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Sadan O, Jeong YS, Cohen-Sadan S, Sathialingam E, Buckley EM, Kandiah PA, Grossberg JA, Asbury W, Jusko WJ, Samuels OB. Cerebrospinal Fluid Pharmacokinetics of Nicardipine Following Intrathecal Administration in Subarachnoid Hemorrhage Patients. J Clin Pharmacol 2024. [PMID: 38923537 DOI: 10.1002/jcph.2488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are common complications following SAH that contribute significantly to the poor outcomes observed in these patients. Intrathecal (IT) nicardipine delivered via an existing external ventricular drain is an off-label intervention that has been shown to be correlated with reduced DCI and improved patient outcomes. The current study aims to characterize the population pharmacokinetic (popPK) properties of intermittent IT nicardipine. Following informed consent, serial cerebrospinal fluid (CSF) samples were obtained from 16 SAH patients (50.4 ± 9.3 years old; 13 females) treated with IT nicardipine every 6 h (q6h, n = 8) or every 8 h (q8h, n = 8) for an average of 72 ± 21 doses. High-performance liquid chromatography was used to quantify CSF concentration from each sample. Our popPK analysis showed that the CSF pharmacokinetics of IT nicardipine in the cohort was adequately described by a two-compartment model with a lag time. Model parameter estimates were reliable (relative standard error <50%). Intracranial pressure influenced both the total clearance and the central volume of nicardipine (i.e., negative correlation, P <-.001). Calculated PK parameters were similar between q6h and q8h dosing regimens. Despite a small cohort of SAH patients, we successfully developed a popPK model to describe the nicardipine disposition kinetics in the CSF following IT administration. These findings may help inform future clinical trials designed to examine the optimal dosing of IT nicardipine.
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Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Yoo-Seong Jeong
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Shany Cohen-Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, USA
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, USA
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA, USA
- Children's Research Scholar, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Prem A Kandiah
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - William Asbury
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - William J Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA, USA
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Wang C, Zhao X, Chen Y, Xia J, Zhang X, Wang T. Optimizing nicardipine dosage for effective control of pituitrin-induced hypertension in laparoscopic myomectomy undergoing total intravenous anesthesia. BMC Anesthesiol 2024; 24:155. [PMID: 38654209 PMCID: PMC11036747 DOI: 10.1186/s12871-024-02521-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND This study aimed to determine the median effective dose (ED50) and 95% effective dose (ED95) of nicardipine for treating pituitrin-induced hypertension during laparoscopic myomectomy, providing guidance for the management of intraoperative blood pressure in such patients. METHODS Among the initial 40 participants assessed, 24 underwent elective laparoscopic myomectomy. A sequential up-and-down method was employed to ascertain the ED50 of nicardipine based on its antihypertensive efficacy. Nicardipine was initially administered at 6 µg/kg following the diagnosis of pituitrin-induced hypertension in the first patient. Dosing adjustments were made to achieve the desired antihypertensive effect, restoring systolic blood pressure and heart rate to within ± 20% of baseline within 120 s. The dosing increment or reduction was set at 0.5 µg/kg for effective or ineffective responses, respectively. The ED50 and ED95 of nicardipine were calculated using Probit regression by Maximum Likelihood Estimation (MLE) to establish dose-response curves and confidence intervals. RESULTS 24 patients were included for analysis finally. The ED50 and ED95 of nicardipine for blood pressure control after pituitrin injection were determined. The study found that the ED50 of nicardipine for treating pituitrin-induced hypertension was 4.839 µg/kg (95% CI: 4.569-5.099 µg/kg), and the ED95 was estimated at 5.308 µg/kg (95% CI: 5.065-6.496 µg/kg). Nicardipine effectively mitigated the hypertensive response caused by pituitrin without inducing significant tachycardia or hypotension. CONCLUSIONS Nicardipine effectively controlled blood pressure after pituitrin injection during laparoscopic myomectomy, with ED50 and ED95 values established. This research highlights the potential utility of nicardipine in addressing hypertensive responses induced by pituitrin, particularly in clinical settings where pituitrin is routinely administered.
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Affiliation(s)
- Chen Wang
- Department of Anaesthesia, Seventh People's Hospital of Shanghai Universityof Traditional Chinese Medicine, Shanghai, 200137, China
| | - Xiaoli Zhao
- Department of Anaesthesia, Seventh People's Hospital of Shanghai Universityof Traditional Chinese Medicine, Shanghai, 200137, China
| | - Yunyun Chen
- Department of Anaesthesia, Changning Maternity and Infant Health Hospital, Shanghai, 200050, China
| | - Jianhua Xia
- Department of Anaesthesia, Shanghai Pudong New Area People´s Hospital, Shanghai, 201299, China
| | - Xixue Zhang
- Department of Anaesthesia, Huadong Hospital affiliated to Fudan University, No 221, West Yan'an Road, Shanghai, 200040, China.
| | - Tingting Wang
- Department of Anaesthesia, Seventh People's Hospital of Shanghai Universityof Traditional Chinese Medicine, Shanghai, 200137, China.
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Sadan O, Jeong YS, Cohen-Sadan S, Sathialingam E, Buckley EM, Kandiah PA, Grossberg JA, Asbury W, Jusko WJ, Samuels OB. Cerebrospinal Fluid Pharmacokinetics of Nicardipine Following Intrathecal Administration in Subarachnoid Hemorrhage Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.17.23297116. [PMID: 37905152 PMCID: PMC10614995 DOI: 10.1101/2023.10.17.23297116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are common complications following SAH and contribute significantly to the poor outcomes observed in these patients. Intrathecal (IT) nicardipine delivered via an existing external ventricular drain has been shown to be correlated with reduced DCI and improved patient outcomes. The current study aims to characterize population pharmacokinetic (popPK) properties of intermittent IT nicardipine. Following informed consent, serial cerebrospinal fluid (CSF) samples were obtained from 16 SAH patients (50.4 ± 9.3 years old; 12 females) treated with IT nicardipine every 6 hours (n=8) or every 8 hours (n=8), which were subject to high-performance liquid chromatography for measurement of its CSF concentration. Our popPK analysis showed that the CSF PK of IT nicardipine in the cohort was adequately described by a two-compartment model with a lag time, with reliable parameter estimates (relative standard error < 50%). The intracranial pressure influenced both the total clearance and the central volume. Calculated PK parameters were similar between q6h and q8h dosing regimens. Despite a small cohort of SAH patients, we successfully developed a popPK model to describe the nicardipine disposition kinetics in the CSF following IT administration. These findings may help inform future clinical trials designed to examine the optimal dosing of IT nicardipine.
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Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Yoo-Seong Jeong
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York, 14214, USA
| | - Shany Cohen-Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Prem A Kandiah
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | | | - William Asbury
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - William J Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York, 14214, USA
| | - Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
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Murayama H, Kanemaru K, Yoshioka H, Fukamachi A, Shimizu T, Omata T, Fukasawa I, Nagasaka M, Nakano S, Asari Y, Kinouchi H. Chronological Change of the Clinical Features and Treatment Outcomes for Subarachnoid Hemorrhage in Japan: A Multicenter Retrospective Study. Neurol Med Chir (Tokyo) 2023; 63:464-472. [PMID: 37612120 PMCID: PMC10687669 DOI: 10.2176/jns-nmc.2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/08/2023] [Indexed: 08/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) treatment has progressed, and patients are rapidly aging in Japan. Consequently, dynamic changes must have emerged in the clinical practice of SAH. This study aimed to elucidate chronological changes of aneurysmal SAH and the prognostic factors in the previous quarter century in Japan. We conducted a retrospective survey regarding aneurysmal SAH in eight institutions in Japan. The study included 848, 863, and 781 patients in the first (1989-1993), second (1999-2003), and third (2009-2013) periods, respectively. The chronological changes of factors that influenced the poor outcomes and differences between the nonelderly (<75 years) and elderly patients were investigated. Mean age was significantly higher in patients in the third period (61.4 years) than in those in the other two periods (first, 57.8 years; second, 59.5 years). During these periods, the proportion of good outcomes did not change; however, the mortality rate significantly decreased from 19% in the first period to 11% and 9.2% in the second and third periods, respectively. The poor outcome was mainly caused by the significantly higher incidence of systemic complication and procedural complication in the first period and the significantly lower incidence of delayed ischemic neurological deficit in the third period. The elderly patients had significantly poorer clinical outcomes than the nonelderly ones. During the last 25 years, the age of patients with aneurysmal SAH has rapidly increased. The study results may contribute to the improvement of the treatment strategy of SAH in advanced countries with a rapidly aging population.
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Affiliation(s)
- Hiroaki Murayama
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Kazuya Kanemaru
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
| | - Akira Fukamachi
- Department of Neurosurgery and Radiology, Nasu Neurosurgical Center
| | - Tsuneo Shimizu
- Department of Neurosurgery, Kanto Neurosurgical Hospital
| | | | | | | | - Shin Nakano
- Department of Neurosurgery, Yamanashi Prefectural Central Hospital
| | | | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
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Chousterman B, Leclère B, Morisson L, Eude Y, Gayat E, Mebazaa A, Cinotti R. A network meta-analysis of therapeutic and prophylactic management of vasospasm on aneurysmal subarachnoid hemorrhage outcomes. Front Neurol 2023; 14:1217719. [PMID: 37662039 PMCID: PMC10469900 DOI: 10.3389/fneur.2023.1217719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Background Vasospasm and cerebral ischemia after aneurysmal subarachnoid hemorrhage are associated with mortality and poor neurological outcomes. We studied the efficacy of all available strategies targeting vasospasm and cerebral ischemia on outcomes in a network meta-analysis. Methods We searched EMBASE and MEDLINE databases from 1 January 1990 and 28 November 2021 according to PRISMA guidelines. Randomized controlled trials and longitudinal studies were included. All curative or preventive strategies targeting vasospasm and/or cerebral ischemia were eligible. A network meta-analysis was performed to compare all interventions with one another in a primary (randomized controlled trials only) and a secondary analysis (both trials and longitudinal studies). Mortality by 3 months was the primary outcome. Secondary outcomes were vasospasm, neurological outcome by 3 months, and dichotomized as "good" or "poor" recovery according to each study definition. Results A total of 2,382 studies were screened which resulted in the selection of 192 clinical trials (92 (47.9%) and 100 cohorts (52.1%) and the inclusion of 41,299 patients. In randomized controlled studies, no strategy decreased mortality by 3 months. Statins (0.79 [0.62-1]), tirilazad (0.82 [0.69-0.97]), CSF drainage (0.47 [0.29-0.77]), and clazosentan (0.51 [0.36-0.71]) significantly decreased the incidence of vasospasm. Cilostazol was the only treatment associated with improved neurological outcomes by 3 months in the primary (OR 1.16, 95% CI [1.05-1.28]) and secondary analyses (OR 2.97, 95% CI [1.39-6.32]). Discussion In the modern era of subarachnoid hemorrhage, all strategies targeting vasospasm failed to decrease mortality. Cilostazol should be confirmed as a treatment to improve neurological outcomes. The link between vasospasm and neurological outcome appears questionable. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=116073, identifier: PROSPERO CRD42018116073.
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Affiliation(s)
- Benjamin Chousterman
- Department of Anesthesia and Critical Care, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, University Hospital of Saint-Louis-Lariboisière, Paris, France
- UMR 942 MASCOT, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Brice Leclère
- Public Health Department, Hôpital Saint-Jacques, University Hospital of Nantes, Nantes, France
- MiHAR, IRS 2, University of Nantes, Nantes, France
| | - Louis Morisson
- Department of Anesthesia and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, Boulevard de l'Assomption, University of Montréal, Montréal, QC, Canada
| | - Yannick Eude
- Public Health Department, Hôpital Saint-Jacques, University Hospital of Nantes, Nantes, France
| | - Etienne Gayat
- Department of Anesthesia and Critical Care, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, University Hospital of Saint-Louis-Lariboisière, Paris, France
- UMR 942 MASCOT, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, University Hospital of Saint-Louis-Lariboisière, Paris, France
- UMR 942 MASCOT, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Raphael Cinotti
- Department of Anesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France
- UMR 1246 SPHERE MethodS in Patients-Centered Outcomes and Health Research, Institut de Recherche en Santé 2, Nantes, France
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6
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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Sathialingam E, Cowdrick KR, Liew AY, Fang Z, Lee SY, McCracken CE, Akbik F, Samuels OB, Kandiah P, Sadan O, Buckley EM. Microvascular cerebral blood flow response to intrathecal nicardipine is associated with delayed cerebral ischemia. Front Neurol 2023; 14:1052232. [PMID: 37006474 PMCID: PMC10064128 DOI: 10.3389/fneur.2023.1052232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 03/19/2023] Open
Abstract
One of the common complications of non-traumatic subarachnoid hemorrhage (SAH) is delayed cerebral ischemia (DCI). Intrathecal (IT) administration of nicardipine, a calcium channel blocker (CCB), upon detection of large-artery cerebral vasospasm holds promise as a treatment that reduces the incidence of DCI. In this observational study, we prospectively employed a non-invasive optical modality called diffuse correlation spectroscopy (DCS) to quantify the acute microvascular cerebral blood flow (CBF) response to IT nicardipine (up to 90 min) in 20 patients with medium-high grade non-traumatic SAH. On average, CBF increased significantly with time post-administration. However, the CBF response was heterogeneous across subjects. A latent class mixture model was able to classify 19 out of 20 patients into two distinct classes of CBF response: patients in Class 1 (n = 6) showed no significant change in CBF, while patients in Class 2 (n = 13) showed a pronounced increase in CBF in response to nicardipine. The incidence of DCI was 5 out of 6 in Class 1 and 1 out of 13 in Class 2 (p < 0.001). These results suggest that the acute (<90 min) DCS-measured CBF response to IT nicardipine is associated with intermediate-term (up to 3 weeks) development of DCI.
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Affiliation(s)
- Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Kyle R. Cowdrick
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Amanda Y. Liew
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Zhou Fang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Seung Yup Lee
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Electrical and Computer Engineering, Kennesaw State University, Marietta, GA, United States
| | - Courtney E. McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States
| | - Feras Akbik
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Owen B. Samuels
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Prem Kandiah
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Erin M. Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, United States
- Children's Research Scholar, Children's Healthcare of Atlanta, Atlanta, GA, United States
- *Correspondence: Erin M. Buckley
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Brain Oxygen-Directed Management of Aneurysmal Subarachnoid Hemorrhage. Temporal Patterns of Cerebral Ischemia During Acute Brain Attack, Early Brain Injury, and Territorial Sonographic Vasospasm. World Neurosurg 2022; 166:e215-e236. [PMID: 35803565 DOI: 10.1016/j.wneu.2022.06.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. METHODS This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40). RESULTS The brain oxygen-directed protocol reduced Lbo2 (Pbto2 [partial pressure of brain tissue oxygen] <20 mm Hg) from 67% to 15% during acute brain attack (<24 hours of ictus), by increasing Pbto2 from 11.31 ± 9.34 to 27.85 ± 6.76 (P < 0.0001) and then to 29.09 ± 17.88 within 72 hours. Day-after-bleed, Fio2 change, ICP, hemoglobin, and oxygen saturation were predictors for Pbto2 during early brain injury. Transcranial Doppler ultrasonography velocities (>20 cm/second) increased at day 2. During DCI caused by territorial sonographic vasospasm (TSV), middle cerebral artery mean velocity (Vm) increased from 45.00 ± 15.12 to 80.37 ± 38.33/second by day 4 with concomitant Pbto2 reduction from 29.09 ± 17.88 to 22.66 ± 8.19. Peak TSV (days 7-12) coincided with decline in Pbto2. Nicardipine mitigated Lbo2 during peak TSV, in contrast to nimodipine, with survival benefit (P < 0.01). Intravenous and cisternal nicardipine combination had survival benefit (Cramer Φ = 0.43 and 0.327; G2 = 28.32; P < 0.001). This study identifies 4 zones of Lbo2 during survival benefit (Cramer Φ = 0.43 and 0.3) TSV, uncompensated; global cerebral ischemia, compensated, and normal Pbto2. Admission Glasgow Coma Scale score (not increased ICP) was predictive of low Pbto2 (β = 0.812, R2 = 0.661, F1,30 = 58.41; P < 0.0001) during early brain injury. Coma was the only credible predictor for mortality (odds ratio, 7.33/>4.8∗; χ2 = 7.556; confidence interval, 1.70-31.54; P < 0.01) followed by basilar aneurysm, poor grade, high ICP and Lbo2 during TSV. Global cerebral ischemia occurs immediately after the ictus, persisting in 30% of patients despite the high therapeutic intensity level, superimposed by DCI during TSV. CONCLUSIONS We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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Dayyani M, Sadeghirad B, Grotta JC, Zabihyan S, Ahmadvand S, Wang Y, Guyatt GH, Amin-Hanjani S. Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials. Stroke 2022; 53:1993-2005. [PMID: 35354302 DOI: 10.1161/strokeaha.121.035699] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials. METHODS We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence. RESULTS We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia. CONCLUSIONS Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.
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Affiliation(s)
- Mojtaba Dayyani
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, TX (M.D.).,Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.).,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. (B.S.).,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada. (B.S.)
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center (J.C.G.)
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Saba Ahmadvand
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
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Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:662-681. [PMID: 34940927 DOI: 10.1007/s12028-021-01372-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
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Abstract
PURPOSE OF REVIEW Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH. RECENT FINDINGS Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes. SUMMARY Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.
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Gupta R, Woodward K, Fiorella D, Woo HH, Liebeskind D, Frei D, Siddiqui A, De Leacy R, Hanel R, Elijovich L, Maud A. Primary results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following Aneurysm Subarachnoid Hemorrhage (VITAL) Study. J Neurointerv Surg 2021; 14:815-819. [PMID: 34493577 DOI: 10.1136/neurintsurg-2021-017859] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is linked to worse neurological outcomes. The NeVa VS is a novel cerebral dilation device based on predicate stent retrievers. We report the results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following aSAH (VITAL) Study. METHODS This was a single-arm prospective multicenter trial to assess the safety and probable benefit of the NeVa VS device to treat CV. Patients were screened and treated if they had CV >50% on non-invasive imaging confirmed by cerebral angiography. The vessel diameters were measured before and after treatment by an independent core laboratory. The primary endpoint was ≥50% vessel diameter immediately after treatment with the NeVa VS device. RESULTS Thirty patients with a mean age of 52±11 years and mean Hunt-Hess grade of 3.1±0.9 were enrolled. A total of 74 vessels were treated with an average of 1.3 deployments per vessel (95 deployments total). The mean pre-treatment narrowing of the target vessel (n=74) was 65.6% with reduction of the narrowing to 29.4% after treatment. The primary endpoint was achieved in 64 of 74 vessels (86.5%). In three of 95 total deployments (3.2%), thrombus at the site of deployment was observed during the procedure without apparent neurological sequelae. CONCLUSIONS The NeVa VS device appears to be a safe treatment to regain vessel diameter in severely narrowed intracranial arteries secondary to CV associated with aSAH. This treatment offers a new tool that allows for controlled vessel expansion to treat CV.
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Affiliation(s)
- Rishi Gupta
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Keith Woodward
- Department of Radiology, Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.,Neurosurgery, SUNY Stony Brook, Stony Brook, New York, USA
| | - Henry H Woo
- Neurosurgery, Northwell Health, Manhasset, New York, USA
| | | | - Donald Frei
- Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
| | - Adnan Siddiqui
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | - Ricardo Hanel
- Neurosurgery, Lyerly Neurosurgery Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Lucas Elijovich
- Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Alberto Maud
- Neurology, Texas Tech University Health Sciences Center - El Paso, El Paso, Texas, USA
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Yu W, Huang Y, Zhang X, Luo H, Chen W, Jiang Y, Cheng Y. Effectiveness comparisons of drug therapies for postoperative aneurysmal subarachnoid hemorrhage patients: network meta‑analysis and systematic review. BMC Neurol 2021; 21:294. [PMID: 34311705 PMCID: PMC8314452 DOI: 10.1186/s12883-021-02303-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/26/2021] [Indexed: 01/01/2023] Open
Abstract
Objective To compare the effectiveness of various drug interventions in improving the clinical outcome of postoperative patients after aneurysmal subarachnoid hemorrhage (aSAH) and assist in determining the drugs of definite curative effect in improving clinical prognosis. Methods Eligible Randomized Controlled Trials (RCTs) were searched in databases of PubMed, EMBASE, and Cochrane Library (inception to Sep 2020). Glasgow Outcome Scale (GOS) score, Extended Glasgow Outcome Scale (GOSE) score or modified Rankin Scale (mRS) score was used as the main outcome measurements to evaluate the efficacy of various drugs in improving the clinical outcomes of postoperative patients with aSAH. The network meta-analysis (NMA) was conducted based on a random-effects model, dichotomous variables were determined by using odds ratio (OR) with 95% confidence interval (CI), and a surface under the cumulative ranking curve (SUCRA) was generated to estimate the ranking probability of comparative effectiveness among different drug therapies. Results From the 493 of initial citation screening, forty-four RCTs (n = 10,626 participants) were eventually included in our analysis. Our NMA results showed that cilostazol (OR = 3.35,95%CI = 1.50,7.51) was the best intervention to improve the clinical outcome of patients (SUCRA = 87.29%, 95%CrI 0.07–0.46). Compared with the placebo group, only two drug interventions [nimodipine (OR = 1.61, 95%CI 1.01,2.57) and cilostazol (OR = 3.35, 95%CI 1.50, 7.51)] achieved significant statistical significance in improving the clinical outcome of patients. Conclusions Both nimodipine and cilostazol have exact curative effect to improve the outcome of postoperative patients with aSAH, and cilostazol may be the best drug to improve the outcome of patients after aSAH operation. Our study provides implications for future studies that, the combination of two or more drugs with relative safety and potential benefits (e.g., nimodipine and cilostazol) may improve the clinical outcome of patients more effectively. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02303-8.
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Affiliation(s)
- Wanli Yu
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yizhou Huang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaolin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Huirong Luo
- Department of Psychiatry, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Weifu Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yongxiang Jiang
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
| | - Yuan Cheng
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
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14
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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15
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Parish JM, Ziechmann R, Guley NM, Joy J, Karimian B, Dyer EH, Wait SD, Stetler WR, Bernard JD. Safety and efficacy of intrathecal nicardipine for aneurysmal subarachnoid hemorrhage induced vasospasm. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2021. [DOI: 10.1016/j.inat.2020.101045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Yokoya S, Hino A, Goto Y, Oka H. Complete relief of vasospasm - Effect of nicardipine coating during direct clipping for the patient with symptomatic vasospasm of subarachnoid hemorrhage. Surg Neurol Int 2020; 11:394. [PMID: 33282456 PMCID: PMC7710454 DOI: 10.25259/sni_640_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/26/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Some patients come to the hospital presenting with ischemic neurological deficits due to postsubarachnoid hemorrhage (SAH) cerebral vasospasm. In such a situation, neurosurgeons tend to avoid direct clipping, since mechanical irritation to the vessels could worsen the vasospasm and exacerbate ischemic symptoms. The optimal timing of direct clipping in patients with evidence of vasospasm is undetermined. Herein, we present the case of a patient who underwent direct clipping in the presence of severe symptomatic and post-SAH angiographic vasospasm. During surgery, we coated the severely spastic artery with nicardipine. Case Description: A 49-year-old woman was admitted to our hospital with the diagnosis of ruptured intracranial aneurysm and severe vasospasm. On the admission day, we performed direct clipping together with direct application of nicardipine to the spastic artery. Postoperative immediate cerebral angiography showed complete disappearance of the vasospasm. Conclusion: Direct clipping should not be contraindicated during the vasospasm period in patients with a ruptured aneurysm, and direct application of nicardipine on the spastic artery would completely relieve vasospasm.
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Affiliation(s)
- Shigeomi Yokoya
- Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Shiga, Japan
| | - Akihiko Hino
- Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Shiga, Japan
| | - Yukihiro Goto
- Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Shiga, Japan
| | - Hideki Oka
- Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Shiga, Japan
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18
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Dawley T, Claus CF, Tong D, Rajamand S, Sigler D, Bahoura M, Garmo L, Soo TM, Kelkar P, Richards B. Efficacy and safety of cilostazol-nimodipine combined therapy on delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a prospective, randomised, double-blinded, placebo-controlled trial protocol. BMJ Open 2020; 10:e036217. [PMID: 33020083 PMCID: PMC7537439 DOI: 10.1136/bmjopen-2019-036217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 07/28/2020] [Accepted: 08/07/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Delayed cerebral ischaemia (DCI) due to cerebral vasospasm (cVS) remains the foremost contributor to morbidity and mortality following aneurysmal subarachnoid haemorrhage (aSAH). Past efforts in preventing and treating DCI have failed to make any significant progress. To date, our most effective treatment involves the use of nimodipine, a calcium channel blocker. Recent studies have suggested that cilostazol, a platelet aggregation inhibitor, may prevent cVS. Thus far, no study has evaluated the effect of cilostazol plus nimodipine on the rate of DCI following aSAH. METHODS AND ANALYSIS This is a multicentre, double-blinded, randomised, placebo-controlled superiority trial investigating the effect of cilostazol on DCI. Data concerning rates of DCI, symptomatic and radiographic vasospasm, length of intensive care unit stay, and long-term functional and quality-of-life (QoL) outcomes will be recorded. All data will be collected with the aim of demonstrating that the use of cilostazol plus nimodipine will safely decrease the incidence of DCI, and decrease the rates of both radiographic and symptomatic vasospasm with subsequent improvement in long-term functional and QoL outcomes when compared with nimodipine alone. ETHICS AND DISSEMINATION Ethical approval was obtained from all participating hospitals by the Ascension Providence Hospital Institutional Review Board. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04148105.
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Affiliation(s)
- Troy Dawley
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Chad F Claus
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Doris Tong
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Sina Rajamand
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Diana Sigler
- Department of Pharmacy, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Matthew Bahoura
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Lucas Garmo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Teck M Soo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Prashant Kelkar
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Boyd Richards
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
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Hafeez S, Grandhi R. Systematic Review of Intrathecal Nicardipine for the Treatment of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 31:399-405. [PMID: 30607826 DOI: 10.1007/s12028-018-0659-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intrathecal nicardipine has been shown to have some efficacy for the treatment of symptomatic cerebral vasospasm in aneurysmal subarachnoid hemorrhage (aSAH). We performed a PRISMA-based systematic review of intrathecal nicardipine for the treatment of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. A total of 825 articles were reviewed. After duplicates were removed and the search criteria was applied, 9 articles remained that were eligible for inclusion and analysis. 377 patients received a total of 6,596 injections of intrathecal nicardipine for aSAH-related cerebral vasospasm. The cumulative ventriculostomy-associated infection risk was 6%. Intrathecal nicardipine injections for aSAH-related cerebral vasospasm appears efficacious and safe. Administration of 4 mg of nicardipine every 12 hours was the most commonly reported dosing regimen. Intrathecal nicardipine decreases mean flow velocities on transcranial Doppler and reduces angiographic and clinical vasospasm. The infection risk appears to be in-line with studies in which rates of EVD-related infections have been reported.
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Affiliation(s)
- Shaheryar Hafeez
- Neurocritical Care, Department of Neurosurgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
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20
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Ehrlich G, Kirschning T, Wenz H, Hegewald AA, Neumaier-Probst E, Seiz-Rosenhagen M. Outcome of Oral and Intra-arterial Nimodipine Administration After Aneurysmal Subarachnoid Haemorrhage - A Single-centre Study. In Vivo 2019; 33:1967-1975. [PMID: 31662526 DOI: 10.21873/invivo.11692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/14/2019] [Accepted: 09/19/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Oral nimodipine is administered to improve clinical outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this study, clinical outcome in patients with and without oral nimodipine administration was assessed. MATERIALS AND METHODS A total of 105 patients did not receive oral nimodipine but did receive intra-arterial nimodipine in the occurrence of hemodynamically relevant vasospasm after aSAH, whereas 74 patients received applications of both. Demographic/radiological details and clinical presentation were abstracted from the case records. RESULTS Patient baseline characteristics were comparable, a predominance of endovascular coiling was shown in cohort 2 (p=0.0135). Severity of initial aSAH and clinical status at admission (Hunt and Hess) was significantly higher in those receiving oral nimodipine. Incidence of angiographic vasospasm was significantly higher in patients not treated with oral nimodipine (p=0.0305); a significantly better outcome measured by the National Institute of Health Stroke Scale (p=0.0213), was noted in those receiving oral nimodipine. CONCLUSION Oral nimodipine administration improved clinical outcome of patients after aSAH and should be administered routinely for such patients.
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Affiliation(s)
- Gregory Ehrlich
- Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Kirschning
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Holger Wenz
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Eva Neumaier-Probst
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marcel Seiz-Rosenhagen
- Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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Neuropharmacology in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Predictive Factors of 2-Year Postoperative Outcomes in Patients with Spontaneous Cerebellar Hemorrhage. J Clin Med 2019; 8:jcm8060818. [PMID: 31181777 PMCID: PMC6617345 DOI: 10.3390/jcm8060818] [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: 04/11/2019] [Revised: 05/28/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022] Open
Abstract
Spontaneous cerebellar hemorrhage (SCH) is associated with high patient mortality and morbidity, but the clinical and radiographic predictors of the postoperative outcome have not been widely addressed in the literature. The purpose of this study was to define the prognostic factors for the two-year postoperative outcome in patients with SCH. We conducted a retrospective study of 48 consecutive patients with SCH who underwent neurosurgical intervention. Correlation analysis was performed to examine the possible link between clinical and radiographic parameters, and the National Institutes of Health Stroke Scale (NIHSS) score at each patient’s discharge and the two-year postoperative outcome as defined according to the Glasgow outcome scale (GOS). A total of 48 patients with SCH underwent neurological surgery, which included suboccipital craniectomy and/or external ventricular drainage (EVD). The mean patient age was 63 years. Nine patients underwent suboccipital craniectomy only; 38 underwent both suboccipital craniectomy and EVD. The overall mortality rate was 35.4%. Fourteen patients (29.2%) had good outcomes. A good outcome on the GOS at 2 years after surgical treatment of SCH was associated with the NIHSS score at discharge. An increase of one point in a patient’s NIHSS score at discharge following neurological surgery will increase the probability of a poor two-year postoperative outcome by 28.5%.
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Al-Mufti F, Amuluru K, Damodara N, Dodson V, Roh D, Agarwal S, Meyers PM, Connolly ES, Schmidt MJ, Claassen J, Park S. Admission neutrophil–lymphocyte ratio predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2019; 11:1135-1140. [DOI: 10.1136/neurintsurg-2019-014759] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/29/2022]
Abstract
BackgroundDelayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) has a multifactorial pathophysiology, with immune dysregulation being an important component. The neutrophil–lymphocyte ratio (NLR) is an established prognostic marker in patients with cancer, cardiac disease, and sepsis.ObjectiveTo determine whether there is a relationship between NLR and DCI in patients with aSAH.MethodsWe evaluated 1067 patients with aSAH between 2006 and 2015 enrolled in a single-center, prospective, observational cohort study. Admission white blood cell differentials (NLR) were analyzed using a cut-off point of ≥5.9. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment, or a decrease in at least two points on the Glasgow Coma Scale, which was not apparent immediately after aneurysm occlusion, and could not be attributed to other causes. Cerebral infarct was defined as a new infarct on CT that was not visible on the admission or immediate postoperative scan, when the cause was thought to be vasospasm by the research team. Logistic regression models were generated.ResultsWe found that 768 (72%) patients had an admission NLR ≥5.9. In a multivariable model, elevated NLR was associated with poor admission Hunt-Hess grade (OR=1.6, 95% CI 1.2 to 2.6, p=0.005), Caucasian ethnicity (OR=2.6, 95% CI 1.9 to 3.7, p<0.001), anterior aneurysm location (OR=1.7, 95% CI 1.2 to 2.4, p=0.004), loss of consciousness at ictus (OR=1.4, 95% CI 1.0 to 2.0, p=0.055), and thick SAH (modified Fisher grade ≥3) (OR=1.8, 95% CI 1.3 to 2.4, p<0.001). Admission NLR predicted development of delayed cerebral ischemia (DCI) (OR=1.7; 95% CI 1.1 to 2.5, p=0.008) after controlling for known predictors such as age, poor admission clinical grade, thick SAH blood, and elevated admission mean arterial pressure.ConclusionsThis study provides further evidence of the association between inflammation and DCI. Admission NLR is a readily available and convenient biomarker that may be a clinically useful tool for prognostication when evaluating aSAH.
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25
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Sadan O, Samuels O, Asbury WH, Hanfelt JJ, Singbartl K. Low-chloride versus high-chloride hypertonic solution for the treatment of subarachnoid hemorrhage-related complications (The ACETatE trial): study protocol for a pilot randomized controlled trial. Trials 2018; 19:628. [PMID: 30428930 PMCID: PMC6236880 DOI: 10.1186/s13063-018-3007-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 10/20/2018] [Indexed: 01/29/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition that results from a ruptured cerebral vessel. Cerebral edema and vasospasm are common complications and frequently require treatment with hypertonic solutions, in particular hypertonic sodium chloride (NaCl). We have previously shown that hyperchloremia in patients with aSAH given hypertonic NaCl is associated with the development of acute kidney injury (AKI), which leads to higher morbidity and mortality. Our current trial aims to study the effect of two hypertonic solutions with different chloride content on serum chloride concentrations in patients with aSAH who are at risk for AKI. Methods A low ChloridE hyperTonic solution for brain Edema (ACETatE) is a single center, double-blinded, double-dummy pilot trial comparing bolus doses of 23.4% NaCl and 16.4% NaCl/Na-Acetate for the treatment of cerebral edema in patients with aSAH. All patients will be enrolled within 36 h following admission. Randomization will occur once patients who receive hypertonic treatment for cerebral edema develop hyperchloremia (serum Cl− concentration ≥ 109 mmol/L). Subsequent treatment will consist of either NaCl 23.4% or NaCl/Na-Acetate 16.4%. The primary outcome of this study will be the change in serum Cl− concentrations during treatment. Secondary outcomes will include incidence of AKI, mortality, changes in intracranial pressure, and extent of hypernatremia. Discussion In patients with aSAH, hyperchloremia is a known risk factor for subsequent development of AKI. The primary goal of this pilot study is to determine the effect of two hypertonic solutions with different Cl− content on serum Cl− concentrations in patients with aSAH who have already developed hyperchloremia. Data will be collected prospectively to determine the extent to which the choice of hypertonic saline solution affects subsequent serum Cl− concentrations and the occurrence of AKI. This approach will allow us to obtain preliminary data to design a large randomized trial assessing the effects of chloride-sparing hypertonic solutions on development of AKI in patients with SAH. This pilot study is the first to prospectively evaluate the relationship between hypertonic solution chloride content and its effect on serum electrolytes and renal function in aSAH patients at risk of AKI due to hyperchloremia. Trial registration Clinicaltrials.gov, NCT03204955. Registered on 28 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3007-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Owen Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - William H Asbury
- Department of Pharmacy, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - John J Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, 85054, USA.
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26
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Al-Mufti F, Amuluru K, Damodara N, El-Ghanem M, Nuoman R, Kamal N, Al-Marsoummi S, Morris NA, Dangayach NS, Mayer SA. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2018; 390:44-51. [DOI: 10.1016/j.jns.2018.02.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 11/27/2022]
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27
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Lidington D, Kroetsch JT, Bolz SS. Cerebral artery myogenic reactivity: The next frontier in developing effective interventions for subarachnoid hemorrhage. J Cereb Blood Flow Metab 2018; 38:17-37. [PMID: 29135346 PMCID: PMC5757446 DOI: 10.1177/0271678x17742548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating cerebral event that kills or debilitates the majority of those afflicted. The blood that spills into the subarachnoid space stimulates profound cerebral artery vasoconstriction and consequently, cerebral ischemia. Thus, once the initial bleeding in SAH is appropriately managed, the clinical focus shifts to maintaining/improving cerebral perfusion. However, current therapeutic interventions largely fail to improve clinical outcome, because they do not effectively restore normal cerebral artery function. This review discusses emerging evidence that perturbed cerebrovascular "myogenic reactivity," a crucial microvascular process that potently dictates cerebral perfusion, is the critical element underlying cerebral ischemia in SAH. In fact, the myogenic mechanism could be the reason why many therapeutic interventions, including "Triple H" therapy, fail to deliver benefit to patients. Understanding the molecular basis for myogenic reactivity changes in SAH holds the key to develop more effective therapeutic interventions; indeed, promising recent advancements fuel optimism that vascular dysfunction in SAH can be corrected to improve outcome.
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Affiliation(s)
- Darcy Lidington
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada
| | - Jeffrey T Kroetsch
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada
| | - Steffen-Sebastian Bolz
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada.,3 Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, Canada
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28
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Zink RC, Marchenko O, Sanchez-Kam M, Ma H, Jiang Q. Sources of Safety Data and Statistical Strategies for Design and Analysis: Clinical Trials. Ther Innov Regul Sci 2017; 52:141-158. [PMID: 29714519 DOI: 10.1177/2168479017738980] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There has been an increased emphasis on the proactive and comprehensive evaluation of safety endpoints to ensure patient well-being throughout the medical product life cycle. In fact, depending on the severity of the underlying disease, it is important to plan for a comprehensive safety evaluation at the start of any development program. Statisticians should be intimately involved in this process and contribute their expertise to study design, safety data collection, analysis, reporting (including data visualization), and interpretation. METHODS In this manuscript, we review the challenges associated with the analysis of safety endpoints and describe the safety data that are available to influence the design and analysis of premarket clinical trials. RESULTS We share our recommendations for the statistical and graphical methodologies necessary to appropriately analyze, report, and interpret safety outcomes, and we discuss the advantages and disadvantages of safety data obtained from clinical trials compared to other sources. CONCLUSIONS Clinical trials are an important source of safety data that contribute to the totality of safety information available to generate evidence for regulators, sponsors, payers, physicians, and patients. This work is a result of the efforts of the American Statistical Association Biopharmaceutical Section Safety Working Group.
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Affiliation(s)
- Richard C Zink
- JMP Life Sciences, SAS Institute, 701 SAS Campus Drive, Cary, NC, 27513, USA. .,Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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29
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30
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Daftari Besheli L, Tan CO, Bell DL, Hirsch JA, Gupta R. Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage. PLoS One 2017; 12:e0174676. [PMID: 28339483 PMCID: PMC5365119 DOI: 10.1371/journal.pone.0174676] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 03/13/2017] [Indexed: 01/03/2023] Open
Abstract
Intra-arterial (IA) vasodilator therapy is one of the recommended treatments to minimize the impact of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm refractory to standard management. However, its usefulness and efficacy is not well established. We evaluated the effect IA vasodilator therapy on middle cerebral artery blood flow and on discharge outcome. We reviewed records for 115 adults admitted to Neurointensive Care Unit to test whether there was a difference in clinical outcome (discharge mRS) in those who received IA infusions. In a subset of 19 patients (33 vessels) treated using IA therapy, we tested whether therapy was effective in reversing the trends in blood flow. All measures of MCA blood flow increased from day -2 to -1 before infusion (maximum Peak Systolic Velocity (PSV) 232.2±9.4 to 262.4±12.5 cm/s [p = 0.02]; average PSV 202.1±8.5 to 229.9±10.9 [p = 0.02]; highest Mean Flow Velocity (MFV) 154.3±8.3 to 172.9±10.5 [p = 0.10]; average MFV 125.5±6.3 to 147.8±9.5 cm/s, [p = 0.02]) but not post-infusion (maximum PSV 261.2±14.6 cm/s [p = .89]; average PSV 223.4±11.4 [p = 0.56]; highest MFV 182.9±12.4 cm/s [p = 0.38]; average MFV 153.0±10.2 cm/s [p = 0.54]). After IA therapy, flow velocities were consistently reduced (day X infusion interaction p<0.01 for all measures). However, discharge mRS was higher in IA infusion group, even after adjusting for sex, age, and admission grades. Thus, while IA vasodilator therapy was effective in reversing the vasospasm-mediated deterioration in blood flow, clinical outcomes in the treated group were worse than the untreated group. There is need for a prospective randomized controlled trial to avoid potential confounding effect of selection bias.
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Affiliation(s)
- Laleh Daftari Besheli
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Can Ozan Tan
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Cerebrovascular Research Laboratory, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States of America
- * E-mail:
| | - Donnie L. Bell
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Joshua A. Hirsch
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Rajiv Gupta
- Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
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31
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Abstract
Subarachnoid hemorrhage (SAH) affects 30,000 people in the Unites States alone each year. Delayed cerebral ischemia occurs days after subarachnoid hemorrhage and represents a potentially treatable cause of morbidity for approximately one-third of those who survive the initial hemorrhage. While vasospasm has been traditionally linked to the development of cerebral ischemia several days after subarachnoid hemorrhage, emerging evidence reveals that delayed cerebral ischemia is part of a much more complicated post-subarachnoid hemorrhage syndrome. The development of delayed cerebral ischemia involves early arteriolar vasospasm with microthrombosis, perfusion mismatch and neurovascular uncoupling, spreading depolarizations, and inflammatory responses that begin at the time of the hemorrhage and evolve over time, culminating in cortical infarction. Large-vessel vasospasm is likely a late contributor to ongoing injury, and effective treatment for delayed cerebral ischemia will require improved detection of critical early pathophysiologic changes as well as therapeutic options that target multiple related pathways.
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32
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Ayling OG, Ibrahim GM, Alotaibi NM, Gooderham PA, Macdonald RL. Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage. Stroke 2016; 47:2945-2951. [DOI: 10.1161/strokeaha.116.014794] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts.
Methods—
A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated.
Results—
Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99–11.57;
P
=0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15–0.48;
P
<0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03–3.13;
P
=0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18–4.67;
P
=0.015).
Conclusions—
Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00111085.
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Affiliation(s)
- Oliver G.S. Ayling
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - George M. Ibrahim
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - Naif M. Alotaibi
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - Peter A. Gooderham
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - R. Loch Macdonald
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
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Abstract
For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.
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Affiliation(s)
- Charles L Francoeur
- Critical Care Division, Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Québec, Canada
| | - Stephan A Mayer
- Department of Neurology (Neurocritical Care), Mount Sinai, New York, NY, USA.
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1522, New York, NY, 10029-6574, USA.
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Qureshi AI, Jahangir N, Qureshi MH, Defillo A, Malik AA, Sherr GT, Suri MFK. A population-based study of the incidence and case fatality of non-aneurysmal subarachnoid hemorrhage. Neurocrit Care 2016; 22:409-13. [PMID: 25421069 DOI: 10.1007/s12028-014-0084-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is a paucity of reliable and recent data regarding epidemiology of non-aneurysmal subarachnoid hemorrhage (SAH) in population-based studies. OBJECTIVES To determine the incidence and case fatality of non-aneurysmal SAH using a population-based design. METHODS Medical records and angiographic data of all patients from Stearns and Benton Counties, Minnesota, admitted with SAH were reviewed to identify incident case of non-aneurysmal SAH. Patients with a first-time diagnosis of non-aneurysmal SAH (based on two negative cerebral angiograms performed ≥7 days apart) between June 1st, 2012 and June 30th, 2014 were considered incident cases. We calculated the incidences of non-aneurysmal and aneurysmal SAH adjusted for age and sex based on the 2010 US census. RESULTS Of the 18 identified SAH among 189,093 resident populations, five were true incident cases of non-aneurysmal SAH in this population-based study. The age- and sex-adjusted incidence of non-aneurysmal SAH were 2.8 [95 % confidence interval (CI) 2.7-2·9] per 100,000 person-years which was lower than aneurysmal SAH incidence of 7.2 [95 % CI 7.1-7.4] per 100,000 person-years. The age-adjusted incidence of non-aneurysmal SAH was similar (compared with aneurysmal SAH) among men; 3.2 [95 % CI 3.1-3.3] per 100,000 person-years versus 2.2 [95 % CI 2.1-2.3] per 100,000 person-years, respectively. The age-adjusted case fatality rate at 3 months was 4.46 and 0.0 per 100,000 persons for aneurysmal and non-aneurysmal SAH, respectively. CONCLUSIONS The incidence of non-aneurysmal SAH was higher than previously reported particularly among men.
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Ko SB, Choi HA, Helbok R, Kurtz P, Schmidt JM, Badjatia N, Claassen J, Connolly ES, Mayer SA, Lee K. Acute effects of intraventricular nicardipine on cerebral hemodynamics: A preliminary finding. Clin Neurol Neurosurg 2016; 144:48-52. [PMID: 26971295 DOI: 10.1016/j.clineuro.2016.02.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 02/26/2016] [Accepted: 02/27/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Intraventricular nicardipine (IVTN) is a treatment option for severe vasospasm in patients with subarachnoid hemorrhage (SAH). However, its acute effects on cerebral hemodynamics have not been studied in detail. METHODS Between June 2008 and December 2010, IVTN was administered (mainly 4mg every 8h) to 11 SAH patients (54 doses) with multimodality monitoring for refractory vasospasm. Retrospective analyses on physiological parameters were made from baseline and up to 6h after IVTN injection. Statistical analysis was performed with a mixed-effects model. RESULTS Mean intracranial pressure (ICP) increased slightly, reaching its peak at 20min after IVTN injection (2.5±0.9mmHg (mean±standard error), P<0.01), and decreased gradually thereafter over the next hour. Mean cerebral perfusion pressure transiently decreased 20-30min after injection (3.7±1.8mmHg, P<0.05). Mean arterial pressure, partial pressure of brain oxygen tension (PbtO2), cerebral blood flow (CBF), autoregulation indices did not change significantly. Lactate/pyruvate ratio and glucose remained stable. One patient underwent transcranial Doppler ultrasonography monitoring while on IVTN, which showed a transient increase in mean flow velocity with concomitant decrease in Pulsatility index, suggesting vasodilation in the distal resistance vessels. CONCLUSIONS The vasodilatory effect of IVTN transiently increased ICP, but did not significantly affect PbtO2, CBF or oxidative glucose metabolism in the immediate phase after injection.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - H Alex Choi
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA
| | - Raimund Helbok
- Clinical Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Pedro Kurtz
- Neuro Intensive Care Unit, Brain Institute Paulo Niemeyer, Rio de Janeiro, RJ, Brazil
| | - J Michael Schmidt
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neeraj Badjatia
- Section of Neurocritical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA.
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Bonow RH, Silber JR, Enzmann DR, Beauchamp NJ, Ellenbogen RG, Mourad PD. Towards use of MRI-guided ultrasound for treating cerebral vasospasm. J Ther Ultrasound 2016; 4:6. [PMID: 26929821 PMCID: PMC4770693 DOI: 10.1186/s40349-016-0050-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 02/19/2016] [Indexed: 12/23/2022] Open
Abstract
Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage (SAH), causing delayed neurological deficits in as many as one third of cases. Existing therapy targets induction of cerebral vasodilation through use of various drugs and mechanical means, with a range of observed efficacy. Here, we perform a literature review supporting our hypothesis that transcranially delivered ultrasound may have the ability to induce therapeutic cerebral vasodilation and, thus, may one day be used therapeutically in the context of SAH. Prior studies demonstrate that ultrasound can induce vasodilation in both normal and vasoconstricted blood vessels in peripheral tissues, leading to reduced ischemia and cell damage. Among the proposed mechanisms is alteration of several nitric oxide (NO) pathways, where NO is a known vasodilator. While in vivo studies do not point to a specific physical mechanism, results of in vitro studies favor cavitation induction by ultrasound, where the associated shear stresses likely induce NO production. Two papers discussed the effects of ultrasound on the cerebral vasculature. One study applied clinical transcranial Doppler ultrasound to a rodent complete middle cerebral artery occlusion model and found reduced infarct size. A second involved the application of pulsed ultrasound in vitro to murine brain endothelial cells and showed production of a variety of vasodilatory chemicals, including by-products of arachidonic acid metabolism. In sum, nine reviewed studies demonstrated evidence of either cerebrovascular dilation or elaboration of vasodilatory compounds. Of particular interest, all of the reviewed studies used ultrasound capable of transcranial application: pulsed ultrasound, with carrier frequencies ranging between 0.5 and 2.0 MHz, and intensities not substantially above FDA-approved intensity values. We close by discussing potential specific treatment paradigms of SAH and other cerebral ischemic disorders based on MRI-guided transcranial ultrasound.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA
| | - John R Silber
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA
| | - Dieter R Enzmann
- Department of Radiology, University of California Los Angeles, 924 Westwood Blvd. Suite 805, Los Angeles, CA 90024 USA
| | - Norman J Beauchamp
- Department of Radiology, University of Washington, RR-218 Health Science Building, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA
| | - Pierre D Mourad
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA ; Department of Radiology, University of Washington, RR-218 Health Science Building, 1959 NE Pacific St, Seattle, WA 98195 USA ; Division of Engineering, University of Washington, 18115 Campus Way NE, Bothell, WA 98011 USA
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Matsukawa H, Tanikawa R, Kamiyama H, Tsuboi T, Noda K, Ota N, Miyata S, Suzuki G, Takeda R, Tokuda S. Effects of Clot Removal by Meticulous Irrigation and Continuous Low-Dose Intravenous Nicardipine on Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Clipping. World Neurosurg 2015; 84:1798-803. [PMID: 26278868 DOI: 10.1016/j.wneu.2015.07.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/26/2015] [Accepted: 07/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Symptomatic cerebral vasospasm (SCV) is the second most common of morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH) after rebleeding. Blood breakdown products are one of the leading causes of vasospasm. We hypothesized that meticulous subarachnoid clot removal in addition to continuous low-dose intravenous nicardipine (CLIN) could reduce the incidence of SCV. METHODS SCV was defined as new focal neurologic signs, consciousness deterioration, or both when the cause was believed to be ischemia attributable to vasospasm after other possible causes of worsening were excluded. Initial brain damage was defined as continued consciousness disturbance after clipping without acute hydrocephalus, ischemic lesions, or focal sign before clipping. Poor outcome was defined as a Glasgow Outcome Scale score of 3-5 at 30 days. We compared the variables for 460 aSAH patients with and without SCV, and with and without poor outcome by multivariate analysis. RESULTS All patients underwent clipping with meticulous irrigation for clot removal, and SCV was observed in 56 patients (12%). SCV was observed in 2 patients (2.9%) among 70 patients treated with CLIN. There was a higher proportion of patients who were older than 65 years (P = 0.032) and female (P = 0.038), and a lower proportion of patients with CLIN (P = 0.026) among patients with SCV. The outcomes for 109 patients (27%) were poor; age greater than 65 years (P < 0.0001) and initial brain damage (P = 0.008) were related to the poor outcomes. CONCLUSIONS The present study showed that meticulous irrigation for clot removal and CLIN might reduce the incidence of SCV in patients with aSAH.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan.
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Toshiyuki Tsuboi
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Shiro Miyata
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Go Suzuki
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Rihei Takeda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
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Durrant JC, Hinson HE. Rescue therapy for refractory vasospasm after subarachnoid hemorrhage. Curr Neurol Neurosci Rep 2015; 15:521. [PMID: 25501582 DOI: 10.1007/s11910-014-0521-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia.
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Affiliation(s)
- Julia C Durrant
- Department of Neurology and Neurocritical Care, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, CR-127, Portland, OR, 97239, USA,
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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Dhar R, Diringer MN. Relationship between angiographic vasospasm, cerebral blood flow, and cerebral infarction after subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:161-5. [PMID: 25366617 DOI: 10.1007/978-3-319-04981-6_27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Delayed cerebral ischemia (DCI) and cerebral infarction are major contributors to poor functional recovery after subarachnoid hemorrhage (SAH). Cerebral vasospasm, the narrowing of proximal intracranial arteries after SAH, has long been assumed to be the primary cause of DCI, and has therefore been the primary therapeutic target in attempts to diminish disability after SAH. However, emerging evidence has questioned the strength and causality of the relationship between vasospasm and DCI. To address this fundamental question, we performed two parallel studies assessing the relationship between the presence of vasospasm in a vascular territory and both regional reductions in cerebral blood flow (CBF) and development of cerebral infarction.In a cohort of SAH patients at high-risk for DCI, we identified regions of hypoperfusion using positron emission tomography (PET) and compared their distribution with territories exhibiting vasospasm on concurrent angiography. We found that regional hypoperfusion was common in the absence of proximal vasospasm and that some patients without any significant vasospasm still could have hypoperfused brain regions. Similarly, our parallel study demonstrated that both patients and brain territories without vasospasm could develop delayed cerebral infarction, and that such vasospasm-independent infarcts account for more than a quarter of the infarct burden from DCI. These findings suggest that other processes, perhaps at a microvascular level, contribute at least part of the burden of DCI and future interventions should also address these other pathophysiologic processes.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology (Neurocritical Care Section), Washington University in St. Louis School of Medicine, 8111, 660S Euclid Avenue, St. Louis, MO, 63110, USA,
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Toyoda T, Yonekura I, Iijima A, Shinozaki M, Tanishima T. Clot-clearance rate in the sylvian cistern is associated with the severity of cerebral vasospasm after subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:275-7. [PMID: 25366636 DOI: 10.1007/978-3-319-04981-6_46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Rapid clot removal and clearance has been proposed as an effective tool for preventing cerebral vasospasm after subarachnoid hemorrhage (SAH). We examined the relationship between clot-clearance rate and the severity of cerebral vasospasm in 110 consecutive patients with aneurysmal SAH. We measured clot-clearance rates per day in the basal and Sylvian cisterns, and evaluated the presence of symptomatic vasospasm based on changes in clinical symptoms and the appearance of a new low-density area on a computed tomography (CT) scan. The severity of symptomatic cerebral vasospasm was associated with age and the SAH grade on admission; however, we observed no significant difference between these variables in patients with urokinase irrigation or fasudil hydrochloride treatment. The mean clot-clearance rates per day for patients with asymptomatic and permanent delayed ischemic neurological deficit were 41.9 and 41.5 %, respectively, in the basal cistern (P = 0.7358) and 37.7 and 23.9 %, respectively, in the Sylvian cistern (P = 0.0021). The reduced clot-clearance rate in the Sylvian cistern increased the risk of vasospasm-related infarction (P = 0.0093) and markedly reduced unfavorable outcomes (P = 0.0115).
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Affiliation(s)
- Tomikatsu Toyoda
- Department of Neurosurgery, JCHO Tokyo Shinjuku Medical Center, 5-1 Tsukudocho Shinjuku, Tokyo, 162-8543, Japan,
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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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Kiser TH. Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions? Hosp Pharm 2014; 49:923-41. [PMID: 25477565 DOI: 10.1310/hpj4910-923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.
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Affiliation(s)
- Tyree H Kiser
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital, University of Colorado Anschutz Medical Campus , 12850 E. Montview Boulevard, C238, Aurora, CO 80045 ; phone: 303-724-2883 ; fax: 303-724-0979 ; e-mail:
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Budohoski KP, Guilfoyle M, Helmy A, Huuskonen T, Czosnyka M, Kirollos R, Menon DK, Pickard JD, Kirkpatrick PJ. The pathophysiology and treatment of delayed cerebral ischaemia following subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2014; 85:1343-53. [PMID: 24847164 DOI: 10.1136/jnnp-2014-307711] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cerebral vasospasm has traditionally been regarded as an important cause of delayed cerebral ischaemia (DCI) which occurs after aneurysmal subarachnoid haemorrhage, and often leads to cerebral infarction and poor neurological outcome. However, data from recent studies argue against a pure focus on vasospasm as the cause of delayed ischaemic complications. Findings that marked reduction in the incidence of vasospasm does not translate to a reduction in DCI, or better outcomes has intensified research into other possible mechanisms which may promote ischaemic complications. Early brain injury and cell death, blood-brain barrier disruption and initiation of an inflammatory cascade, microvascular spasm, microthrombosis, cortical spreading depolarisations and failure of cerebral autoregulation, have all been implicated in the pathophysiology of DCI. This review summarises the current knowledge about the mechanisms underlying the development of DCI. Furthermore, it aims to describe and categorise the known pharmacological treatment options with respect to the presumed mechanism of action and its role in DCI.
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Affiliation(s)
- Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Mathew Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Terhi Huuskonen
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK Department of Neurosurgery, Kuopio Neurocenter, Kuopio University Hospital, Kuopio, Finland
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ramez Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Department of Anaesthesiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. INTERVENTIONAL NEUROLOGY 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
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Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
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Vivancos J, Gilo F, Frutos R, Maestre J, García-Pastor A, Quintana F, Roda J, Ximénez-Carrillo A, Díez Tejedor E, Fuentes B, Alonso de Leciñana M, Álvarez-Sabin J, Arenillas J, Calleja S, Casado I, Castellanos M, Castillo J, Dávalos A, Díaz-Otero F, Egido J, Fernández J, Freijo M, Gállego J, Gil-Núñez A, Irimia P, Lago A, Masjuan J, Martí-Fábregas J, Martínez-Sánchez P, Martínez-Vila E, Molina C, Morales A, Nombela F, Purroy F, Ribó M, Rodríguez-Yañez M, Roquer J, Rubio F, Segura T, Serena J, Simal P, Tejada J. Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2012.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Zink RC, Wolfinger RD, Mann G. Summarizing the incidence of adverse events using volcano plots and time intervals. Clin Trials 2014; 10:398-406. [PMID: 23690094 DOI: 10.1177/1740774513485311] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adverse event incidence analyses are a critical component for describing the safety profile of any new intervention. The results typically are presented in lengthy summary tables. For therapeutic areas where patients have frequent adverse events, analysis and interpretation are made more difficult by the sheer number and variety of events that occur. Understanding the risk in these instances becomes even more crucial. PURPOSE We describe a space-saving graphical summary that overcomes the limitations of traditional presentations of adverse events and improves interpretability of the safety profile. METHODS We present incidence analyses of adverse events graphically using volcano plots to highlight treatment differences. Data from a clinical trial of patients experiencing an aneurysmal subarachnoid hemorrhage are used for illustration. Adjustments for multiplicity are illustrated. RESULTS Color is used to indicate the treatment with higher incidence; bubble size represents the total number of events that occur in the treatment arms combined. Adjustments for multiple comparisons are displayed in a manner to indicate clearly those events for which the difference between treatment arms is statistically significant. Furthermore, adverse events can be displayed by time intervals, with multiple volcano plots or animation to appreciate changes in adverse event risk over time. Such presentations can emphasize early differences across treatments that may resolve later or highlight events for which treatment differences may become more substantial with longer follow-up. LIMITATIONS Treatment arms are compared in a pairwise fashion. CONCLUSIONS Volcano plots are space-saving tools that emphasize important differences between the adverse event profiles of two treatment arms. They can incorporate multiplicity adjustments in a manner that is straightforward to interpret and, by using time intervals, can illustrate how adverse event risk changes over the course of a clinical trial.
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Affiliation(s)
- Richard C Zink
- JMP Life Sciences, SAS Institute Inc., Cary, NC 27513, USA.
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Zink RC, Huang Q, Zhang LY, Bao WJ. Statistical and graphical approaches for disproportionality analysis of spontaneously-reported adverse events in pharmacovigilance. Chin J Nat Med 2013; 11:314-20. [PMID: 23725848 DOI: 10.1016/s1875-5364(13)60035-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Indexed: 11/16/2022]
Abstract
AIM Combine disproportionality analysis with dynamically interactive graphics to understand spontaneously-reported adverse events in pharmacovigilance. METHODS Four statistical methods, including Reporting Odds Ratio, Proportional Reporting Ratio, Multi-Item Gamma Poisson Shrinker and Bayesian Confidence Propagation Neural Network that are used for computing disproportionality are described. Tree maps and other graphical techniques are used to display the disproportionality results. RESULTS Spontaneously-reported adverse events in pharmacovigilance are collected from physicians, patients, or the medical literature by regulatory agencies, pharmaceutical companies and device manufacturers to monitor the safety of a product once it reaches the market. In order to identify potential safety-signals, disproportionality analysis methods compare the rate at which a particular event of interest co-occurs with a given drug with the rate this event occurs without the drug in the event database. Tree maps are employed to interactively display the adverse events for particular drugs and compare the adverse events among the drugs. CONCLUSION Interactive graphical displays of disproportionality allow the analyst to quickly identify safety signals and perform additional follow-up analyses. Combining statistical methods with dynamically interactive graphics affords insights into the data inaccessible by traditional analysis methods.
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Pandey AS, Elias AE, Chaudhary N, Thompson BG, Gemmete JJ. Endovascular Treatment of Cerebral Vasospasm. Neuroimaging Clin N Am 2013; 23:593-604. [DOI: 10.1016/j.nic.2013.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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