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Szabo V, Baccialone S, Kucharczak F, Dargazanli C, Garnier O, Pavillard F, Molinari N, Costalat V, Perrigault PF, Chalard K. CT perfusion-guided administration of IV milrinone is associated with a reduction in delayed cerebral infarction after subarachnoid hemorrhage. Sci Rep 2024; 14:14856. [PMID: 38937568 PMCID: PMC11211472 DOI: 10.1038/s41598-024-65706-w] [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: 12/21/2023] [Accepted: 06/24/2024] [Indexed: 06/29/2024] Open
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a singular pathological entity necessitating early diagnostic approaches and both prophylactic and curative interventions. This retrospective before-after study investigates the effects of a management strategy integrating perfusion computed tomography (CTP), vigilant clinical monitoring and standardized systemic administration of milrinone on the occurrence of delayed cerebral infarction (DCIn). The "before" period included 277 patients, and the "after" one 453. There was a higher prevalence of Modified Fisher score III/IV and more frequent diagnosis of vasospasm in the "after" period. Conversely, the occurrence of DCIn was reduced with the "after" management strategy (adjusted OR 0.48, 95% CI [0.26; 0.84]). Notably, delayed ischemic neurologic deficits were less prevalent at the time of vasospasm diagnosis (24 vs 11%, p = 0.001 ), suggesting that CTP facilitated early detection. In patients diagnosed with vasospasm, intravenous milrinone was more frequently administered (80 vs 54%, p < 0.001 ) and associated with superior hemodynamics. The present study from a large cohort of aSAH patients suggests, for one part, the interest of CTP in early diagnosis of vasospasm and DCI, and for the other the efficacy of CT perfusion-guided systemic administration of milrinone in both preventing and treating DCIn.
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Affiliation(s)
- Vivien Szabo
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France
| | - Sarah Baccialone
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Florentin Kucharczak
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), Nîmes University Hospital Center, Univ. Montpellier, Nimes, France
- Department of Nuclear Medicine, Gui de Chauliac University Hospital of Montpellier, University of Montpellier, Montpellier, France
| | - Cyril Dargazanli
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Oceane Garnier
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Frederique Pavillard
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Nicolas Molinari
- Epidemiology and Clinical Research Department, University Hospital of Montpellier, Montpellier, France
- IMAG, Univ Montpellier, CNRS, CHU Montpellier, Montpellier, France
| | - Vincent Costalat
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Pierre-Francois Perrigault
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Kevin Chalard
- Department of Critical Care Medicine and Anesthesiology (DAR GDC), Gui de Chauliac University Hospital of Montpellier, Montpellier, France.
- IGF, Univ. Montpellier, CNRS UMR5203, Inserm U1191, Montpellier, France.
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Bellapart J, Laupland KB, Malacova E, Roberts JA, Paratz J. Nimodipine prophylaxis in aneurysmal subarachnoid hemorrhage, a question of tradition or evidence: A scoping review. J Clin Neurosci 2024; 123:91-99. [PMID: 38564967 DOI: 10.1016/j.jocn.2024.03.016] [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: 11/15/2023] [Revised: 03/14/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The prophylactic use of nimodipine following subarachnoid hemorrhage is a practice established four decades ago when clinical management differed from current and the concept of Delayed Cerebral Ischemia (DCI) was not established. The applicability of the original studies is limited by the fact of not reflecting current practice; by utilising a dichotomised outcome measure such as good neurological outcome versus death and vegetative state; by applying variable dosing regimens and including all causes of poor neurological outcome different than DCI. This study aims to review the available evidence to discuss the ongoing role of nimodipine in contemporaneous clinical practice. METHODS PRISMA guidelines based review, evaluated the evidence on the prophylactic use of nimodipine. The following search engines: Medline, Embase, Cochrane, Web of Science and PubMed, identified Randomized Control Trials (RCTs) with neurological benefit as outcome measure and the impact of fixed versus weight-based nimodipine dosing regimens. RESULTS Eight RCT were selected. Three of those trials with a total of 349 patients, showed a reduction on death and vegetative state (pooled RR: 0.62; 95 % confidence interval-CI: 0.45, 0.86) related to DCI. Amongst all studies, all cause death (pooled RR = 0.73, [95 % CI: 0.56, 0.97]) favoured a fixed-dose regimen (pooled RR: 0.60; [95 % CI: 0.43, 0.85]). CONCLUSION Available evidence demonstrates that nimodipine only reduces the risk for DCI-related death or vegetative state and that fixed-dose regimens favour all cause infarct and death independent of DCI. Contemporaneous studies assessing the benefit of nimodipine beyond death or vegetative states and applying individualized dosing are warranted.
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Affiliation(s)
- Judith Bellapart
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Burns Trauma and Critical Care Research Centre, the University of Queensland, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029, Brisbane, Australia.
| | - Kevin B Laupland
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Queensland University of Technology (QUT), Brisbane, Australia.
| | - Eva Malacova
- QIMR Berghofer Medical Research Institute, Herston, Brisbane, QLD, 4006, Australia.
| | - Jason A Roberts
- University of Queensland Centre of Clinical Research (UQCCR), the University of Queensland, Herston, Brisbane, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Jennifer Paratz
- School of Allied Health Sciences, Griffith University, Brisbane, Australia; Department of Physiotherapy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Ditz C, Matone MV, Schwachenwald B, Küchler J. Risks of nimodipine dose reduction during the high-risk period for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2024; 47:37. [PMID: 38191859 DOI: 10.1007/s10143-023-02273-0] [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: 11/07/2023] [Revised: 12/12/2023] [Accepted: 12/31/2023] [Indexed: 01/10/2024]
Abstract
Nimodipine dose reduction is recommended in case of high vasopressor demand after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess potential adverse effects of nimodipine reduction during the high-risk period for delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) between days 5 and 10 after hemorrhage. Demographic and clinical data as well as daily nimodipine dose of aSAH patients admitted between 2010 and 2019 were retrospectively analyzed. Univariable and multivariable regression analyses were performed to identify factors associated with DCI, angiographic CVS, DCI-related infarction, and unfavorable outcome. A total of 205 patients were included. Nimodipine dose reduction occurred in 108 (53%) patients ('nimodipine reduction group'), while 97 patients (47%) received the full dose ('no nimodipine reduction group'), Patients in the 'nimodipine reduction group' had significant worse WFNS and Fisher grades and developed significantly more often DCI and angiographic CVS. DCI-related infarction and unfavorable outcome were also significantly increased in the 'nimodipine reduction group.' 'Reduced nimodipine dose' was the only independent predictor for the occurrence of DCI and angiographic CVS in multivariable regression analysis. 'Poor WFNS grade' and 'reduced nimodipine dose' were identified as independent risk factors for DCI-related infarction while 'older age,' 'poor WFNS grade,' and 'reduced nimodipine dose' were associated with unfavorable outcome at 3 months after discharge. Nimodipine dose reduction during the high-risk period of DCI and CVS between days 5 and 10 after hemorrhage might abrogate the positive prognostic effects of nimodipine and should be critically evaluated.
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Affiliation(s)
- Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Maria V Matone
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Bram Schwachenwald
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Rigoard P, Billot M, Moens M, Goudman L, El-Hajj H, Ingrand P, Ounajim A, Roulaud M, Page P, Babin E, Et Talby M, Dany J, Johnson S, Bataille B, David R, Slavin KV. Evaluation of External Trigeminal Nerve Stimulation to Prevent Cerebral Vasospasm after Subarachnoid Hemorrhage Due to Aneurysmal Rupture: A Randomized, Double-Blind Proof-of-Concept Pilot Trial (TRIVASOSTIM Study). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105836. [PMID: 37239562 DOI: 10.3390/ijerph20105836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
Cerebral vasospasm remains the most frequent and devastating complication after subarachnoid aneurysmal hemorrhage because of secondary cerebral ischemia and its sequelae. The underlying pathophysiology involves vasodilator peptide release (such as CGRP) and nitric oxide depletion at the level of the precapillary sphincters of the cerebral (internal carotid artery network) and dural (external carotid artery network) arteries, which are both innervated by craniofacial autonomic afferents and tightly connected to the trigeminal nerve and trigemino-cervical nucleus complex. We hypothesized that trigeminal nerve modulation could influence the cerebral flow of this vascular network through a sympatholytic effect and decrease the occurrence of vasospasm and its consequences. We conducted a prospective double-blind, randomized controlled pilot trial to compare the effect of 10 days of transcutaneous electrical trigeminal nerve stimulation vs. sham stimulation on cerebral infarction occurrence at 3 months. Sixty patients treated for aneurysmal SAH (World Federation of Neurosurgical Societies scale between 1 and 4) were included. We compared the radiological incidence of delayed cerebral ischemia (DCI) on magnetic resonance imaging (MRI) at 3 months in moderate and severe vasospasm patients receiving trigeminal nerve stimulation (TNS group) vs. sham stimulation (sham group). Our primary endpoint (the infarction rate at the 3-month follow-up) did not significantly differ between the two groups (p = 0.99). Vasospasm-related infarctions were present in seven patients (23%) in the TNS group and eight patients (27%) in the sham group. Ultimately, we were not able to show that TNS can decrease the rate of cerebral infarction secondary to vasospasm occurrence. As a result, it would be premature to promote trigeminal system neurostimulation in this context. This concept should be the subject of further research.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
- Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Radiology, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Research Foundation-Flanders (FWO), 1090 Brussels, Belgium
| | - Hassan El-Hajj
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Pierre Ingrand
- CIC 1402, Clinical Investigation Center, Bio-Statistic and Epidemiology, University of Poitiers, 86021 Poitiers, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Philippe Page
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Etienne Babin
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Mohamed Et Talby
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Jonathan Dany
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Simona Johnson
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Benoit Bataille
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
- Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, 86021 Poitiers, France
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA
- Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, IL 60612, USA
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