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Riordan K, Mamaril-Davis J, Aguilar-Salinas P, Dumont TM, Weinand ME. Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 232:107877. [PMID: 37441930 DOI: 10.1016/j.clineuro.2023.107877] [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: 04/06/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis. RESULTS Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively. CONCLUSIONS The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.
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Affiliation(s)
- Katherine Riordan
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - James Mamaril-Davis
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Martin E Weinand
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States.
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2
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Wang J, Li R, Li S, Ma T, Zhang X, Ren Y, Chen X, Peng Y. Intraoperative arterial pressure and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage after surgical clipping: A retrospective cohort study. Front Neurosci 2023; 17:1064987. [PMID: 36875639 PMCID: PMC9982002 DOI: 10.3389/fnins.2023.1064987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Background Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive. Methods All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups. Results Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI. Conclusions The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age.
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Affiliation(s)
- Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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3
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Shamshad A, Persad-Paisley EM, Wendell LC, Thompson BB, Reznik ME, Furie KL, Mahta A. Association of asymptomatic cerebral vasospasm with outcomes in survivors of aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106821. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 11/21/2022] Open
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4
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Li R, Lin F, Chen Y, Lu J, Han H, Yan D, Li R, Yang J, Li Z, Zhang H, Yuan K, Jin Y, Hao Q, Li H, Zhang L, Shi G, Zhou J, Zhao Y, Zhang Y, Li Y, Wang S, Chen X, Zhao Y. In-hospital complication-related risk factors for discharge and 90-day outcomes in patients with aneurysmal subarachnoid hemorrhage after surgical clipping and endovascular coiling: a propensity score-matched analysis. J Neurosurg 2022; 137:381-392. [PMID: 34972088 DOI: 10.3171/2021.10.jns211484] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE More than 10 years have passed since the two best-known clinical trials of ruptured aneurysms (International Subarachnoid Aneurysm Trial [ISAT] and Barrow Ruptured Aneurysm Trial [BRAT]) indicated that endovascular coiling (EC) was superior to surgical clipping (SC). However, in recent years, the development of surgical techniques has greatly improved; thus, it is necessary to reanalyze the impact of the differences in treatment modalities on the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS The authors retrospectively reviewed all aSAH patients admitted to their institution between January 2015 and December 2020. The functional outcomes at discharge and 90 days after discharge were assessed using the modified Rankin Scale (mRS). In-hospital complications, hospital charges, and risk factors derived from multivariate logistic regression were analyzed in the SC and EC groups after 1:1 propensity score matching (PSM). The area under the receiver operating characteristic curve was used to calculate each independent predictor's prediction ability between treatment groups. RESULTS A total of 844 aSAH patients were included. After PSM to control for sex, aneurysm location, Hunt and Hess grade, World Federation of Neurosurgical Societies (WFNS) grade, modified Fisher Scale grade, and current smoking and alcohol abuse status, 329 patients who underwent SC were compared with 329 patients who underwent EC. Patients who underwent SC had higher incidences of unfavorable discharge and 90-day outcomes (46.5% vs 33.1%, p < 0.001; and 19.6% vs 13.8%, p = 0.046, respectively), delayed cerebral ischemia (DCI) (31.3% vs 20.1%, p = 0.001), intracranial infection (20.1% vs 1.2%, p < 0.001), anemia (42.2% vs 17.6%, p < 0.001), hypoproteinemia (46.2% vs 21.6%, p < 0.001), and pneumonia (33.4% vs 24.9%, p = 0.016); but a lower incidence of urinary tract infection (1.2% vs 5.2%, p = 0.004) and lower median hospital charges ($12,285 [IQR $10,399-$15,569] vs $23,656 [IQR $18,816-$30,025], p < 0.001). A positive correlation between the number of in-hospital complications and total hospital charges was indicated in the SC (r = 0.498, p < 0.001) and EC (r = 0.411, p < 0.001) groups. The occurrence of pneumonia and DCI, WFNS grade IV or V, and age were common independent risk factors for unfavorable outcomes at discharge and 90 days after discharge in both treatment modalities. CONCLUSIONS EC shows advantages in discharge and 90-day outcomes, in-hospital complications, and the number of risk factors but increases the economic cost on patients during their hospital stay. Severe in-hospital complications such as pneumonia and DCI may have a long-lasting impact on the prognosis of patients.
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Affiliation(s)
- Runting Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junlin Lu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Debin Yan
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongchen Jin
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Hao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongliang Li
- 2Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- 2Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- 2Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- 2Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhao
- 3Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yukun Zhang
- 3Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Youxiang Li
- 4Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; and
| | - Shuo Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 5China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 3Department of Neurosurgery, Peking University International Hospital, Beijing, China
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5
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Li R, Lin F, Chen Y, Lu J, Han H, Ma L, Zhao Y, Yan D, Li R, Yang J, He S, Li Z, Zhang H, Yuan K, Wang K, Hao Q, Ye X, Wang H, Li H, Zhang L, Shi G, Zhou J, Zhao Y, Zhang Y, Li Y, Wang S, Chen X, Zhao Y. Elevated blood hemoglobin on admission as an independent predictor of unfavorable outcomes in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 45:2689-2699. [DOI: 10.1007/s10143-022-01780-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
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6
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Croci DM, Sivanrupan S, Wanderer S, Agnoletto GJ, Chiappini A, Grüter BE, Andereggen L, Mariani L, Taussky P, Marbacher S. Preclinical and clinical role of interleukin-6 in the development of delayed cerebral vasospasm and neuronal cell death after subarachnoid hemorrhage: towards a potential target therapy? Neurosurg Rev 2021; 45:395-403. [PMID: 34448990 PMCID: PMC8391870 DOI: 10.1007/s10143-021-01628-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 12/28/2022]
Abstract
Delayed cerebral vasospasm (DCVS), early brain injury (EBI), and delayed cerebral ischemia (DCI) are devastating complications after aneurysmal subarachnoid hemorrhage (SAH). Interleukin (IL)-6 seems to be an important interleukin in the inflammatory response after SAH, and many studies describe a strong correlation between IL-6 and worse outcome. The aim of this study was to systematically review preclinical and clinical studies that evaluated systemic and cerebral IL-6 levels after SAH and their relation to DCVS, neuronal cell death, and DCI. We conducted two systematic literature searches using PubMed to identify preclinical and clinical studies evaluating the role of IL-6 after SAH. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 61 and 30 preclinical and clinical articles, respectively, were included in the systematic reviews. Of the preclinical studies in which IL-6 was measured in cerebrospinal fluid (CSF), parenchyma, and systemically, 100%, 94.4%, and 81.3%, respectively, showed increased expression of IL-6 after SAH. Preclinical results were mirrored by clinical findings in which elevated levels of IL-6 in CSF and plasma were found after SAH, correlating with DCVS, DCI, and worse outcome. Only two preclinical studies analyzed the direct inhibition of IL-6, which resulted in reduced DCVS and neuronal cell death. IL-6 is a marker of intracranial inflammation and plays a role in the pathophysiology of DCVS and DCI after SAH in preclinical animal models and clinical studies. Its inhibition might have therapeutic potential to improve the outcome of SAH patients.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA. .,Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland. .,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland.
| | - Sivani Sivanrupan
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Stefan Wanderer
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Guilherme J Agnoletto
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Alessio Chiappini
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Basil E Grüter
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Lukas Andereggen
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Serge Marbacher
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
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7
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Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, Starke RM, Hosaka K, Polifka AJ, Hoh BL, Chalouhi N. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc 2021; 10:e021845. [PMID: 34325514 PMCID: PMC8475656 DOI: 10.1161/jaha.121.021845] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/09/2021] [Indexed: 01/23/2023]
Abstract
Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.
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Affiliation(s)
- William S. Dodd
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Dimitri Laurent
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Aaron S. Dumont
- Department of Neurological SurgerySchool of MedicineTulane UniversityNew OrleansLA
| | - David M. Hasan
- Department of NeurosurgeryCarver College of MedicineUniversity of IowaIowa CityIA
| | - Pascal M. Jabbour
- Department of Neurological SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPA
| | - Robert M. Starke
- Department of Neurological SurgeryMiller School of MedicineUniversity of MiamiFL
| | - Koji Hosaka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Adam J. Polifka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Brian L. Hoh
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Nohra Chalouhi
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
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8
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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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9
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Walker M, Erdoes MP, Stricker CG, Bothell J, Kelly CM, Levitt MR. Hybrid microcatheter angioplasty for refractory cerebral vasospasm. J Cerebrovasc Endovasc Neurosurg 2021; 23:159-168. [PMID: 34038994 PMCID: PMC8256023 DOI: 10.7461/jcen.2021.e2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/28/2020] [Indexed: 01/02/2023] Open
Abstract
Cerebral vasospasm is a significant cause of morbidity and mortality associated with aneurysmal subarachnoid hemorrhage (aSAH). Intra-arterial chemical and mechanical angioplasty, performed alone or in combination, have been shown to ameliorate cerebral vasospasm and improve patient outcomes. Few options exist for patients who fail these traditional endovascular tactics. We propose a hybrid microcatheter technique that combines the mechanical benefit of transient high pressure induced by microcatheter fluid bolus with a low-dose vasodilator infusion. Five patients with moderate to severe symptomatic vasospasm who failed medical and traditional endovascular management were treated using a hybrid microcatheter technique. All angioplasty procedures were technically successful, and the degree of vasospasm improved following angioplasty. There were no complications related to the cerebral angioplasty procedures. None of the patients required repeat endovascular intervention. Hybrid microcatheter angioplasty may be a useful complement to mechanical or pharmacological techniques in the endovascular management of intractable cerebral vasospasm after aSAH.
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Affiliation(s)
- Melanie Walker
- Department of Neurological Surgery Stroke and Applied Neuroscience Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | - Cory M Kelly
- Department of Neurological Surgery Stroke and Applied Neuroscience Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Michael R Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering and Stroke and Applied Neuroscience Center, University of Washington School of Medicine, Seattle, WA, USA
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10
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Chan AY, Choi EH, Yuki I, Suzuki S, Golshani K, Chen JW, Hsu FP. Cerebral vasospasm after subarachnoid hemorrhage: Developing treatments. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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11
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Angermann M, Jablawi F, Keulers A, Angermann M, Schubert GA, Weiss M, Reich A, Wiesmann M, Nikoubashman O. Posterior reversible encephalopathy syndrome after induced hypertension therapy for delayed cerebral ischemia after subarachnoid hemorrhage: A case-control study. J Neurol Sci 2021; 421:117313. [PMID: 33461062 DOI: 10.1016/j.jns.2021.117313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is associated with arterial hypertension. Our aim was to investigate whether induced hypertension (IH) as therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with PRES and to identify risk factors for PRES. MATERIAL AND METHODS We retrospectively searched our database for patients with SAH and IH in our institution between 2009 and 2018 and identified additional cases of PRES after SAH with IH from the literature. We then analyzed demographic findings and clinical features of these patients. RESULTS 172 patients with acute SAH received IH. PRES was diagnosed in 3/172 (1.7%) patients. Our literature search revealed 17 additional cases. The pooled PRES group (n = 20) was non-significantly older than the non-PRES group (n = 169) (median, 62.5 years vs. 52 years, p = 0.06). No significant differences were found between both groups with regard to sex (p = 0.73), Hunt & Hess-Score (p = 0.9), aneurysm treatment (p = 0.13), and time from diagnosis of SAH to the start of IH (p = 0.14). CONCLUSIONS PRES after IH in SAH patients occurred in 1.7% of our patients. Our results imply that it is important to be aware of a possible development of a PRES in older SAH patients with IH, irrespective of sex, initial clinical status, and treatment modality.
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Affiliation(s)
- Maike Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University Gießen, Germany
| | - Annika Keulers
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Manuel Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany.
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12
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Gál J, Fülesdi B, Varga D, Fodor B, Varga E, Siró P, Bereczki D, Szabó S, Molnár C. Assessment of two prophylactic fluid strategies in aneurysmal subarachnoid hemorrhage: A randomized trial. J Int Med Res 2020; 48:300060520927526. [PMID: 32689849 PMCID: PMC7375726 DOI: 10.1177/0300060520927526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the effect of two prophylactic euvolemic fluid strategy regimens on the incidence of cerebral vasospasm and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS Ninety-six patients with a basal intravenous intake of 15 mL/kg/day of Ringer's lactate solution were included, and an additional 15 to 50 mL/kg/day Ringer's lactate (RL-group) or hydroxyethyl starch 130/0.4 solution (HES-group) was administered to maintain the targeted mean arterial pressure. The primary end point was the occurrence of cerebral vasospasm during the first 14 days. The secondary end points were case fatality, Barthel's index, and Glasgow Outcome Scores (GOS) at 30 days after SAH. RESULTS Cerebral vasospasm developed in 42 patients (43.7%), and nine of these events were severe. The vasospasm rate among the RL- and HES-based groups was 25/48 and 17/48, respectively. For the secondary endpoint, four patients (4%) died by the end of follow-up (two in each group). Unfavorable outcome cases were not different in the RL and HES groups (9 vs. 14, respectively). There was no difference between the Barthel's scores at 30 days between the two groups. CONCLUSIONS Using starches in a prophylactic treatment strategy in aneurysmal SAH in not supported by the study.The trial was registered at Clinicaltrials.gov under the number NCT02064075.
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Affiliation(s)
- Judit Gál
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Dávid Varga
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Babett Fodor
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Eszter Varga
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Péter Siró
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Dániel Bereczki
- Department of Neurology Semmelweis University, Budapest, Hungary
| | - Sándor Szabó
- Department of Neurosurgery, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Csilla Molnár
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
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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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Duangthongphon P, Souwong B, Munkong W, Kitkhuandee A. Results of a Preventive Rebleeding Protocol in Patients with Ruptured Cerebral Aneurysm: A Retrospective Cohort Study. Asian J Neurosurg 2019; 14:748-753. [PMID: 31497096 PMCID: PMC6703019 DOI: 10.4103/ajns.ajns_32_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol. Methodology: Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140–180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4–6 on a modified Rankin scale at 6 and 12 months). Results: Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10–1.63) and in the proportion of patients who presented with good WFNS grades (1–3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17–0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04–0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28–2.28). Conclusion: Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.
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Affiliation(s)
- Pichayen Duangthongphon
- Department of Surgery, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bunika Souwong
- Department of Surgery, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Waranon Munkong
- Department of Radiology, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Amnat Kitkhuandee
- Department of Surgery, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Jabbarli R, Pierscianek D, Rölz R, Darkwah Oppong M, Kaier K, Shah M, Taschner C, Mönninghoff C, Urbach H, Beck J, Sure U, Forsting M. Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage. Neurology 2019; 93:e458-e466. [DOI: 10.1212/wnl.0000000000007862] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 12/20/2022] Open
Abstract
ObjectiveDelayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.MaterialsData from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.ResultsThe final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.ConclusionsA preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.Classification of evidenceThis study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.
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16
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Yamaki VN, Cavalcanti DD, Figueiredo EG. Delayed Ischemic Neurologic Deficit after Aneurysmal Subarachnoid Hemorrhage. Asian J Neurosurg 2019; 14:641-647. [PMID: 31497080 PMCID: PMC6703066 DOI: 10.4103/ajns.ajns_15_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Delayed ischemic neurologic deficit (DIND) is the main preventable cause of poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Of 50% of survivors from a SAH, approximately 30% of patients will present clinical vasospasm (VS). The cornerstone of the DIND management comprises prevention and early identification. Several diagnostic methods have been proposed differing in efficacy, invasiveness, and costs. Serial neurological examination is the most reliable method to detect a new neurological deficit. On the other hand, comatose patients require advanced monitoring methods which identify changes in the microcirculatory environment, brain autoregulation, and spreading depolarization. Multimodality monitoring with continuous electroencephalography, microdialysis, and intracranial pressure monitoring represents altogether the current state-of-art technology for the intensive care of SAH patients. Moreover, advances in genetic biomarkers to predict clinical VS have shown consistent accuracy which may in the near future allow the early prediction of DIND through a simple blood test. Several clinical trials have tested drugs with theoretical effects on DIND prevention or treatment. Nevertheless, nimodipine remains the Holy Grail in the prevention of clinical VS. Among rescue therapies, the endovascular treatment through intra-arterial vasodilator (verapamil or nicardipine) infusion is the most employed method for DIND reversal; however, there is no good quality evidence comparing results of intra-arterial infusion of vasodilators versus balloon angioplasty. Although we have addressed the most refined technology in the management of SAH and DIND, the clinical experience and strict follow-up in neurointensive care will be determinant for favorable long-term outcomes.
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Affiliation(s)
- Vitor Nagai Yamaki
- Department of Neurosurgery, Universidade De Sao Paulo, São Paulo, SP, Brazil
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17
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Murphy A, de Oliveira Manoel AL, Macdonald RL, Baker A, Lee TY, Marotta T, Montanera W, Aviv R, Bharatha A. Changes in Cerebral Perfusion with Induced Hypertension in Aneurysmal Subarachnoid Hemorrhage: A Pilot and Feasibility Study. Neurocrit Care 2018; 27:3-10. [PMID: 28244000 DOI: 10.1007/s12028-017-0379-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The effects of induced hypertension (IH) on cerebral perfusion after subarachnoid hemorrhage (SAH) are unclear. The objectives of this investigation are to: (1) determine whether there are differences in cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) measured with computed tomography perfusion (CTP) before and after IH; (2) evaluate differences in the presence of infarction and clinical outcome between patients with and without IH. METHODS We performed a retrospective cohort analysis of 25 aneurysmal SAH patients. IH was initiated as per the standard institutional protocol when patients showed clinical symptoms of delayed cerebral ischemia (DCI). Differences in CBF, CBV, and MTT between early (<72 h after aneurysm rupture) and late (7-10 days after aneurysm rupture) CTP were quantified in patients with (n = 13) and without IH (n = 12). Outcome measures included cerebral infarction and clinical outcome at 3 months. RESULTS Early MTT was significantly greater in the IH group compared to the no-IH group. There was no difference in early or late CBV or CBF between the two groups. In patients that received IH, there was a significant decrease in MTT between the early (7.0 ± 1.2 s) and late scans (5.8 ± 1.6 s; p = 0.005). There was no difference in the incidence of infarction (5/13 vs. 2/11) or poor outcome (3/11 vs. 6/13) between the IH and no-IH groups, respectively (p > 0.05). CONCLUSIONS Elevated MTT is a significant factor for the development of DCI in patients eventually requiring IH therapy and is improved by IH treatment. Therapies to prevent DCI and improve clinical outcome may need to be initiated earlier, when cerebral perfusion abnormalities are first identified.
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Affiliation(s)
- Amanda Murphy
- Department of Medical Imaging, University of Toronto, 30 Bond Street, Room 3-077CC, Toronto, ON, M5B 1W8, Canada.
| | | | - R Loch Macdonald
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew Baker
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Tom Marotta
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Walter Montanera
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
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18
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Abstract
PURPOSE OF REVIEW With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm. RECENT FINDINGS Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome. SUMMARY Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.
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19
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Van Haren F, Velloza P, Chan S, Mews P, Lueck CJ. Induced hypertension for preventing complications of delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage. Hippokratia 2017. [DOI: 10.1002/14651858.cd012842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Frank Van Haren
- Canberra Hospital; ICU; PO Box 11 Woden ACT Australia 2606
- Australian National University; Canberra Australia
- University of Canberra; Canberra Australia
| | - Peter Velloza
- Canberra Hospital; ICU; PO Box 11 Woden ACT Australia 2606
| | - Sean Chan
- Canberra Hospital; ICU; PO Box 11 Woden ACT Australia 2606
| | - Peter Mews
- Canberra Hospital; Department of Neurosurgery; PO Box 11 Woden ACT Australia 2606
| | - Christian J Lueck
- Australian National University; Canberra Australia
- Canberra Hospital; Department of Neurology; P.O Box 11 Woden Australia 2606
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Burrell C, Avalon NE, Siegel J, Pizzi M, Dutta T, Charlesworth MC, Freeman WD. Precision medicine of aneurysmal subarachnoid hemorrhage, vasospasm and delayed cerebral ischemia. Expert Rev Neurother 2016; 16:1251-1262. [PMID: 27314601 DOI: 10.1080/14737175.2016.1203257] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Precision medicine provides individualized treatment of diseases through leveraging patient-to-patient variation. Aneurysmal subarachnoid hemorrhage carries tremendous morbidity and mortality with cerebral vasospasm and delayed cerebral ischemia proving devastating and unpredictable. Lack of treatment measures for these conditions could be improved through precision medicine. Areas covered: Discussed are the pathophysiology of CV and DCI, treatment guidelines, and evidence for precision medicine used for prediction and prevention of poor outcomes following aSAH. A PubMed search was performed using keywords cerebral vasospasm or delayed cerebral ischemia and either biomarkers, precision medicine, metabolomics, proteomics, or genomics. Over 200 peer-reviewed articles were evaluated. The studies presented cover biomarkers identified as predictive markers or therapeutic targets following aSAH. Expert commentary: The biomarkers reviewed here correlate with CV, DCI, and neurologic outcomes after aSAH. Though practical use in clinical management of aSAH is not well established, using these biomarkers as predictive tools or therapeutic targets demonstrates the potential of precision medicine.
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Affiliation(s)
| | - Nicole E Avalon
- a Department of Neurology , Mayo Clinic , Jacksonville , FL , USA
| | - Jason Siegel
- a Department of Neurology , Mayo Clinic , Jacksonville , FL , USA
| | - Michael Pizzi
- a Department of Neurology , Mayo Clinic , Jacksonville , FL , USA
| | - Tumpa Dutta
- b Endocrine Research Unit , Mayo Clinic , Rochester , MN , USA
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21
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Ehlert A, Manthei G, Hesselmann V, Mathias K, Bein B, Pluta R. A Case of Hyperacute Onset of Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Refractory Vasospasm Treated with Intravenous and Intraventricular Nitric Oxide: A Mini Review. World Neurosurg 2016; 91:673.e11-8. [PMID: 27109628 DOI: 10.1016/j.wneu.2016.04.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/13/2016] [Accepted: 04/14/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND A case of hyperacute vasospasm, indicating a poor prognosis after aneurysmal subarachnoid hemorrhage (SAH), is reported, and a review is presented of the literature addressing use of nitric oxide (NO) donors in cases of refractory vasospasm and recurrent delayed cortical ischemias (DCI). CASE DESCRIPTION A 65-year-old woman was admitted within 1 hour after aneurysmal SAH (Hunt and Hess grade III, Fisher modified by Frontera grade IV). A hyperacute vasospasm had been confirmed arteriographically, the right middle cerebral artery (MCA) aneurysm was immediately coiled and a standard antivasospastic therapy was started. Within 48 hours, the patient developed cerebral vasospasm with DCI. Because the standard therapy failed to control clinical symptoms and to address severe vasospasm, an individualized rescue treatment with NO donors was initiated. A continuous intravenous molsidomine infusion was started and clinical stabilization was achieved for a week (Hunt and Hess grade I; World Federation of Neurological Surgeons grade I; Glasgow Coma Scale score, 15) after which vasospasm and DCI recurred. During a subsequent DCI, we escalated NO donor therapy by adding intraventricular boluses of sodium nitroprusside (SNP). Over the course of the following 22 days, 7 transient DCIs (Glasgow Coma Scale score, 8) were treated with boluses of SNP during continued molsidomine therapy and each time vasospasm and DCI were completely reversed. Despite initial poor prognosis, the clinical outcome was excellent; at 3, 6, and 12 months follow-up the patient's modified National Institutes of Health-Stroke Scale and modified Rankin Scale scores were 0, with no cognitive deficits. CONCLUSIONS The review of the literature suggested that combined intravenous molsidomine with intraventricular SNP treatment reversed refractory, recurrent vasospasm and DCIs probably by addressing the hemoglobin NO sink effect, NO depletion, and decreased NO availability after aneurysmal SAH.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Klinik St. Georg, Hamburg, Germany.
| | - Gerd Manthei
- Department of Neurosurgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Volker Hesselmann
- Department of Neuroradiology, Asklepios Clinic North, Hamburg, Germany
| | - Klaus Mathias
- Department of Neuroradiology, Asklepios Clinic, St. Georg, Hamburg, Germany
| | - Berthold Bein
- Department of Anesthesiology, Asklepios Clinic, St. Georg, Hamburg, Germany
| | - Ryszard Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, Maryland, USA
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Poor outcome is associated with less negative fluid balance in patients with aneurysmal subarachnoid hemorrhage treated with prophylactic vasopressor-induced hypertension. Ann Intensive Care 2016; 6:25. [PMID: 27033710 PMCID: PMC4816937 DOI: 10.1186/s13613-016-0128-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/14/2016] [Indexed: 11/23/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (SAH) is a serious condition associated with high mortality rates and long-term disability. We investigated the impact of fluid balance on neurologic outcome after adjustment for possible confounders related to intensive care therapy and extra-cerebral organ failure during the early phase after SAH. Methods In this retrospective study, we analyzed data from all 142 adult patients admitted to our university hospital surgical intensive care unit (ICU) with SAH between March 2004 and November 2010. Results The mean patient age was 54 ± 14 years, 62.7 % were female, and the median Hunt and Hess score was 3. The proportions of patients with poor outcome (Glasgow Outcome Score ≤3) were 58.4, 54.2, and 52.1 % at 3, 6, and 12 months, respectively, after the SAH. The ICU and hospital mortality rates were both 12.7 %, and the median lengths of stay in the ICU and the hospital were 16 (IQ 7–25) and 26 (IQ 18–34) days, respectively. In multivariable analysis, older age and greater cumulative fluid balance within the first 7 days in the ICU were independently associated with a greater risk of poor outcome. Conclusion In this cohort of patients, older age and greater cumulative fluid balance were independently associated with a greater risk of poor outcome up to 1 year after the initial insult. Our data suggest that mild hypovolemia may be beneficial in the management of these patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0128-6) contains supplementary material, which is available to authorized users.
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Bashir A, Andresen M, Bartek J, Cortsen M, Eskesen V, Wagner A. Intra-arterial nimodipine for cerebral vasospasm after subarachnoid haemorrhage: Influence on clinical course and predictors of clinical outcome. Neuroradiol J 2016; 29:72-81. [PMID: 26825134 DOI: 10.1177/1971400915626429] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intra-arterial nimodipine (IAN) has shown a promising effect on cerebral vasospasm (CV) after aneurysmal subarachnoid haemorrhage. At our institution, Rigshospitalet, IAN treatment has been used since 2009, but the short- and long-term clinical efficacy of IAN has not yet been assessed. The purpose was to evaluate the efficacy and clinical outcome of IAN treatment of symptomatic CV, and to assess the predictors of clinical outcome. Medical records of 25 patients undergoing a total of 41 IAN treatment sessions were retrospectively reviewed. Data on angiographic results, blood-flow velocities and the clinical condition before and after the IAN treatment were recorded. Predictors of the clinical outcome were assessed with a linear regression model. Positive angiographic response was achieved in 95.1% of 41 IAN treatment sessions. Flow-velocity measurements showed no relationship with angiographic responses of IAN. The immediate clinical improvement was observed in three patients (12%). Five patients (20%) had a favourable outcome at discharge and at three-month follow-up; 10 patients (40%) had a moderate to poor outcome; and the rest (40%) died. Increased number of affected vessels and number of procedures carried out per patient, and a trend toward an increased delay time from symptomatic CV to confirming angiographic CV and thus instituting IAN treatment predicted the poor clinical outcome. IAN treatment appears to be effective in reversing angiographic CV. However, it is not always effective in reversing clinical deterioration, as several other factors including treatment delay affect the clinical course.
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Affiliation(s)
- Asma Bashir
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jiri Bartek
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Cortsen
- Department of Radiology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Aase Wagner
- Department of Radiology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Assessment of circulating blood volume with fluid administration targeting euvolemia or hypervolemia. Neurocrit Care 2016; 22:82-8. [PMID: 25142828 DOI: 10.1007/s12028-014-9993-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The occurrence of hypovolemia in the setting of cerebral vasospasm reportedly increases the risk for delayed ischemic neurologic deficits. Few studies have objectively assessed blood volume (BV) in response to fluid administration targeting normovolemia (NV) or hypervolemia (HV) and none have done so with crystalloids alone. The primary purpose was to evaluate the BV of patients with SAH receiving crystalloid fluid administration targeting NV or HV. METHODS The University of Washington IRB approved the study. Prospectively collected data was obtained from patients enrolled in a clinical trial and a concurrent group of patients who received IV fluids during the ICU stay. We defined a normovolemia (NV) and hypervolemia (HV) group based on the cumulative amount of IV fluid administered in mL/kg from ICU admission to day 5; ≥30-60 mL/kg/day (NV) and ≥60 mL/kg/day (HV), respectively. In a subgroup of patients, BV was measured on day 5 post ictus using iodinated (131)I-labeled albumin injection and the BVA-100 (Daxor Corp, New York, NY). Differences between the NV and HV groups were compared using Student's t-test with assumption for unequal variance. RESULTS Twenty patients in the NV and 19 in the HV groups were included. The HV group received more fluid and had a higher fluid balance than the NV group. The subgroup of patients in whom BV was measured on day 5 (n = 19) was not different from the remainder of the cohort with respect to the total amount of administered fluid and net cumulative fluid balance by day 5. BV was not different between the two groups and varied widely. CONCLUSIONS Routinely targeting prophylactic HV using crystalloids does not result in a higher circulating BV compared to targeting NV, but the possibility of clinically unrecognized hypovolemia remains.
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Anaesthetic and ICU management of aneurysmal subarachnoid haemorrhage: a survey of European practice. Eur J Anaesthesiol 2015; 32:168-76. [PMID: 25303971 DOI: 10.1097/eja.0000000000000163] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many aspects of the perioperative management of aneurysmal subarachnoid haemorrhage (SAH) remain controversial. It would be useful to assess differences in the treatment of SAH in Europe to identify areas for improvement. OBJECTIVE To determine the clinical practice of physicians treating SAH and to evaluate any discrepancy between practice and published evidence. DESIGN An electronic survey. PARTICIPANTS Physicians identified through each national society of neuroanaesthesiology and neurocritical care. INTERVENTIONS A 31-item online questionnaire was distributed by the ENIG group. Questions were designed to investigate anaesthetic management of SAH and diagnostic and treatment approaches to cerebral vasospasm. The survey was available from early October to the end of November 2012. RESULTS Completed surveys were received from 268 respondents, of whom 81% replied that aneurysm treatment was conducted early (within 24 h). Sixty-five percent of centres treated more than 60% of SAH by coiling, 19% had high-volume clipping (>60% of aneurysms clipped) and 16% used both methods equally. No clear threshold for arterial blood pressure target was identified during coiling, temporary clipping or in patients without vasospasm after the aneurysm had been secured. Almost all respondents used nimodipine (97%); 21% also used statins and 20% used magnesium for prevention of vasospasm. A quarter of respondents used intra-arterial vasodilators alone, 5% used cerebral angioplasty alone and 48% used both endovascular methods to treat symptomatic vasospasm. In high-volume clipping treatment centres, 58% of respondents used endovascular methods to manage vasospasm compared with 86% at high-volume coiling treatment centres (P < 0.001). The most commonly used intra-arterial vasodilator was nimodipine (82%), but milrinone was used by 23% and papaverine by 19%. More respondents (44%) selected 'triple-H' therapy over hypertension alone (30%) to treat vasospasm. CONCLUSION We found striking variability in the practice patterns of European physicians involved in early treatment of SAH. Significant differences were noted among countries and between high and low-volume coiling centres.
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Abstract
AbstractCerebral vasospasm is a prolonged but reversible narrowing of cerebral arteries beginning days after subarachnoid hemorrhage. Progression to cerebral ischemia is tied mostly to vasospasm severity, and its pathogenesis lies in artery encasement by blood clot, although the complex interactions between hematoma and surrounding structures are not fully understood. The delayed onset of vasospasm provides a potential opportunity for its prevention. It is disappointing that recent randomized, controlled trials did not demonstrate that the endothelin antagonist clazosentan, the cholesterol-lowering agent simvastatin, and the vasodilator magnesium sulfate improve patient outcome. Minimizing ischemia by avoiding inadequate blood volume and pressure, administering the calcium antagonist nimodipine, and intervention with balloon angioplasty, when necessary, constitutes current best management. Over the past two decades, our ability to manage vasospasm has led to a significant decline in patient morbidity and mortality from vasospasm, yet it still remains an important determinant of outcome after aneurysm rupture.
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Kissoon NR, Mandrekar JN, Fugate JE, Lanzino G, Wijdicks EFM, Rabinstein AA. Positive Fluid Balance Is Associated With Poor Outcomes in Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:2245-51. [PMID: 26277290 DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/19/2015] [Accepted: 05/28/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Strict maintenance of normovolemia is standard of care in the treatment of aneurysmal subarachnoid hemorrhage (aSAH), and induced hypervolemia is often used to treat delayed cerebral ischemia from vasospasm. We tested the hypothesis that positive fluid balance could adversely affect clinical outcomes in aSAH. METHODS We reviewed 288 patients with aSAH admitted to the Neuroscience Intensive Care Unit (NICU) from October 2001 to June 2011. We collected data on fluid balance during NICU stay, clinical and radiographic evidence of vasospasm, cardiopulmonary complications, and functional outcomes by modified Rankin Scale (mRS) on follow-up (mean 8 ± 8 months). Poor functional outcome was defined as an mRS score 3-6. Associations of variables of interest with outcome were assessed using univariable and multivariable logistic regression. Propensity scores were estimated to account for imbalances between patients with positive versus negative fluid balance and were included in multivariable models. RESULTS Average net fluid balance during the NICU stay was greater in patients with poor functional outcome (3.52 ± 5.51 L versus -.02 ± 5.30 L in patients with good outcome; P < .001). On multivariate analysis, positive fluid balance (P = .002) was independently associated with poor functional outcome along with World Federation of Neurosurgical Societies grade (P < .001), transfusion (P = .003), maximum glucose (P = .005), and radiological evidence of cerebral infarction (P = .008). After regression adjustment with propensity scores, the association of positive fluid balance with poor functional outcome remained significant (odds ratio, 1.18; 95% confidence interval, 1.08-1.29; P < .001). CONCLUSIONS Greater positive net fluid balance is independently associated with poorer functional outcome in patients with aSAH.
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Affiliation(s)
| | - Jay N Mandrekar
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
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Baker M, Bastin MT, Cook AM, Fraser J, Hessel E. Hypoxemia associated with nimodipine in a patient with an aneurysmal subarachnoid hemorrhage. Am J Health Syst Pharm 2015; 72:39-43. [PMID: 25511836 DOI: 10.2146/ajhp140196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE A case of probable nimodipine-induced hypoxemia in a patient undergoing treatment for aneurysmal subarachnoid hemorrhage (SAH) is reported. SUMMARY A 62-year-old man hospitalized for SAH developed symptoms of respiratory distress on several occasions within days of initiation of nimodipine therapy (60 mg every four hours, with three doses withheld during intubation for intracranial surgery). Several hours after extubation (on hospital day 5), the patient had rapidly worsening tachypnea and declining arterial oxygen saturation (SPO2) despite increased oxygen delivery by mask, necessitating reintubation. When a nurse noted that the declines in SPO2 occurred soon after nimodipine administration, the patient's respiratory and hemodynamic functions were closely monitored after a single dose of nimodipine via nasogastic tube; the monitoring results supported the suspicion that nimodipine's vascular effects were a causal or contributory factor in the hypoxemia episodes. With subsequent fractionated dosing (30 mg every two hours), the patient completed the prescribed 21-day course of nimodipine therapy. Using the rating scale of Naranjo et al., this case was assigned a score of 7, indicating a probable pulmonary adverse reaction to nimodipine. As nimodipine is commonly used in cases of SAH to reduce delayed neurologic deficits due to persistent cerebral vasospasm, clinicians should be mindful of its potential hypoxemic effects in vulnerable patients. CONCLUSION A patient with aneurysmal SAH developed hypoxemia associated with the administration of nimodipine. Hypoxemia is a known complication of treatment with other vasodilatory agents, particularly in patients who have concomitant pulmonary disease.
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Affiliation(s)
- Matthew Baker
- Matthew Baker, M.D., is Assistant Professor, Anesthesiology, Department of Anesthesiology, University of Kentucky (UK) College of Medicine, Lexington. Melissa Thompson Bastin, Pharm.D., is Critical Care Pharmacist, Pharmacy Services, UK HealthCare, and Department of Pharmacy Practice and Science, UK College of Pharmacy, Lexington. Aaron M. Cook, Pharm.D., is Coordinator, Neuroscience-Pulmonary/Critical Care, Pharmacy Services, UK HealthCare, and Assistant Adjunct Professor, Department of Pharmacy Practice and Science, UK College of Pharmacy. Justin Fraser, M.D., is Assistant Professor, Neurosurgery, Department of Neurosurgery; and Eugene Hessel II, M.D., is Professor, Anesthesiology, Department of Anesthesiology, UK College of Medicine
| | - Melissa Thompson Bastin
- Matthew Baker, M.D., is Assistant Professor, Anesthesiology, Department of Anesthesiology, University of Kentucky (UK) College of Medicine, Lexington. Melissa Thompson Bastin, Pharm.D., is Critical Care Pharmacist, Pharmacy Services, UK HealthCare, and Department of Pharmacy Practice and Science, UK College of Pharmacy, Lexington. Aaron M. Cook, Pharm.D., is Coordinator, Neuroscience-Pulmonary/Critical Care, Pharmacy Services, UK HealthCare, and Assistant Adjunct Professor, Department of Pharmacy Practice and Science, UK College of Pharmacy. Justin Fraser, M.D., is Assistant Professor, Neurosurgery, Department of Neurosurgery; and Eugene Hessel II, M.D., is Professor, Anesthesiology, Department of Anesthesiology, UK College of Medicine
| | - Aaron M Cook
- Matthew Baker, M.D., is Assistant Professor, Anesthesiology, Department of Anesthesiology, University of Kentucky (UK) College of Medicine, Lexington. Melissa Thompson Bastin, Pharm.D., is Critical Care Pharmacist, Pharmacy Services, UK HealthCare, and Department of Pharmacy Practice and Science, UK College of Pharmacy, Lexington. Aaron M. Cook, Pharm.D., is Coordinator, Neuroscience-Pulmonary/Critical Care, Pharmacy Services, UK HealthCare, and Assistant Adjunct Professor, Department of Pharmacy Practice and Science, UK College of Pharmacy. Justin Fraser, M.D., is Assistant Professor, Neurosurgery, Department of Neurosurgery; and Eugene Hessel II, M.D., is Professor, Anesthesiology, Department of Anesthesiology, UK College of Medicine.
| | - Justin Fraser
- Matthew Baker, M.D., is Assistant Professor, Anesthesiology, Department of Anesthesiology, University of Kentucky (UK) College of Medicine, Lexington. Melissa Thompson Bastin, Pharm.D., is Critical Care Pharmacist, Pharmacy Services, UK HealthCare, and Department of Pharmacy Practice and Science, UK College of Pharmacy, Lexington. Aaron M. Cook, Pharm.D., is Coordinator, Neuroscience-Pulmonary/Critical Care, Pharmacy Services, UK HealthCare, and Assistant Adjunct Professor, Department of Pharmacy Practice and Science, UK College of Pharmacy. Justin Fraser, M.D., is Assistant Professor, Neurosurgery, Department of Neurosurgery; and Eugene Hessel II, M.D., is Professor, Anesthesiology, Department of Anesthesiology, UK College of Medicine
| | - Eugene Hessel
- Matthew Baker, M.D., is Assistant Professor, Anesthesiology, Department of Anesthesiology, University of Kentucky (UK) College of Medicine, Lexington. Melissa Thompson Bastin, Pharm.D., is Critical Care Pharmacist, Pharmacy Services, UK HealthCare, and Department of Pharmacy Practice and Science, UK College of Pharmacy, Lexington. Aaron M. Cook, Pharm.D., is Coordinator, Neuroscience-Pulmonary/Critical Care, Pharmacy Services, UK HealthCare, and Assistant Adjunct Professor, Department of Pharmacy Practice and Science, UK College of Pharmacy. Justin Fraser, M.D., is Assistant Professor, Neurosurgery, Department of Neurosurgery; and Eugene Hessel II, M.D., is Professor, Anesthesiology, Department of Anesthesiology, UK College of Medicine
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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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Effect of triple-h prophylaxis on global end-diastolic volume and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 21:462-9. [PMID: 24865266 DOI: 10.1007/s12028-014-9973-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although prophylactic triple-H therapy has been used in a number of institutions globally to prevent delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), limited evidence is available for the effectiveness of triple-H therapy on hemodynamic variables. Recent studies have suggested an association between low global end-diastolic volume index (GEDI), measured using a transpulmonary thermodilution method, and DCI onset. The current study aimed at assessing the effects of prophylactic triple-H therapy on GEDI. METHODS This prospective multicenter study included aneurysmal SAH patients admitted to 9 hospitals in Japan. The decision to administer prophylactic triple-H therapy and the management protocols were left to the physician in charge (physician-directed therapy) of each participating institution. The primary endpoints were the changes in the hemodynamic variables as analyzed using a generalized linear mixed model. RESULTS Of 178 patients, 62 (34.8 %) received prophylactic triple-H therapy and 116 (65.2 %) did not. DCI was observed in 35 patients (19.7 %), with no significant difference between the two groups [15 (24.2 %) vs. 20 (17.2 %), p = 0.27]. Although a greater amount of fluid (p < 0.001) and a higher mean arterial pressure (p = 0.005) were observed in the triple-H group, no significant difference was observed between the groups in GEDI (p = 0.81) or cardiac output (p = 0.62). CONCLUSIONS Physician-directed prophylactic triple-H administration was not associated with improved clinical outcomes or quantitative hemodynamic indicators for intravascular volume. Further, GEDI-directed intervention studies are warranted to better define management algorithms for SAH patients with the aim of preventing DCI.
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Abstract
BACKGROUND Despite intensive research, neurological morbidity from delayed cerebral ischemia remains common after aneurysmal subarachnoid hemorrhage (SAH). In the current study, we evaluate the neuroprotective effects of a pH-dependent GluN2B subunit-selective NMDA receptor antagonist in a murine model of SAH. METHODS Following induction of SAH, 12 ± 2 week old male C57-BL/6 mice received NP10075, a pH-dependent NMDA receptor antagonist, or vehicle. In a separate series of experiments, NP10075 and the non-pH sensitive NMDA antagonist, NP10191, were administered to normoglycemic and hyperglycemic mice. Both histological (right middle cerebral artery diameter, NeuN, and Fluoro-Jade B staining) and functional endpoints (rotarod latency and neuroseverity score) were evaluated to assess the therapeutic benefit of NP10075. RESULTS Administration of NP10075 was well tolerated and had minimal hemodynamic effects following SAH. Administration of the pH-sensitive NMDA antagonist NP10075, but not NP10191, was associated with a durable improvement in the functional performance of both normoglycemic and hyperglycemic animals. NP10075 was also associated with a reduction in vasospasm in the middle cerebral artery associated with hemorrhage. There was no significant difference between treatment with nimodipine + NP10075, as compared to NP10075 alone. CONCLUSIONS These data demonstrate that use of a pH-dependent NMDA antagonist has the potential to work selectively in areas of ischemia known to undergo acidic pH shifts, and thus may be associated with selective regional efficacy and fewer behavioral side effects than non-selective NMDA antagonists.
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Togashi K, Joffe AM, Sekhar L, Kim L, Lam A, Yanez D, Broeckel-Elrod JA, Moore A, Deem S, Khandelwal N, Souter MJ, Treggiari MM. Randomized Pilot Trial of Intensive Management of Blood Pressure or Volume Expansion in Subarachnoid Hemorrhage (IMPROVES). Neurosurgery 2015; 76:125-34; discussion 134-5; quiz 135. [DOI: 10.1227/neu.0000000000000592] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Pathological mechanisms underlying aneurysmal subarachnoid haemorrhage and vasospasmElsevier Ltd. J Clin Neurosci 2015; 22:1-5. [DOI: 10.1016/j.jocn.2014.05.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/27/2014] [Accepted: 05/04/2014] [Indexed: 11/18/2022]
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A Non-Human Primate Model of Aneurismal Subarachnoid Hemorrhage (SAH). Transl Stroke Res 2014; 5:681-91. [DOI: 10.1007/s12975-014-0371-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/04/2014] [Accepted: 09/04/2014] [Indexed: 02/04/2023]
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Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy. ACTA ACUST UNITED AC 2014; 52:77-84. [DOI: 10.1016/j.aat.2014.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/08/2014] [Indexed: 11/23/2022]
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Ibrahim GM, Macdonald RL. The effects of fluid balance and colloid administration on outcomes in patients with aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis. Neurocrit Care 2014; 19:140-9. [PMID: 23715669 DOI: 10.1007/s12028-013-9860-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Delayed ischemic neurological deficit (DIND) following aneurysmal subarachnoid hemorrhage (SAH) remains a significant cause of mortality and disability. The administration of colloids and the induction of a positive fluid balance during the vasospasm risk period remain controversial. Here, we compared DIND and outcomes among propensity score-matched cohorts who did and did not receive colloids and also tested the effect of a positive fluid balance on these endpoints. METHODS Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1, a prospective randomized trial of clazosentan for the prevention of angiographic vasospasm. Propensity score matching was performed on the basis of age, gender, pre-existing heart conditions, hypertension, nicotine use, World Federation of Neurosurgical Societies scores, aneurysm location, clazosentan treatment, subarachnoid clot burden, and severity of angiographic vasospasm. Inferential statistics were used for group-wise comparisons. RESULTS One hundred twenty-three subjects were matched (41 received colloids, whereas 82 did not). The covariate balance and propensity score distributions were acceptable. There was no difference between the groups with respect to DIND (17 vs. 22%; p = 0.64) or the presence (48 vs. 51%; p = 0.71) or volume of delayed infarcts (volume >7.5 cm3; 62 vs. 48%; p = 0.41). Similarly, no differences were found on multivariate analysis between patients who did and did not have a positive fluid balance, although patients with severe angiographic vasospasm had more delayed infarcts with a negative fluid balance (p = 0.01). Among all subjects, the administration of colloids and a positive fluid balance were associated with worse outcomes on the NIHSS (p = 0.04) and modified Rankin (p = 0.02) scales, respectively. CONCLUSIONS Colloid administration and induction of a positive fluid balance during the vasospasm risk period may be associated with poor outcomes in specific patient groups. Patient selection is of utmost importance when managing the fluid status of patients with aneurysmal SAH.
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Affiliation(s)
- George M Ibrahim
- Division of Neurosurgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada,
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Mutoh T, Kazumata K, Terasaka S, Taki Y, Suzuki A, Ishikawa T. Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage. Stroke 2014; 45:1280-4. [PMID: 24692480 DOI: 10.1161/strokeaha.114.004739] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The results of previous studies suggest that early goal-directed fluid therapy (EGDT) reduces delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but the effects of EGDT on clinical outcomes are still unclear. This study aimed to determine whether EGDT improves outcomes compared with standard less-invasive hemodynamic therapy. METHODS This study included 160 patients treated within 24 hours after subarachnoid hemorrhage, randomized to receive either (1) EGDT guided by preload volume and cardiac output monitored by transpulmonary thermodilution (treatment group) or (2) standard therapy guided by fluid balance or central venous pressure, assisted by uncalibrated less-invasive cardiac output monitoring during hyperdynamic therapy in patients with clinical or radiological indications of DCI (control group). DCI determined by clinical or radiological findings and functional outcome determined by the modified Rankin Scale score at 3 months were compared between groups. RESULTS For all clinical grades combined, there were no significant differences in the rates of DCI (33% versus 42%; P=0.33) or modified Rankin Scale score of 0 to 3 at 3 months (67% versus 57%; P=0.22) between the 2 groups. For patients with poor clinical grade, those who received EGDT had a significantly lower rate of DCI (5% versus 14%; P=0.036), modified Rankin Scale score of 0 to 3 at 3 months (52% versus 36%; P=0.026), and shorter length of intensive care unit stay (14 versus 17 days; P=0.043) than those who received standard therapy. CONCLUSIONS EGDT is beneficial for reducing DCI and improving postoperative functional outcome in patients with poor clinical grade. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: UMIN000007509.
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Affiliation(s)
- Tatsushi Mutoh
- From the Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan (T.M., A.S., T.I.); Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Japan (K.K.); Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan (T.M., Y.T.); and Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan (K.K., S.T.)
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Kim BC, Kwon OK, Oh CW, Bang JS, Hwang G, Jin SC, Park H. Endovascular internal carotid artery trapping for ruptured blood blister-like aneurysms: long-term results from a single centre. Neuroradiology 2014; 56:211-7. [PMID: 24430115 DOI: 10.1007/s00234-014-1317-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Endovascular internal carotid artery (ICA) trapping was performed to treat ruptured blood blister-like aneurysms (BBAs). The aim of this study was to evaluate the procedural risks and long-term follow-up results. METHODS The records of 11 consecutive patients with BBAs who underwent endovascular ICA trapping between 2005 and 2010 were reviewed. Clinical outcomes were assessed with modified Rankin Scale (mRS) scores. RESULTS Endovascular ICA trapping was performed in 11 patients as either the primary treatment (7 patients) or the secondary treatment (4 patients) after the patient underwent other treatments. Three patients underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass when balloon test occlusion (BTO) revealed inadequate collateral circulation. In the primary ICA trapping group (seven patients), six patients had good outcomes (mRS 0 in five, mRS 1 in one), and one patient had a poor outcome (mRS 6: dead). In the secondary ICA trapping group (four patients), two patients had good outcomes (mRS 0), and two patients had poor outcomes (mRS 4, 5). All ten of the surviving patients were clinically stable during the follow-up period (mean 39 months). A radiological follow-up of nine patients (mean 22 months) demonstrated stable occlusion, with the exception of one reopening of the ICA because of coil migration. Perfusion studies of nine patients (mean: 23 months) demonstrated no perfusion decrease. CONCLUSION Endovascular ICA trapping is an effective and durable treatment for BBAs.
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Affiliation(s)
- Byong-Cheol Kim
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, South Korea
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Naranjo D, Arkuszewski M, Rudzinski W, Melhem ER, Krejza J. Brain ischemia in patients with intracranial hemorrhage: pathophysiological reasoning for aggressive diagnostic management. Neuroradiol J 2013; 26:610-28. [PMID: 24355179 PMCID: PMC4202872 DOI: 10.1177/197140091302600603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/15/2013] [Indexed: 11/15/2022] Open
Abstract
Patients with intracranial hemorrhage have to be managed aggressively to avoid or minimize secondary brain damage due to ischemia, which contributes to high morbidity and mortality. The risk of brain ischemia, however, is not the same in every patient. The risk of complications associated with an aggressive prophylactic therapy in patients with a low risk of brain ischemia can outweigh the benefits of therapy. Accurate and timely identification of patients at highest risk is a diagnostic challenge. Despite the availability of many diagnostic tools, stroke is common in this population, mostly because the pathogenesis of stroke is frequently multifactorial whereas diagnosticians tend to focus on one or two risk factors. The pathophysiological mechanisms of brain ischemia in patients with intracranial hemorrhage are not yet fully elucidated and there are several important areas of ongoing research. Therefore, this review describes physiological and pathophysiological aspects associated with the development of brain ischemia such as the mechanism of oxygen and carbon dioxide effects on the cerebrovascular system, neurovascular coupling and respiratory and cardiovascular factors influencing cerebral hemodynamics. Consequently, we review investigations of cerebral blood flow disturbances relevant to various hemodynamic states associated with high intracranial pressure, cerebral embolism, and cerebral vasospasm along with current treatment options.
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Affiliation(s)
- Daniel Naranjo
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Michal Arkuszewski
- Department of Neurology, Medical University of Silesia, Central University Hospital; Katowice, Poland
| | - Wojciech Rudzinski
- Department of Cardiology, Robert Packer Hospital; Sayre, Pennsylvania USA
| | - Elias R. Melhem
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Jaroslaw Krejza
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
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Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand? Neurol Res Int 2013; 2013:373458. [PMID: 24228177 PMCID: PMC3817677 DOI: 10.1155/2013/373458] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 09/02/2013] [Accepted: 09/04/2013] [Indexed: 11/21/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 persons in the United States each year. Around 30 percent of patients with aneurysmal subarachnoid hemorrhage suffer from cerebral ischemia and infarction due to cerebral vasospasm, a leading cause of treatable death and disability following aneurysmal subarachnoid hemorrhage. Methods used to predict, diagnose, and manage vasospasm are the topic of recent active research. This paper utilizes a comprehensive review of the recent literature to address controversies surrounding these topics. Evidence regarding the effect of age, smoking, and cocaine use on the incidence and outcome of vasospasm is reviewed. The abilities of different computed tomography grading schemes to predict vasospasm in the aftermath of subarachnoid hemorrhage are presented. Additionally, the utility of different diagnostic methods for the detection and visualization of vasospasm, including transcranial Doppler ultrasonography, CT angiography, digital subtraction angiography, and CT perfusion imaging is discussed. Finally, the recent literature regarding interventions for the prophylaxis and treatment of vasospasm, including hyperdynamic therapy, albumin, calcium channel agonists, statins, magnesium sulfate, and endothelin antagonists is summarized. Recent studies regarding each topic were reviewed for consensus recommendations from the literature, which were then presented.
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Latorre JGS, Lodi Y, El-Zammar Z, Devasenapathy A. Is asymptomatic vasospasm associated with poor outcome in subarachnoid hemorrhage? Neurohospitalist 2013; 1:165-71. [PMID: 23983851 DOI: 10.1177/1941875211413134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Vasospasm occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH), but only half becomes symptomatic. It is unclear whether asymptomatic vasospasm (AV) detected by noninvasive testing affects outcome. Prophylactic hemodilutional, hypertensive, and hypervolemic (HHH) therapy is widely used but the benefit remains unproven. We aim to determine whether AV increases the risk of poor outcome and whether HHH is safe. METHODS A total of 175 consecutive patients with aSAH without clinical vasospasm were included. Patients with sonographic (transcranial doppler) or radiologic (computed tomography [CT] Angiography) vasospasm were assigned to AV group, while those without were assigned to no vasospasm (NV) group. Logistic regression was used to determine the association between AV and HHH on poor outcome, defined as modified Rankin scale (mRS) >3 at discharge or 3 to 6 months' follow-up. RESULTS In all, 106 patients had NV and 25 received HHH. A total of 69 patients had AV and 54 received HHH. Asymptomatic vasospasm compared to NV was not associated with poor outcome (odds ratio [OR] 2.6, 95% confidence interval [CI]: 0.75-8.9; P = .1). Hemodilutional, hypertensive, and hypervolemic use in patients with AV did not improve the outcome (OR 0.16, 95%CI: 0.009-2.84; P = .2). In patients with NV, HHH use showed trend toward poor outcome after multivariable adjustment (OR 12.6, 95%CI: 1.08-146.5 P = .04). CONCLUSION Asymptomatic vasospasm does not appear to be associated with poor outcome in aSAH. Hemodilutional, hypertensive, and hypervolemic therapy in AV was not associated with improved outcome and may be harmful to patients who do not have vasospasm. Further research is needed to validate this finding.
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Carlson AP, Yonas H. Radiographic assessment of vasospasm after aneurysmal subarachnoid hemorrhage: the physiological perspective. Neurol Res 2013; 31:593-604. [DOI: 10.1179/174313209x455754] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Titova E, Ostrowski RP, Zhang JH, Tang J. Experimental models of subarachnoid hemorrhage for studies of cerebral vasospasm. Neurol Res 2013; 31:568-81. [DOI: 10.1179/174313209x382412] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Gathier CS, van den Bergh WM, Slooter AJC. HIMALAIA (Hypertension Induction in the Management of AneurysmaL subArachnoid haemorrhage with secondary IschaemiA): a randomized single-blind controlled trial of induced hypertension vs. no induced hypertension in the treatment of delayed cerebral ischemia after subarachnoid hemorrhage. Int J Stroke 2013; 9:375-80. [PMID: 23692645 DOI: 10.1111/ijs.12055] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 11/20/2012] [Indexed: 11/28/2022]
Abstract
RATIONALE Delayed cerebral ischemia (DCI) is a major complication after aneurysmal subarachnoid hemorrhage (SAH). One option to treat delayed cerebral ischemia is to use induced hypertension, but its efficacy on the eventual outcome has not been proven in a randomized clinical trial. This article describes the design of the HIMALAIA trial (Hypertension Induction in the Management of AneurysmaL subArachnoid haemorrhage with secondary IschaemiA), designed to assess the effectiveness of induced hypertension on neurological outcome in patients with DCI after SAH. AIMS To investigate whether induced hypertension improves the functional outcome in patients with delayed cerebral ischemia after SAH. DESIGN The HIMALAIA trial is a multicenter, singe-blinded, randomized controlled trial in patients with DCI after a recent SAH. Eligible patients will be randomized to either induced hypertension (n = 120) or to no induced hypertension (n = 120). In selected centers, the efficacy of induced hypertension in augmenting cerebral blood flow will be measured by means of cerebral perfusion computerized tomography scanning. Follow-up assessments will be performed at 3 and 12 months after randomization by trial nurses who are blinded to the treatment allocation and management. We will include patients during five years. STUDY OUTCOMES The primary outcome is the proportion of subarachnoid hemorrhage patients with delayed cerebral ischemia with poor outcome three-months after randomization, defined as a modified Rankin scale of more than 3. Secondary outcome measures are related to treatment failure, functional outcome, adverse events, and cerebral hemodynamics. The HIMALAIA trial is registered at clinicaltrials.gov under identifier NCT01613235.
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Affiliation(s)
- C S Gathier
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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Medical Management of Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage: A Review of Current and Emerging Therapeutic Interventions. Neurol Res Int 2013; 2013:462491. [PMID: 23691312 PMCID: PMC3649802 DOI: 10.1155/2013/462491] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 03/23/2013] [Indexed: 12/17/2022] Open
Abstract
Cerebral vasospasm is a major source of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Evidence suggests a multifactorial etiology and this concept remains supported by the assortment of therapeutic modalities under investigation. The authors provide an updated review of the literature for previous and recent clinical trials evaluating medical treatments in patients with cerebral vasospasm secondary to aSAH. Currently, the strongest evidence supports use of prophylactic oral nimodipine and initiation of triple-H therapy for patients in cerebral vasospasm. Other agents presented in this report include magnesium, statins, endothelin receptor antagonists, nitric oxide promoters, free radical scavengers, thromboxane inhibitors, thrombolysis, anti-inflammatory agents and neuroprotectants. Although promising data is beginning to emerge for several treatments, few prospective randomized clinical trials are presently available. Additionally, future investigational efforts will need to resolve discrepant definitions and outcome measures for cerebral vasospasm in order to permit adequate study comparisons. Until then, definitive recommendations cannot be made regarding the safety and efficacy for each of these therapeutic strategies and medical management practices will continue to be implemented in a wide-ranging manner.
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The impact of experimental preconditioning using vascular endothelial growth factor in stroke and subarachnoid hemorrhage. Stroke Res Treat 2013; 2013:948783. [PMID: 23634319 PMCID: PMC3619542 DOI: 10.1155/2013/948783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/28/2013] [Indexed: 01/17/2023] Open
Abstract
Vascular endothelial growth factor (VEGF) stimulating angiogenesis was shown to be a potential novel therapeutic approach for the treatment of ischemic vascular diseases. The goal of the present study was to examine whether transfection of VEGF before occurrence of major stroke (part I) and cerebral vasospasm after experimental subarachnoid hemorrhage (SAH; part II) develops neuroprotective qualities. A total of 25 (part I) and 26 (part II) brains were analyzed, respectively. In part one, a significant reduction of infarct volume in the VEGF-treated stroke animals (43% reduction, P < 0.05) could be detected. In part two, significant vasospasm was induced in all hemorrhage groups (P < 0.02). Analyzing microperfusion, a significant higher amount of perfused vessels could be detected (P < 0.01), whereas no significant effect could be detected towards macroperfusion. Histologically, no infarctions were observed in the VEGF-treated SAH group and the sham-operated group. Minor infarction in terms of vasospasm-induced small lesions could be detected in the control vector transduced group (P = 0.05) and saline-treated group (P = 0.09). The present study demonstrates the preconditioning impact of systemic intramuscular VEGF injection in animals after major stroke and induced severe vasospasm after SAH.
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Martini RP, Deem S, Brown M, Souter MJ, Yanez ND, Daniel S, Treggiari MM. The association between fluid balance and outcomes after subarachnoid hemorrhage. Neurocrit Care 2013; 17:191-8. [PMID: 21688008 DOI: 10.1007/s12028-011-9573-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We sought to determine the association between early fluid balance and neurological/vital outcome of patients with subarachnoid hemorrhage. METHODS Hospital admission, imaging, ICU and outcome data were retrospectively collected from the medical records of adult patients with aneurysmal SAH admitted to a level-1 trauma and stroke referral center during a 5-year period. Two groups were identified based on cumulative fluid balance by ICU day 3: (i) patients with a positive fluid balance (n = 221) and (ii) patients with even or negative fluid balance (n = 135). Multivariable logistic regression was used to adjust for age, Hunt-Hess and Fisher scores, mechanical ventilation and troponin elevation (>0.40 ng/ml) at ICU admission. The primary outcome was a composite of hospital mortality or new stroke. RESULTS Patients with positive fluid balance had worse admission GCS and Hunt-Hess score, and by ICU day 3 had cumulatively received more IV fluids, but had less urine output when compared with the negative fluid balance group. There was no difference in the odds of hospital death or new stroke (adjusted OR: 1.47, 95%CI: 0.85, 2.54) between patients with positive and negative fluid balance. However, positive fluid balance was associated with increased odds of TCD vasospasm (adjusted OR 2.25, 95%CI: 1.37, 3.71) and prolonged hospital length of stay. CONCLUSIONS Although handling of IV fluid administration was not an independent predictor of mortality or new stroke, patients with early positive fluid balance had worse clinical presentation and had greater resource use during the hospital course.
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Affiliation(s)
- Ross P Martini
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Washington, USA.
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Rondeau N, Cinotti R, Rozec B, Roquilly A, Floch H, Groleau N, Michel P, Asehnoune K, Blanloeil Y. Dobutamine-induced high cardiac index did not prevent vasospasm in subarachnoid hemorrhage patients: a randomized controlled pilot study. Neurocrit Care 2013; 17:183-90. [PMID: 22826137 DOI: 10.1007/s12028-012-9732-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prevention of vasospasm is a challenging issue in subarachnoid hemorrhage (SAH) patients and the objective is to compare high dobutamine-induced cardiac index (CI) and high norepinephrine-induced hypertension for the prevention of vasospasm in SAH patients. METHODS Single center, single blind, controlled randomized study. Patients hospitalized in intensive care unit (ICU) for a moderate to severe SAH (WFNS grade ≥2) were randomized to receive dobutamine to reach a 25 % increase in cardiac index or norepinephrine to reach a mean arterial pressure ≥100 mmHg. Norepinephrine could be used in the dobutamine group to maintain a cerebral pressure perfusion ≥60 mmHg. Primary endpoint was the incidence of angiographic vasospasm in the first 14 days in the ICU setting, which was upheld by a cerebral arteriography. Secondary endpoints were the incidence of delayed ischemic deficits, duration of mechanical ventilation, and ICU length of stay (LOS). RESULTS During the 3-year study, 41 patients were randomized. Six patients were excluded--3 because of consent withdrawal and 3 who did not receive the assigned treatment. Respectively, 17 and 18 patients in the dobutamine and the norepinephrine group were kept in analysis. Five (28 %) patients in the dobutamine group and 5 (27 %) patients in the norepinephrine group developed vasospasm in ICU (p = 1). Seven (41 %) patients presented a delayed ischemic deficit in the dobutamine group and 9 (50 %) in the norepinephrine group (p = 0.24). Duration of mechanical ventilation was 8 [0.5-11.5] days in the dobutamine group and 19 [2.7-23] days in the norepinephrine group (p = 0.01). ICU LOS was 11 [6-15] days in the dobutamine group and 21 [9-28] days in the norepinephrine group (p = 0.01). CONCLUSION As compared to norepinephrine-induced hypertension, dobutamine-induced high CI did not reduce the rate of vasospasm in SAH patients. Dobutamine may reduce durations of mechanical ventilation and ICU LOS.
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Affiliation(s)
- Nelly Rondeau
- Service Anesthésie-Réanimation, Hôpital Guillaume et René Laennec, Boulevard Jacques Monod, Centre Hospitalo-Universitaire, 44093 cedex Nantes, France.
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Abstract
Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.
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Lannes M, Teitelbaum J, del Pilar Cortés M, Cardoso M, Angle M. Milrinone and homeostasis to treat cerebral vasospasm associated with subarachnoid hemorrhage: the Montreal Neurological Hospital protocol. Neurocrit Care 2012; 16:354-62. [PMID: 22528278 DOI: 10.1007/s12028-012-9701-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION For the treatment of cerebral vasospasm, current therapies have focused on increasing blood flow through blood pressure augmentation, hypervolemia, the use of intra-arterial vasodilators, and angioplasty of proximal cerebral vessels. Through a large case series, we present our experience of treating cerebral vasospasm with a protocol based on maintenance of homeostasis (correction of electrolyte and glucose disturbances, prevention and treatment of hyperthermia, replacement of fluid losses), and the use of intravenous milrinone to improve microcirculation (the Montreal Neurological Hospital protocol). Our objective is to describe the use milrinone in our practice and the neurological outcomes associated with this approach. METHODS Large case series based on the review of all patients diagnosed with delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage between April 1999 and April 2006. RESULTS 88 patients were followed for a mean time of 44.6 months. An intravenous milrinone infusion was used for a mean of 9.8 days without any significant side effects. No medical complications associated with this protocol were observed. There were five deaths; of the surviving patients, 48.9 % were able to go back to their previous baseline and 75 % had a good functional outcome (modified Rankin scale ≤ 2). CONCLUSION A protocol using intravenous milrinone, and the maintenance of homeostasis is simple to use and requires less intensive monitoring and resources than the standard triple H therapy. Despite the obvious limitations of this study's design, we believe that it would be now appropriate to proceed with formal prospective studies of this protocol.
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Affiliation(s)
- Marcelo Lannes
- Department of Anesthesia, Faculty of Medicine McGill University, Montreal Neurological Hospital, Room 548, 3801 University Street, Montreal, QC H3A 2B4, Canada.
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