorporated into ethylene-vinyl acetate (EVAc) polymers. Animals (n = 52) were randomized to two experimental groups. In the first group (n = 32), animals received SAH and implantation of either 20% DETA-NO/EVAc polymer at a dose of 0.5 mg/kg of DETA-NO (n = 16) or empty EVAc polymer (n = 16). Polymers were implanted 24 (n = 16) or 48 hours (n = 16) after SAH. In the second group (n = 20), animals received SAH and implantation of either 20% DETA-NO/EVAc polymer at a dose of 1.3 mg/kg (n = 10) or empty EVAc (n = 10). Polymers were implanted 24 (n = 10) or 48 hours (n = 10) after SAH. An additional group (n = 16) underwent either sham operation (n = 6) or SAH only (n = 10). Animals were killed 3 days after hemorrhage, and the basilar arteries were processed for morphometric measurements. Results were analyzed using Student's t test. RESULTS Treatment with 20% DETA-NO/EVAc polymers at a dose of 1.3 mg/kg significantly increased basilar artery lumen patency when administered at 24 (97 +/- 6% versus 73 +/- 10%; P = 0.0396) or 48 hours (94 +/- 6% versus 71 +/- 9%; P = 0.03) after SAH. Treatment with 20% DETA-NO/EVAc polymers at a dose of 0.5 mg/kg administered 48 hours after SAH significantly increased lumen patency (82 +/- 8% versus 68 +/- 12%; P = 0.03); a dose of 0.5 mg/kg, 24 hours after SAH, did not reach statistical significance (74 +/- 7% versus 65 +/- 9%; P = 0.16). The SAH-only group had a lumen patency of 67 +/- 12%. CONCLUSION Delayed treatment of SAH with controlled-release DETA-NO polymers prevented experimental posthemorrhagic vasospasm in the rabbit. This inhibition was dose-dependent. This further confirms the role of NO in the pathogenesis of vasospasm.
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Affiliation(s)
- Gustavo Pradilla
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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18
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Pradilla G, Wang PP, Legnani FG, Ogata L, Dietsch GN, Tamargo RJ. Prevention of vasospasm by anti-CD11/CD18 monoclonal antibody therapy following subarachnoid hemorrhage in rabbits. J Neurosurg 2004; 101:88-92. [PMID: 15255256 DOI: 10.3171/jns.2004.101.1.0088] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECT Adhesion of leukocytes and their migration into the periadventitial space may be critical in the pathophysiology of vasospasm following subarachnoid hemorrhage (SAH). The cell adhesion molecules involved in this process are lymphocyte function-associated antigen-1 (CD11a/CD18) and macrophage antigen-1 (CD11b/CD18), which are present on neutrophils/macrophages, and intercellular adhesion molecule-1 (CD54), which is present in endothelial cells. A humanized monoclonal antibody (mAb), Hu23F2G, targets CD11/CD18 and prevents leukocyte adhesion to endothelial cells. In this study, systemic administration of Hu23F2G prevented vasospasm in the rabbit model of SAH. METHODS Twenty-six New Zealand White rabbits were injected with autologous blood into the cisterna magna to induce SAH, after which they were randomized to receive injections of either Hu23F2G (10 animals) or a placebo at 30 minutes and 24 and 48 hours after SAH (six animals). Control animals underwent sham operations (four animals) or SAH alone (six animals). The animals were killed 72 hours after SAH, their bodies perfused and fixed, and their basilar arteries processed for morphometric analysis. Peripheral white blood cells (WBCs) were counted at 72 hours. The percentages of lumen patency were compared using the Student t-test. The presence of neutrophils and macrophages was confirmed by immunohistochemical analysis in which a rat anti-rabbit anti-CD18 mAb and cresyl violet were used. Treatment with Hu23F2G resulted in the significant prevention of vasospasm. Animals treated with Hu23F2G had 90 +/- 7% lumen patency compared with 65 +/- 7% in the placebo group (p = 0.025). The percentage of lumen patency in the SAH-only group was 59 +/- 10%. The mean WBC count was 16,300 +/- 2710/microl in the treatment group, compared with 7000 +/- 386/microl in the control group (p = 0.02). Administration of Hu23F2G produced increased numbers of WBCs in 70% of the animals treated. CONCLUSIONS This study supports the concept that leukocyte-endothelial cell interactions play an important role in the pathophysiology of chronic vasospasm after SAH. Systemic therapy with an anti-CD11/CD18 mAb prevents vasospasm after SAH by inhibiting adhesion of neutrophils and macrophages and their migration into the periadventitial space.
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Affiliation(s)
- Gustavo Pradilla
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Frazier JL, Pradilla G, Wang PP, Tamargo RJ. Inhibition of cerebral vasospasm by intracranial delivery of ibuprofen from a controlled-release polymer in a rabbit model of subarachnoid hemorrhage. J Neurosurg 2004; 101:93-8. [PMID: 15255257 DOI: 10.3171/jns.2004.101.1.0093] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Leukocyte-endothelial cell interactions may play a role in the development of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) because the extravasation of circulating leukocytes into the periadventitial space within 24 hours after the hemorrhage appears to be a critical event in this process. Ibuprofen is an antiinflammatory agent that inhibits the expression of specific cell adhesion molecules and, consequently, disrupts leukocyte-endothelial cell interactions. The authors investigated the efficacy of ibuprofen delivered locally from controlled-release polymers in the rabbit basilar artery (BA) model of cerebral vasospasm. METHODS Ibuprofen was incorporated into controlled-release ethylene-vinyl acetate copolymer (EVAc) constituting 45% of the resulting polymer by weight. Fifty-four New Zealand White rabbits were randomized to 10 groups: sham operation (seven animals); SAH only (seven animals); and SAH plus either empty EVAc or ibuprofen-EVAc polymer at 30 minutes or 6, 12, or 24 hours (five animals per group; 40 total). The rabbits were killed 72 hours after induction of SAH, at the time of maximal vasospasm. The efficacy of ibuprofen in preventing vasospasm was assessed by measuring lumen patency of the rabbit's BAs. The intracranial controlled release of ibuprofen resulted in a significant inhibition of vasospasm when treatment was initiated at 30 minutes (patency 92.3 +/- 5.1% compared with 52.1 +/- 5.1% in animals given empty EVAc; p < 0.001) and 6 hours (patency 69.5 +/- 3.5% compared with 47.2 +/- 1.5% in animals given empty EVAc; p < 0.03) after blood deposition compared with treatment with empty EVAc. No effect was observed when treatment was begun at either 12 or 24 hours. CONCLUSIONS Local intracranial delivery of ibuprofen accomplished using controlled-release polymers prevents vasospasm in the rabbit BA model of vasospasm when administered within 6 hours after blood exposure.
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Affiliation(s)
- James L Frazier
- Department of Neurological Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-7713, USA
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20
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Pradilla G, Wang PP, Legnani FG, Frazier JL, Tamargo RJ. Pharmacokinetics of controlled-release polymers in the subarachnoid space after subarachnoid hemorrhage in rabbits. J Neurosurg 2004; 101:99-103. [PMID: 15255258 DOI: 10.3171/jns.2004.101.1.0099] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Implantation of controlled-release polymers into the subarachnoid space to deliver drugs for treatment of vasospasm after subarachnoid hemorrhage (SAH) is currently of interest. Among the issues regarding local delivery of drugs in the subarachnoid space, however, are the extent of diffusion and the rate of release of the loaded agents. In this study Evans blue dye (EBD) was loaded into controlled-release polymers and its pharmacokinetic properties were determined in vitro and in vivo by using a rabbit model of SAH.
Methods. Ethylene—vinyl acetate copolymer (EVAc) was loaded 40% (w:w) with EBD and its pharmacokinetics were spectrophotometrically determined in vitro by examining three EBD—EVAc polymers. Additional polymers were implanted either into the frontal lobe or into the cisterna magna of 16 New Zealand White rabbits. Subarachnoid hemorrhage was induced in eight of the animals by an injection of 1.5 ml of arterial blood into the cisterna magna. The animals were killed 3 or 14 days postoperatively, their brains and spinal cords were harvested, and samples of each were placed in formamide for dye extraction and quantification. Specimens were examined macroscopically and the concentrations of EBD were determined with the aid of a spectrophotometer.
The EBD—EVAc polymers continuously released EBD over a 133-day period. The controlled release of the dye into the subarachnoid space in either location resulted in staining of the entire central nervous system (CNS) in rabbits when the polymers were placed either on the frontal lobe or in the cisterna magna. The EBD diffusion covered a distance of at least 40 cm. The presence of blood in the subarachnoid space did not interfere with the diffusion.
Conclusions. In this study the authors define the rate and extent of diffusion of EBD from controlled-release polymers placed in the subarachnoid space under conditions of SAH. Evans blue dye diffused through the entire rabbit CNS, covering a distance greater than that of the longest dimension of the hemicircumference of the subarachnoid space around the human brain. The pharmacokinetic properties of EBD—EVAc polymers are comparable to those of antivasospasm agents that are successfully used in animal models of SAH.
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Affiliation(s)
- Gustavo Pradilla
- Department of Neurosurgery, School of Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA
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Schürkämper M, Medele R, Zausinger S, Schmid-Elsaesser R, Steiger HJ. Dexamethasone in the treatment of subarachnoid hemorrhage revisited: a comparative analysis of the effect of the total dose on complications and outcome. J Clin Neurosci 2004; 11:20-4. [PMID: 14642360 DOI: 10.1016/s0967-5868(03)00155-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The benefit of dexamethasone in aneurysmal subarachnoid hemorrhage (SAH) is unproven. This actual study re-examined the impact on complications and outcome. Two hundred and forty-two patient records were analyzed. Dexamethasone had been prescribed individually. Group A consisted of patients in WFNS-grade I to III that were given at least 12mg/day dexamethasone for at least five days. All other patients in WFNS-grade I to III were assigned to group B. Groups C and D resulted from WFNS-grades IV and V, subdivided according to dexamethasone medication as groups A and B. Hydrocephalus and re-hemorrhage were significantly less frequent in group A than B (19% vs. 37%, P=0.011, and 3% vs. 13%, P=0.037, respectively). Favorable outcomes (Glasgow Outcome Scale, GOS 4 and 5) were more frequent in group A than B (99% vs. 85%; P=0.003). Frequencies of vasospasm and infections did not differ. In groups C and D significant differences were demonstrated for frequencies of hydrocephalus (C: 16%, D: 57%; P=0.006) and complications other than infection (C: 33%, D: 79%; P=0.002). Favorable outcomes were more frequent in group C than D (79% vs. 47%; P=0.046). Frequencies of vasospasm and infections did not differ.
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Affiliation(s)
- Manuel Schürkämper
- Department of Neurosurgery, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany
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22
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Maher CO, Anderson RE, Martin HS, McClelland RL, Meyer FB. Interleukin-1β and adverse effects on cerebral blood flow during long-term global hypoperfusion. J Neurosurg 2003; 99:907-12. [PMID: 14609172 DOI: 10.3171/jns.2003.99.5.0907] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The effects of interleukin (IL)-1β on the cerebral vasculature are complex and incompletely understood. Many pathophysiological states in which inflammatory cascades have been implicated also have varying degrees of cerebral hypoperfusion. The purpose of this investigation was to examine the long-term effects of this proinflammatory cytokine and its antagonist on cerebral blood flow (CBF) following global cerebral hypoperfusion.
Methods. Sprague—Dawley rats were randomly assigned to 12 groups and given continuous intracerebroventricular (ICV) infusions of IL-1β, the IL-1 receptor antagonist (IL-1ra), or saline vehicle (control). Global cerebral hypoperfusion was produced by occlusion of both carotid arteries and one vertebral artery. Cerebral blood flow was measured at baseline and again after initiation of the infusions by performing a 133Xe clearance study.
Prolonged ICV administration of IL-1β resulted in a significant decrease in CBF compared with that in controls. Prolonged administration of the antagonist IL-1ra resulted in significant increases in CBF compared with that in both IL-1β—treated animals and controls.
Conclusions. This experiment demonstrates that long-term treatment with the proinflammatory cytokine IL-1β adversely affects CBF.
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Affiliation(s)
- Cormac O Maher
- T. M. Sundt Jr. Cerebrovascular Research Laboratory, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Clatterbuck RE, Gailloud P, Ogata L, Gebremariam A, Dietsch GN, Murphy KJ, Tamargo RJ. Prevention of cerebral vasospasm by a humanized anti-CD11/CD18 monoclonal antibody administered after experimental subarachnoid hemorrhage in nonhuman primates. J Neurosurg 2003; 99:376-82. [PMID: 12924713 DOI: 10.3171/jns.2003.99.2.0376] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECT Leukocyte-endothelial cell interactions occurring in the first hours after subarachnoid hemorrhage (SAH) initiate changes in the endothelium and vessel wall that lead to an influx of leukocytes and the development of chronic vasospasm days later. Upregulation of intercellular adhesion molecule-1 (ICAM-1), also called CD54, appears to be a crucial step in this process. There is increasing experimental evidence that blocking the interaction between ICAM-1, which is expressed on endothelium, and integrins such as lymphocyte function-associated antigen-1 (CD11a/CD18) and macrophage antigen-1 (complement receptor 3, CD11b/CD18), which are expressed on the surface of leukocytes,prevents not only inflammation of vessel walls but also chronic vasospasm. The authors extend their previous work with monoclonal antibody (mAb) blockade of leukocyte migration to a nonhuman primate model of chronic, posthemorrhagic cerebral vasospasm. METHODS Before surgery was performed, six young adult male cynomolgus monkeys underwent baseline selective biplane common carotid and vertebrobasilar artery cerebral angiography via a transfemoral route. On Day 0, a right frontosphenotemporal craniectomy was performed with arachnoid microdissection and placement of 2 to 3 ml of clotted autologous blood in the ipsilateral basal cisterns. The animals were given daily intravenous infusions of 2 mg/kg of either a humanized anti-CD11/CD18 or a placebo mAb beginning 30 to 60 minutes postoperatively. The monkeys were killed on Day 7 after a repeated selective cerebral angiogram was obtained. The area of contrast-containing vessels observed in each hemisphere on anteroposterior angiographic views was calculated for the angiograms obtained on Day 7 and expressed as a percentage of the area on baseline angiograms (percent control areal fraction). Review of flow cytometry and enzyme immunoassay data confirmed the presence of the anti-CD11/CD18 antibody in the serum and bound to leukocytes in the peripheral blood of treated animals. Comparisons of the groups revealed 53 +/- 4.8% control vascular areal fraction in the placebo group (two animals) and 95.8 +/- 9.4% in the anti-CD11/CD18-treated group (three animals), a statistically significant difference (p = 0.043, t-test). CONCLUSIONS These results show that blockade of leukocyte migration into the subarachnoid space by an anti-CD11/CD18 mAb is effective in preventing experimental cerebral vasospasm in nonhuman primates, despite the unaltered presence of hemoglobin in the subarachnoid space. These experimental data support the hypothesis that inflammation plays a role in cerebral vasospasm after SAH.
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Affiliation(s)
- Richard E Clatterbuck
- Department of Neurological Surgery, Division of Interventional Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Dumont AS, Dumont RJ, Chow MM, Lin CL, Calisaneller T, Ley KF, Kassell NF, Lee KS. Cerebral vasospasm after subarachnoid hemorrhage: putative role of inflammation. Neurosurgery 2003; 53:123-33; discussion 133-5. [PMID: 12823881 DOI: 10.1227/01.neu.0000068863.37133.9e] [Citation(s) in RCA: 327] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2002] [Accepted: 03/11/2003] [Indexed: 12/25/2022] Open
Abstract
Cerebral vasospasm is a common, formidable, and potentially devastating complication in patients who have sustained subarachnoid hemorrhage (SAH). Despite intensive research efforts, cerebral vasospasm remains incompletely understood from both the pathogenic and therapeutic perspectives. At present, no consistently efficacious and ubiquitously applied preventive and therapeutic measures are available in clinical practice. Recently, convincing data have implicated a role of inflammation in the development and maintenance of cerebral vasospasm. A burgeoning (although incomplete) body of evidence suggests that various constituents of the inflammatory response, including adhesion molecules, cytokines, leukocytes, immunoglobulins, and complement, may be critical in the pathogenesis of cerebral vasospasm. Recent studies attempting to dissect the cellular and molecular basis of the inflammatory response accompanying SAH and cerebral vasospasm have provided a promising groundwork for future studies. It is plausible that the inflammatory response may indeed represent a critical common pathway in the pathogenesis of cerebral vasospasm pursuant to SAH. Investigations into the nature of the inflammatory response accompanying SAH are needed to elucidate the precise role(s) of inflammatory events in SAH-induced pathologies.
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Affiliation(s)
- Aaron S Dumont
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA.
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25
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Fukusaki M, Miyako M, Miyoshi H, Takada M, Terao Y, Konishi H, Sumikawa K. Prostaglandin E1 but not corticosteroid increases nerve root blood flow velocity after lumbar diskectomy in surgical patients. J Neurosurg Anesthesiol 2003; 15:76-81. [PMID: 12657990 DOI: 10.1097/00008506-200304000-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The purpose of this study was to clarify whether prostaglandin E1 (PGE(1)) or corticosteroid could increase blood flow in the nerve root because neurologic symptoms in spinal stenosis may be based on the vascular insufficiency in the nerve root. Fifty-seven patients undergoing lumbar diskectomy were randomly assigned to one of three groups. Each group received one of three protocols for intravenous injection: 10 mL of saline solution, group A (n = 19); 10 mL of PGE(1) (20 microg) solution, group B (n = 19); and 10 mL of dexamethasone (8 mg) solution, group C (n = 19). After lumbar diskectomy, a probe for laser Doppler flowmetry was placed directly on the lumbar nerve root. Nerve root blood flow (RBF) velocity and mean arterial pressure (MAP) were measured before injection (T0), 5 minutes after the start of injection (T1), 10 minutes after the start of injection (T2), and 10 minutes after the end of injection (T3). In groups A and C, these did not change throughout the time course. In group B, MAP decreased significantly at T1 (92%; P <.001), T2 (89%; P <.0001), and T3 (91%; P <.0001), while RBF velocity increased significantly at T1 (125%; P <.05), T2 (128%; P <.05), and T3 (121%; P <.05) compared with T0. The values in group B were different from those in group A (P <.05) and group C (P <.05) at T1 and T2. The results show that intravenous injection of low-dose PGE(1), but not corticosteroid, increases RBF velocity after lumbar diskectomy.
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Affiliation(s)
- Makoto Fukusaki
- Department of Anesthesia, Nagasaki Rosai Hospital, Sasebo, Japan.
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Iplikcioglu AC, Berkman MZ. The effect of short-term antifibrinolytic therapy on experimental vasospasm. SURGICAL NEUROLOGY 2003; 59:10-6; discussion 16-7. [PMID: 12633948 DOI: 10.1016/s0090-3019(02)00867-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antifibrinolytic therapy is effective in preventing rebleeding in cases of aneurysmal subarachnoid hemorrhage (SAH). The major disadvantage of this therapy is the increase in ischemic complications, which is supposed to be due to cerebral vasospasm. In this study the effect of short-term antifibrinolytic therapy on arterial vessel narrowing after SAH was investigated utilizing the rat femoral artery vasospasm model. METHODS Twenty-four rats were divided into four groups of six animals each. Autologous blood (0.1 mL) was applied to the 1-cm segment of right femoral artery wrapped with a silicone cuff. In Group 1 the animals did not receive any treatment. In Groups 2, 3, and 4 150 mg/kg tranexamic acid (AMCA) was given orally for 3, 5, or 7 days respectively, starting from postoperative day 1. A 1 cm segment of each femoral artery was harvested on the 8(th) postoperative day. Morphologic analyses were performed using the parameters, radial wall thickness and cross luminal area under the light microscope. In addition, two samples from each group were examined by transmission electron microscope (TEM) to confirm the morphologic changes. RESULTS There was a gradual decrease in cross luminal area and gradual increase in vessel wall thickness directly proportional with time. However, the vasospastic changes that occurred in Group 2 (received AMCA for 3 days) were not significantly different from those of Group 1 (nontreated). CONCLUSION It was concluded that antifibrinolytic treatment for the first 3 days may prove useful in cases of clinical aneurysmal SAH. However, if this treatment is used for more than 3 days, arterial vessel narrowing is significantly increased.
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Affiliation(s)
- A Celal Iplikcioglu
- Department of Neurosurgery, Okmeydani Social Security Hospital, Halaskargazi Cad. No: 368/21 Sisli, Istanbul, Turkey
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McGirt MJ, Lynch JR, Blessing R, Warner DS, Friedman AH, Laskowitz DT. Serum von Willebrand factor, matrix metalloproteinase-9, and vascular endothelial growth factor levels predict the onset of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery 2002; 51:1128-34; discussion 1134-5. [PMID: 12383357 DOI: 10.1097/00006123-200211000-00005] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2002] [Accepted: 05/31/2002] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Endothelial damage and intimal proliferation occur in vasospastic cerebral arteries after subarachnoid hemorrhage (SAH). In the peripheral vasculature, endothelial damage increases intimal matrix metalloproteinase-9 (MMP-9) and vascular endothelial growth factor (VEGF) levels, causing neointimal proliferation. We hypothesized that serum von Willebrand factor (vWF) (a marker of endothelial cell death), MMP-9, and VEGF levels could serve as prognostic markers in predicting the occurrence of cerebral vasospasm. METHODS Venous serum vWF, MMP-9, and VEGF levels were prospectively measured daily, for 12 days or until the onset of vasospasm, for 45 consecutive patients admitted with SAH (n = 38) or admitted for elective aneurysm clipping (control subjects, n = 7). The development of transcranial Doppler flow velocities of more than 180 cm/s and/or new focal neurological deficits with angiographically confirmed vasospasm was considered the onset of vasospasm. To establish whether these markers were specific for vasospasm versus ischemia, blood samples were obtained from a concurrent group of 42 patients within 24 hours after stroke onset unrelated to SAH. RESULTS Fifty-seven percent of patients (22 of 38 patients) developed vasospasm, 4 to 11 days after SAH (median, 7 d). Mean peak serum vWF, MMP-9, and VEGF levels were increased in the SAH prevasospasm cohort, compared with the SAH nonvasospasm cohort (vWF, 5526 +/- 929 versus 4934 +/- 599 ng/ml, P = 0.01; MMP-9, 705 +/- 338 versus 438 +/- 154 ng/ml, P = 0.006; VEGF, 0.12 +/- 0.06 versus 0.06 +/- 0.06 ng/ml, P = 0.023). Mean peak vWF, MMP-9, and VEGF levels for the focal ischemia cohort (vWF, 4645 +/- 875 ng/ml, P = 0.01; MMP-9, 250 +/- 308 ng/ml, P = 0.001; VEGF, 0.03 +/- 0.04 ng/ml, P = 0.001) were markedly lower in comparison with the SAH prevasospasm cohort and were unchanged in comparison with the control cohort. vWF levels of more than 5500 ng/ml, VEGF levels of more than 0.12 ng/ml, and MMP levels of more than 700 ng/ml each independently increased the odds of subsequent vasospasm (18-, 20-, and 25-fold, respectively). CONCLUSION The development of cerebral vasospasm after SAH was preceded by increases in serum vWF, MMP-9, and VEGF levels. Increased serum vWF, MMP-9, and VEGF levels could accurately predict the onset of cerebral vasospasm after SAH. These factors were not elevated by SAH alone or in a separate cohort of patients with ischemic stroke, suggesting that these factors might play a role in the pathogenesis of human cerebral vasospasm.
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Affiliation(s)
- Matthew J McGirt
- Multidisciplinary Neuroprotection Laboratory, Medical Center, Duke University School of Medicine, Durham, NC 27710, USA
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Macomson SD, Brophy CM, Miller W, Harris VA, Shaver EG. Heat shock protein expression in cerebral vessels after subarachnoid hemorrhage. Neurosurgery 2002; 51:204-10; discussion 210-1. [PMID: 12182419 DOI: 10.1097/00006123-200207000-00029] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The mechanisms of cerebral vasospasm after subarachnoid hemorrhage (SAH) remain controversial. Recent data have implicated two small heat shock proteins (HSPs), namely HSP20 and HSP27, in the regulation of vascular tone. Increases in the phosphorylation of HSP20 are associated with vasorelaxation, and increases in the phosphorylation of HSP27 are associated with impaired vasorelaxation. Therefore, we hypothesized that alterations in the expression and/or phosphorylation of these two small HSPs might play a role in cerebral vasospasm after SAH. METHODS A rat model of endovascular perforation was used to induce SAH. Middle cerebral arteries were harvested from control animals, sham-treated animals, and animals with SAH, 48 hours after SAH induction. Dose-response curves for endothelium-independent (sodium nitroprusside, 10(-8) to 10(-4) mol/L) and endothelium-dependent (bradykinin, 10(-10) to 10(-5) mol/L) relaxing agents were recorded ex vivo. Physiological responses were correlated with the expression and phosphorylation of HSP20 and HSP27 by using one- and two-dimensional immunoblots. RESULTS There was impaired endothelium-independent and endothelium-dependent relaxation in cerebral vessels after SAH. These changes were associated with decreased expression of both total and phosphorylated HSP20 and increases in the amount of phosphorylated HSP27. CONCLUSION In this model, impaired relaxation of cerebral vessels after SAH was associated with increases in the amount of phosphorylated HSP27 and decreases in the expression and phosphorylation of HSP20. These data are consistent with alterations in the expression and phosphorylation of these small HSPs in other models of vasospasm.
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Affiliation(s)
- Samuel D Macomson
- Department of Surgery, Medical College of Georgia, Augusta 30912, USA
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29
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Chen D, Nishizawa S, Yokota N, Ohta S, Yokoyama T, Namba H. High-dose methylprednisolone prevents vasospasm after subarachnoid hemorrhage through inhibition of protein kinase C activation. Neurol Res 2002; 24:215-22. [PMID: 11877907 DOI: 10.1179/016164102101199639] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We have previously shown that the inflammatory process after subarachnoid hemorrhage causes vasospasm. The efficacy of methylprednisolone by suppression of the inflammatory process has been reported, although pharmacological mechanisms have not been clarified. The purpose of this study was to investigate the pharmacological mechanism of methylprednisolone on vasospasm. Using the 'two-hemorrhage' canine model, progression of angiographic vasospasm was assessed in nontreated and treated groups with methylprednisolone. Methylprednisolone 10 mg kg-1 was injected i.v. after the first injection of blood, and the same dose was injected every 12 h until day 7. Protein kinase C (PKC) activity of canine basilar arteries in both groups was measured during the course of vasospasm. In the isometric tension study, the effect of methylprednisolone on tensions induced by phorbol 12-myristate 13-acetate (PMA), or high-K+ solution, was also evaluated. Methylprednisolone significantly reduced severity of vasospasm. In the treated group, PKC activity was not enhanced compared with the nontreated group at any point. Methylprednisolone inhibited tonic tension induced by PMA, but not that induced by high-K+ solution. We conclude that methylprednisolone prevents severity of vasospasm through inhibition of PKC activation, but does not work as a Ca2+ channel blocker.
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MESH Headings
- Angiography
- Animals
- Anti-Inflammatory Agents/blood
- Anti-Inflammatory Agents/pharmacology
- Anti-Inflammatory Agents/therapeutic use
- Basilar Artery/drug effects
- Basilar Artery/enzymology
- Basilar Artery/physiopathology
- Disease Models, Animal
- Disease Progression
- Dogs
- Dose-Response Relationship, Drug
- Isometric Contraction/drug effects
- Isometric Contraction/physiology
- Methylprednisolone/blood
- Methylprednisolone/pharmacology
- Methylprednisolone/therapeutic use
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/physiopathology
- Potassium/metabolism
- Potassium/pharmacology
- Protein Kinase C/antagonists & inhibitors
- Protein Kinase C/metabolism
- Subarachnoid Hemorrhage/complications
- Subarachnoid Hemorrhage/drug therapy
- Subarachnoid Hemorrhage/physiopathology
- Tetradecanoylphorbol Acetate/pharmacology
- Vasoconstriction/drug effects
- Vasoconstriction/physiology
- Vasospasm, Intracranial/drug therapy
- Vasospasm, Intracranial/enzymology
- Vasospasm, Intracranial/etiology
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Affiliation(s)
- Duo Chen
- Department of Neurosurgery, Hamamatsu University School of Medicine, 3600 Handacho, Hamamatsu, Shizuoka 431-3192, Japan
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Sercombe R, Dinh YRT, Gomis P. Cerebrovascular inflammation following subarachnoid hemorrhage. JAPANESE JOURNAL OF PHARMACOLOGY 2002; 88:227-49. [PMID: 11949877 DOI: 10.1254/jjp.88.227] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Aneurysmal subarachnoid hemorrhage frequently results in complications including intracranial hypertension, rebleeding and vasospasm. The extravasated blood is responsible for a cascade of reactions involving release of various vasoactive and pro-inflammatory factors (several of which are purported to induce vasospasm) from blood and vascular components in the subarachnoid space. The authors review the available evidence linking these factors to the development of inflammatory lesions of the cerebral vasculature, emphasizing: 1) neurogenic inflammation due to massive release of sensory nerve neuropeptides; 2) hemoglobin from lysed erythrocytes, which creates functional lesions of endothelial and smooth muscle cells; 3) activity, expression and metabolites of lipoxygenases cyclooxygenases and nitric oxide synthases; 4) the possible role of endothelin-1 as a pro-inflammatory agent; 5) serotonin, histamine and bradykinin which are especially involved in blood-brain barrier disruption; 6) the prothrombotic and pro-inflammatory action of complement and thrombin towards endothelium; 7) the multiple actions of activated platelets, including platelet-derived growth factor production; 8) the presence of perivascular and intramural macrophages and granulocytes and their interaction with adhesion molecules; 9) the evolution, origins, and effects of pro-inflammatory cytokines, especially IL-1, TNF-alpha and IL-6. Human and animal studies on the use of anti-inflammatory agents in subarachnoid hemorrhage include superoxide and other radical scavengers, lipid peroxidation inhibitors, iron chelators, NSAIDs, glucocorticoids, and serine protease inhibitors. Many animal studies claim reduced vasospasm, but these effects are not always confirmed in human trials, where symptomatic vasospasm and outcome are the major endpoints. Despite recent work on penetrating vessel constriction, there is a paucity of studies on inflammatory markers in the microcirculation.
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Affiliation(s)
- Richard Sercombe
- Laboratoire de Recherches Cérébrovasculaires, CNRS UPR 646, IFR Circulation Lariboisière, Université Paris VI, Faculté de Médecine Lariboisière-St Louis, Paris, France.
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31
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Barbosa MD, Arthur AS, Louis RH, MacDonald T, Polin RS, Gazak C, Kassell NF. The novel 5-lipoxygenase inhibitor ABT-761 attenuates cerebral vasospasm in a rabbit model of subarachnoid hemorrhage. Neurosurgery 2001; 49:1205-12; discussion 1212-3. [PMID: 11846914 DOI: 10.1097/00006123-200111000-00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2000] [Accepted: 06/28/2001] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Eicosanoids have been implicated in the pathogenesis of cerebral vasospasm after subarachnoid hemorrhage (SAH). Leukotrienes, 5-hydroxyperoxyeicosatetraenoic acid, and 5-hydroxyeicosatetraenoic acid are part of this group of substances, resulting from the 5-lipoxygenase activity on arachidonic acid metabolism. This study examined the effects of ABT-761, a new 5-lipoxygenase inhibitor, on cerebral vasospasm in an in vivo rabbit model of SAH. METHODS A total of 48 rabbits were assigned to one of six groups: SAH + placebo (n = 8), SAH + ABT-761 20 mg/kg (n = 8), SAH + ABT-761 30 mg/kg (n = 8), control + placebo (n = 8), control + ABT-761 20 mg/kg (n = 8), and control + ABT-761 30 mg/kg (n = 8). Drug administration was initiated 30 minutes after induction of SAH and repeated 24 hours later. The animals were killed 48 hours after SAH, using the perfusion-fixation method. The cross sectional areas of basilar artery histological sections were measured by an investigator blinded to the treatment groups of the individual samples. RESULTS In placebo-treated animals, the average luminal cross sectional area of the basilar artery was reduced by 68% after SAH as compared with controls (P < 0.0001). After SAH, the vasospastic response was attenuated in animals treated with 20 or 30 mg/kg representing a 28 or 35% reduction, respectively (P = 0.0011 and P = 0.0038). CONCLUSION The results demonstrated that ABT-761 is effective in attenuating experimental cerebral vasospasm, indicating that this new drug represents a potential therapeutic agent for the treatment of vasospasm after SAH.
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Affiliation(s)
- M D Barbosa
- Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA
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32
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Barbosa MD, Arthur AS, Louis RH, MacDonald T, Polin RS, Gazak C, Kassell NF. The Novel 5-Lipoxygenase Inhibitor ABT-761 Attenuates Cerebral Vasospasm in a Rabbit Model of Subarachnoid Hemorrhage. Neurosurgery 2001. [DOI: 10.1227/00006123-200111000-00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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33
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Nakai K, Morimoto Y, Wada K, Nawashiro H, Shima K, Kikuchi M. Pretreatment with continuous-wave ultraviolet irradiation to prevent the development of delayed vasospasm in the rabbit common carotid artery model. J Neurosurg 2000; 92:671-5. [PMID: 10761658 DOI: 10.3171/jns.2000.92.4.0671] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ultraviolet (UV) light irradiation can lead to immunomodulation. The purpose of this study was to determine the preventive effect of UV light on cerebral vasospasm by using a rabbit common carotid artery (CCA) model. METHODS Rabbit CCAs were constricted for a long period by application of autologous blood within a silicon sheath. Before immersion in blood, the CCAs were adventitiously exposed to UV light emitted from a helium-cadmium laser (wavelength 325 nm) yielding an irradiation energy of 10 mJ/mm2. The occurrence of vasospasm was evaluated using angiography 48 hours after blood exposure in this model. The UV light treatment significantly reduced the degree of vasospasm. Compared with luminal diameters measured on Day 0, prior to treatment, the luminal diameters of UV light-treated arteries (six animals) decreased by only 6%, whereas that of the sham-treated arteries (eight animals) significantly decreased by 26% (p<0.001). Histological examination of UV light-treated CCAs revealed no endothelial damage and extended smooth-muscle cells, in which some fragmented nuclei were confirmed by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling. Twenty-eight days after blood exposure, examination of UV light-treated CCAs revealed only myointimal proliferation, similar to that of the sham-treated CCAs. CONCLUSIONS These results are the first to provide evidence of a prophylactic effect of UV light on vasospasm and are suggestive of involvement of apoptosis in the mechanism of this effect.
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MESH Headings
- Animals
- Apoptosis
- Blood
- Cadmium
- Carotid Artery, Common/diagnostic imaging
- Carotid Artery, Common/pathology
- Carotid Artery, Common/radiation effects
- Cell Division
- Cell Nucleus/radiation effects
- Cell Nucleus/ultrastructure
- Disease Models, Animal
- Elastic Tissue/radiation effects
- Endothelium, Vascular/pathology
- Endothelium, Vascular/radiation effects
- Helium
- Immersion
- In Situ Nick-End Labeling
- Male
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/radiation effects
- Rabbits
- Radiography
- Statistics as Topic
- Tunica Intima/pathology
- Tunica Intima/radiation effects
- Ultraviolet Therapy
- Vasoconstriction/radiation effects
- Vasospasm, Intracranial/prevention & control
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Affiliation(s)
- K Nakai
- Department of Medical Engineering, National Defense Medical College, Saitama, Japan
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34
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Langley SM, Chai PJ, Jaggers JJ, Ungerleider RM. Preoperative high dose methylprednisolone attenuates the cerebral response to deep hypothermic circulatory arrest. Eur J Cardiothorac Surg 2000; 17:279-86. [PMID: 10758389 DOI: 10.1016/s1010-7940(00)00336-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the effects of preoperative high dose methylprednisolone on cerebral recovery following a period of deep hypothermic circulatory arrest (DHCA). METHODS Sixteen 1-week-old piglets were randomized to placebo (n=8), or 30 mg/kg intramuscular methylprednisolone sodium succinate (MPRED) given at 8 and 2 h before induction of anaesthesia. All piglets underwent cardiopulmonary bypass, cooling to 18 degrees C, 60 min of circulatory arrest followed by 60 min of reperfusion and rewarming. The radiolabelled microsphere method was used to determine the global and regional cerebral blood flow (CBF) and cerebral oxygen metabolism (CMRO(2)) at baseline before DHCA and after 60 min of reperfusion. RESULTS In controls, mean global CBF (+/-1 standard error) before DHCA was 53.7+/-2.4 ml/100 g per min and fell to 23.8+/-1.2 ml/100 g per min following DHCA (P<0.0001). This represents a post-DHCA recovery to 45.1+/-3.3% of the pre-DHCA value. In the MPRED group recovery of global CBF post-DHCA was significantly higher at 63.6+/-5.2% of the pre-DHCA value (P=0.009). The regional recovery of CBF in the cerebellum, brainstem and basal ganglia was 80, 75 and 69% of pre-DHCA values in the MPRED group respectively compared to 66, 60 and 55% in controls (P<0.05). Global CMRO(2) in controls fell from 3.9+/-0.2 ml/100 g per min before to 2. 3+/-0.2 ml/100 g per min after DHCA (P=0.0001). This represents a post-DHCA recovery to 58.6+/-4.4% of the pre-DHCA value. In the MPRED group, however, recovery of global CMRO(2) post-DHCA was significantly higher at 77.9+/-7.1% of the pre-DHCA value (P=0.04). CONCLUSIONS Treatment with high dose methylprednisolone at 8 and 2 h preoperatively attenuates the normal cerebral response to a period of deep hypothermic ischaemia. This technique may therefore offer a safe and inexpensive strategy for cerebral protection during repair of congenital heart defects with the use of DHCA.
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Affiliation(s)
- S M Langley
- Department of Pediatric Cardiac Surgery, Duke University Medical Center, Durham, NC, USA.
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Onda H, Kasuya H, Takakura K, Hori T, Imaizumi T, Takeuchi T, Inoue I, Takeda J. Identification of genes differentially expressed in canine vasospastic cerebral arteries after subarachnoid hemorrhage. J Cereb Blood Flow Metab 1999; 19:1279-88. [PMID: 10566975 DOI: 10.1097/00004647-199911000-00013] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To understand the molecular processes of continuous vasospasm of cerebral arteries after subarachnoid hemorrhage, mRNA differential display and screening of cDNA expression array were performed to identify genes that are differentially expressed in vasospastic arteries of canine two-hemorrhage models. The expression levels of 18 genes were found to be upregulated, and those of two genes to be downregulated. Of these, 12 represent known genes or homologues of genes characterized previously, and the other eight genes are not related to any sequences in the databases. The known genes include five upregulated inflammation-related genes encoding monocyte chemotactic protein-1, cystatin B, inter-alpha-trypsin inhibitor family heavy chain-related protein, serum amyloid A protein, and glycoprotein 130, suggesting that inflammatory reaction may be involved in the development of cerebral vasospasm. The upregulation of three known genes encoding stress-related proteins of vascular endothelial growth factor, BiP protein, and growth-arrest and DNA-damage-inducible protein may be involved in possible cell survival in the damaged arteries. A full-length cDNA for the unknown clone DVS 27, whose expression was most highly upregulated, was isolated from the cerebral artery cDNA library by hybridization. Characterization of these genes should help to clarify the molecular mechanism of continuous cerebral vasospasm after subarachnoid hemorrhage.
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Affiliation(s)
- H Onda
- Department of Cell Biology, Institute for Molecular and Cellular Regulation, Gunma University, Maebashi, Japan
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Thai QA, Oshiro EM, Tamargo RJ. Inhibition of experimental vasospasm in rats with the periadventitial administration of ibuprofen using controlled-release polymers. Stroke 1999; 30:140-7. [PMID: 9880402 DOI: 10.1161/01.str.30.1.140] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The chronic phase of vasospasm after an aneurysmal subarachnoid hemorrhage may be mediated in part by early leukocyte-endothelial cell interactions. Ibuprofen is an anti-inflammatory agent that inhibits expression of certain cell adhesion molecules and therefore disrupts leukocyte-endothelial cell interactions. Its systemic administration, however, has dose-limiting side effects. We evaluated the effect of the periadventitial delivery of ibuprofen using controlled-release polymers in the rat femoral artery model of chronic posthemorrhagic vasospasm. METHODS Before the animal studies, the release pharmacokinetics of the ibuprofen-loaded ethylene-vinyl acetate polymers were determined in vitro. Subsequently, the femoral arteries (n=266) of Fischer 344 rats (n=133) were enclosed in latex pouches bilaterally. In the toxicity study (n=15 rats), the animals were randomized into 5 dose groups in which 0%-, 10%-, 20%-, 30%-, or 50%-loaded ibuprofen polymers were evaluated. In the efficacy study, the animals were randomized into 5 time groups in which 50%-loaded ibuprofen polymers were inserted at 0 (n=58 rats), 6 (n=16), 12 (n=13), 24 (n=11), or 48 hours (n=12) after blood injection into the pouch. The rats were killed 12 days after blood exposure, at the time of maximal vasospasm in this model. Vasospasm was expressed as percent lumen patency. To evaluate the effect of ibuprofen on leukocyte migration, 8 rats were randomized into 2 groups. Macrophages and granulocytes were stained by immunohistochemistry with the use of a mouse OX-41 monoclonal antibody and counted in the periadventitial space 24 hours after blood exposure. RESULTS In vitro pharmacokinetics showed that the 50%-loaded ibuprofen polymer released its total drug load over a 12-day period. In the toxicity study, a nonsignificant arterial vasodilatation with ibuprofen treatment was seen at higher doses, and no deleterious effects were noted on the vessel wall histologically. In the efficacy study, ibuprofen treatment resulted in significant vasospasm inhibition when treatment was initiated at 0 hour (73.7+/-4.9% versus 94.5+/-3.3% [mean+/-SEM percent lumen patency]; P<0.001) and 6 hours (69.2+/-5.7% versus 98.0+/-3.9%; P=0. 002) after blood exposure, but not at 12, 24, or 48 hours. Leukocyte immunohistochemistry showed that ibuprofen treatment resulted in significantly lower periadventitial macrophage and granulocyte counts of 25.0+/-3.9 cells per high-powered field compared with counts of 140.5+/-18.2 cells per high-powered field in the untreated vessels (P<0.001). CONCLUSIONS The periadventitial, controlled release of ibuprofen from surgically implanted polymers significantly inhibits chronic posthemorrhagic vasospasm in this model when treatment is initiated within 6 hours of blood exposure. Vasospasm inhibition with ibuprofen correlates with a significant decrease in the number of macrophages and granulocytes in the periadventitial space. This study supports the hypothesis that inflammation mediates in part the chronic phase of posthemorrhagic vasospasm and suggests a potential alternative treatment for this condition.
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Affiliation(s)
- Q A Thai
- Department of Neurosurgery, Division of Vascular Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-7713, USA
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Nomura H, Hirashima Y, Endo S, Takaku A. Anticardiolipin antibody aggravates cerebral vasospasm after subarachnoid hemorrhage in rabbits. Stroke 1998; 29:1014-8; discussion 1018-9. [PMID: 9596252 DOI: 10.1161/01.str.29.5.1014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE We previously reported that patients with antiphospholipid antibodies (aPLs) frequently demonstrate cerebral infarction due to cerebral vasospasm after subarachnoid hemorrhage (SAH). To examine the participation of aPLs in the pathogenesis of vasospasm after SAH, we studied the relationships of aPLs and SAH in an animal model. METHODS SAH was produced in 34 rabbits that received two subarachnoid injections of autologous arterial blood. The animals were divided into four experimental groups: SAH was induced in group A (n=9), intracutaneous injection of cardiolipin (CL) was performed before the induction of SAH in group B (n=5), intravenous injection of CL was performed before SAH in group C (n=12), and cyclosporin A was infused intravenously after the intravenous injection of CL and induction of SAH in group D (n=8). Enzyme-linked immunosorbent assay identifying the titer of IgG CL antibodies, neurological evaluation, cerebral angiography, and histological examination were performed in all four groups. RESULTS A significant elevation of anti-CL antibodies, aggravation of neurological deficit, and reduction of caliber of the basilar artery were observed in rabbits that received the intravenous immunization of CL (group C). The administration of cyclosporin A reduced the titer of anti-CL antibody, aggravation of neurological deficit, constriction of basilar artery, and the incidence of cerebral infarction (group D). CONCLUSIONS Anti-CL antibodies may therefore be involved in the deterioration of cerebral vasospasm after SAH.
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Affiliation(s)
- H Nomura
- Department of Neurosurgery, Toyama Medical and Pharmaceutical University, Sugitani, Japan
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Sato S, Yonetani Y, Fujimoto M, Kita T, Kubo K, Nakashima T. Effects of an endothelin ET(A)-receptor antagonist, S-0139, on cerebral vasospasm and behavioral changes in dogs intracisternally administered endothelin-1. Life Sci 1998; 62:PL191-7. [PMID: 9519805 DOI: 10.1016/s0024-3205(98)00050-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The effects of an endothelin ET(A)-receptor selective antagonist, S-0139, were examined using dogs given endothelin-1 (ET-1) into the subarachnoid space. ET-1 at 40 pmol apparently constricted the basilar artery in anesthetized dogs and caused various grades of ataxia, facial clonus, nystagmus and other features in conscious dogs, partially mimicking those which have been reported for conscious rats. S-0139 could completely inhibit both the vasoconstriction and behavioral changes. It could also alleviate the behavioral changes caused by ET-1 in conscious dogs when given after the severe ataxia. We concluded that ET-1 in the subarachnoid space produces behavioral changes via endothelin ET(A)-receptor mediation similar to its cerebral vasoconstricting action, at least, in dogs.
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Affiliation(s)
- S Sato
- Discovery Research Laboratories II, Shionogi & Co., Ltd, Toyonaka, Osaka, Japan
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Mima T, Mostafa MG, Mori K. Therapeutic dose and timing of administration of RNA synthesis inhibitors for preventing cerebral vasospasm after subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 1998; 70:65-7. [PMID: 9416280 DOI: 10.1007/978-3-7091-6837-0_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A RNA synthesis inhibitor, dactinomycin, intended to suppress induction of vasoconstrictor peptide endothelin, prevented cerebral vasospasm almost completely in the dog subarachnoid hemorrhage (SAM) model [8]. Since endothelin receptor antagonists have not shown so potent effect as dactinomycin in animal SAH models, we aimed clinical use of dactinomycin for improvement of final outcomes of severe SAH patients now suffering vasospasm. Before clinical application, we examined therapeutic dose and timing of administration of dactinomycin in animal models. In the dog two-hemorrhage model, dactinomycin treatment (0.01 mg/kg i.v. for 5 days) started at 6 hours after the second blood injection on Day 2 prevented vasospasm, but that started on Day 3 did not. Low dose of dactinomycin (0.003 mg/kg i.v. for 5 days) rather aggravated vasospasm even though the treatment started on Day 0. In the rat vasospasm model, high dose of dactinomycin (0.03 mg/kg i.p. for 3 days) or relatively low dose of doxorubicin (0.6 mg/kg i.p. once) prevented vasospasm even though the treatment started on Day 4. The present study suggests that RNA synthesis inhibitors, such as dactinomycin and doxorubicin, may aufficiently prevent or ameliorate cerebral vasospasm in severe SAH patients.
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Affiliation(s)
- T Mima
- Department of Neurosurgery, Kochi Medical School, Nankoku, Japan
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Oshiro EM, Hoffman PA, Dietsch GN, Watts MC, Pardoll DM, Tamargo RJ. Inhibition of experimental vasospasm with anti-intercellular adhesion molecule-1 monoclonal antibody in rats. Stroke 1997; 28:2031-7; discussion 2037-8. [PMID: 9341715 DOI: 10.1161/01.str.28.10.2031] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Inflammation may play a role in delayed chronic vasospasm after aneurysmal subarachnoid hemorrhage. We investigated the role of intercellular adhesion molecule-1 (ICAM-1) and macrophage/granulocyte infiltration in the rat femoral artery model of vasospasm using systemic administration of a murine anti-ICAM-1 monoclonal antibody (MAb). METHODS The femoral arteries (n = 72) in Sprague-Dawley rats (n = 36) were enclosed in latex pouches bilaterally. Autologous blood was injected into the pouch on one side, and saline was injected on the contralateral side. Chronic vessel narrowing was evaluated with the use of 29 rats, which were randomized into one of three groups for intraperitoneal injections: (1) anti-ICAM-1 MAb (2 mg/kg per dose, n = 10), (2) isotype-matched MAb (2 mg/kg per dose, n = 9), or (3) saline (n = 10), given at 3 hours and 3, 6, and 9 days after blood exposure. These rats were killed 12 days after blood exposure, and femoral artery lumen cross-sectional areas were determined by computerized image analysis. Saturation of ICAM-1 binding sites with this dosing schedule was evaluated by fluorescence-activated cell sorter (FACS) analysis of splenocytes. Immunohistochemical studies with objective cell counts were performed to evaluate macrophage/granulocyte infiltration at 24 hours in 7 rats, comparing anti-ICAM-1 MAb treatment (n = 4) with isotype-matched control MAb (n = 3). RESULTS Animals treated with anti-ICAM-1 MAb showed a significant inhibition of arterial narrowing at 12 days (P = .0081), with lumen patency of 96.5 +/- 5.3% (mean +/- SEM), compared with 77.3 +/- 5.6% for isotype-matched MAb and 72.2 +/- 5.3% for saline-treated controls. FACS analysis of splenocytes from animals treated with anti-ICAM-1 MAb confirmed saturation of ICAM-1 binding sites. Vessels treated with anti-ICAM-1 MAb showed a significant decrease in inflammatory cell infiltrates, with objective macrophage/granulocyte counts of 31.3 +/- 26.6 (mean +/- SEM) per high-powered field, compared with 171.4 +/- 30.7 for isotype-matched control MAb (P = .0027). CONCLUSIONS Anti-ICAM-1 MAb administered systemically starting 3 hours after blood exposure results in significant inhibition of chronic vasospasm in the rat femoral artery model and is correlated with a reduction in the number of infiltrating macrophages and granulocytes in the periadventitial region of blood-exposed arteries. We conclude that inflammatory changes associated with ICAM-1-mediated macrophage and granulocyte migration play an important role in the development of posthemorrhagic chronic vasospasm in this model.
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Affiliation(s)
- E M Oshiro
- Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Md, USA
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Willette RN, Shiloh AO, Sauermelch CF, Sulpizio A, Michell MP, Cieslinski LB, Torphy TJ, Ohlstein EH. Identification, characterization, and functional role of phosphodiesterase type IV in cerebral vessels: effects of selective phosphodiesterase inhibitors. J Cereb Blood Flow Metab 1997; 17:210-9. [PMID: 9040501 DOI: 10.1097/00004647-199702000-00011] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The role of the phosphodiesterase type IV isozyme (PDE IV) in the regulation of cerebrovascular tone was investigated in the canine basilar artery in vitro and in vivo. The PDE isozymes extracted from the canine basilar artery were isolated by diethylaminoethanol (DEAE)-Sepharose affinity chromatography and identified based on sensitivity to isozyme-selective PDE inhibitors. [3H]cAMP hydrolysis was observed in one major and one minor peak of activity. The predominant peak was inhibited by the addition of cGMP (25%), siguazodan (26%), rolipram (39%), and the combination of siguazodan and rolipram (95%). Selective PDE IV inhibitors BRL 61063, rolipram, and denbufylline were equieffective inhibitors of [3H]-ccAMP hydrolysis mediated by PDE IV isolated from the canine basilar artery [concentrations producing 50% inhibition (IC50S) = 0.21 +/- 0.05 microM, 0.67 +/- 0.23 microM, and 0.73 +/- 0.16 microM, respectively]. In precontracted isolated ring segments of the canine basilar artery, selective PDE IV inhibitors produced potent and complete relaxation (IC50S < 150 nM). In contrast, zaprinast (a selective PDE V inhibitor) and siguazodan (a selective PDE III inhibitor) produced only weak relaxation of the basilar artery (IC50S = 4.5 microM and > 10 microM, respectively). Vasorelaxation produced by PDE IV inhibitors was not altered by removing the endothelium, 1-NAME, or adenosine receptor antagonism. In a canine model of acute cerebral vasospasm, all three selective PDE IV inhibitors reversed basilar artery spasm produced by autologous blood without altering mean arterial blood pressure. In contrast, prolonged treatment with BRL 61063 failed to alter the development of basilar spasm in the two hemorrhage canine models of chronic cerebral vasospasm. Denbufylline-induced relaxation in vitro was also significantly impaired in basilar arteries obtained from the model of chronic vasospasm. In conclusion, PDE IV appears to be the predominant isozyme regulating vascular tone mediated by cAMP hydrolysis in cerebral vessels. In addition, vasorelaxation modulated by PDE IV is compromised in chronic cerebral vasospasm associated with subarachnoid hemorrhage.
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MESH Headings
- 15-Hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5,13-dienoic Acid
- 3',5'-Cyclic-AMP Phosphodiesterases
- Animals
- Basilar Artery
- Cerebral Arteries/enzymology
- Cyclic AMP/physiology
- Cyclic Nucleotide Phosphodiesterases, Type 4
- Dogs
- Drug Evaluation, Preclinical
- Ischemic Attack, Transient/complications
- Ischemic Attack, Transient/drug therapy
- Ischemic Attack, Transient/enzymology
- Isoenzymes/isolation & purification
- Isoenzymes/physiology
- Male
- Phosphodiesterase Inhibitors/pharmacology
- Phosphodiesterase Inhibitors/therapeutic use
- Phosphoric Diester Hydrolases/isolation & purification
- Phosphoric Diester Hydrolases/physiology
- Prostaglandin Endoperoxides, Synthetic/pharmacology
- Prostaglandin Endoperoxides, Synthetic/toxicity
- Pyrrolidinones/pharmacology
- Pyrrolidinones/therapeutic use
- Rolipram
- Second Messenger Systems
- Subarachnoid Hemorrhage/enzymology
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/prevention & control
- Thromboxane A2/analogs & derivatives
- Thromboxane A2/pharmacology
- Thromboxane A2/toxicity
- Vasoconstrictor Agents/pharmacology
- Vasoconstrictor Agents/toxicity
- Vasodilator Agents/pharmacology
- Vasodilator Agents/therapeutic use
- Xanthines/pharmacology
- Xanthines/therapeutic use
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Affiliation(s)
- R N Willette
- Department of Cardiovascular Pharmacology, SmithKline Beecham Pharmaceutics, King of Prussia, Pennsylvania, USA
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German JW, Gross CE, Giclas P, Watral W, Bednar MM. Systemic complement depletion inhibits experimental cerebral vasospasm. Neurosurgery 1996; 39:141-5; discussion 145-6. [PMID: 8805150 DOI: 10.1097/00006123-199607000-00028] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Cerebral vasospasm is the leading cause of morbidity and mortality in patients who are hospitalized because of aneurysmal subarachnoid hemorrhage (SAH). Recent work has suggested that activation of the complement cascade contributes to the development of cerebral vasospasm. To further examine this hypothesis, a rabbit model of SAH was employed. METHODS Two milliliters of autologous arterial blood was injected into the region of the perimesencephalic cistern. Forty-eight hours after SAH was induced, intravital perfusion-fixation was performed. Morphometric analysis of the basilar artery was used to assess the extent of cerebral vasospasm after pretreatment with the complement depleting agent, cobra venom factor (CVF), or vehicle. Rabbits were randomized to one of four groups: 1) sham (n = 5); 2) sham + CVF (n = 4); 3) SAH (n = 10); or 4) SAH + CVF (n = 7). Twenty-four hours before induction of SAH, the animals received either 100 units/kg CVF or vehicle. The total hemolytic potential of the serum confirmed a significant (P < 0.05) reduction in serum complement activity 24 hours after the administration of CVF. RESULTS Pretreatment with CVF significantly (P < 0.0083) reduced the extent of vasospasm, as assessed by lumen diameter from 393.9 +/- 100.1 microns (mean +/- standard deviation) in the SAH group to 510.7 +/- 72.8 microns in the SAH + CVF group, when compared with the sham (594.5 +/- 27.9 microns) and sham + CVF (587.7 +/- 47.3 microns) groups. CONCLUSION The results suggest a role for complement activation in SAH.
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Affiliation(s)
- J W German
- Department of Surgery, University of Vermont College of Medicine, Burlington, USA
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Tsuji T, Cook DA, Weir BK, Handa Y. Effect of clot removal on cerebrovascular contraction after subarachnoid hemorrhage in the monkey: pharmacological study. Heart Vessels 1996; 11:69-79. [PMID: 8836754 DOI: 10.1007/bf01744506] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Clot removal at early surgery has been reported to be clinically effective for the prevention of cerebral vasospasm following subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm. We examined the most efficacious timing of mechanical clot removal on pharmacological responses in a monkey SAH model. Cynomolgus monkeys (Macaca fascicularis) were randomized into five groups: sham-operated, clot removal in which the clot was removed 48, 72, or 96 h after SAH, and clot groups. An autologous blood clot was placed around the bilateral major cerebral arteries after craniectomy to mimic the hemorrhage. Seven days after the SAH, proximal and successively distal parts of the middle cerebral arteries were cut into rings for isometric tension measurement. The contractile responses to potassium chloride, 5-hydroxytryptamine, norepinephrine, adenosine triphosphate, prostaglandin F20, and hemoglobin were greater in the proximal parts than in the distal parts in each group. Compared with the sham-operated group, the responses of the clot-removal and clot groups to the drugs were progressively attenuated. The maximum responses to 5-hydroxytryptamine in the proximal parts and to adenosine triphosphate in the distal parts started to decrease, significantly, in the clot-removal group 48 h after SAH, while most of the responses to the other agonists began to decrease in the clot-removal groups later than 72 h after SAH. These results suggest that the attenuation of cerebrovascular contractile responses 7 days after SAH is pharmacologically inevitable, even if the clot is removed as early as 48 h after the SAH. Clot removal may thus be recommended within 48h after SAH to ameliorate the severity of cerebral vasospasm following SAH.
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Affiliation(s)
- T Tsuji
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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Fujii Y, Takahashi A, Yoshimoto T. Percutaneous transluminal angioplasty in a canine model of cerebral vasospasm: angiographic, histologic, and pharmacologic evaluation. SURGICAL NEUROLOGY 1995; 44:163-70; discussion 170-1. [PMID: 7502207 DOI: 10.1016/0090-3019(95)00071-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cerebral vasospasm following subarachnoid hemorrhage (SAH) is one of the leading factors that deteriorate the clinical outcome after aneurysmal surgery. Percutaneous transluminal angioplasty (PTA) is a method to directly dilate the constricted vessel using the intravascular neurosurgical technique. METHODS Angiographic, histologic, and pharmacologic evaluations related to PTA are presented, using a canine double-injection model of SAH. In angiographic evaluation, we studied the effect of PTA performed on day 1, 4, or 7 of SAH. We performed sequential histologic study by light microscopy using the same for the angiographic evaluation. In pharmacologic evaluation, we measured in vitro isotonic constrictive force using two vasoconstrictors immediately after PTA on normal basilar arteries (control group) and basilar arteries on day 7 of SAH. RESULTS In angiographic evaluation, we observed the effective dilation of spastic artery immediately after PTA and saw no recurrence of vessel constriction when PTA was performed on day 7 of SAH. However, the preventive effect of PTA was inconsistent when it was performed earlier after SAH (days 1, 4). In histologic evaluation, PTA segments immediately after PTA showed denuding of endothelial cells and stretching of the internal elastic lamina without disruption of the muscle layer. In pharmacologic evaluation, there was no difference in isotonic constrictive force created by vasoconstrictors between the PTA and non-PTA segments without SAH. However, there was a statistically significant reduction of isotonic constrictive force on the PTA segment with SAH. CONCLUSIONS We suggest that the mechanism of PTA vasodilation in vasospasm after SAH may result from mild functional changes in the vascular wall when PTA was applied on day 7 of SAH. The functional changes would not be adequately induced to prevent recurrence of vasoconstriction when PTA was applied soon after SAH.
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Affiliation(s)
- Y Fujii
- Department of Neurosurgery, Tohoku University School of Medicine, Sendai, Japan
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Fujii Y, Takahashi A, Yoshimoto T. Effect of balloon angioplasty on high grade symptomatic vasospasm after subarachnoid hemorrhage. Neurosurg Rev 1995; 18:7-13. [PMID: 7566534 DOI: 10.1007/bf00416470] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Of 455 cases of ruptured intracranial aneurysm treated with radical surgery from January 1987 to March 1992, 19 cases with high grade symptomatic vasospasm were treated by percutaneous transluminal balloon angioplasty (PTA). The indication for PTA was high grade symptomatic vasospasm which does not respond to conservative medical treatment. Of the 36 segments of vasospastic arteries, severe vasospasm (angiographical constriction more than 50% of diameter on admission) was observed in 67%. PTA dilated these vasospastic arteries significantly (diameter of more than 75% of diameter on admission) in 83%. Follow up angiography revealed neither recurrence of vasospasm nor chronic atherosclerotic changes. Clinical improvement within 24 hours after PTA was observed in 63% of cases (7 of 17 cases with consciousness disturbance, 5 of 16 cases with motor weakness and one of 7 cases with aphasia). Outcomes at the time of discharge were excellent in 10 cases, good in 3, fair in 4, and lethal in 2. SPECT study before and after PTA confirmed improvement of cerebral blood flow in 3 out of 5 cases investigated. PTA for high grade symptomatic vasospasm after subarachnoid hemorrhage is considered an effective treatment method for the patient who does not respond to medical therapy. Immediate improvement of angiographical and clinical findings were frequently observed immediately after PTA. Exact indication and timing of PTA should be postulated after much more cases have been treated with this methal.
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Affiliation(s)
- Y Fujii
- Department of Intravascular Neurosurgery, Kohnan Hospital, Sendai, Japan
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Willette RN, Zhang H, Mitchell MP, Sauermelch CF, Ohlstein EH, Sulpizio AC. Nonpeptide endothelin antagonist. Cerebrovascular characterization and effects on delayed cerebral vasospasm. Stroke 1994; 25:2450-5; discussion 2456. [PMID: 7974589 DOI: 10.1161/01.str.25.12.2450] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE (+/-)-SB 209670, a potent nonpeptide endothelin (ET) receptor antagonist, was used to investigate the potential role of ET in cerebral vasospasm associated with subarachnoid hemorrhage. METHODS The effects of (+/-)-SB 209670 were evaluated in isolated segments of canine posterior cerebral arteries in vitro, vascular smooth muscle cells in culture, and in the canine two-hemorrhage model of delayed cerebral vasospasm in vivo. RESULTS In the canine basilar and anterior spinal arteries, (+/-)-SB 209670 caused a dose-related inhibition of contractile responses mediated by ET (KB = 4.6 nmol/L and apparent KB = 2.7 nmol/L, respectively). The effects of (+/-)-SB 209670 were mediated by inhibition of ETA receptors since the ETB selective agonist sarafotoxin 6c did not contract these posterior cerebral vessels. (+/-)-SB 209670 also produced a concentration-dependent inhibition (IC50 = 1 nmol/L) of the mitogenic response induced by ET-1 in vascular smooth muscle cell culture. In the canine model of delayed cerebral vasospasm, animals received intracisternal vehicle (saline) or (+/-)-SB 209670 (360 +/- 10 micrograms/d) via osmotic minipump for 7 days. On day 7, the cross-sectional areas in the (+/-)-SB 209670 group were significantly greater than those in the vehicle group in both the basilar artery (68% versus 27%) and anterior spinal artery (78% versus 38%). No differences in blood pressure or heart rate were noted in the two groups, and the vasospasm in the vehicle group did not differ from that of historic controls in this model. CONCLUSIONS The results suggest that ET plays a significant role in the development of delayed cerebral vasospasm via an interaction with ETA receptors. Furthermore, ETA receptor antagonists may represent a novel therapeutic approach to the treatment of subarachnoid hemorrhage.
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Affiliation(s)
- R N Willette
- SmithKline Beecham Pharmaceuticals, Department of Cardiovascular Pharmacology, King of Prussia, Pa 19406
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Haciyakupoğlu S, Ildan F, Polat S, Cetinalp E, Boyar B, Kaya M. Effect of GSH on cerebral vasospasm in dogs. Neurosurg Rev 1994; 17:283-9. [PMID: 7753417 DOI: 10.1007/bf00306819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Reduced glutathinone (tau-glutamylcysteinglycine, GSH) is a scavenger for oxygen radicals and plays in important role in protection of cells from ischemia and from the harmful effects of free oxygen radicals. Free oxygen radicals due to cerebral vasospasm increase in both vasospasm and proliferative vasculopathy. This experiment was performed to determine whether GSH plays a role in cerebral vasospasm after subarachnoid hemorrhage by preventing the harmful effects of free oxygen radicals. In this study, GSH was administered intraarterially and intracisternally following vasospasm of the canine basilar artery. Less vasospasm was observed in the group treated with GSH intraarterially following subarachnoid hemorrhage than in the one treated with GSH intracisternally and in the control group. The arterial wall was investigated ultrastructurally. We evaluated the effect of the anti-oxidating substance through the activity of superoxide dismutase in the arterial wall. We compared the effect of glutathione reductase in the two groups treated with GSH intraarterially and intracisternally. Arterial degeneration was more prominent in the group in which GSH was used intracisternally, while the superoxide dismutase levels were low. In contrast, arterial degeneration was less in the other group in which GSH was used intraarterially, while the superoxide dismutase levels were high.
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MESH Headings
- Animals
- Cerebral Angiography/drug effects
- Dogs
- Endothelium, Vascular/pathology
- Endothelium, Vascular/physiopathology
- Female
- Free Radicals
- Glutathione/pharmacology
- Injections, Intra-Arterial
- Injections, Intraventricular
- Ischemic Attack, Transient/pathology
- Ischemic Attack, Transient/physiopathology
- Male
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/physiopathology
- Reactive Oxygen Species/metabolism
- Subarachnoid Hemorrhage/pathology
- Subarachnoid Hemorrhage/physiopathology
- Superoxide Dismutase/blood
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Affiliation(s)
- S Haciyakupoğlu
- Department of Neurosurgery, Cukurova University, School of Medicine, Balcali Adana, Turkey
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Yanamoto H, Kikuchi H, Okamoto S. Effects of protease inhibitor and immunosuppressant on cerebral vasospasm after subarachnoid hemorrhage in rabbits. SURGICAL NEUROLOGY 1994; 42:382-7. [PMID: 7974141 DOI: 10.1016/0090-3019(94)90340-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The possible role of the immune-defense system in the development of cerebral vasospasm after subarachnoid hemorrhage (SAH) was investigated in rabbits. We used a synthetic serine protease inhibitor, gabexate mesilate (GM), a glucocorticoid, betamethasone sodium phosphate (B-P), and an immunosuppressant, ciclosporin (Cyclosporin A, CYA), to prevent cerebral vasospasm. These agents were administered intra-venously every 12 hours for three injections, starting 20 minutes after SAH. In the group treated with GM, B-P, or CYA, there were no statistically significant differences in arterial calibers between treated and untreated controls on day 2. The synthetic serine protease inhibitor, FUT-175 has been reported to prevent cerebral vasospasm when the treatment is started 20 minutes after SAH in rabbits [38]. In rabbits treated with FUT-175 at different starting times from 3 to 6 hours, reductions in arterial caliber on day 2 were significantly prevented in each group. The contrasting effects of the two serine protease inhibitors, GM and FUT-175, are discussed.
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Affiliation(s)
- H Yanamoto
- Department of Neurosurgery, Kyoto University Medical School, Japan
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Yanamoto H, Kikuchi H, Okamoto S, Nozaki K. Cerebral vasospasm caused by cisternal injection of polystyrene latex beads in rabbits is inhibited by a serine protease inhibitor. SURGICAL NEUROLOGY 1994; 42:374-81. [PMID: 7974140 DOI: 10.1016/0090-3019(94)90339-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
During subarachnoid hemorrhage (SAH), coagulated blood in the subarachnoid space may be regarded as foreign by the immune system. To investigate how cerebral arteries are affected by activation of the host immune system, foreign body, polystyrene latex beads were injected into the cerebrospinal fluid (CSF) space of rabbits, and the caliber changes of the basilar arteries were studied for 7 days by angiography. Prolonged arterial narrowing peaking on day 2 was observed after cisternal injection of the beads. The increase in peak narrowing correlated with an increase in the number of beads injected. The course of the change in vessel caliber over 7 days was similar to that seen in cerebral vasospasm caused by SAH. Also investigated was the preventive effect of the synthetic serine protease inhibitor, FUT-175 on the arterial narrowing caused by the cisternal injection of the latex beads. The administration of FUT-175 significantly prevented latex beads-induced vasospasm (p < 0.01). The possible role of a non-specific immune response is discussed, and also the role of the serine protease cascades in the development of cerebral vasospasm.
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Affiliation(s)
- H Yanamoto
- Department of Neurosurgery, Kyoto University Medical School, Japan
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Suzuki S, Ogane K, Souma M, Ohkuma H, Iwabuchi T. Efficacy of steroid hormone in solution for intracranial irrigation during aneurysmal surgery for prevention of the vasospasm syndrome. Acta Neurochir (Wien) 1994; 131:184-8. [PMID: 7754818 DOI: 10.1007/bf01808610] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A series of 55 patients with ruptured cerebral aneurysms were treated with moderate removal of subarachnoid clot followed by intracranial irrigation with pH 8.0 Hartmann solution containing 1 mg/ml of methylpredonisolone sodium succinate after the aneurysmal clipping during early (before day 3) operation. Six (11%) of the 55 patients suffered vasospasm syndrome postoperatively. The clinical results are significantly better than a series of 68 patients operated on and treated before day 3 by intracranial irrigation with Hartmann solution (pH 8.0) only. The possible preventive effect of direct intracranial administration of steroid hormone is discussed.
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Affiliation(s)
- S Suzuki
- Department of Neurosurgery, Hirosaki University School of Medicine, Japan
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