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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: 54] [Impact Index Per Article: 27.0] [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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George AG, Farrell JS, Colangeli R, Wall AK, Gom RC, Kesler MT, Rodriguez de la Hoz C, Villa BR, Perera T, Rho JM, Kurrasch D, Teskey GC. Sudden unexpected death in epilepsy is prevented by blocking postictal hypoxia. Neuropharmacology 2023; 231:109513. [PMID: 36948357 DOI: 10.1016/j.neuropharm.2023.109513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/21/2023] [Accepted: 03/18/2023] [Indexed: 03/24/2023]
Abstract
Epilepsy is at times a fatal disease. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related mortality in people with intractable epilepsy and is defined by exclusion; non-accidental, non-toxicologic, and non-anatomic causes of death. While SUDEP often follows a bilateral tonic-clonic seizure, the mechanisms that ultimately lead to terminal apnea and then asystole remain elusive and there is a lack of preventative treatments. Based on the observation that discrete seizures lead to local and postictal vasoconstriction, resulting in hypoperfusion, hypoxia and behavioural disturbances in the forebrain we reasoned those similar mechanisms may play a role in SUDEP when seizures invade the brainstem. Here we tested this neurovascular-based hypothesis of SUDEP in awake non-anesthetized mice by pharmacologically preventing seizure-induced vasoconstriction, with cyclooxygenase-2 or L-type calcium channel antagonists. In both acute and chronic mouse models of seizure-induced premature mortality, ibuprofen and nicardipine extended life while systemic drug levels remained high enough to be effective. We also examined the potential role of spreading depolarization in the acute model of seizure-induced premature mortality. These data provide a proof-of-principle for the neurovascular hypothesis of SUDEP rather than spreading depolarization and the use of currently available drugs to prevent it.
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Affiliation(s)
- Antis G George
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada
| | - Jordan S Farrell
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Neurosurgery, Stanford University, Palo Alto, CA, 94305, USA
| | - Roberto Colangeli
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada; Department of Experimental and Clinical Medicine, Section of Neuroscience and Cell Biology, Marche Polytechnic University, Ancona, Italy
| | - Alexandra K Wall
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada
| | - Renaud C Gom
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada
| | - Mitchell T Kesler
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada
| | | | - Bianca R Villa
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada
| | - Tefani Perera
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Jong M Rho
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Neurosciences, Pediatrics and Pharmacology, University of California, San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Deborah Kurrasch
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Medical Genetics, University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - G Campbell Teskey
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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3
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Brain Oxygen-Directed Management of Aneurysmal Subarachnoid Hemorrhage. Temporal Patterns of Cerebral Ischemia During Acute Brain Attack, Early Brain Injury, and Territorial Sonographic Vasospasm. World Neurosurg 2022; 166:e215-e236. [PMID: 35803565 DOI: 10.1016/j.wneu.2022.06.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. METHODS This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40). RESULTS The brain oxygen-directed protocol reduced Lbo2 (Pbto2 [partial pressure of brain tissue oxygen] <20 mm Hg) from 67% to 15% during acute brain attack (<24 hours of ictus), by increasing Pbto2 from 11.31 ± 9.34 to 27.85 ± 6.76 (P < 0.0001) and then to 29.09 ± 17.88 within 72 hours. Day-after-bleed, Fio2 change, ICP, hemoglobin, and oxygen saturation were predictors for Pbto2 during early brain injury. Transcranial Doppler ultrasonography velocities (>20 cm/second) increased at day 2. During DCI caused by territorial sonographic vasospasm (TSV), middle cerebral artery mean velocity (Vm) increased from 45.00 ± 15.12 to 80.37 ± 38.33/second by day 4 with concomitant Pbto2 reduction from 29.09 ± 17.88 to 22.66 ± 8.19. Peak TSV (days 7-12) coincided with decline in Pbto2. Nicardipine mitigated Lbo2 during peak TSV, in contrast to nimodipine, with survival benefit (P < 0.01). Intravenous and cisternal nicardipine combination had survival benefit (Cramer Φ = 0.43 and 0.327; G2 = 28.32; P < 0.001). This study identifies 4 zones of Lbo2 during survival benefit (Cramer Φ = 0.43 and 0.3) TSV, uncompensated; global cerebral ischemia, compensated, and normal Pbto2. Admission Glasgow Coma Scale score (not increased ICP) was predictive of low Pbto2 (β = 0.812, R2 = 0.661, F1,30 = 58.41; P < 0.0001) during early brain injury. Coma was the only credible predictor for mortality (odds ratio, 7.33/>4.8∗; χ2 = 7.556; confidence interval, 1.70-31.54; P < 0.01) followed by basilar aneurysm, poor grade, high ICP and Lbo2 during TSV. Global cerebral ischemia occurs immediately after the ictus, persisting in 30% of patients despite the high therapeutic intensity level, superimposed by DCI during TSV. CONCLUSIONS We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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Kadicheeni M, Robinson TG, Divall P, Parry-Jones AR, Minhas JS. Therapeutic Variation in Lowering Blood Pressure: Effects on Intracranial Pressure in Acute Intracerebral Haemorrhage. High Blood Press Cardiovasc Prev 2021; 28:115-128. [PMID: 33599966 DOI: 10.1007/s40292-021-00435-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/03/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Intracerebral haemorrhage (ICH) is associated with high morbidity and mortality. Blood pressure (BP) control is one of the main management strategies in acute ICH. Limited data currently exist regarding intracranial pressure (ICP) in acute ICH. The relationship between BP lowering and ICP is yet to be fully elucidated. METHODS We conducted a systematic review to investigate the effects of BP lowering on ICP in acute ICH. The study protocol was registered on PROSPERO (CRD42019134470). RESULTS Following PRISMA guidelines, MEDLINE, EMBASE and CENTRAL were searched for studies on ICH with BP and ICP or surrogate measures. 1096 articles were identified after duplicates were removed; 18 studies meeting the inclusion criteria. Dihydropyridine calcium channel blockers (CCBs) were the most common agent used to lower BP, but had a varying effect on ICP. Other BP-lowering agents used also had a varying effect on ICP. DISCUSSION AND CONCLUSION Further work, including large observational or randomized interventional studies, is needed to develop a better understanding of the effect of BP lowering on ICP in acute ICH, which will assist the development of more effective management strategies. TRIAL REGISTRATION The study protocol was registered on PROSPERO (CRD42019134470) on 29/05/2019.
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Affiliation(s)
- Meeriam Kadicheeni
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
| | - Thompson G Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
| | - Pip Divall
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, UK
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
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Post R, Germans MR, Tjerkstra MA, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Willems PWA, Wolfs JFC, de Beer FC, Kieft H, Nanda D, van der Pol B, Roks G, de Beer F, Halkes PHA, Reichman LJA, Brouwers PJAM, van den Berg-Vos RM, Kwa VIH, van der Ree TC, Bronner I, van de Vlekkert J, Bienfait HP, Boogaarts HD, Klijn CJM, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWEM, Vandertop WP, Verbaan D. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet 2021; 397:112-118. [PMID: 33357465 DOI: 10.1016/s0140-6736(20)32518-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients with aneurysmal subarachnoid haemorrhage, short-term antifibrinolytic therapy with tranexamic acid has been shown to reduce the risk of rebleeding. However, whether this treatment improves clinical outcome is unclear. We investigated whether ultra-early, short-term treatment with tranexamic acid improves clinical outcome at 6 months. METHODS In this multicentre prospective, randomised, controlled, open-label trial with masked outcome assessment, adult patients with spontaneous CT-proven subarachnoid haemorrhage in eight treatment centres and 16 referring hospitals in the Netherlands were randomly assigned to treatment with tranexamic acid in addition to care as usual (tranexamic acid group) or care as usual only (control group). Tranexamic acid was started immediately after diagnosis in the presenting hospital (1 g bolus, followed by continuous infusion of 1 g every 8 h, terminated immediately before aneurysm treatment, or 24 h after start of the medication, whichever came first). The primary endpoint was clinical outcome at 6 months, assessed by the modified Rankin Scale, dichotomised into a good (0-3) or poor (4-6) clinical outcome. Both primary and safety analyses were according to intention to treat. This trial is registered at ClinicalTrials.gov, NCT02684812. FINDINGS Between July 24, 2013, and July 29, 2019, we enrolled 955 patients; 480 patients were randomly assigned to tranexamic acid and 475 patients to the control group. In the intention-to-treat analysis, good clinical outcome was observed in 287 (60%) of 475 patients in the tranexamic acid group, and 300 (64%) of 470 patients in the control group (treatment centre adjusted odds ratio 0·86, 95% CI 0·66-1·12). Rebleeding after randomisation and before aneurysm treatment occurred in 49 (10%) patients in the tranexamic acid and in 66 (14%) patients in the control group (odds ratio 0·71, 95% CI 0·48-1·04). Other serious adverse events were comparable between groups. INTERPRETATION In patients with CT-proven subarachnoid haemorrhage, presumably caused by a ruptured aneurysm, ultra-early, short-term tranexamic acid treatment did not improve clinical outcome at 6 months, as measured by the modified Rankin Scale. FUNDING Fonds NutsOhra.
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Affiliation(s)
- René Post
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
| | - Radboud W Koot
- Department of Neurosurgery, Leids University Medical Center, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leids University Medical Center, Netherlands
| | - Peter W A Willems
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Jasper F C Wolfs
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Frits C de Beer
- Department of Neurosurgery, Isala Hospital, Zwolle, Netherlands
| | - Hans Kieft
- Department of Intensive Care, Isala Hospital, Zwolle, Netherlands
| | - Dharmin Nanda
- Department of Neurosurgery, Isala Hospital, Zwolle, Netherlands
| | - Bram van der Pol
- Department of Neurosurgery, Elisabeth Tweesteden ziekenhuis, Tilburg, Netherlands
| | - Gerwin Roks
- Department of Neurology, Elisabeth Tweesteden ziekenhuis, Tilburg, Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, Netherlands
| | | | - Loes J A Reichman
- Department of Neurology, Ziekenhuisgroep Twente, Almelo, Netherlands
| | | | | | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | | | - Irene Bronner
- Department of Neurology, Flevo Hospital, Almere, Netherlands
| | | | | | | | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 1182] [Impact Index Per Article: 236.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Lahiri S, Nezhad M, Schlick KH, Rinsky B, Rosengart A, Mayer SA, Lyden PD. Paradoxical cerebrovascular hemodynamic changes with nicardipine. J Neurosurg 2018; 128:1015-1019. [DOI: 10.3171/2016.11.jns161992] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIntravenous nicardipine is commonly used for blood pressure reduction in patients with acute stroke. However, few studies have described its effects on cerebrovascular hemodynamics as measured by transcranial Doppler (TCD) waveform analysis and pulsatility index (PI). In this study, the authors report examples of a consistent but paradoxical finding associated with nicardipine that suggests intracranial vasoconstriction, contrary to what is expected from a vasodilator.METHODSThe data presented are from a convenience sample of patients who underwent TCD monitoring before, after, or during nicardipine administration. In each case, TCD waveform morphologies and PIs were compared.RESULTSThe TCD waveforms during nicardipine infusion are characterized by a prominent systolic peak and dicrotic notch. Systolic deceleration was more pronounced and PIs were significantly elevated in patients who were on nicardipine (p < 0.001). This finding was not evident when patients were not on nicardipine.CONCLUSIONSThis study provides the first evidence of paradoxical intracranial vasoconstriction associated with intravenous nicardipine. In the authors' experience, this finding is consistently encountered in the vast majority of patients who are treated with intravenous nicardipine, and is contradictory to what is expected from a vasodilator. Future studies are needed to confirm this finding in larger populations and diverse clinical settings and to examine mechanisms that explain this phenomenon.
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Affiliation(s)
- Shouri Lahiri
- Departments of 1Neurosurgery and
- 2Neurology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Mani Nezhad
- 2Neurology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Konrad H. Schlick
- 2Neurology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Brenda Rinsky
- 2Neurology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Axel Rosengart
- Departments of 1Neurosurgery and
- 2Neurology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Stephan A. Mayer
- 3Departments of Neurology and Neurosurgery, Icahn School of Medicine, New York, New York
| | - Patrick D. Lyden
- 2Neurology, Cedars-Sinai Medical Center, Los Angeles, California; and
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Acute blood pressure elevation: Therapeutic approach. Pharmacol Res 2018; 130:180-190. [DOI: 10.1016/j.phrs.2018.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/21/2017] [Accepted: 02/21/2018] [Indexed: 12/25/2022]
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Chiba T, Yamanaka M, Takagi S, Shimizu K, Takahashi M, Shirai K, Takahara A. Cardio-ankle vascular index (CAVI) differentiates pharmacological properties of vasodilators nicardipine and nitroglycerin in anesthetized rabbits. J Pharmacol Sci 2015; 128:185-92. [PMID: 26238254 DOI: 10.1016/j.jphs.2015.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/29/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022] Open
Abstract
Cardio-ankle vascular index (CAVI) has been developed for measurement of vascular stiffness from the aorta to tibial artery, which is clinically utilized for assessing the progress of arteriosclerosis. In this study, we established measuring system of the CAVI in rabbits, and assessed whether the index could reflect different pharmacological actions of nitroglycerin and nicardipine on the systemic vasculature. Rabbits were anesthetized with halothane, and the CAVI was calculated from the well-established basic equations with variables obtained from brachial and tibial blood pressure and phonocardiogram. Nicardipine (1, 3 and 10 μg/kg, i.v.) decreased the blood pressure, femoral vascular resistance, and heart-ankle pulse wave velocity (haPWV). Meanwhile, no significant change was detected in the CAVI at the low or middle dose, which reflects the defining feature of the CAVI that is independent of blood pressure. The index increased at the high dose. Nitroglycerin (2, 4 and 8 μg/kg, i.v.) decreased the blood pressure, femoral vascular resistance, and haPWV. Meanwhile, the CAVI was decreased during the nitroglycerin infusion, which may reflect its well-known pharmacological action dilating conduit arteries. These results suggest that the CAVI differentiates the properties of these vasodilators in vivo.
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Affiliation(s)
- Tatsuo Chiba
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Chiba 274-8510, Japan; Department of Pharmacy, Toho University Ohashi Medical Center, Meguro-ku, Tokyo 153-8515, Japan
| | - Mari Yamanaka
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Chiba 274-8510, Japan
| | - Sachie Takagi
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Chiba 274-8510, Japan
| | - Kazuhiro Shimizu
- Cardiovascular Center, Toho University Sakura Medical Center, Sakura, Chiba 285-8741, Japan
| | - Mao Takahashi
- Cardiovascular Center, Toho University Sakura Medical Center, Sakura, Chiba 285-8741, Japan
| | - Kohji Shirai
- Department of Vascular Function, Toho University Sakura Medical Center, Chiba 285-8741, Japan; Mihama Hospital, Chiba 261-0013, Japan
| | - Akira Takahara
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Chiba 274-8510, Japan.
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Sakima A, Ohya Y. [Hypertension The Points of Management of Hypertension for All Physicians--Based on the JSH 2014 Hypertension Guidelines--. Topics: IX. Evaluation and management of hypertensive emergencies]. ACTA ACUST UNITED AC 2015; 104:268-74. [PMID: 26571706 DOI: 10.2169/naika.104.268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Narotam PK, Morrison JF, Schmidt MD, Nathoo N. Physiological complexity of acute traumatic brain injury in patients treated with a brain oxygen protocol: utility of symbolic regression in predictive modeling of a dynamical system. J Neurotrauma 2014; 31:630-41. [PMID: 24195645 DOI: 10.1089/neu.2013.3104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Predictive modeling of emergent behavior, inherent to complex physiological systems, requires the analysis of large complex clinical data streams currently being generated in the intensive care unit. Brain tissue oxygen protocols have yielded outcome benefits in traumatic brain injury (TBI), but the critical physiological thresholds for low brain oxygen have not been established for a dynamical patho-physiological system. High frequency, multi-modal clinical data sets from 29 patients with severe TBI who underwent multi-modality neuro-clinical care monitoring and treatment with a brain oxygen protocol were analyzed. The inter-relationship between acute physiological parameters was determined using symbolic regression (SR) as the computational framework. The mean patient age was 44.4±15 with a mean admission GCS of 6.6±3.9. Sixty-three percent sustained motor vehicle accidents and the most common pathology was intra-cerebral hemorrhage (50%). Hospital discharge mortality was 21%, poor outcome occurred in 24% of patients, and good outcome occurred in 56% of patients. Criticality for low brain oxygen was intracranial pressure (ICP) ≥22.8 mm Hg, for mortality at ICP≥37.1 mm Hg. The upper therapeutic threshold for cerebral perfusion pressure (CPP) was 75 mm Hg. Eubaric hyperoxia significantly impacted partial pressure of oxygen in brain tissue (PbtO2) at all ICP levels. Optimal brain temperature (Tbr) was 34-35°C, with an adverse effect when Tbr≥38°C. Survivors clustered at [Formula: see text] Hg vs. non-survivors [Formula: see text] 18 mm Hg. There were two mortality clusters for ICP: High ICP/low PbtO2 and low ICP/low PbtO2. Survivors maintained PbtO2 at all ranges of mean arterial pressure in contrast to non-survivors. The final SR equation for cerebral oxygenation is: [Formula: see text]. The SR-model of acute TBI advances new physiological thresholds or boundary conditions for acute TBI management: PbtO2≥25 mmHg; ICP≤22 mmHg; CPP≈60-75 mmHg; and Tbr≈34-37°C. SR is congruous with the emerging field of complexity science in the modeling of dynamical physiological systems, especially during pathophysiological states. The SR model of TBI is generalizable to known physical laws. This increase in entropy reduces uncertainty and improves predictive capacity. SR is an appropriate computational framework to enable future smart monitoring devices.
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Miller J, Kinni H, Lewandowski C, Nowak R, Levy P. Management of Hypertension in Stroke. Ann Emerg Med 2014; 64:248-55. [DOI: 10.1016/j.annemergmed.2014.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/16/2014] [Accepted: 03/07/2014] [Indexed: 11/25/2022]
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Abstract
OBJECT Observational studies, such as cohort and case-control studies, are valuable instruments in evidence-based medicine. Case-control studies, in particular, are becoming increasingly popular in the neurosurgical literature due to their low cost and relative ease of execution; however, no one has yet systematically assessed these types of studies for quality in methodology and reporting. METHODS The authors performed a literature search using PubMed/MEDLINE to identify all studies that explicitly identified themselves as "case-control" and were published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Each paper was evaluated for 22 descriptive variables and then categorized as having either met or missed the basic definition of a case-control study. All studies that evaluated risk factors for a well-defined outcome were considered true case-control studies. The authors sought to identify key features or phrases that were or were not predictive of a true case-control study. Those papers that satisfied the definition were further evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. RESULTS The search detected 67 papers that met the inclusion criteria, of which 32 (48%) represented true case-control studies. The frequency of true case-control studies has not changed with time. Use of odds ratios (ORs) and logistic regression (LR) analysis were strong positive predictors of true case-control studies (for odds ratios, OR 15.33 and 95% CI 4.52-51.97; for logistic regression analysis, OR 8.77 and 95% CI 2.69-28.56). Conversely, negative predictors included focus on a procedure/intervention (OR 0.35, 95% CI 0.13-0.998) and use of the word "outcome" in the Results section (OR 0.23, 95% CI 0.082-0.65). After exclusion of nested case-control studies, the negative correlation between focus on a procedure/intervention and true case-control studies was strengthened (OR 0.053, 95% CI 0.0064-0.44). There was a trend toward a negative association between the use of survival analysis or Kaplan-Meier curves and true case-control studies (OR 0.13, 95% CI 0.015-1.12). True case-control studies were no more likely than their counterparts to use a potential study design "expert" (OR 1.50, 95% CI 0.57-3.95). The overall average STROBE score was 72% (range 50-86%). Examples of reporting deficiencies were reporting of bias (28%), missing data (55%), and funding (44%). CONCLUSIONS The results of this analysis show that the majority of studies in the neurosurgical literature that identify themselves as "case-control" studies are, in fact, labeled incorrectly. Positive and negative predictors were identified. The authors provide several recommendations that may reverse the incorrect and inappropriate use of the term "case-control" and improve the quality of design and reporting of true case-control studies in neurosurgery.
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Tang C, Zhang TS, Zhou LF. Risk factors for rebleeding of aneurysmal subarachnoid hemorrhage: a meta-analysis. PLoS One 2014; 9:e99536. [PMID: 24911172 PMCID: PMC4049799 DOI: 10.1371/journal.pone.0099536] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/15/2014] [Indexed: 11/19/2022] Open
Abstract
Background Rebleeding is a serious complication of aneurysmal subarachnoid hemorrhaging. To date, there are conflicting data regarding the factors contributing to rebleeding and their significance. Methods A systematic review of PubMed and Embase databases was conducted for studies pertaining to aneurysmal subarachnoid hemorrhage (aSAH) and rebleeding in order to assess the associated risk factors. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated from fourteen studies comprised of a total of 5693 patients that met the inclusion criteria. Results Higher rebleeding rates were observed < 6 h after the initial aSAH (OR = 3.22, 95% CI = 1.46–7.12), and were associated with high systolic blood pressure (OR = 1.93, 95% CI = 1.31–2.83), poor Hunt-Hess grade (III–IV) (OR = 3.43, 95% CI = 2.33–5.05), intracerebral or intraventricular hematomas (OR = 1.65, 95% CI = 1.33–2.05), posterior circulation aneurysms (OR = 2.15, 95% CI = 1.32–3.49), and aneurysms >10 mm in size (OR = 1.70, 95% CI = 1.35–2.14). Conclusions Aneurysmal rebleeding occurs more frequently within the first 6 hours after the initial aSAH. Risk factors associated with rebleeding include high systolic pressure, the presence of an intracerebral or intraventricular hematoma, poor Hunt-Hess grade (III-IV), aneurysms in the posterior circulation, and an aneurysm >10 mm in size.
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Affiliation(s)
- Chao Tang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Tian-Song Zhang
- Department of TCM, Shanghai Jing-an District Central hospital, Shanghai, China
| | - Liang-Fu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- * E-mail:
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Chapter 12. Hypertension under special conditions. Hypertens Res 2014. [DOI: 10.1038/hr.2014.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Huang BR, Chang PC, Yeh WL, Lee CH, Tsai CF, Lin C, Lin HY, Liu YS, Wu CYJ, Ko PY, Huang SS, Hsu HC, Lu DY. Anti-neuroinflammatory effects of the calcium channel blocker nicardipine on microglial cells: implications for neuroprotection. PLoS One 2014; 9:e91167. [PMID: 24621589 PMCID: PMC3951295 DOI: 10.1371/journal.pone.0091167] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 02/11/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE Nicardipine is a calcium channel blocker that has been widely used to control blood pressure in severe hypertension following events such as ischemic stroke, traumatic brain injury, and intracerebral hemorrhage. However, accumulating evidence suggests that inflammatory processes in the central nervous system that are mediated by microglial activation play important roles in neurodegeneration, and the effect of nicardipine on microglial activation remains unresolved. METHODOLOGY/PRINCIPAL FINDINGS In the present study, using murine BV-2 microglia, we demonstrated that nicardipine significantly inhibits microglia-related neuroinflammatory responses. Treatment with nicardipine inhibited microglial cell migration. Nicardipine also significantly inhibited LPS plus IFN-γ-induced release of nitric oxide (NO), and the expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2). Furthermore, nicardipine also inhibited microglial activation by peptidoglycan, the major component of the Gram-positive bacterium cell wall. Notably, nicardipine also showed significant anti-neuroinflammatory effects on microglial activation in mice in vivo. CONCLUSION/SIGNIFICANCE The present study is the first to report a novel inhibitory role of nicardipine on neuroinflammation and provides a new candidate agent for the development of therapies for inflammation-related neurodegenerative diseases.
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Affiliation(s)
- Bor-Ren Huang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Neurosurgery Department, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Pei-Chun Chang
- Department of Bioinformatics, Asia University, Taichung, Taiwan
| | - Wei-Lan Yeh
- Department of Cell and Tissue Engineering, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Hao Lee
- Department of Genetics and Complex Diseases, Harvard School of Public Health, Boston, United States of America
| | - Cheng-Fang Tsai
- Department of Biotechnology, Asia University, Taichung, Taiwan
| | - Chingju Lin
- Department of Physiology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiao-Yun Lin
- Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Yu-Shu Liu
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan
| | - Caren Yu-Ju Wu
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan
| | - Pei-Ying Ko
- Department of Medical Laboratory Science and Biotechnology, China Medical University, Taichung, Taiwan
| | - Shiang-Suo Huang
- Department of Pharmacology and Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Horng-Chaung Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Dah-Yuu Lu
- Graduate Institute of Neural and Cognitive Sciences, China Medical University, Taichung, Taiwan
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Narotam PK. Eubaric hyperoxia: controversies in the management of acute traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:197. [PMID: 24499710 PMCID: PMC4056002 DOI: 10.1186/cc13065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Controversy exists on the role of hyperoxia in major trauma with brain injury. Hyperoxia on arterial blood gas has been associated with acute lung injury and pulmonary complications, impacting clinical outcome. The hyperoxia could be reflective of the physiological interventions following major systemic trauma. Despite the standard resuscitation of patients with acute traumatic brain injury, up to 60% demonstrate low brain oxygen upon admission to the ICU. While eubaric hyperoxia has been beneficial in experimental studies, clinical brain oxygen protocols incorporating intracranial pressure control, maintenance of cerebral perfusion pressure, and the effective use of fraction of inspired oxygen adjustments to maintain cerebral oxygenation levels >20 to 25 mmHg have demonstrated mortality reductions and improved clinical outcomes. The risk of low brain oxygen is most acute in the first 24 to 48 hours after injury. The administration of a high fraction of inspired oxygen (0.6 to 1.0) in the emergency room may be justifiable until ICU admission for the placement of invasive neurocritical care monitoring systems. Thereafter, fraction of inspired oxygen levels need to be careful titrated to prevent low brain oxygen levels.
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Bilotta F, Titi L, Lanni F, Stazi E, Rosa G. Training anesthesiology residents in providing anesthesia for awake craniotomy: learning curves and estimate of needed case load. J Clin Anesth 2013; 25:359-366. [PMID: 23965201 DOI: 10.1016/j.jclinane.2013.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 01/22/2013] [Accepted: 01/29/2013] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To measure the learning curves of residents in anesthesiology in providing anesthesia for awake craniotomy, and to estimate the case load needed to achieve a "good-excellent" level of competence. DESIGN Prospective study. SETTING Operating room of a university hospital. SUBJECTS 7 volunteer residents in anesthesiology. MEASUREMENTS Residents underwent a dedicated training program of clinical characteristics of anesthesia for awake craniotomy. The program was divided into three tasks: local anesthesia, sedation-analgesia, and intraoperative hemodynamic management. The learning curve for each resident for each task was recorded over 10 procedures. Quantitative assessment of the individual's ability was based on the resident's self-assessment score and the attending anesthesiologist's judgment, and rated by modified 12 mm Likert scale, reported ability score visual analog scale (VAS). This ability VAS score ranged from 1 to 12 (ie, very poor, mild, moderate, sufficient, good, excellent). The number of requests for advice also was recorded (ie, resident requests for practical help and theoretical notions to accomplish the procedures). MAIN RESULTS Each task had a specific learning rate; the number of procedures necessary to achieve "good-excellent" ability with confidence, as determined by the recorded results, were 10 procedures for local anesthesia, 15 to 25 procedures for sedation-analgesia, and 20 to 30 procedures for intraoperative hemodynamic management. CONCLUSIONS Awake craniotomy is an approach used increasingly in neuroanesthesia. A dedicated training program based on learning specific tasks and building confidence with essential features provides "good-excellent" ability.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy.
| | - Luca Titi
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
| | - Fabiana Lanni
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
| | - Elisabetta Stazi
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
| | - Giovanni Rosa
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
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Salgado DR, Silva E, Vincent JL. Control of hypertension in the critically ill: a pathophysiological approach. Ann Intensive Care 2013; 3:17. [PMID: 23806076 PMCID: PMC3704960 DOI: 10.1186/2110-5820-3-17] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 05/14/2013] [Indexed: 01/21/2023] Open
Abstract
Severe acute arterial hypertension can be associated with significant morbidity and mortality. After excluding a reversible etiology, choice of therapeutic intervention should be based on evaluation of a number of factors, such as age, comorbidities, and other ongoing therapies. A rational pathophysiological approach should then be applied that integrates the effects of the drug on blood volume, vascular tone, and other determinants of cardiac output. Vasodilators, calcium channel blockers, and beta-blocking agents can all decrease arterial pressure but by totally different modes of action, which may be appropriate or contraindicated in individual patients. There is no preferred agent for all situations, although some drugs may have a more attractive profile than others, with rapid onset action, short half-life, and fewer adverse reactions. In this review, we focus on the main mechanisms underlying severe hypertension in the critically ill and how using a pathophysiological approach can help the intensivist decide on treatment options.
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Affiliation(s)
- Diamantino Ribeiro Salgado
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, Brussels 1070, Belgium
- Dept of Internal Medicine, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255 Sala 4A, Rio de Janeiro 12-21941-913, Brazil
| | - Eliezer Silva
- Intensive Care Unit, Albert Einstein Hospital, Sao Paulo, Brazil
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, Brussels 1070, Belgium
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Kim SY, Kim SM, Park MS, Kim HK, Park KS, Chung SY. Effectiveness of nicardipine for blood pressure control in patients with subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2012; 14:84-9. [PMID: 23210033 PMCID: PMC3471255 DOI: 10.7461/jcen.2012.14.2.84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 06/08/2012] [Accepted: 06/14/2012] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH). METHODS We prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure. RESULTS The blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p < 0.001). In each subgroups of Fisher grade and different dose, SBP/DBP also decreased after the use of nicardipine. These were statistically significant (p < 0.05), but there was no significant difference in effectiveness between subgroups (p > 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications. CONCLUSION Nicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.
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Affiliation(s)
- Sang Yong Kim
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
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Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711-37. [PMID: 22556195 DOI: 10.1161/str.0b013e3182587839] [Citation(s) in RCA: 2327] [Impact Index Per Article: 179.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
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Rhoney DH, McAllen K, Liu-DeRyke X. Current and future treatment considerations in the management of aneurysmal subarachnoid hemorrhage. J Pharm Pract 2010; 23:408-24. [PMID: 21507846 DOI: 10.1177/0897190010372334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a type of hemorrhagic stroke that can cause significant morbidity and mortality. Although guidelines have been published to help direct the care of these patients, there is insufficient quality literature regarding the medical and pharmacological management of patients with aSAH. Treatment is divided into 3 categories: supportive therapy, prevention of complications, and treatment of complications. There are numerous pharmacological therapies that are targeted at prevention and treatment of the neurological and medical complications that may arise. Rebleeding, hydrocephalus, cerebral vasospasm, and seizures are the most common neurological complications while the most common medical complications include hyponatremia, pulmonary edema, cardiac arrhythmias, neurogenic stunned myocardium, fever, anemia, infection, hyperglycemia, and venous thromboembolism. Risk factors, clinical presentation, diagnosis, pathophysiology, as well as initial management, prevention, and treatment of complications will be the focus of this discussion.
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Affiliation(s)
- Denise H Rhoney
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI 48201, USA.
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Varelas PN, Abdelhak T, Wellwood J, Shah I, Hacein-Bey L, Schultz L, Mitsias P. Nicardipine Infusion for Blood Pressure Control in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2010; 13:190-8. [DOI: 10.1007/s12028-010-9393-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
PURPOSE OF REVIEW In this review we focus on recent findings in the anesthetic management of patients undergoing craniotomy while awake, and propose a structured approach to the clinical practice of 'anesthesia' for awake neurosurgery. RECENT FINDINGS The increasing use of functional neurosurgery and recent evidence favoring resection of tumor involving eloquent cortex has expanded the indications for awake craniotomy, a procedure needing a fully cooperative patient and expert intraoperative anesthetic management. Despite the shorter hospital stay, the more recently published studies have highlighted perioperative anesthetic complications and have proposed ways to improve anesthesia techniques for awake procedures in adults and children. SUMMARY Although anesthesia for awake craniotomy is usually a well tolerated procedure it requires an extensive knowledge of the principles underlying neuroanesthesia and of specific technical strategies including local anesthesia for scalp blockade, advanced airway management, dedicated sedation protocols, and skillful management of hemodynamics.
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Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. J Neurosurg 2009; 111:672-82. [PMID: 19463048 DOI: 10.3171/2009.4.jns081150] [Citation(s) in RCA: 215] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI). Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients. In this study, the authors describe their 5-year experience with brain tissue oxygen (PbtO(2)) monitoring, and the effect of a brain tissue oxygen-directed critical care guide (PbtO(2)-CCG) on the 6-month clinical outcome (based on the 6-month Glasgow Outcome Scale score) in patients with TBIs. METHODS One hundred thirty-nine patients admitted to Creighton University Medical Center with major traumatic injuries (Injury Severity Scale [ISS] scores >or= 16) and TBI underwent prospective evaluation. All patients were treated with a PbtO(2)-CCG to maintain a brain oxygen level > 20 mm Hg, and control ICP < 20 mm Hg. The role of demographic, clinical, and imaging parameters in the identification of patients at risk for cerebral hypooxygenation and the influence of hypooxygenation on clinical outcome were recorded. Outcomes were compared with those in a historical ICP/CPP patient cohort. Subgroup analysis of severe TBI was performed and compared to data reported in the Traumatic Coma Data Bank. RESULTS The majority of injuries were sustained in motor vehicle crashes (63%), and diffuse brain injury was the most common abnormality (58%). Mechanism of injury, severity of TBI, pathological entity, neuroimaging results, and trauma indices were not predictive of ischemia. Factors affecting death included gunshot injury, poor trauma indices, subarachnoid hemorrhage, and coma. After standard resuscitation, 65% of patients had an initially low PbtO(2). Data are presented as means +/- SDs. Treatment with the PbtO(2)-CCG resulted in a 44% improvement in mean PbtO(2) (16.21 +/- 12.30 vs 23.65 +/- 14.40 mm Hg; p < 0.001), control of ICP (mean 12.76 +/- 6.42 mm Hg), and the maintenance of CPP (mean 76.13 +/- 15.37 mm Hg). Persistently low cerebral oxygenation was seen in 37% of patients at 2 hours, 31% at 24 hours, and 18% at 48 hours of treatment. Thus elevated ICP and a persistent low PbtO(2) after 2 hours represented increasing odds of death (OR 14.3 at 48 hours). Survivors and patients with good outcomes generally had significantly higher mean daily PbtO(2) and CPP values compared to nonsurvivors. Polytrauma, associated with higher ISS scores, presented an increased risk of vegetative outcome (OR 9.0). Compared to the ICP/CPP cohort, the mean Glasgow Outcome Scale score at 6 months in patients treated with PbtO(2)-CCG was higher (3.55 +/- 1.75 vs 2.71 +/- 1.65, p < 0.01; OR for good outcome 2.09, 95% CI 1.031-4.24) as was the reduction in mortality rate (25.9 vs 41.50%; relative risk reduction 37%), despite higher ISS scores in the PbtO(2) group (31.6 +/- 13.4 vs 27.1 +/- 8.9; p < 0.05). Subgroup analysis of severe closed TBI revealed a significant relative risk reduction in mortality rate of 37-51% compared with the Traumatic Coma Data Bank data, and an increased OR for good outcome especially in patients with diffuse brain injury without mass lesions (OR 4.9, 95% CI 2.9-8.4). CONCLUSIONS The prevention and aggressive treatment of cerebral hypooxygenation and control of ICP with a PbtO(2)-directed protocol reduced the mortality rate after TBI in major trauma, but more importantly, resulted in improved 6-month clinical outcomes over the standard ICP/CPP-directed therapy at the authors' institution.
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Abstract
Although systemic hypertension is a common clinical condition, hypertensive emergencies are unusual in clinical practice. There are some situations, however, that qualify as hypertensive emergencies or urgencies. It is important, therefore, to diagnose these acute conditions, in which immediate treatment of hypertension is indicated. The diagnosis of hypertensive emergencies depends on consideration of the clinical manifestations as well as the absolute level of blood pressure. Manifestations of hypertensive emergencies can be quite profound, but they vary depending on the target organ that is affected. Thus, an accurate clinical diagnosis is necessary to render appropriate therapy. Fortunately, effective drug therapy is available to lower the blood pressure quickly in hypertensive emergencies. Physicians should be familiar with the pharmacologic and clinical actions of drugs in treating hypertensive emergencies. With proper clinical diagnosis, hypertensive emergencies can be successfully treated, and complications can be largely prevented with timely intervention.
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