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Lee KS, Chari A, Motiwala M, Khan NR, Arthur AS, Lawton MT. Effectiveness of Cerebrospinal Fluid Lumbar Drainage Among Patients with Aneurysmal Subarachnoid Hemorrhage: An Updated Systematic Review and Meta-Analysis. World Neurosurg 2024; 183:246-253.e12. [PMID: 38246528 DOI: 10.1016/j.wneu.2024.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH. METHODS Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality. RESULTS A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99). CONCLUSIONS For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, King's College Hospital, London, United Kingdom; Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Aswin Chari
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mustafa Motiwala
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Lele AV, Theard MA, Vavilala MS. Cerebrospinal fluid diversion devices and shunting procedures: a narrative review for the anesthesiologist. Int Anesthesiol Clin 2023; 61:29-36. [PMID: 37249174 DOI: 10.1097/aia.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Abhijit Vijay Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Kim DY, Cho YH, Kim S, Jeong JH, Choi JH, Kang M, Park HS. Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 175:e1032-e1040. [PMID: 37087037 DOI: 10.1016/j.wneu.2023.04.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. METHODS Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. RESULTS The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P = 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P = 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P = 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P = 0.272). CONCLUSIONS Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.
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Affiliation(s)
- Dae Young Kim
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Yong-Hwan Cho
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Sanghyeon Kim
- Department of Radiology, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jin-Heon Jeong
- Department of Critical Care Medicine, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jae Hyung Choi
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Myongjin Kang
- Department of Radiology, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Hyun-Seok Park
- Department of Neurosurgery, Cerebrovascular Center, Ulsan Medical Center, Nam-gu, Ulsan, Republic of Korea.
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Continuous lumbar drainage after aneurysmal subarachnoid hemorrhage decreased malondialdehyde in cerebrospinal fluid and improved outcome. J Formos Med Assoc 2023; 122:164-171. [PMID: 36117035 DOI: 10.1016/j.jfma.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/31/2022] [Accepted: 09/01/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The use of a continuous lumbar drain (LD) for the treatment of aneurysmal subarachnoid hemorrhage (aSAH), and malondialdehyde (MDA), a marker of oxidative stress, is correlated with clinical outcome. This study aimed to investigate the relationship between LD placement and MDA level after aSAH. METHODS Patients with modified Fisher's grade III and IV aSAH who underwent early aneurysm obliteration were enrolled. Cerebrospinal fluid (CSF) was obtained on day 7 after aSAH in non-LD group. In LD group, the LD was inserted on day 3 after aSAH for continuous CSF drainage. The levels of intrathecal hemoglobin, total bilirubin, ferritin, and MDA were measured. RESULTS There were 41 patients in non-LD group (age: 58.7 ± 13.7 years; female: 61.0%) and 48 patients in LD group (age: 58.3 ± 10.4 years; female: 79.2%). There were more favorable outcomes (Glasgow Outcome Scale ≥4) at 3 months after aSAH in LD group (p = 0.0042). The intrathecal hemoglobin, total bilirubin, ferritin, and MDA levels at day 7 after aSAH were all significantly lower in LD group. An older age (>60 years) (p = 0.0293), higher MDA level in the CSF (p = 0.0208), and delayed ischemic neurological deficit (p = 0.0451) were independent factors associated with unfavorable outcomes. LD placement was associated with a decreased intrathecal MDA level on day 7 after aSAH (p < 0.001). CONCLUSION The intrathecal MDA level at day 7 after aSAH can be an effective outcome indicator in modified Fisher's grade III/IV aSAH. Continuous CSF drainage via a LD can decrease the intrathecal MDA level and improve the functional outcome.
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Lee CY, Jang KM, Wui SH, Park SW. The Benefits and Feasibility of External Lumbar Cerebrospinal Fluid Drainage for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis and Trial Sequential Analysis. World Neurosurg 2022; 167:e549-e560. [PMID: 35977676 DOI: 10.1016/j.wneu.2022.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral vasospasm after aneurysmal subarachnoid hemorrhage is a main cause contributing to poor outcomes. Removal of blood from the subarachnoid may decrease development of cerebral vasospasm. The purpose of this study is to determine the effect of lumbar cerebrospinal fluid (CSF) drainage on cerebral vasospasm and related complications through meta-analysis and trial sequential analysis (TSA). METHODS A systematic search of the literature was performed. Case-control studies of the effects of external lumbar drainage in patients with subarachnoid hemorrhage were included. The association between lumbar drain and vasospasm, cerebral infarction, subsequent treatment, and mortality were evaluated. RESULTS Eleven of 122 articles were included in the meta-analysis. Lumbar CSF drainage reduces occurrence of vasospasm and related complications. In meta-analysis, the pooled odds ratio for symptomatic vasospasm, cerebral infarct, endovascular treatment for vasospasm, and mortality was 0.40 (95% confidence interval [CI], 0.31-0.51; P = 0.00001), 0.47 (95% CI, 0.35-0.62; P < 0.0001), 0.29 (95% CI, 0.18-0.46; P < 0.0001), and 0.41, (95% CI, 0.23-0.74; P = 0.003), respectively, compared with the non-lumbar drainage group. In TSA, the cumulative Z line crossed α-spending boundaries and reached the required sample size in analysis of symptomatic vasospasm and endovascular treatment for vasospasm. CONCLUSIONS Lumbar CSF drainage can decrease symptomatic vasospasm, cerebral infarction, subsequent endovascular treatment, and mortality. Through TSA, the accuracy and reliability of the effect of lumbar CSF drainage-related cerebral vasospasm and endovascular treatment are increased. Further studies of the association between lumbar drain and cerebral infarction and mortality are required to confirm the generalization of the results.
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Affiliation(s)
- Cheol Young Lee
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea.
| | - Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seong Hyun Wui
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
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Zeineddine HA, Honarpisheh P, McBride D, Pandit PKT, Dienel A, Hong SH, Grotta J, Blackburn S. Targeting Hemoglobin to Reduce Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Transl Stroke Res 2022; 13:725-735. [PMID: 35157256 PMCID: PMC9375776 DOI: 10.1007/s12975-022-00995-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
Abstract
Delayed cerebral ischemia (DCI) continues to be a sequela of aneurysmal subarachnoid hemorrhage (aSAH) that carries significant morbidity and mortality. Aside from nimodipine, no therapeutic agents are available to reduce the incidence of DCI. Pathophysiologic mechanisms contributing to DCI are poorly understood, but accumulating evidence over the years implicates several factors. Those have included microvessel vasoconstriction, microthrombosis, oxidative tissue damage, and cortical spreading depolarization as well as large vessel vasospasm. Common to these processes is red blood cell leakage into the cerebrospinal fluids (CSF) and subsequent lysis which releases hemoglobin, a central instigator in these events. This has led to the hypothesis that early blood removal may improve clinical outcome and reduce DCI. This paper will provide a narrative review of the evidence of hemoglobin as an instigator of DCI. It will also elaborate on available human data that discuss blood clearance and CSF drainage as a treatment of DCI. Finally, we will address a recent novel device that is currently being tested, the Neurapheresis CSF Management System™. This is an automated dual-lumen lumbar drainage system that has an option to filter CSF and return it to the patient.
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Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Pedram Honarpisheh
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Devin McBride
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Peeyush Kumar Thankamani Pandit
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Ari Dienel
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - Sung-Ha Hong
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA
| | - James Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA.
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Lumbar Drainage After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:261-267.e9. [PMID: 35868504 DOI: 10.1016/j.wneu.2022.07.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study reviews the use of lumbar drains (LDs) after aneurysmal subarachnoid hemorrhage (aSAH) and compares the outcomes to those associated with external ventricular drains (EVDs) and controls. METHODS A comprehensive search of the literature was performed. English language studies with a sample size of more than 10 patients were included. One-arm and 2-arm meta-analyses were designed to compare external drainage groups. Random-effects models, heterogeneity measures, and risk of bias were calculated. RESULTS Seventeen studies were included in the meta-analysis. The 2-arm meta-analysis comparing the LD to no drainage after aSAH found a significant improvement in the postoperative modified Rankin Scale (mRS) score (0-2) within 1 month of hospital discharge in the LD group (P = 0.003), a lower mortality rate (P = 0.03), fewer cases of clinical vasospasm (P = 0.007), and a lower incidence of ischemic stroke or delayed ischemic neurological deficits (P = 0.003). When the LD was compared to EVDs, a significant improvement in the postoperative mRS score (0-2) within 1 month of discharge was found in the LD group (P < 0.001). In the LD group, rebleeding occurred in 15 (3.4%) cases and meningitis occurred in 50 (4.7%) cases. CONCLUSIONS Compared with patients without cerebrospinal fluid drainage, patients with the LD after aSAH had lower mortality rates, lower risk of clinical vasospasm, and lower risk of ischemic stroke, and they were more likely to have an mRS score of 0-2 within 1 month of discharge. Compared with patients with EVDs, patients with the LD were more likely to have an mRS score of 0-2 within 1 month of discharge.
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Vetsa S, Nadar A, Vasandani S, Gorelick E, Bungard J, Barak T, Fulbright RK, Marianayagam NJ, Moliterno J. Criteria for Cerebrospinal Fluid Diversion in Retractorless Sphenoid Wing Meningioma Surgery: A Technical Report. J Neurol Surg Rep 2022; 83:e100-e104. [PMID: 36060292 PMCID: PMC9439877 DOI: 10.1055/s-0042-1753518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 05/11/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Sphenoid wing meningiomas (SWMs) can present surgical challenges, in that they are often obscured by overlying brain, encase critical neurovascular structures, and obliterate cerebrospinal fluid (CSF) cisterns. While brain retraction can enable access, its use can have potentially deleterious effects. We report the benefits and outcomes of the criteria we have developed for use of cerebrospinal diversion to perform retractorless surgery for SWMs. Design Technical report. Setting Yale School of Medicine and Yale New Haven Hospital. Participants Between May, 2019 and December, 2020, ten consecutive patients were included who met the presented criteria for SWM surgery with preoperative lumbar drain (LD) placement. Main Outcome Measures Length of hospital stay, surgical complications, and extent of resection. Results We have developed the following criteria for LD placement in patients with SWMs such that LDs are preoperatively placed in patients with tumors with one or more of the following criteria: (1) medial location along the sphenoid wing, (2) vascular encasement resulting in obliteration of the optic carotid cistern and/or proximal sylvian fissure, and/or (3) the presence of associated edema. CSF release, after craniotomy and sphenoid wing removal, allowed for optimization of exposure, leading to the maximal safe extent of tumor resection without brain retraction or any complications. Conclusions Preoperative LD placement is effective in allowing for maximal extent of resection of SWMs and may be considered in cases where local CSF release is not possible. This technique is useful in those tumors located more medially, with encasement of the vasculature and/or associated with edema.
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Affiliation(s)
- Shaurey Vetsa
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Arushii Nadar
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Sagar Vasandani
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Evan Gorelick
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Jillian Bungard
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Tanyeri Barak
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Robert K. Fulbright
- Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States,Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, United States
| | - Neelan J. Marianayagam
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States,Yale Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, United States,Address for correspondence Jennifer Moliterno, MD Department of Neurosurgery, Yale School of Medicine15 York St, LLCI 810, New Haven, CT 06520-8082United States
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Grossen AA, Ernst GL, Bauer AM. Update on intrathecal management of cerebral vasospasm: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E10. [PMID: 35231885 DOI: 10.3171/2021.12.focus21629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) accounts for a relatively small portion of strokes but has the potential to cause permanent neurological deficits. Vasospasm with delayed ischemic neurological deficit is thought to be responsible for much of the morbidity associated with aSAH. This has illuminated some treatment options that have the potential to target specific components of the vasospasm cascade. Intrathecal management via lumbar drain (LD) or external ventricular drain (EVD) offers unique advantages in this patient population. The aim of this review was to provide an update on intrathecal vasospasm treatments, emphasizing the need for larger-scale trials and updated protocols using data-driven evidence. METHODS A search of PubMed, Ovid MEDLINE, and Cochrane databases included the search terms (subarachnoid hemorrhage) AND (vasospasm OR delayed cerebral ischemia) AND (intrathecal OR intraventricular OR lumbar drain OR lumbar catheter) for 2010 to the present. Next, a meta-analysis was performed of select therapeutic regimens. The primary endpoints of analysis were vasospasm, delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome. RESULTS Twenty-nine studies were included in the analysis. There were 10 studies in which CSF drainage was the primary experimental group. Calcium channel antagonists were the focus of 7 studies. Fibrinolytics and other vasodilators were each examined in 6 studies. The meta-analysis included studies examining CSF drainage via LD (n = 4), tissue plasminogen activator in addition to EVD (n = 3), intraventricular nimodipine (n = 2), and cisternal magnesium (n = 2). Results showed that intraventricular nimodipine decreased vasospasm (OR 0.59, 95% CI 0.37-0.94; p = 0.03). Therapies that significantly reduced DCI were CSF drainage via LD (OR 0.47, 95% CI 0.25-0.88; p = 0.02) and cisternal magnesium (OR 0.27, 95% CI 0.07-1.02; p = 0.05). CSF drainage via LD was also found to significantly reduce the incidence of cerebral infarction (OR 0.35, 95% 0.24-0.51; p < 0.001). Lastly, functional outcome was significantly better in patients who received CSF drainage via LD (OR 2.42, 95% CI 1.39-4.21; p = 0.002). CONCLUSIONS The authors' results showed that intrathecal therapy is a safe and feasible option following aSAH. It has been shown to attenuate cerebral vasospasm, reduce the incidence of DCI, and improve clinical outcome. The authors support the use of intrathecal management in the prevention and rescue management of cerebral vasospasm. More randomized controlled trials are warranted to determine the best combination of pharmaceutical agents and administration route in order to formulate a standardized treatment approach.
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Application effect of two modalities for placing lumbar drain catheters in patients with postcraniotomy aseptic meningitis. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Safety and effectiveness of lumbar cerebrospinal fluid drainage to prevent delayed cerebral ischemia after Fisher grade 3 subarachnoid hemorrhage with minimal intraventricular hemorrhage. Neurochirurgie 2020; 66:225-231. [DOI: 10.1016/j.neuchi.2020.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/22/2020] [Accepted: 03/07/2020] [Indexed: 01/29/2023]
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Shimohata N, Echigo R, Karatsu K, Uchikawa S, Suzuki S, Chung UI, Sasaki N, Mochizuki M. Trehalose decreases blood clotting in the cerebral space after experimental subarachnoid hemorrhage. J Vet Med Sci 2020; 82:566-570. [PMID: 32173691 PMCID: PMC7273599 DOI: 10.1292/jvms.19-0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) frequently results in several serious complications, such as cerebral vasospasm. We previously reported the effect of trehalose on vasospasm, inflammatory
responses, and lipid peroxidation induced by blood exposure. Herein, to further elucidate the mechanism of action of trehalose, we investigated whether or not post-administration of
trehalose can directly influence blood clotting in the cistern. As a result of trehalose injection after the onset of experimental SAH, blood clotting around the basilar artery was clearly
inhibited. We also found that trehalose positively impacted coagulation and fibrinolysis parameters in rat, rabbit and human plasma in vitro. These findings suggest that
trehalose has suppressive effects on blood clotting in addition to vasospasm, inflammatory responses, and lipid peroxidation after SAH.
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Affiliation(s)
- Nobuyuki Shimohata
- Department of Biomedical Sciences, College of Life Sciences, Ritsumeikan University, 1-1-1 Nojihigashi, Kusatsu, Shiga 525-8577, Japan
| | - Ryosuke Echigo
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan.,Faculty of Veterinary Medicine, Hokkaido University, Kita 18, Nishi 9, Kita-ku, Sapporo, Hokkaido 080-0818, Japan
| | - Kensuke Karatsu
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Saori Uchikawa
- Department of Biomedical Sciences, College of Life Sciences, Ritsumeikan University, 1-1-1 Nojihigashi, Kusatsu, Shiga 525-8577, Japan
| | - Shigeki Suzuki
- NEXT21 K.K., 3-38-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Ung-Il Chung
- Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 2-11-16 Yayoi, Bunkyo-ku, Tokyo 113-8656, Japan.,Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Nobuo Sasaki
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Manabu Mochizuki
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
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Khani M, Sass LR, McCabe AR, Zitella Verbick LM, Lad SP, Sharp MK, Martin BA. Impact of Neurapheresis System on Intrathecal Cerebrospinal Fluid Dynamics: A Computational Fluid Dynamics Study. J Biomech Eng 2020; 142:021006. [PMID: 31343659 PMCID: PMC7104775 DOI: 10.1115/1.4044308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 07/18/2019] [Indexed: 11/08/2022]
Abstract
It has been hypothesized that early and rapid filtration of blood from cerebrospinal fluid (CSF) in postsubarachnoid hemorrhage patients may reduce hospital stay and related adverse events. In this study, we formulated a subject-specific computational fluid dynamics (CFD) model to parametrically investigate the impact of a novel dual-lumen catheter-based CSF filtration system, the Neurapheresis™ system (Minnetronix Neuro, Inc., St. Paul, MN), on intrathecal CSF dynamics. The operating principle of this system is to remove CSF from one location along the spine (aspiration port), externally filter the CSF routing the retentate to a waste bag, and return permeate (uncontaminated CSF) to another location along the spine (return port). The CFD model allowed parametric simulation of how the Neurapheresis system impacts intrathecal CSF velocities and steady-steady streaming under various Neurapheresis flow settings ranging from 0.5 to 2.0 ml/min and with a constant retentate removal rate of 0.2 ml/min simulation of the Neurapheresis system were compared to a lumbar drain simulation with a typical CSF removal rate setting of 0.2 ml/min. Results showed that the Neurapheresis system at a maximum flow of 2.0 ml/min increased average steady streaming CSF velocity 2× in comparison to lumbar drain (0.190 ± 0.133 versus 0.093 ± 0.107 mm/s, respectively). This affect was localized to the region within the Neurapheresis flow loop. The mean velocities introduced by the flow loop were relatively small in comparison to normal cardiac-induced CSF velocities.
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Affiliation(s)
- Mohammadreza Khani
- Department of Biological Engineering, University of Idaho, Moscow, ID 83844
| | - Lucas R. Sass
- Department of Biological Engineering, University of Idaho, Moscow, ID 83844
| | | | | | - Shivanand P. Lad
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC 27710
| | - M. Keith Sharp
- Department of Mechanical Engineering, University of Louisville, Louisville, KY 40292
| | - Bryn A. Martin
- Department of Biological Engineering, University of Idaho, Moscow, ID 83844
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Abstract
External ventricular drains (EVD) are essential in the early management of hydrocephalus and elevated intracranial pressure after subarachnoid hemorrhage (SAH). Once in place, management of the EVD is thought to influence long-term patient outcomes, rates of ventriculitis, incidence of delayed cerebral ischemia, need for a ventriculoperitoneal shunt, and intensive care unit (ICU) and hospital length of stay. The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies.
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15
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Cheng YW, Guo YC, Li GL, Deng YN, Li WJ, Xu GF, Deng Z, Cao YX, Luo GG. Effects of a new magnesium-rich artificial cerebrospinal fluid on contractile 5-hydroxytryptamine and endothelin receptors in rat cerebral arteries. Neurol Res 2019; 41:1015-1023. [PMID: 31559927 DOI: 10.1080/01616412.2019.1672383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives Cerebral vasospasm after subarachnoid haemorrhage (SAH) is associated with cerebrovascular contractile receptor upregulation resulted from haemolysis in the subarachnoid space. This study developed a new magnesium-rich artificial cerebrospinal fluid (MACSF) formula and investigated its effects on receptor-mediated contraction in rat basilar arteries. Methods Clear and haemorrhagic cerebrospinal fluid (CSF) were collected from patients with hydrocephalus or SAH. MACSF was freshly prepared using clinical intravenous injections. Rat basilar arteries were segmented and incubated with clear CSF, haemorrhagic CSF or MACSF. The contractile responses were studied by myograph. The messenger ribonucleic acid (mRNA) and protein expression of 5-hydroxytryptamine 1B (5-HT1B), endothelin subtype B (ETB) and endothelin subtype A (ETA) receptors were evaluated by real-time polymerase chain reaction (PCR) and Western blot analyses. Results Haemorrhagic CSF exposure shifted the contractile curves induced by 5-hydroxytryptamine (5-HT), sarafotoxins 6c (S6c) and endothelin-1 (ET-1) leftward with increased maximal contraction values. Furthermore, mRNA and protein expression were markedly elevated for 5-HT1B, ETB and ETA receptors on arteries exposed to haemorrhagic CSF. However, the contractile responses to 5-HT, S6c or ET-1 and expression of 5-HT1B, ETB and ETA receptors in rat cerebral arteries exposed to MACSF remained unaffected compared to those exposed to clear CSF. Besides, unlike normal saline which can inactive in-vitro vessels, MACSF can maintain their physiological activity. Conclusion Haemorrhagic CSF induces upregulation of 5-HT1B, ETB and ETA receptors in rat cerebral arteries. However, MACSF can maintain in-vitro rat basilar arteries in good physiological activity and normal expression of contractile 5-HT and ET receptors.
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Affiliation(s)
- Ya-Wen Cheng
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
| | - Yi-Chen Guo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
| | - Guo-Liang Li
- Department of Cardiovascular, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
| | - Yong-Ning Deng
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
| | - Wen-Juan Li
- Department of Neurology, Second Affiliated Hospital, Lanzhou University , Lanzhou , China
| | - Gao-Feng Xu
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
| | - Zhong Deng
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
| | - Yong-Xiao Cao
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center , Xi'an , China
| | - Guo-Gang Luo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , China
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Wang HY, Song J, Gao F, Duan XD, Gao X, Wang Y, Cheng HB, Nan CR, Zhao D. Outcomes of microsurgical clipping vs coil embolization for ruptured aneurysmal subarachnoid hemorrhage: A multicenter real-world analysis of 583 patients in China. Medicine (Baltimore) 2019; 98:e16821. [PMID: 31415399 PMCID: PMC6831274 DOI: 10.1097/md.0000000000016821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a complex neurovascular syndrome with high disability and mortality. SAH patients may be managed with surgical clipping or coil embolization. In this study, we provided a real-world analysis of the outcome and prognostic factors of aneurysmal SAH in patients treated with coil embolization or microsurgical clipping.We retrospectively analyzed the medical records of aneurysmal SAH patients (n = 583) who underwent treatment at the First Hospital and the Second Hospital of Hebei Medical University, and Tangshan Worker's Hospital in China. All patients were evaluated by a combined neurosurgery and interventional neuroradiology team. Microsurgical aneurysmal clipping was performed using the skull base approach, while coil embolization was performed with bare platinum coils (with or without balloon assistance). The primary outcome was the Glasgow Outcome Scale (GOS) score at discharge.A total of 583 patients were included in this study, of which 397 (68.1%) of them underwent clipping and 186 (31.9%) received coil embolization. The patient cohort consisted of both poor grade and good grade aneurysmal SAH: 441 (75.6%) patients had good-grade (Hunt and Hess grade II or III) and 142 (24.4%) had poor grade (Hunt and Hess grade IV or V). Overall, 123 (21%) patients had unfavorable neurologic outcome (GOS score 1-3) and 460 (78.9%) patients had favorable neurologic outcome (GOS score 4 or 5). The mean GOS score at discharge was comparable for patients who underwent clipping and those received coil embolization (P > .05). Multivariate analysis showed that clipping only [OR (95%CI): 0.03 (0.01, 0.36); P = .000] and clipping with CSF drainage [OR (95%CI): 0.41 (0.18, 0.89); P = .001] were independent factors of a favorable outcome in patients with aneurysmal SAH. Coil embolization with hematoma removal [OR (95%CI): 0.03 (0.01, 0.36); P = .000] was also an independent determinant of a favorable outcome. High baseline Fisher grades were associated with significantly increased risk of an unfavorable outcome [OR (95%CI): 2.08 (1.30, 3.33); P = .002].Our findings suggested that both coil embolization and microsurgical clipping are viable treatment options for aneurysmal SAH patients. Procedures, such as CSF drainage and hematoma removal, performed in parallel with coil embolization and chipping should be considered when treating individual patients.
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Affiliation(s)
- Hong-Yu Wang
- Department of Neurosurgery, Tangshan Gongren Hospital, Tangshan, Hebei
| | - Jian Song
- Department of Neurosurgery, The Second Hospital of Hebei Medical University
| | - Fei Gao
- Hebei Provincial Procurement Centers for Medical Drugs and Devices
| | - Xu-Dong Duan
- Department of TCM Surgery, The Second Hospital of Hebei Medical University
| | | | - Yuan Wang
- Department of Neurosurgery, Tangshan Gongren Hospital, Tangshan, Hebei
| | - Hong-Bo Cheng
- Department of Neurosurgery, The Second Hospital of Hebei Medical University
| | - Cheng-Rui Nan
- Department of Neurosurgery, The Second Hospital of Hebei Medical University
| | - Di Zhao
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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The effectiveness of lumbar cerebrospinal fluid drainage in aneurysmal subarachnoid hemorrhage with different bleeding amounts. Neurosurg Rev 2019; 43:739-747. [DOI: 10.1007/s10143-019-01116-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/07/2019] [Accepted: 05/17/2019] [Indexed: 11/27/2022]
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18
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Safety and feasibility of lumbar drainage in the management of poor grade aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2019; 64:64-70. [DOI: 10.1016/j.jocn.2019.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 02/20/2019] [Accepted: 04/12/2019] [Indexed: 11/23/2022]
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19
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Yu Z, Zheng J, Ma L, Li H, You C, Jiang Y. Predictive Value of Cerebral Autoregulation Impairment for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. World Neurosurg 2019; 126:e853-e859. [PMID: 30862594 DOI: 10.1016/j.wneu.2019.02.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) happens in about 30% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is related to higher mortality and disability. Some studies have shown cerebral autoregulation impairment can be a predictor of DCI in aneurysmal SAH. We conducted this meta-analysis to evaluate the predictive value of cerebral autoregulation impairment for DCI based on the current literature. METHODS A systematic literature search was performed in PubMed and Embase. According to inclusion and exclusion criteria, 2 authors screened the records and extracted data from the included studies. Pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained. To investigate the overall accuracy, a summary receiver operating characteristic (SROC) curve was built and the area under SROC curve was calculated. Deeks' linear regression was used to assess the publication bias. All statistical analyses were performed with Stata 14.0. RESULTS A total of 7 studies were finally included in this meta-analysis. The pooled sensitivity and specificity values of impaired cerebral autoregulation for DCI prediction were 0.79 (95% CI, 0.65-0.88) and 0.85 (95% CI, 0.615-0.96). Moreover, the area under the SROC curve of cerebral autoregulation impairment for DCI prediction was 0.87 (95% CI, 0.835-0.89). No obvious publication bias was found in Deeks' linear regression (P = 0.99). CONCLUSIONS Cerebral autoregulation impairment can be a helpful predictor of DCI in aneurysmal SAH. Its accuracy for DCI prediction should be verified by more studies in the future.
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Affiliation(s)
- Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Jiang
- Department of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Eom TO, Park ES, Park JB, Kwon SC, Sim HB, Lyo IU, Kim MS. Does Neurosurgical Clipping or Endovascular Coiling Lead to More Cases of Delayed Hydrocephalus in Patients with Subarachnoid Hemorrhage? J Cerebrovasc Endovasc Neurosurg 2018; 20:87-95. [PMID: 30370242 PMCID: PMC6196142 DOI: 10.7461/jcen.2018.20.2.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/11/2018] [Accepted: 05/20/2018] [Indexed: 11/24/2022] Open
Abstract
Objective We investigated whether clipping or endovascular treatment (EVT) can reduce the incidence of delayed hydrocephalus. We also investigated whether additional procedures, namely lumbar drainage and extra-ventricular drainage (EVD), decrease the incidence of delayed hydrocephalus in patients with subarachnoid hemorrhage (SAH). Materials and Methods One-hundred and fifty-two patients who had undergone an operation for SAH were enrolled in this study. Clinical data, radiological data, and procedural data were investigated. Procedural data included the operating technique (clipping vs. EVT) and the use of additional procedures (no procedure, lumbar drainage, or EVD). Delayed hydrocephalus was defined as a condition in which the Evan's index was 0.3 or higher, as assessed using brain computed tomography more than 2 weeks after surgery, requiring shunt placement due to neurological deterioration. Results Of the 152 patients, 45 (29.6%) underwent surgical clipping and 107 (70.4%) underwent EVT. Twenty-five (16.4%) patients developed delayed hydrocephalus. Age (p = 0.019), procedure duration (p = 0.004), and acute hydrocephalus (p = 0.030) were significantly correlated with the incidence of delayed hydrocephalus. However, the operation technique (p = 0.593) and use of an additional procedure (p = 0.378) were not significantly correlated with delayed hydrocephalus incidence. Conclusion No significant difference in the incidence of delayed hydrocephalus was associated with operation technique or use of an additional procedure in patients with SAH. However, delayed hydrocephalus was significantly correlated with old age, long procedural duration, and acute hydrocephalus. Therefore, we recommend that additional procedures should be discontinued as soon as possible.
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Affiliation(s)
- Tae Oong Eom
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jun Bum Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soon Chan Kwon
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hong Bo Sim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - In Uk Lyo
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Min Soo Kim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Li X, Sun S, Wang Q, Zhao Z. Population Pharmacokinetics of Combined Intravenous and Local Intrathecal Administration of Meropenem in Aneurysm Patients with Suspected Intracranial Infections After Craniotomy. Eur J Drug Metab Pharmacokinet 2018; 43:45-53. [PMID: 28616823 DOI: 10.1007/s13318-017-0422-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE For patients with intracranial infection, local intrathecal administration of meropenem may be a useful method to obtain a sufficient drug concentration in the cerebral spinal fluid (CSF). However, a large inter-individual variability may pose treatment efficacy at risk. This study aimed to identify factors affecting drug concentration in the CSF using population pharmacokinetics method. METHODS After craniotomy, aneurysm patients with an indwelling lumbar cistern drainage tube who received a combined intravenous and intrathecal administration of meropenem for the treatment of suspected intracranial infection were enrolled. Venous blood and CSF specimens were collected for determining meropenem concentrations. Nonlinear mixed-effects modeling method was used to fit blood and CSF concentrations simultaneously and to develop the population pharmacokinetic model. The proposed model was applied to simulate dosage regimens. RESULTS A three-compartmental model was established to describe meropenem in vivo behavior. Lumbar CSF drainage resulted in a drug loss, and drug clearance in CSF (CLCSF) was employed to describe this. The covariate analysis found that the drainage volume (mL/day) was strongly associated with CLCSF, and the effect of creatinine clearance was significant on the clearance of meropenem in blood (CL). Visual predictive check suggested that the proposed pharmacokinetic model agreed well with the observations. Simulation showed that both intravenous and intrathecal doses should be increased with the increases of minimum inhibitory concentration and daily CSF drainage volume. CONCLUSION This model incorporates covariates of the creatinine clearance and the drainage volume, and a simple to use dosage regimen table was created to guide clinicians with meropenem dosing.
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Affiliation(s)
- Xingang Li
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Shusen Sun
- College of Pharmacy, Western New England University, Springfield, MA, 01119, USA
| | - Qiang Wang
- Intensive Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
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Lee JW, Woo JH, Baik HJ, Kim DY, Chae JS, Yang NR, Seo EK. The effect of anesthetic agents on cerebral vasospasms after subarachnoid hemorrhage: A retrospective study. Medicine (Baltimore) 2018; 97:e11666. [PMID: 30075557 PMCID: PMC6081172 DOI: 10.1097/md.0000000000011666] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cerebral vasospasm is the most important cause of morbidity after an aneurysm clipping in the early postoperative period. The aim of this retrospective study was to evaluate whether the incidence of vasospasms differs when using propofol or desflurane for an emergent aneurysm clipping.The data from 102 patients (50 in the propofol group, 52 in the desflurane group) were analyzed. The occurrence of vasospasm based on daily transcranial Doppler, angiography, and cerebral infarction during 14 days after surgery were compared by anesthetic agents. Postoperative data including Glasgow Coma Scale (GCS) score on day 14 after surgery, and the Glasgow Outcome Scale (GOS) score at 3 months were documented.Patients that intraoperatively received propofol for anesthesia maintenance, had higher incidence of transcranial Doppler (TCD)-evident vasospasm than those that received desflurane (54% vs 30.8%, P = .027). The occurrence of TCD-evident vasospasm was still higher (odds ratio: 2.84; 95% confidence interval: 1.12-7.20) in the propofol group than in the desflurane group after adjusting for confounding factors. However, the incidence of angiographic vasospasm, cerebral infarction, and interventions to treat cerebral vasospasms were similar between both groups. GCS score on day 14 after surgery and the GOS score at 3 months were similar between groups.No effect of anesthetic agents on angiographic vasospasm, cerebral infarction, or clinical outcome was observed, whereas desflurane anesthesia was associated with a lower incidence of TCD-evident vasospasms compared to propofol anesthesia. Our study provides a basis for further randomized controlled studies in a larger patient population to clarify the effects of anesthetic agents on the occurrence of cerebral vasospasms.
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Affiliation(s)
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine
| | | | | | | | - Na Rae Yang
- Department of Neurosurgery, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Eui Kyo Seo
- Department of Neurosurgery, College of Medicine, Ewha Womans University, Seoul, Korea
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Al-Mufti F, Amuluru K, Damodara N, El-Ghanem M, Nuoman R, Kamal N, Al-Marsoummi S, Morris NA, Dangayach NS, Mayer SA. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2018; 390:44-51. [DOI: 10.1016/j.jns.2018.02.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 11/27/2022]
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24
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Blackburn SL, Swisher CB, Grande AW, Rubi A, Verbick LZ, McCabe A, Lad SP. Novel Dual Lumen Catheter and Filtration Device for Removal of Subarachnoid hemorrhage: First Case Report. Oper Neurosurg (Hagerstown) 2018; 16:E148-E153. [DOI: 10.1093/ons/opy151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/16/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
The amount of subarachnoid blood and the presence of toxic blood breakdown products in the cerebrospinal fluid (CSF) have long been associated with poor outcomes in aneurysmal subarachnoid hemorrhage. The Neurapheresis™ system (Minnetronix Inc, St. Paul, Minnesota) has been developed to filter CSF and remove blood products, and is being investigated for safety and feasibility in the ExtracorPoreal FILtration of subarachnoid hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device.
CLINICAL PRESENTATION
A 65-yr-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 h of filtration during 31 h of catheter indwelling resulted in 309.47 mL of processed CSF without complication. Computed tomography images demonstrated an interval reduction of subarachnoid hemorrhage immediately after filtration. The patient was discharged home on postbleed day 11 and at 30 d showed good recovery.
CONCLUSION
Safety of the Neurapheresis procedure was confirmed in this first case, and we will continue to evaluate safety of the Neurapheresis system through the PILLAR trial.
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Affiliation(s)
- Spiros L Blackburn
- Department of Neurosurgery, University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Christa B Swisher
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Alba Rubi
- Department of Neurosurgery, University of Texas Health Sciences Center at Houston, Houston, Texas
| | | | | | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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van Lieshout JH, Pumplün I, Fischer I, Kamp MA, Cornelius JF, Steiger HJ, Boogaarts HD, Petridis AK, Beseoglu K. Volume of cerebrospinal fluid drainage as a predictor for pretreatment aneurysmal rebleeding. J Neurosurg 2018; 128:1778-1784. [DOI: 10.3171/2017.2.jns162748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEInitiation of external CSF drainage has been associated with a significant increase in rebleeding probability after aneurysmal subarachnoid hemorrhage (aSAH). However, the implications for acute management are uncertain. The purpose of this study was to evaluate the role of the amount of drained CSF on aneurysmal rebleeding.METHODSConsecutive patients with aSAH were analyzed retrospectively. Radiologically confirmed cases of aneurysmal in-hospital rebleeding were identified and predictor variables for rebleeding were retrieved from hospital records. Clinical predictors were identified through multivariate analysis, and logistic regression analysis was performed to ascertain the cutoff value for the rebleeding probability.RESULTSThe study included 194 patients. Eighteen cases (9.3%) of in-hospital rebleeding could be identified. Using multivariate analysis, in-hospital rebleeding was significantly associated with initiation of CSF drainage (p = 0.001) and CSF drainage volume (63 ml [interquartile range (IQR) 55–69 ml] vs 25 ml [IQR 10–35 ml], p < 0.001). Logistic regression showed that 58 ml of CSF drainage within 6 hours results in a 50% rebleeding probability. The relative risk (RR) for rebleeding after drainage of more than 60 ml in 6 hours was 5.4 times greater compared with patients with less CSF drainage (RR 5.403, 95% CI 2.481–11.767; p < 0.001, number needed to harm = 1.687).CONCLUSIONSVolume of CSF drainage was highly correlated with the probability of in-hospital aneurysmal rebleeding. These findings suggest that the rebleeding probability can be affected in acute management should the placement of an external ventricular catheter be necessary. This finding necessitates meticulous control of the amount of drained CSF and the development of a definitive treatment protocol for this group of patients.
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Affiliation(s)
- Jasper H. van Lieshout
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Ina Pumplün
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Igor Fischer
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Marcel A. Kamp
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Jan F. Cornelius
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Hans J. Steiger
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | | | - Athanasios K. Petridis
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
| | - Kerim Beseoglu
- 1Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany; and
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Abstract
PURPOSE OF REVIEW With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm. RECENT FINDINGS Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome. SUMMARY Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.
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Reappraisal of the causes of spontaneous epidural hematomas: A case after stent-assisted coiling for ruptured posterior communicating artery aneurysm. INTERDISCIPLINARY NEUROSURGERY 2017. [DOI: 10.1016/j.inat.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.
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Affiliation(s)
- Charles L Francoeur
- Critical Care Division, Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Québec, Canada
| | - Stephan A Mayer
- Department of Neurology (Neurocritical Care), Mount Sinai, New York, NY, USA.
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1522, New York, NY, 10029-6574, USA.
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Qian C, Yu X, Chen J, Gu C, Wang L, Chen G, Dai Y. Effect of the drainage of cerebrospinal fluid in patients with aneurismal subarachnoid hemorrhage: A meta-analysis. Medicine (Baltimore) 2016; 95:e5140. [PMID: 27741143 PMCID: PMC5072970 DOI: 10.1097/md.0000000000005140] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vasospasm-related injury such as delayed ischemic neurological defect (DIND) or cerebral infarction is an important prognostic factor for aneurismal subarachnoid hemorrhage (SAH). Whether cerebrospinal fluid (CSF) drainage can achieve a better outcome in aneurismal SAH patients after coiling or clipping remains the subject of debate. Here, we report a meta-analysis of the related available literature to assess the effect of continuous CSF drainage on clinical outcomes in patients with aneurismal SAH. METHODS Case-control studies regarding the association between aneurismal SAH and CSF drainage were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized. RESULTS This meta-analysis included 11 studies. Continuous CSF drainage obviously improved patients' long-term outcome (odds ratio [OR] of 2.86, 95% confidence interval [CI], 1.37-5.98, P < 0.01). CSF drainage also reduced angiographic vasospasm (OR of 0.35, 95% CI, 0.23-0.51, P < 0.01), symptomatic vasospasm (OR of 0.32, 95% CI, 0.32-0.43, P < 0.01), and DIND (OR of 0.48, 95% CI, 0.25-0.91, P = 0.03), but there was no significant difference between the CSF drainage group and the no CSF drainage group on shunt-dependent hydrocephalus (SDHC) prevention (OR of 1.04, 95% CI, 0.52-2.07, P = 0.91). Further analysis on lumbar drainage (LD) and external ventricular drainage (EVD) indicated that LD had a better outcome (OR of 3.11, 95% CI, 1.18-8.23, P = 0.02), whereas no significant difference in vasospasm-related injury was detected between the groups (OR of 1.13, 95% CI, 0.54-2.37, P = 0.75). CONCLUSION Continuous CSF drainage is an effective treatment for aneurismal SAH patients; lumbar drainage showed lower complications, but more well-designed studies are required to verify and consolidate this conclusion.
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Affiliation(s)
- Cong Qian
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Xiaobo Yu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Jingyin Chen
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Chi Gu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Lin Wang
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Gao Chen
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Correspondence: Gao Chen, Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China (e-mail: ); Yuying Dai, Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China (e-mail: )
| | - Yuying Dai
- Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China
- Correspondence: Gao Chen, Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China (e-mail: ); Yuying Dai, Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China (e-mail: )
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Tangen K, Narasimhan NS, Sierzega K, Preden T, Alaraj A, Linninger AA. Clearance of Subarachnoid Hemorrhage from the Cerebrospinal Fluid in Computational and In Vitro Models. Ann Biomed Eng 2016; 44:3478-3494. [DOI: 10.1007/s10439-016-1681-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/18/2016] [Indexed: 12/30/2022]
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Veldeman M, Höllig A, Clusmann H, Stevanovic A, Rossaint R, Coburn M. Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review. Br J Anaesth 2016; 117:17-40. [PMID: 27160932 DOI: 10.1093/bja/aew095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED : The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials. CLINICAL TRIAL REGISTRATION This systematic review was registered in the international prospective register of systematic reviews. PROSPERO CRD42015019817.
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Affiliation(s)
- M Veldeman
- Department of Neurosurgery Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | | | | | - A Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - M Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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