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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Weiland J, Beez A, Westermaier T, Kunze E, Sirén AL, Lilla N. Neuroprotective Strategies in Aneurysmal Subarachnoid Hemorrhage (aSAH). Int J Mol Sci 2021; 22:5442. [PMID: 34064048 PMCID: PMC8196706 DOI: 10.3390/ijms22115442] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) remains a disease with high mortality and morbidity. Since treating vasospasm has not inevitably led to an improvement in outcome, the actual emphasis is on finding neuroprotective therapies in the early phase following aSAH to prevent secondary brain injury in the later phase of disease. Within the early phase, neuroinflammation, thromboinflammation, disturbances in brain metabolism and early neuroprotective therapies directed against delayed cerebral ischemia (DCI) came into focus. Herein, the role of neuroinflammation, thromboinflammation and metabolism in aSAH is depicted. Potential neuroprotective strategies regarding neuroinflammation target microglia activation, metalloproteases, autophagy and the pathway via Toll-like receptor 4 (TLR4), high mobility group box 1 (HMGB1), NF-κB and finally the release of cytokines like TNFα or IL-1. Following the link to thromboinflammation, potential neuroprotective therapies try to target microthrombus formation, platelets and platelet receptors as well as clot clearance and immune cell infiltration. Potential neuroprotective strategies regarding metabolism try to re-balance the mismatch of energy need and supply following aSAH, for example, in restoring fuel to the TCA cycle or bypassing distinct energy pathways. Overall, this review addresses current neuroprotective strategies in aSAH, hopefully leading to future translational therapy options to prevent secondary brain injury.
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Affiliation(s)
- Judith Weiland
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Alexandra Beez
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
- Department of Neurosurgery, Helios-Amper Klinikum Dachau, Krankenhausstr. 15, 85221 Dachau, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Anna-Leena Sirén
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider Str. 11, 97080 Würzburg, Germany; (A.B.); (T.W.); (E.K.); (A.-L.S.)
- Department of Neurosurgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
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Neuroprotective effect of magnesium supplementation on cerebral ischemic diseases. Life Sci 2021; 272:119257. [PMID: 33631176 DOI: 10.1016/j.lfs.2021.119257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 01/31/2021] [Accepted: 02/19/2021] [Indexed: 02/07/2023]
Abstract
Ischemic encephalopathy is associated with a high mortality and rate of disability. The most common type of ischemic encephalopathy, ischemic stroke, is the second leading cause of death in the world. At present, the main treatment for ischemic stroke is to reopen blocked blood vessels. However, despite revascularization, many patients are not able to achieve good functional results. At the same time, the strict time window (<4.5 h) of thrombolytic therapy limits clinical application. Therefore, it is important to explore effective neuroprotective drugs for the treatment of ischemic stroke. Magnesium is a natural calcium antagonist, which exerts neuroprotective effects through various mechanisms. However, while most basic studies have shown that magnesium supplementation can help treat cerebral ischemia, intravenous magnesium supplementation in large clinical trials has failed to improve prognosis of ischemic patients. Therefore, we review the basic and clinical studies of magnesium supplementation for cerebral ischemia. According to the route of administration, treatment can be divided into intraperitoneal magnesium supplementation, intravenous magnesium supplementation, arterial magnesium supplementation and intracranial magnesium supplementation. We also summarized the potential influencing factors of magnesium ion intervention in cerebral ischemia injury. Finally, in combination with influencing factors derived from basic research, this article proposes three future research directions, including magnesium supplementation into the circulatory system combined with magnesium supplementation in the lateral ventricle, magnesium supplementation in the lateral ventricle combined with hypothermia therapy, and lateral ventricle magnesium supplementation combined with intracarotid magnesium supplementation combined with selective hypothermia.
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Ma Q, Liu D, Gong R, Chen S, Fang F, Zhuang Y. Mechanically Induced Vasospasm-Evaluation of Spasmolytic Efficacy of 10 Pharmaceutical Agents Using Laser Speckle Contrast Imaging. Lasers Surg Med 2020; 53:684-694. [PMID: 33259664 DOI: 10.1002/lsm.23347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Vasospasm is a thorny problem often encountered in microvascular surgery that seriously threatens the survival of vascularized tissue transfers. This investigation is dedicated to establishing a model of vasospasm and to evaluating the antispasmodic efficacy of 10 pharmacologic agents. STUDY DESIGN/MATERIALS AND METHODS Eighty Sprague-Dawley rats were used. After anesthesia and depilation, the femoral neurovascular bundle was exposed, and a pair of microsurgical forceps were used to trigger vasospasm of the femoral vessels by blunt dissection. Then, 10 pharmacological agents, namely, prostaglandin E1, sodium nitroprusside, magnesium sulfate, papaverine, normal saline, phentolamine, verapamil, 2% lidocaine hydrochloride, amrinone, and 12% lidocaine hydrochloride, were dripped to the femoral vessels, after which laser speckle contrast imaging was used to collect perfusion images, acquiring the perfusion and the inner caliber of the femoral vessels at multiple timepoints. Furthermore, blood perfusion and the time consumed to escape vasospasm and reach hyperperfusion in each group were calculated. The difference of spasmolytic efficacy among the agents was statistically analyzed by one-way analysis of variance. RESULTS There was a significant difference in antispasmodic ability among the 10 agents (P < 0.001). 10% magnesium sulfate and 12% lidocaine were distinguished among the 10 agents in resolving the vasospasm. 10% magnesium sulfate demonstrated the best antispasmodic potency, which enabled the shortest time consumed for vessels to escape spasm and reach hyperperfusion. 12% lidocaine ranked second in efficacy, demonstrating a similar effect except that it could not propel the femoral vein to a state of hyperperfusion. For the remaining agents, the time consumed for the artery to escape spasm was all significantly shortened when compared with normal saline (P < 0.001). For the venous spasm, all agents except prostaglandin E1 could significantly shorten the time consumed for the vein to escape spasm (P < 0.001). CONCLUSIONS In terms of resolving mechanically induced vasospasm, 10% magnesium sulfate is the best antispasmodic, followed by 12% lidocaine. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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Affiliation(s)
- Qiming Ma
- Fujian Key Laboratory of Brain Aging and Neurodegenerative Diseases, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, 350108, China
| | - Donghong Liu
- Aesthetic Department, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, 271000, China
| | - Renyan Gong
- Department of clinical medicine, Fujian Health College, Fuzhou, 350108, China
| | - Shaofeng Chen
- Fujian Key Laboratory of Brain Aging and Neurodegenerative Diseases, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, 350108, China
| | - Fang Fang
- Department of Pharmacology, Fujian Medical University, Fuzhou, China
| | - Yuehong Zhuang
- Fujian Key Laboratory of Brain Aging and Neurodegenerative Diseases, School of Basic Medical Sciences, Institute of Clinical Applied Anatomy, Fujian Medical University, Fuzhou, 350108, China
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The role of nimodipine and magnesium sulfate in the prevention and treatment of vascular spasm in patients in the acute rupture of cerebral aneurysms. ACTA ACUST UNITED AC 2020. [DOI: 10.17816/clinpract19137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vascular spasm in patients with hemorrhage from rupture of cerebral aneurysms is the main cause of adverse outcomes of the disease. One way to treat persistent contraction of cerebral arteries is to use nimodipine and magnesium sulfate. This literature review presents studies on the use of nimodipine and magnesium sulfate in the treatment of vascular spasm, and highlights the main links of pathogenesis and drug action mechanisms.
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Fábián ÁI, Csernoch V, Tassonyi E, Fedor M, Fülesdi B. The effect of magnesium on the reversal of rocuronium-induced neuromuscular block with sugammadex: an ex vivo laboratory study. BMC Anesthesiol 2019; 19:64. [PMID: 31043175 PMCID: PMC6495643 DOI: 10.1186/s12871-019-0734-6] [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] [Received: 08/31/2018] [Accepted: 04/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Magnesium dose-dependently potentiates the effect of non-depolarizing neuromuscular blocking agents. We investigated whether the potentiation of rocuronium-induced blockade by magnesium reduces the effect of sugammadex in an ex-vivo environment and how this influences the safety margin of reversal. METHODS Phrenic nerve - hemidiaphragm tissue preparations were isolated from male Wistar rats. The specimens were suspended in a tissue holder that allowed registering muscle contraction amplitude following electrical stimulation of the nerve. Concentration-response relationships were elucidated for magnesium, as well as for rocuronium and sugammadex. RESULTS The mean (95% confidence interval [CI]) half effective concentrations (EC50) of rocuronium in the presence of magnesium 1 mM or 1.5 mM were 7.50 μM (6.97-8.07 μM) and 4.25 μM (4.09-4.41 μM), respectively (p < 0.0001). Increasing magnesium from 1 mM to 1.5 mM during reversal of rocuronium-induced block increased the mean (95% CI) EC50 of sugammadex from 3.67 μM (3.43-3.92 μM) to 5.36 μM (5.18-5.53 μM), whereas mean (95% CI) effective concentrations for 95% effect (EC95) were not significantly different at 7.22 μM (6.09-8.54 μM) and 7.61 μM (7.05-8.20 μM), respectively (p = 0.542). When rocuronium-induced block was reversed to a train-of-four (TOF) ratio > 0.9, but with still visible fade, increasing magnesium from 1 mM to 2 mM decreased the TOF ratio to below 0.9. If there was no visible fade after reversal, increasing magnesium concentration did not reduce the TOF ratio. CONCLUSIONS Magnesium potentiates the neuromuscular effect of rocuronium and shifts the concentration-response curve to the left. Magnesium decreases the safety margin of reversal of rocuronium-induced neuromuscular block with sugammadex.
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Affiliation(s)
- Ákos I Fábián
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, 4012, Hungary
| | - Vera Csernoch
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, 4012, Hungary
| | - Edömér Tassonyi
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, 4012, Hungary
| | - Marianna Fedor
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, 4012, Hungary
| | - Béla Fülesdi
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, 4012, Hungary.
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7
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Soliman R, Zohry G. [Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. Rev Bras Anestesiol 2018; 69:64-71. [PMID: 30409409 DOI: 10.1016/j.bjan.2018.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/19/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.
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Affiliation(s)
- Rabie Soliman
- Cairo University, Department of Anesthesia, Cairo, Egito.
| | - Gomaa Zohry
- Cairo University, Department of Anesthesia, Cairo, Egito
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Soliman R, Zohry G. [Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2018; 69. [PMID: 30409409 PMCID: PMC9391725 DOI: 10.1016/j.bjane.2018.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.
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Affiliation(s)
- Rabie Soliman
- Cairo University, Department of Anesthesia, Cairo, Egito.
| | - Gomaa Zohry
- Cairo University, Department of Anesthesia, Cairo, Egito
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Kunze E, Lilla N, Stetter C, Ernestus RI, Westermaier T. Magnesium Protects in Episodes of Critical Perfusion after Aneurysmal SAH. Transl Neurosci 2018; 9:99-105. [PMID: 30191076 PMCID: PMC6124155 DOI: 10.1515/tnsci-2018-0016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/20/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To analyze whether magnesium has a neuroprotective effect during episodes that indicate a critical brain perfusion after aneurysmal subarachnoid hemorrhage (SAH). METHODS 107 patients with aSAH were randomized to continuously receive intravenous magnesium sulfate with target serum levels of 2.0 - 2.5 mmol/l (n = 54) or isotonic saline (n = 53). Neurological examination and transcranial Doppler sonography (TCD) were performed daily, Perfusion-CT (PCT) was acquired in 3-day intervals, angiography in case of suspected vasospasm. The primary endpoint was the development of secondary infarction following episodes of delayed ischemic neurological deficit (DIND), elevated mean flow velocity (MFV) in TCD or pathological findings in PCT. RESULTS In the magnesium group, 9 episodes of DIND were registered, none was followed by secondary infarction. In the control group, 23 episodes of DIND were registered, 9 were followed by secondary infarction (p < 0.05). In the magnesium group, 114 TCD-measurements showed an elevated MFV(> 140 cm/s). 7 were followed by new infarction. In control patients, 135 measurements showed elevated MFV, 32 were followed by new infarction (p < 0.05). 10 of 117 abnormal PCT-findings were followed by new infarction, compared to 30 of 122 in the control-group (p < 0.05). CONCLUSION DIND, elevated MFV in TCD and abnormal PCT are findings which are associated with an increased risk to develop delayed secondary infarction. The results of this analysis suggest that magnesium-treatment may reduce the risk to develop infarction in a state of critical brain perfusion.
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Affiliation(s)
- Ekkehard Kunze
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
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Park ES, Kim DW, Kang SD. Endovascular Treatment of Symptomatic Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Three-year Experience. J Cerebrovasc Endovasc Neurosurg 2017; 19:155-161. [PMID: 29159148 PMCID: PMC5680078 DOI: 10.7461/jcen.2017.19.3.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/28/2017] [Accepted: 09/17/2017] [Indexed: 11/23/2022] Open
Abstract
Objective The cause of severe clinical vasospasm after aneurysmal subarachnoid hemorrhage remains unknown, despite extensive research over the past 30 years. However, the intra-arterial administration of vasodilating agents and balloon angioplasty have been successfully used in severe refractory cerebral vasospasm. Materials and Methods We retrospectively analyzed the data of 233 patients admitted to our institute with aneurysmal subarachnoid hemorrhage (SAH) over the past 3 years. Results Of these, 27 (10.6%) developed severe symptomatic vasospasm, requiring endovascular therapy. Vasospasm occurred at an average of 5.3 days after SAH. A total of 46 endovascular procedures were performed in 27 patients. Endovascular therapy was performed once in 18 (66.7%) patients, 2 times in 4 (14.8%) patients, 3 or more times in 5 (18.5%) patients. Intra-arterial vasodilating agents were used in 44 procedures (27 with nimodipine infusion, 17 with nicardipine infusion). Balloon angioplasty was performed in only 2 (7.4%) patients. The Average nimodipine infusion volume was 2.47 mg, and nicardipine was 3.78 mg. Most patients recovered after the initial emergency room visit. Two patients (7.4%) worsened, but there were no deaths. Conclusion With advances in endovascular techniques, administration of vasodilating agents and balloon angioplasty reduces the morbidity and mortality of vasospasm after aneurysmal SAH.
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Affiliation(s)
- Eun-Sung Park
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
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Panahi Y, Mojtahedzadeh M, Najafi A, Ghaini MR, Abdollahi M, Sharifzadeh M, Ahmadi A, Rajaee SM, Sahebkar A. The role of magnesium sulfate in the intensive care unit. EXCLI JOURNAL 2017; 16:464-482. [PMID: 28694751 PMCID: PMC5491924 DOI: 10.17179/excli2017-182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/22/2017] [Indexed: 01/27/2023]
Abstract
Magnesium (Mg) has been developed as a drug with various clinical uses. Mg is a key cation in physiological processes, and the homeostasis of this cation is crucial for the normal function of body organs. Magnesium sulfate (MgSO4) is a mineral pharmaceutical preparation of magnesium that is used as a neuroprotective agent. One rationale for the frequent use of MgSO4 in critical care is the high incidence of hypomagnesaemia in intensive care unit (ICU) patients. Correction of hypomagnesaemia along with the neuroprotective properties of MgSO4 has generated a wide application for MgSO4 in ICU.
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Affiliation(s)
- Yunes Panahi
- Clinical Pharmacy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ghaini
- Department of Neurosurgery and Neurology, Sina Hospital, Tehran University, Iran
| | - Mohammad Abdollahi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sharifzadeh
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyyed Mahdi Rajaee
- Clinical Pharmacy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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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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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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Humphrey S, Kirby R, Rudloff E. Magnesium physiology and clinical therapy in veterinary critical care. J Vet Emerg Crit Care (San Antonio) 2014; 25:210-25. [PMID: 25427407 DOI: 10.1111/vec.12253] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 09/30/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To review magnesium physiology including absorption, excretion, and function within the body, causes of magnesium abnormalities, and the current applications of magnesium monitoring and therapy in people and animals. ETIOLOGY Magnesium plays a pivotal role in energy production and specific functions in every cell in the body. Disorders of magnesium can be correlated with severity of disease, length of hospital stay, and recovery of the septic patient. Hypermagnesemia is seen infrequently in people and animals with significant consequences reported. Hypomagnesemia is more common in critically ill people and animals, and can be associated with platelet, immune system, neurological, and cardiovascular dysfunction as well as alterations in insulin responsiveness and electrolyte imbalance. DIAGNOSIS Measurement of serum ionized magnesium in critically or chronically ill veterinary patients is practical and provides information necessary for stabilization and treatment. Tissue magnesium concentrations may be assessed using nuclear magnetic resonance spectroscopy as well as through the application of fluorescent dye techniques. THERAPY Magnesium infusions may play a therapeutic role in reperfusion injury, myocardial ischemia, cerebral infarcts, systemic inflammatory response syndromes, tetanus, digitalis toxicity, bronchospasms, hypercoagulable states, and as an adjunct to specific anesthetic or analgesic protocols. Further veterinary studies are needed to establish the frequency and importance of magnesium disorders in animals and the potential benefit of magnesium infusions as a therapeutic adjunct to specific diseases. PROGNOSIS The prognosis for most patients with magnesium disorders is variable and largely dependent on the underlying cause of the disorder.
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Affiliation(s)
- Sarah Humphrey
- From the Animal Emergency Center and Specialty Services, Glendale, WI 52309
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15
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Upadhyay Dhungel K, Kim TW, Sharma N, Bhattarai JP, Ah Park S, Han SK, Kim CJ. Magnesium increases iberiotoxin-sensitive large conductance calcium activated potassium currents on the basilar artery smooth muscle cells in rabbits. Neurol Res 2013; 34:11-6. [DOI: 10.1179/1743132811y.0000000049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Kshitiz Upadhyay Dhungel
- Cerebrovascular Laboratory-Department of NeurosurgeryResearch Institute of Clinical Medicine, Chonbuk National University Medical School & Hospital, Jeonju, Korea
| | - Tae Woon Kim
- Cerebrovascular Laboratory-Department of NeurosurgeryResearch Institute of Clinical Medicine, Chonbuk National University Medical School & Hospital, Jeonju, Korea
| | - Naveen Sharma
- Cerebrovascular Laboratory-Department of NeurosurgeryResearch Institute of Clinical Medicine, Chonbuk National University Medical School & Hospital, Jeonju, Korea
| | - Janardhan Prasad Bhattarai
- Department of Oral Physiology & Institute of Oral BioscienceSchool of Dentistry, Chonbuk National University, Jeonju, Korea
| | - Seon Ah Park
- Department of Oral Physiology & Institute of Oral BioscienceSchool of Dentistry, Chonbuk National University, Jeonju, Korea
| | - Seong Kyu Han
- Department of Oral Physiology & Institute of Oral BioscienceSchool of Dentistry, Chonbuk National University, Jeonju, Korea
| | - Chul Jin Kim
- Cerebrovascular Laboratory-Department of NeurosurgeryResearch Institute of Clinical Medicine, Chonbuk National University Medical School & Hospital, Jeonju, Korea
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Intravenous magnesium therapy in adult patients with an aneurysmal subarachnoid haemorrhage: A systematic review and meta-analysis. Aust Crit Care 2013; 26:105-17. [DOI: 10.1016/j.aucc.2013.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 05/21/2013] [Accepted: 05/27/2013] [Indexed: 11/30/2022] Open
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Kerz T, Victor A, Beyer C, Trapp I, Heid F, Reisch R. A case control study of statin and magnesium administration in patients after aneurysmal subarachnoid hemorrhage: incidence of delayed cerebral ischemia and mortality. Neurol Res 2013; 30:893-7. [DOI: 10.1179/174313208x338034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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18
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Odom MJ, Zuckerman SL, Mocco J. The role of magnesium in the management of cerebral vasospasm. Neurol Res Int 2013; 2013:943914. [PMID: 23766903 PMCID: PMC3674682 DOI: 10.1155/2013/943914] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 04/29/2013] [Accepted: 05/01/2013] [Indexed: 11/17/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is characterized by bleeding into the subarachnoid space, often caused by ruptured aneurysm. Aneurysmal rupture occurs in 700,000 individuals per year worldwide, with 40,000 cases taking place in the United States. Beyond the high mortality associated with SAH alone, morbidity and mortality are further increased with the occurrence of cerebral vasospasm, a pathologic constriction of blood vessels that can lead to delayed ischemic neurologic deficits (DIND). Treatment of cerebral vasospasm is a source of contention. One extensively studied therapy is Magnesium (Mg) as both a competitive antagonist of calcium at the N-methyl D-aspartate (NMDA) receptor, and a noncompetitive antagonist of both IP3 and voltage-gated calcium channels, leading to smooth muscle relaxation. In our literature review, several animal and human studies are summarized in addition to two Phase III trials assessing the use of intravenous Mg in the treatment of SAH (IMASH and MASH-2). Though many studies have shown promise for the use of Mg in SAH, there has been inconsistency in study design and outcomes. Furthermore, the results of the recently completed clinical trials have shown no significant benefit from using intravenous Mg as adjuvant therapy in the treatment of cerebral vasospasm.
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Affiliation(s)
- Mitchell J. Odom
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Scott L. Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - J Mocco
- Department of Neurological Surgery, Vanderbilt University School of Medicine, 1211 Medical Center Drive, Nashville, TN 37232, USA
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Muradov JM, Hagg T. Intravenous infusion of magnesium chloride improves epicenter blood flow during the acute stage of contusive spinal cord injury in rats. J Neurotrauma 2013; 30:840-52. [PMID: 23302047 PMCID: PMC3660110 DOI: 10.1089/neu.2012.2670] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Vasospasm, hemorrhage, and loss of microvessels at the site of contusive or compressive spinal cord injury lead to infarction and initiate secondary degeneration. Here, we used intravenous injection of endothelial-binding lectin followed by histology to show that the number of perfused microvessels at the injury site is decreased by 80-90% as early as 20 min following a moderate T9 contusion in adult female rats. Hemorrhage within the spinal cord also was maximal at 20 min, consistent with its vasoconstrictive actions in the central nervous system (CNS). Microvascular blood flow recovered to up to 50% of normal volume in the injury penumbra by 6 h, but not at the epicenter. A comparison with an endothelial cell marker suggested that many microvessels fail to be reperfused up to 48 h post-injury. The ischemia was probably caused by vasospasm of vessels penetrating the parenchyma, because repeated Doppler measurements over the spinal cord showed a doubling of total blood flow over the first 12 h. Moreover, intravenous infusion of magnesium chloride, used clinically to treat CNS vasospasm, greatly improved the number of perfused microvessels at 24 and 48 h. The magnesium treatment seemed safe as it did not increase hemorrhage, despite the improved parenchymal blood flow. However, the treatment did not reduce acute microvessel, motor neuron or oligodendrocyte loss, and when infused for 7 days did not affect functional recovery or spared epicenter white matter over a 4 week period. These data suggest that microvascular blood flow can be restored with a clinically relevant treatment following spinal cord injury.
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Affiliation(s)
- Johongir M. Muradov
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Theo Hagg
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, Kentucky
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Westermaier T, Stetter C, Kunze E, Willner N, Raslan F, Vince GH, Ernestus RI. Magnesium treatment for neuroprotection in ischemic diseases of the brain. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2013; 5:6. [PMID: 23618347 PMCID: PMC3642016 DOI: 10.1186/2040-7378-5-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 04/21/2013] [Indexed: 01/01/2023]
Abstract
This article reviews experimental and clinical data on the use of magnesium as a neuroprotective agent in various conditions of cerebral ischemia. Whereas magnesium has shown neuroprotective properties in animal models of global and focal cerebral ischemia, this effect could not be reproduced in a large human stroke trial. These conflicting results may be explained by the timing of treatment. While treatment can be started before or early after ischemia in experimental studies, there is an inevitable delay of treatment in human stroke. Magnesium administration to women at risk for preterm birth has been investigated in several randomized controlled trials and was found to reduce the risk of neurological deficits for the premature infant. Postnatal administration of magnesium to babies after perinatal asphyxia has been studied in a number of controlled clinical trials. The results are promising but the trials have, so far, been underpowered. In aneurysmal subarachnoid hemorrhage (SAH), cerebral ischemia arises with the onset of delayed cerebral vasospasm several days after aneurysm rupture. Similar to perinatal asphyxia in impending preterm delivery, treatment can be started prior to ischemia. The results of clinical trials are conflicting. Several clinical trials did not show an additive effect of magnesium with nimodipine, another calcium antagonist which is routinely administered to SAH patients in many centers. Other trials found a protective effect after magnesium therapy. Thus, it may still be a promising substance in the treatment of secondary cerebral ischemia after aneurysmal SAH. Future prospects of magnesium therapy are discussed.
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Affiliation(s)
- Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Nadine Willner
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Furat Raslan
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Giles H Vince
- Department of Neurosurgery, Klinikum Klagenfurt, Feschnigstraße 11, Klagenfurt am Wörthersee 9020, Austria
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
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Siasios I, Kapsalaki EZ, Fountas KN. Cerebral vasospasm pharmacological treatment: an update. Neurol Res Int 2013; 2013:571328. [PMID: 23431440 PMCID: PMC3572649 DOI: 10.1155/2013/571328] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 12/27/2012] [Indexed: 11/17/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage- (aSAH-) associated vasospasm constitutes a clinicopathological entity, in which reversible vasculopathy, impaired autoregulatory function, and hypovolemia take place, and lead to the reduction of cerebral perfusion and finally ischemia. Cerebral vasospasm begins most often on the third day after the ictal event and reaches the maximum on the 5th-7th postictal days. Several therapeutic modalities have been employed for preventing or reversing cerebral vasospasm. Triple "H" therapy, balloon and chemical angioplasty with superselective intra-arterial injection of vasodilators, administration of substances like magnesium sulfate, statins, fasudil hydrochloride, erythropoietin, endothelin-1 antagonists, nitric oxide progenitors, and sildenafil, are some of the therapeutic protocols, which are currently employed for managing patients with aSAH. Intense pathophysiological mechanism research has led to the identification of various mediators of cerebral vasospasm, such as endothelium-derived, vascular smooth muscle-derived, proinflammatory mediators, cytokines and adhesion molecules, stress-induced gene activation, and platelet-derived growth factors. Oral, intravenous, or intra-arterial administration of antagonists of these mediators has been suggested for treating patients suffering a-SAH vasospam. In our current study, we attempt to summate all the available pharmacological treatment modalities for managing vasospasm.
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Affiliation(s)
- Ioannis Siasios
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Eftychia Z. Kapsalaki
- Department of Diagnostic Radiology, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Biopolis, 41110 Larissa, Greece
- Institute of Biomolecular & Biomedical Research (BIOMED), Center for Research and Technology - Thessaly (CERETETH), 38500 Larissa, Greece
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22
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Barry C, Turner RJ, Corrigan F, Vink R. New therapeutic approaches to subarachnoid hemorrhage. Expert Opin Investig Drugs 2012; 21:845-59. [DOI: 10.1517/13543784.2012.683113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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Velat GJ, Kimball MM, Mocco JD, Hoh BL. Vasospasm after aneurysmal subarachnoid hemorrhage: review of randomized controlled trials and meta-analyses in the literature. World Neurosurg 2012; 76:446-54. [PMID: 22152574 DOI: 10.1016/j.wneu.2011.02.030] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 02/08/2011] [Accepted: 02/12/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Cerebral vasospasm is a major source of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). A variety of therapies have been utilized to prevent or treat vasospasm. Despite the large number of clinical trials, few randomized controlled trials (RCTs) of sufficient quality have been published. We review the RCTs and meta-analyses in the literature regarding the treatment and prevention of cerebral vasospasm following aneurysmal SAH. METHODS A literature search of MEDLINE, the Cochrane Controlled Trials Registry, and the National Institutes of Health/National Library of Medicine clinical trials registry was performed in January 2010 using predefined search terms. These trials were critically reviewed and categorized based on therapeutic modality. RESULTS Forty-four RCTs and 9 meta-analyses met the search criteria. Significant findings from these trials were analyzed. The results of this study were as follows: nimodipine demonstrated benefit following aneurysmal SAH; other calcium channel blockers, including nicardipine, do not provide unequivocal benefit; triple-H therapy, fasudil, transluminal balloon angioplasty, thrombolytics, endothelin receptor antagonists, magnesium, statins, and miscellaneous therapies such as free radical scavengers and antifibrinolytics require additional study. Tirilazad is ineffective. CONCLUSIONS There are many possible successful treatment options for preventing vasospasm, delayed ischemic neurologic deficits, and poor neurologic outcome following aneurysmal subarachnoid hemorrhage; however, further multicenter RCTs need to be performed to determine if there is a significant benefit from their use. Nimodipine is the only treatment that provided a significant benefit across multiple studies.
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Affiliation(s)
- Gregory J Velat
- Department of Neurological Surgery, University of Florida, McKnight Brain Institute, Gainesville, Florida, USA
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Abstract
Magnesium offers theoretic vascular and neuroprotective benefits for patients with subarachnoid hemorrhage. An electronic literature search was conducted to identify original research studies describing intravenous magnesium treatment in patients with SAH published in English between January 1990 and October 2010. Seventeen articles were identified and reviewed, including one phase III randomized-controlled clinical trial and six phase II randomized-controlled trials. Study quality was low for most of the included studies, with the phase III trial considered to be of moderate quality. Due to inconsistently reported benefits and the occurrence of side effects, phase II data suggested that intravenous magnesium for SAH provided either no overall net benefit or uncertain trade-offs. Benefit was likewise not supported in the single phase III clinical trial.
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Affiliation(s)
- Jose I Suarez
- Department of Neurology, Baylor College of Medicine, 6501 Fannin St, NB302, Houston, TX 77030, USA,
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25
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Kumar R, Friedman JA. Subarachnoid hemorrhage: the first 24 hours. A surgeon's perspective. Neurocrit Care 2011; 14:287-90. [PMID: 21076892 DOI: 10.1007/s12028-010-9466-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The first 24 h in the management of aneurysmal subarachnoid hemorrhage (SAH) represent a critical time period for medical intervention. METHODS We review the current literature and discuss our current clinical practices related to management of acute SAH. RESULTS A brief objective review of the current evidence along with a subjective overview of the authors practices in the management of aneurysmal subarachnoid hemorrhage in the first 24 h is outlined. CONCLUSIONS The first 24 h following aneurysmal subarachnoid hemorrhage is a critical time period in which medical and interventional management paradigms continue to evolve.
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Affiliation(s)
- R Kumar
- Department of Neuroscience and Experimental Therapeutics, Texas A&M Health Science Center College of Medicine, Bryan-College Station, TX 77802, USA.
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Mori K, Yamamoto T, Miyazaki M, Hara Y, Aiko Y, Koike N, Sakamoto S, Nakao Y, Esaki T. Effect of intrathecal magnesium sulfate solution injection via a microcatheter in the cisterna magna on cerebral vasospasm in the canine subarachnoid haemorrhage model. Br J Neurosurg 2011; 26:64-8. [PMID: 21767131 DOI: 10.3109/02688697.2011.591948] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate intracisternal injection of magnesium sulfate (MgSO(4)) solution via a lumbar catheter for the treatment of cerebral vasospasm in the canine subarachnoid haemorrhage (SAH) model. MATERIALS AND METHODS SAH was induced in 7 beagle dogs using the dual haemorrhage model. Vertebral angiography was repeated on Day 1 (before SAH), and on Day 7 (during cerebral vasospasm) before and 1.5 hours after injection of 0.5 mL/kg of 15 mmol/L MgSO(4) in Ringer solution via the tip of a microcatheter placed in the cisterna magna from the lumbar spine. RESULTS After injection of MgSO(4) solution, the cerebrospinal fluid magnesium ion concentration significantly increased to 3.89 ± 0.97 mEq/L (P < 0.01) from the baseline value (1.49 ± 0.07 mEq/L). The arterial diameters of the basilar artery (BA), vertebral artery (VA), and superior cerebral artery (SCA) on Day 1 were 1.26 ± 0.19 mm, 1.10 ± 0.13 mm, and 0.74 ± 0.21 mm, respectively. On Day 7 before injection, the arterial diameters of the BA, VA, and SCA significantly decreased to 0.75 ± 0.27 mm, 0.74 ± 0.25 mm, and 0.36 ± 0.21 mm, respectively (P < 0.01), due to vasospasm, and were significantly increased to 0.91 ± 0.27 mm (P < 0.01), 0.91 ± 0.31 mm (P < 0.05), and 0.54 ± 0.14 mm (P < 0.01), respectively, after intracisternal injection of MgSO(4) solution. CONCLUSIONS Intracisternal MgSO(4) therapy using a microcatheter from the lumbar spine may be effective against vasospasm in the clinical setting of endovascular treatment of ruptured aneurysm.
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Affiliation(s)
- Kentaro Mori
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
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Vasomotor response induced by change of extracellular potassium and magnesium in cerebral penetrating arterioles. Neurosci Res 2011; 70:30-4. [DOI: 10.1016/j.neures.2011.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 01/10/2011] [Accepted: 01/25/2011] [Indexed: 11/18/2022]
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Mori K, Yamamoto T, Miyazaki M, Hara Y, Aiko Y, Koike N, Sakamoto S, Nakao Y, Esaki T. Optimal cerebrospinal fluid magnesium ion concentration for vasodilatory effect and duration after intracisternal injection of magnesium sulfate solution in a canine subarachnoid hemorrhage model. J Neurosurg 2011; 114:1168-75. [DOI: 10.3171/2010.10.jns10866] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The optimal CSF Mg++ concentration for vasodilation of spastic cerebral arteries after subarachnoid hemorrhage (SAH) and its duration are unknown. The temporal profile of the vasodilatory effect and optimal CSF Mg++ concentration after the intracisternal injection of MgSO4 solution were investigated in an SAH model in canines.
Methods
Cerebral vasospasm was induced by experimental SAH using a 2-hemorrhage model in 26 female beagles. On Day 7, 0.5 ml/kg of 15, 10, 5, or 0 mmol/L MgSO4 in Ringer solution was injected into the cerebellomedullary cistern. Angiography was performed on Day 1 (before SAH) and before and 1, 3, and 6 hours after the intracisternal injection on Day 7 to measure arterial diameters of the basilar artery (BA), superior cerebellar artery (SCA), and vertebral artery (VA). Cerebrospinal fluid Mg++ was also measured at the same time.
Results
Arterial diameters of the BA, SCA, and VA were significantly decreased by vasospasm on Day 7. Arterial diameter ratios (ratio of arterial diameter after MgSO4 injection to diameter before injection on Day 7) of the BA and SCA at 1 and 3 hours after and the VA at 1 hour after intracisternal injection of the MgSO4 solution were positively correlated with the CSF Mg++ concentration. All arterial diameter ratios, except 1 point of the SCA, exceeded 1 if the CSF Mg++ concentration was > 3 mEq/L at 1 hour after injection. Animals with CSF Mg++ concentrations > 3 mEq/L at 1 hour after injection (11 dogs) showed significantly increased arterial diameters of the BA at 1 and 3 hours after and of the SCA and VA at 1, 3, and 6 hours after injection, as compared with the diameters before injection. The CSF Mg++ concentration significantly increased at 1 hour (3.73 ± 0.69 mEq/L, p < 0.01) and 3 hours (2.05 ± 0.35 mEq/L, p < 0.01) after the intracisternal injection as compared with the baseline value (1.41 ± 0.20 mEq/L).
Conclusions
The reversible effect of an intracisternal injection of MgSO4 solution on the spastic artery requires CSF Mg++ concentrations > 3 mEq/L. The vasodilatory effect continues for 3–6 hours after injection. These results suggest that the continuous infusion or intermittent intracisternal injection of MgSO4 is needed to maintain the optimal CSF Mg++ concentration and constantly ameliorate cerebral vasospasm.
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Affiliation(s)
| | | | | | - Yasukazu Hara
- 2Radiology, Juntendo University, Shizuoka Hospital; and
| | - Yasuhisa Aiko
- 2Radiology, Juntendo University, Shizuoka Hospital; and
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Temporal profile of the effects of intracisternal injection of magnesium sulfate solution on vasodilation of spastic cerebral arteries in the canine SAH model. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011. [PMID: 21125443 DOI: 10.1007/978-3-7091-0356-2_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
PURPOSE the temporal profiles of the effects of intracisternal injection of magnesium sulfate (MgSO(4)) on vasodilation and cerebrospinal fluid (CSF) magnesium ion (Mg(2+)) concentration were investigated in the canine subarachnoid hemorrhage (SAH) model. METHOD cerebral vasospasm was induced using the two-hemorrhage model in seven female beagles. On day 7, 0.5 ml/kg of 15 mmol/l MgSO(4) in Ringer solution was injected into the cerebellomedullary cistern. Angiography was performed on day 1 (before SAH), and before and 1, 3, and 6 h after the intracisternal injection on day 7. CSF Mg(2+) was measured at the same time. RESULTS the diameters of the basilar artery (BA), vertebral artery (VA), and superior cerebellar artery (SCA) before the intracisternal injection on day 7 were 0.59 ± 0.15, 0.41 ± 0.17, and 0.35 ± 0.17 mm, respectively, and were significantly decreased (p < 0.01) compared with the baseline diameters on day 1. The BA diameters at 1 h (0.74 ± 0.16 mm) and 3 h (0.73 ± 0.13 mm), the VA diameter at 1 h (0.64 ± 0.14 mm), and the SCA diameter at 3 h (0.54 ± 0.08 mm) after the injection were significantly increased (p < 0.05). The CSF Mg(2+) concentration was significantly increased (p < 0.01) at 1 h (3.59 ± 0.76 mEq/l) and 3 h (2.00 ± 0.31 mEq/l) after the injection compared with the baseline value (1.35 ± 0.23 mEq/l). CONCLUSIONS the reversible effect of intracisternal MgSO(4) solution injection on the spastic artery depends on maintenance of the optimal CSF Mg(2+) concentration.
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Chen T, Carter BS. Role of magnesium sulfate in aneurysmal subarachnoid hemorrhage management: A meta-analysis of controlled clinical trials. Asian J Neurosurg 2011; 6:26-31. [PMID: 22059101 PMCID: PMC3205548 DOI: 10.4103/1793-5482.85632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been longstanding controversy over the use of magnesium sulfate infusion in the medical management of aneurysmal subarachnoid hemorrhage (SAH). Several clinical trials evaluating the beneficial effects of magnesium on cerebral vasospasm and their poor outcome have been published. However, results from the majority of these studies have been inconclusive. This meta-analysis was performed to evaluate the effectiveness of magnesium on patient outcomes after aneurysmal SAH. MATERIALS AND METHODS PubMed and the Cochrane library were searched for controlled clinical trials assessing the efficacy of magnesium sulfate infusion after aneurysmal SAH. Eight studies consisting of 936 patients were included. RESULTS There was a decreased risk of poor outcome at 3-6 months after SAH in magnesium treatment groups when compared to placebo [0.78 (95% CI 0.66-0.93)]. Poor outcome was defined as severe disability, persistent vegetative state, or death, as measured by the Glasgow outcome scale (GOS), extended Glasgow outcome scale (GOSE) or modified Rankin scale (mRS). The risk of mortality after SAH was unaffected by magnesium treatment [RR 0.68 (95% CI 0.58-1.27)]. CONCLUSION Magnesium sulfate infusion decreases risk of poor outcome after aneurysmal SAH. Current studies in the literature do not suggest a role for magnesium sulfate in mortality reduction after SAH.
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Affiliation(s)
- Tsinsue Chen
- Department of Neurosurgery, University of California, San Diego, CA, USA
| | - Bob S. Carter
- Department of Neurosurgery, University of California, San Diego, CA, USA
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Hansen-Schwartz J. Advances in treatment of cerebral vasospasm: an update. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 110:23-26. [PMID: 21116909 DOI: 10.1007/978-3-7091-0353-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
An update of published clinical advances in the treatment of cerebral vasospasm after subarachnoid haemorrhage was provided. Searching MEDLINE using the search terms "cerebral vasospasm" and "clinical trials" 46 papers were identified that had been published since the International Conference on Cerebral Vasospasm in Istanbul, Turkey in 2006. Of these 26 were either safety studies or case reports leaving 20 papers for consideration. The major topics covered were calcium antagonists, magnesium sulphate, statins, and fasudil hydrochloride. The studies published did not reach an impact justified recommended routine use, but certainly as options. Results of the CONSCIOUS trials on endothelin receptor antagonists are awaited.
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Affiliation(s)
- Jacob Hansen-Schwartz
- Department of Neurosurgery, Glostrup University Hospital, DK-2600, Glostrup, Denmark.
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Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: A randomized, placebo-controlled, clinical study*. Crit Care Med 2010; 38:1284-90. [DOI: 10.1097/ccm.0b013e3181d9da1e] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ma L, Liu WG, Zhang JM, Chen G, Fan J, Sheng HS. Magnesium sulphate in the management of patients with aneurysmal subarachnoid haemorrhage: A meta-analysis of prospective controlled trials. Brain Inj 2010; 24:730-5. [DOI: 10.3109/02699051003610516] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sorimachi T, Yajima N, Sasaki O, Koike T, Fujii Y. Hematoma in the splenium of the corpus callosum in the subacute stage of subarachnoid hemorrhage--three case reports. Neurol Med Chir (Tokyo) 2010; 50:209-12. [PMID: 20339269 DOI: 10.2176/nmc.50.209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Three patients developed hemorrhage in the splenium of the corpus callosum 2 weeks after the onset of subarachnoid hemorrhage (SAH) associated with acute hydrocephalus. Computed tomography performed a few days after the onset showed a low density area in the splenium of corpus callosum in all three patients, and preventive measures against symptomatic vasospasm were begun, including vasodilator administration. Computed tomography showed hemorrhage in the splenium of the corpus callosum 17 to 22 days after onset of SAH, manifesting as mental deterioration or headache. Antivasospasm agents were immediately discontinued, and strict blood control measures were instituted. Splenial hematoma is another potential cause of neurological deterioration after surgery for SAH, in addition to vasospasm, hydrocephalus, and rebleeding.
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Zhao XD, Zhou YT, Zhang X, Zhuang Z, Shi JX. A meta analysis of treating subarachnoid hemorrhage with magnesium sulfate. J Clin Neurosci 2009; 16:1394-7. [DOI: 10.1016/j.jocn.2009.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 05/05/2009] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
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Amenta F, Lanari A, Mignini F, Silvestrelli G, Traini E, Tomassoni D. Nicardipine use in cerebrovascular disease: A review of controlled clinical studies. J Neurol Sci 2009; 283:219-23. [DOI: 10.1016/j.jns.2009.02.335] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Deshaies EM, Boulos AS, Popp AJ. Peri-operative medical management of cerebral vasospasm. Neurol Res 2009; 31:644-650. [DOI: 10.1179/174313209x382340] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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38
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Mack WJ, Kellner CP, Sahlein DH, Ducruet AF, Kim GH, Mocco J, Zurica J, Komotar RJ, Haque R, Sciacca R, Quest DO, Solomon RA, Connolly ES, Heyer EJ. Intraoperative magnesium infusion during carotid endarterectomy: a double-blind placebo-controlled trial. J Neurosurg 2009; 110:961-7. [PMID: 19199498 DOI: 10.3171/2008.9.17671] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Recent data from both experimental and clinical studies have supported the use of intravenous magnesium as a potential therapy in the setting of cerebral ischemia. This study assessed whether intraoperative magnesium therapy improves neuropsychometric testing (NPT) following carotid endarterectomy (CEA). METHODS One hundred eight patients undergoing CEA were randomly assigned to receive placebo infusion or 1 of 3 magnesium-dosing protocols. Neuropsychometric testing was performed 1 day after surgery and compared with baseline performance. Assessment was also performed on a set of 35 patients concurrently undergoing lumbar laminectomy to serve as a control group for NPT. A forward stepwise logistic regression analysis was performed to evaluate the impact of magnesium therapy on NPT. A subgroup analysis was then performed, analyzing the impact of each intraoperative dose on NPT. RESULTS Patients treated with intravenous magnesium infusion demonstrated less postoperative neurocognitive impairment than those treated with placebo (OR 0.27, 95% CI 0.10-0.74, p = 0.01). When stratified according to dosing bolus and intraoperative magnesium level, those who were treated with low-dose magnesium had less cognitive decline than those treated with placebo (OR 0.09, 95% CI 0.02-0.50, p < 0.01). Those in the high-dose magnesium group demonstrated no difference from the placebo-treated group. CONCLUSIONS Low-dose intraoperative magnesium therapy protects against neurocognitive decline following CEA.
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Affiliation(s)
- William J Mack
- Departments of Neurological Surgery, Columbia University Medical Center, New York, USA.
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Shah QA, Memon MZ, Suri MFK, Rodriguez GJ, Kozak OS, Taylor RA, Tummala RP, Vazquez G, Georgiadis AL, Qureshi AI. Super-Selective Intra-arterial Magnesium Sulfate in Combination With Nicardipine for the Treatment of Cerebral Vasospasm in Patients With Subarachnoid Hemorrhage. Neurocrit Care 2009; 11:190-8. [DOI: 10.1007/s12028-009-9209-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 02/27/2009] [Indexed: 11/29/2022]
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MORI K, YAMAMOTO T, NAKAO Y, OSADA H, HARA Y, OYAMA K, ESAKI T. Initial Clinical Experience of Vasodilatory Effect of Intra-cisternal Infusion of Magnesium Sulfate for the Treatment of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurol Med Chir (Tokyo) 2009; 49:139-44; discussion 144-5. [DOI: 10.2176/nmc.49.139] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kentaro MORI
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
| | - Takuji YAMAMOTO
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
| | - Yasuaki NAKAO
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
| | - Hideo OSADA
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
| | - Yasukazu HARA
- Department of Radiology, Juntendo University Shizuoka Hospital
| | - Kazutaka OYAMA
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
| | - Takanori ESAKI
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
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Mori K, Miyazaki M, Hara Y, Aiko Y, Yamamoto T, Nakao Y. Novel vasodilatory effect of intracisternal injection of magnesium sulfate solution on spastic cerebral arteries in the canine two-hemorrhage model of subarachnoid hemorrhage. J Neurosurg 2009; 110:73-8. [DOI: 10.3171/2008.4.17494] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The extracellular Mg++ has a vasodilatory effect on the cerebral artery. The present study investigated the effect of intracisternal injection of MgSO4 solution on cerebral vasospasm in a canine model of subarachnoid hemorrhage (SAH).
Methods
Subarachnoid hemorrhage was induced in 10 beagles using the two-hemorrhage model. Angiography of the vertebrobasilar artery was performed on Day 1 (baseline values before SAH) and on Day 7 (during cerebral vasospasm after induced SAH) before and after intracisternal injection of 0.5 ml/kg of 15 mmol/L MgSO4 solution into the cerebellomedullary cistern.
Results
The cerebrospinal fluid Mg++ concentration was significantly increased to 3.15 ± 1.14 mEq/L after intracisternal injection from the preinjection value (1.45 ± 0.09 mEq/L; p < 0.01). The diameters of the basilar artery, vertebral artery, and superior cerebellar artery on Day 7 were significantly decreased to 58.0 ± 10.9%, 71.0 ± 10.1%, and 60.9 ± 13.8%, respectively, of their baseline diameters on Day 1 (p < 0.01). After intracisternal injection of MgSO4, these diameters significantly increased to 73.8 ± 14.3%, 83.0 ± 14.8%, and 74.1 ± 13.5%, respectively (p < 0.01).
Conclusions
Intracisternal injection of MgSO4 solution causes significant dilation of spastic cerebral arteries in the canine two-hemorrhage model of SAH.
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Affiliation(s)
| | | | - Yasukazu Hara
- 3Juntendo Casualty Center, Izunokuni, Shizuoka, Japan
| | - Yasuhisa Aiko
- 3Juntendo Casualty Center, Izunokuni, Shizuoka, Japan
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42
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Greer DM. Management of subarachnoid hemorrhage, unruptured cerebral aneurysms, and arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2009; 94:1239-1249. [PMID: 18793898 DOI: 10.1016/s0072-9752(08)94061-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- David M Greer
- Havard Medical School, Massachussetts General Hospital, Boston, MA, USA.
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Abstract
Patients with acute aneurysmal subarachnoid hemorrhage (SAH) often present with more than just neurological compromise. A wide spectrum of complicating cardiopulmonary abnormalities have been documented in patients with acute SAH, presenting additional challenges to the healthcare providers who attempt to treat and stabilize these patients. The patients described in this article presented with both acute aneurysmal SAH and cardiopulmonary compromise. Education and further research on this connection is needed to provide optimal care and outcomes for this vulnerable population. Nurses play a key role in balancing the critical and diverse needs of patients presenting with these symptoms.
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44
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Mori K, Miyazaki M, Iwata J, Yamamoto T, Nakao Y. Intracisternal infusion of magnesium sulfate solution improved reduced cerebral blood flow induced by experimental subarachnoid hemorrhage in the rat. Neurosurg Rev 2008; 31:197-203; discussion 203. [DOI: 10.1007/s10143-008-0122-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 11/15/2007] [Accepted: 01/01/2008] [Indexed: 11/24/2022]
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Muroi C, Terzic A, Fortunati M, Yonekawa Y, Keller E. Magnesium sulfate in the management of patients with aneurysmal subarachnoid hemorrhage: a randomized, placebo-controlled, dose-adapted trial. SURGICAL NEUROLOGY 2008; 69:33-39. [PMID: 18054611 DOI: 10.1016/j.surneu.2007.07.015] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 07/08/2007] [Indexed: 05/25/2023]
Abstract
BACKGROUND Recent studies suggest that high-dose MgSO4 therapy is safe and reduces the incidence of DIND and subsequent poor outcome after SAH. We intended to assess the safety and efficacy of high-dose MgSO4 therapy after SAH as means to prevent DIND and to evaluate the impact on clinical outcome. METHODS This was a prospective, randomized, single-blind, placebo-controlled study. The MgSO4 infusion was adjusted every 12 hours until day 12 according to the target serum Mg2+ level. The occurrence of DIND, secondary infarction, side effects, and the outcome after 3 and 12 months were assessed. RESULTS Fifty-eight patients were randomized; 27 received placebo and 31 MgSO4. The difference in occurrence of DIND and secondary infarction was not significant. The intention-to-treat analysis revealed a trend toward better outcome (P = .083) after 3 months. On-treatment analysis showed a significantly better outcome after 3 months (P = .017) and a trend toward better outcome after 1 year (P = .083). Significantly more often hypotension (P = .040) and hypocalcemia (P = .005) occurred as side effects in the treatment group. In 16 patients (52%), the MgSO4 therapy had to be stopped before day 12 because of side effects. No predictive factor leading to termination was found in a postrandomization analysis. CONCLUSIONS High-dose MgSO4 therapy might be efficient as a prophylactic adjacent therapy after SAH to reduce the risk for poor outcome. Nevertheless, because of the high frequency of the side effects, patients should be observed in an intensive or intermediate care setting.
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Affiliation(s)
- Carl Muroi
- Department of Neurosurgery, University Hospital Zurich, Zurich CH-8091, Switzerland.
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46
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Lehmann E, Sagher O. Novel treatments for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 105:225-228. [PMID: 19066114 DOI: 10.1007/978-3-211-09469-3_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Cerebral vasospasm is a major cause of cerebral ischemia and poor outcomes in the setting of aneurysmal subarachnoid hemorrhage (SAH). Despite advances in diagnosis and treatment of SAH, the pathophysiology of vasospasm is still poorly understood and outcomes remain disappointing. Recent advances in understanding the role of hemoglobin in initiating an inflammatory cascade in the subarachnoid space open new avenues for therapy. Preliminary experimental and clinical evidence indicate that targets in the inflammatory and oxidative cascades hold promise in reducing the incidence and impact of cerebral vasospasm.
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Affiliation(s)
- E Lehmann
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI 48109-5338, USA
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