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Rajajee V. Transcranial Ultrasound in the Neurocritical Care Unit. Neuroimaging Clin N Am 2024; 34:191-202. [PMID: 38604704 DOI: 10.1016/j.nic.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Ultrasound evaluation of the brain is performed through acoustic windows. Transcranial Doppler has long been used to monitor patients with subarachnoid hemorrhage for cerebral vasospasm. Transcranial color-coded sonography permits parenchymal B-mode imaging and duplex evaluation. Transcranial ultrasound may also be used to assess the risk of delayed cerebral ischemia, screen patients for the presence of elevated intracranial pressure, confirm the diagnosis of brain death, measure midline shift, and detect ventriculomegaly. Transcranial ultrasound should be integrated with other point-of-care ultrasound techniques as an essential skill for the neurointensivist.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurosurgery & Neurology, University of Michigan, 3552 Taubman Health Care Center, SPC 5338 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Klepinowski T, Pala B, Pettersson SD, Łątka K, Taterra D, Ogilvy CS, Sagan L. Differential DNA methylation associated with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review. Neurosurg Rev 2024; 47:144. [PMID: 38594575 PMCID: PMC11003906 DOI: 10.1007/s10143-024-02381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
Recent studies suggest that differential DNA methylation could play a role in the mechanism of cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Considering the significance of this matter and a lack of effective prophylaxis against DCI, we aim to summarize the current state of knowledge regarding their associations with DNA methylation and identify the gaps for a future trial. PubMed MEDLINE, Scopus, and Web of Science were searched by two authors in three waves for relevant DNA methylation association studies in DCI after aSAH. PRISMA checklist was followed for a systematic structure. STROBE statement was used to assess the quality and risk of bias within studies. This research was funded by the National Science Centre, Poland (grant number 2021/41/N/NZ2/00844). Of 70 records, 7 peer-reviewed articles met the eligibility criteria. Five studies used a candidate gene approach, three were epigenome-wide association studies (EWAS), one utilized bioinformatics of the previous EWAS, with two studies using more than one approach. Methylation status of four cytosine-guanine dinucleotides (CpGs) related to four distinct genes (ITPR3, HAMP, INSR, CDHR5) have been found significantly or suggestively associated with DCI after aSAH. Analysis of epigenetic clocks yielded significant association of lower age acceleration with radiological CVS but not with DCI. Hub genes for hypermethylation (VHL, KIF3A, KIFAP3, RACGAP1, OPRM1) and hypomethylation (ALB, IL5) in DCI have been indicated through bioinformatics analysis. As none of the CpGs overlapped across the studies, meta-analysis was not applicable. The identified methylation sites might potentially serve as a biomarker for early diagnosis of DCI after aSAH in future. However, a lack of overlapping results prompts the need for large-scale multicenter studies. Challenges and prospects are discussed.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland.
| | - Bartłomiej Pala
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Samuel D Pettersson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kajetan Łątka
- Department of Neurology, St Hedwig's Regional Specialist Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dominik Taterra
- Department of Orthopedics and Rehabilitation, Jagiellonian University Medical College, Zakopane, Poland
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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Julian N, Gaugain S, Labeyrie MA, Barthélémy R, Froelich S, Houdart E, Mebazaa A, Chousterman BG. Systemic tolerance of intravenous milrinone administration for cerebral vasospasm secondary to non-traumatic subarachnoid hemorrhage. J Crit Care 2024; 82:154807. [PMID: 38579430 DOI: 10.1016/j.jcrc.2024.154807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/18/2024] [Accepted: 03/27/2024] [Indexed: 04/07/2024]
Abstract
PURPOSE Delayed cerebral ischemia (DCI) is a severe subarachnoid hemorrhage (SAH) complication, closely related to cerebral vasospasm (CVS). CVS treatment frequently comprises intravenous milrinone, an inotropic and vasodilatory drug. Our objective is to describe milrinone's hemodynamic, respiratory and renal effects when administrated as treatment for CVS. METHODS Retrospective single-center observational study of patients receiving intravenous milrinone for CVS with systemic hemodynamics, oxygenation, renal disorders monitoring. We described these parameters' evolution before and after milrinone initiation (day - 1, baseline, day 1 and day 2), studied treatment cessation causes and assessed neurological outcome at 3-6 months. RESULTS Ninety-one patients were included. Milrinone initiation led to cardiac output increase (4.5 L/min [3.4-5.2] at baseline vs 6.6 L/min [5.2-7.7] at day 2, p < 0.001), Mean Arterial Pressure decrease (101 mmHg [94-110] at baseline vs 95 mmHg [85-102] at day 2, p = 0.001) norepinephrine treatment requirement increase (32% of patients before milrinone start vs 58% at day 1, p = 0.002) and slight PaO2/FiO2 ratio deterioration (401 [333-406] at baseline vs 348 [307-357] at day 2, p = 0.016). Milrinone was interrupted in 8% of patients. 55% had a favorable outcome. CONCLUSION Intravenous milrinone for CVS treatment seems associated with significant impact on systemic hemodynamics leading sometimes to treatment discontinuation.
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Affiliation(s)
- Nathan Julian
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France.
| | - Samuel Gaugain
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Marc-Antoine Labeyrie
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France
| | - Romain Barthélémy
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, University of Paris, France
| | - Emmanuel Houdart
- Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France
| | - Alexandre Mebazaa
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Benjamin G Chousterman
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
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Wendel C, Oberhauser C, Schiff J, Henkes H, Ganslandt O. Stellate Ganglion Block and Intraarterial Spasmolysis in Patients with Cerebral Vasospasm: A Retrospective Cohort Study. Neurocrit Care 2024; 40:603-611. [PMID: 37498456 PMCID: PMC10959776 DOI: 10.1007/s12028-023-01762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/17/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND In patients with symptomatic cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage who do not respond to medical therapy, urgent treatment escalation has been suggested to be beneficial for brain tissue at risk. In our routine clinical care setting, we implemented stellate ganglion block (SGB) as a rescue therapy with subsequent escalation to intraarterial spasmolysis (IAS) with milrinone for refractory CV. METHODS In this retrospective analysis from 2012 to 2021, patients with CV following aneurysmal subarachnoid hemorrhage who received an SGB or IAS were identified. Patients were assessed through neurological examination and transcranial Doppler. Rescue therapy was performed in patients with mean cerebral blood flow velocity (CBFV) ≥ 120 cm/s and persistent neurological deterioration/intubation under induced hypertension. Patients were reassessed after therapy and the following day. The Glasgow Outcome Scale was assessed at discharge and 6-month follow-up. RESULTS A total of 82 patients (mean age 50.16 years) with 184 areas treated with SGB and/or IAS met the inclusion criteria; 109 nonaffected areas were extracted as controls. The mean CBFV decrease in the middle cerebral artery on the following day was - 30.1 (± 45.2) cm/s with SGB and - 31.5 (± 45.2) cm/s with IAS. Mixed linear regression proved the significance of the treatment categories; other fixed effects (sex, age, aneurysm treatment modality [clipping or coiling], World Federation of Neurological Surgeons score, and Fisher score) were insignificant. In logistic regression, the presence of cerebral infarction on imaging before discharge from the intensive care unit (34/82) was significantly associated with unfavorable outcomes (Glasgow Outcome Scale ≤ 3) at follow-up. CONCLUSIONS Stellate ganglion block and IAS decreased CBFV the following 24 h in patients with CV. We suggest SGB alone for patients with mild symptomatic CV (CBFV < 180 cm/s), while subsequent escalation to IAS proved to be beneficial in patients with refractory CV and severe CBFV elevation (CBFV ≥ 180 cm/s).
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Affiliation(s)
- Christopher Wendel
- Neurosurgical Clinic, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Chair of Public Health and Health Services Research, Ludwig-Maximilians-University, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Cornelia Oberhauser
- Institute for Medical Information Processing, Biometry, and Epidemiology, Chair of Public Health and Health Services Research, Ludwig-Maximilians-University, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Jan Schiff
- Department of Anesthesiology and Operative Intensive Care Medicine, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
- Department of Neurosurgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Feulner J, Weidinger CS, Dörfler A, Birkholz T, Buchfelder M, Sommer B. Early Intravenous Magnesium Sulfate and Its Impact on Cerebral Vasospasm as well as Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Retrospective Matched Case-Control Analysis. World Neurosurg 2024:S1878-8750(24)00448-0. [PMID: 38514031 DOI: 10.1016/j.wneu.2024.03.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Magnesium sulfate (MgSO4) is a potential neuroprotective agent for patients with aneurysmal subarachnoid hemorrhage (SAH). We analyzed the effect of early application of intraoperative intravenous MgSO4 and compared cerebral vasospasm (CV), delayed cerebral ischemia (DCI), and neurological outcome in 2 patient cohorts. METHODS A retrospective matched-pair analysis from patients at a single center in Germany was performed without (group A) and with (group B) MgSO4 application <24 hours after diagnosis. Pairs were matched according to the known risk factors for DCI and CV (age, Fisher grade, smoking, severity of SAH). Incidence of CV and DCI and neurological outcome using the modified Rankin Scale score 3 and 12 months after SAH were recorded. RESULTS The inclusion criteria were met by 196 patients. After risk stratification, 48 patients were included in the final analysis (age 54.2 ± 8.1 years; 30 women and 18 men) and were assigned to group A (n = 24) or group B (n = 24). CV occurred less frequently in group B (33%) than in group A (46%). Likewise, DCI was present in 13% in group B compared with 42% in group A. After 12 months, 22 patients in group B had a favorable functional outcome (modified Rankin Scale score 0-3) compared with 15 patients in group A. CONCLUSIONS In this study, the incidence of CV and DCI was lower in patients receiving intravenous MgSO4 within 24 hours after aneurysmal SAH onset. Favorable functional outcome was more likely in the MgSO4 group after 12 months of follow-up.
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Affiliation(s)
- Julian Feulner
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany; Department of Neurosurgery, Klinikum Fürth, Fürth, Germany
| | | | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Torsten Birkholz
- Department of Anesthesiology, University Hospital Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Björn Sommer
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany; Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany.
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Vandenbulcke A, Messerer M, Garvayo Navarro M, Peters DR, Starnoni D, Giammattei L, Ben-Hamouda N, Puccinelli F, Saliou G, Cossu G, Daniel RT. Cisternal nicardipine for prevention of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a comparative retrospective cohort study. Acta Neurochir (Wien) 2024; 166:133. [PMID: 38472426 DOI: 10.1007/s00701-024-06023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile. METHODS We performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group). RESULTS Seventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group. CONCLUSION Administration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Marta Garvayo Navarro
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - David R Peters
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Lorenzo Giammattei
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Chen L, Jin Y, Wang L, Wei K, Li X, Jiang T, Cao X, Xue L, Cheng Q. Impact of human serum albumin level on symptomatic cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Neurol Sci 2024; 45:213-222. [PMID: 37574504 DOI: 10.1007/s10072-023-07014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To investigate the impact of human serum albumin (HSA) levels on symptomatic cerebral vasospasm (SCVS) in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the medical records. SCVS was defined as the development of a new neurological deterioration when the cause was considered to be ischemia attributable to vasospasm after other possible causes of worsening had been excluded. The aSAH patients were divided into two groups: those with SCVS (group 1) and those without SCVS (group 2). The HSA level data on the 1st, 2nd, and 3rd day after admission was collected. Multivariate logistical regression and receiver operating characteristic (ROC) analysis were performed to evaluate the ability of HSA level to predict the development of SCVS. RESULTS A total of 270 patients were included in our study, of which 74 (27.4%) developed SCVS. The average and lowest HSA levels were lower in group 1 (P < 0.001). In univariate logistic regression, white blood cell count, neutrophil count, and average and lowest HSA levels were associated with SCVS. After adjustment for age, CT Fisher grade, Hunt-Hess grade, and WFNS grade, both the average and lowest HSA levels remained independent predictors of SCVS (P < 0.001). The CT Fisher grade was confirmed to be an independent predictor of SCVS across each model. ROC analysis revealed that the lowest HSA level was a better predictor for SCVS than average HSA level and CT Fisher grade. CONCLUSION Clinicians are encouraged to measure HSA levels for the first 3 days after admission to predict the occurrence of SCVS after aSAH.
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Affiliation(s)
- Ling Chen
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Yang Jin
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huaian, Jiangsu, China
| | - Ling Wang
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Kai Wei
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Xin Li
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Tao Jiang
- Anhui Public Health Clinical Center, Hefei, China
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiangyang Cao
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huaian, Jiangsu, China.
| | - Liujun Xue
- Department of Neurology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, Jiangsu, China.
| | - Qiantao Cheng
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
- Anhui Public Health Clinical Center, Hefei, China.
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Trofimov AO, Trofimova SY, Agarkova DI, Trofimova KA, Semyachkina-Glushkovskaya O, Atochin D, Bragina OA, Nemoto EM, Bragin DE. Intracranial dynamics biomarkers at traumatic cerebral vasospasm. Brain Spine 2023; 4:102727. [PMID: 38178989 PMCID: PMC10765010 DOI: 10.1016/j.bas.2023.102727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
Introduction Patients who suffer severe traumatic brain injury (sTBI) and cerebral vasospasm (CVS) frequently have posttraumatic cerebral ischemia (PCI). The research question was to study changes in cerebral microcirculatory bed parameters in sTBI patients with CVS and with or without PCI. Material and methods A total of 136 severe TBI patients were recruited in the study. All patients underwent perfusion computed tomography, intracranial pressure monitoring, and transcranial Doppler. The levels of cerebrovascular resistance (CVR), cerebral arterial compliance (CAC), cerebrovascular time constant (CTC), and critical closing pressure (CCP) were measured using the neuromonitoring complex. Statistical analysis was performed using parametric and nonparametric methods and factor analysis. The patients were dichotomized into PCI-positive (n = 114) and PCI-negative (n = 22) groups. Data are presented as mean values (standard deviations). Results CVR was significantly increased, whereas CAC, CTC, and CCP were significantly decreased in sTBI patients with CVS and PCI development (p < 0.05). Factor analyses revealed that all studied microcirculatory bed parameters were significantly associated with the development of PCI (p < 0.05). Discussion and conclusion The changes in all studied microcirculatory bed parameters in TBI patients with CVS were significantly associated with PCI development, which enables us to regard them as the biomarkers of CVS and PCI development. The causes of the described microcirculatory bed parameters changes might include complex (cytotoxic and vasogenic) brain edema development, regional microvascular spasm, and dysfunction of pericytes. A further prospective study is warranted.
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Affiliation(s)
- Alexey O. Trofimov
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Svetlana Y. Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Darya I. Agarkova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Kseniia A. Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | | | - Dmitriy Atochin
- Department of Psychiatry, Boston VA Medical Center West Roxbury, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Olga A. Bragina
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - Edwin M. Nemoto
- Department of Neurology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Denis E. Bragin
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
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Hu Z, Deng X, Zhou S, Zhou C, Shen M, Gao X, Huang Y. Pathogenic mechanisms and therapeutic implications of extracellular matrix remodelling in cerebral vasospasm. Fluids Barriers CNS 2023; 20:81. [PMID: 37925414 PMCID: PMC10625254 DOI: 10.1186/s12987-023-00483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023] Open
Abstract
Cerebral vasospasm significantly contributes to poor prognosis and mortality in patients with aneurysmal subarachnoid hemorrhage. Current research indicates that the pathological and physiological mechanisms of cerebral vasospasm may be attributed to the exposure of blood vessels to toxic substances, such as oxyhaemoglobin and inflammation factors. These factors disrupt cerebral vascular homeostasis. Vascular homeostasis is maintained by the extracellular matrix (ECM) and related cell surface receptors, such as integrins, characterised by collagen deposition, collagen crosslinking, and elastin degradation within the vascular ECM. It involves interactions between the ECM and smooth muscle cells as well as endothelial cells. Its biological activities are particularly crucial in the context of cerebral vasospasm. Therefore, regulating ECM homeostasis may represent a novel therapeutic target for cerebral vasospasm. This review explores the potential pathogenic mechanisms of cerebral vasospasm and the impacts of ECM protein metabolism on the vascular wall during ECM remodelling. Additionally, we underscore the significance of an ECM protein imbalance, which can lead to increased ECM stiffness and activation of the YAP pathway, resulting in vascular remodelling. Lastly, we discuss future research directions.
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Affiliation(s)
- Ziliang Hu
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Liuting Street 59, Ningbo, 315010, Zhejiang, China
- Cixi Biomedical Research Institute, Wenzhou Medical University, Cixi, 315302, Zhejiang, China
| | - Xinpeng Deng
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Liuting Street 59, Ningbo, 315010, Zhejiang, China
| | - Shengjun Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Liuting Street 59, Ningbo, 315010, Zhejiang, China
| | - Chenhui Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Liuting Street 59, Ningbo, 315010, Zhejiang, China
| | - Menglu Shen
- Cixi Third People's Hospital, Cixi, 315324, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Liuting Street 59, Ningbo, 315010, Zhejiang, China.
| | - Yi Huang
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Liuting Street 59, Ningbo, 315010, Zhejiang, China.
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, 315010, Zhejiang, China.
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11
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Kula O, Günay B, Kayabaş MY, Aktürk Y, Kula E, Tütüncüler B, Süt N, Solak S. Neutrophil to Lymphocyte Ratio and Serum Biomarkers : A Potential Tool for Prediction of Clinically Relevant Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2023; 66:681-689. [PMID: 37634893 PMCID: PMC10641424 DOI: 10.3340/jkns.2023.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVE Subarachnoid hemorrhage (SAH) is a condition characterized by bleeding in the subarachnoid space, often resulting from the rupture of a cerebral aneurysm. Delayed cerebral ischemia caused by vasospasm is a significant cause of mortality and morbidity in SAH patients, and inflammatory markers such as systemic inflammatory response index (SIRI), systemic inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), and derived NLR (dNLR) have shown potential in predicting clinical vasospasm and outcomes in SAH patients. This article aims to investigate the relationship between inflammatory markers and cerebral vasospasm after aneurysmatic SAH (aSAH) and evaluate the predictive value of various indices, including SIRI, SII, NLR, and dNLR, in predicting clinical vasospasm. METHODS A retrospective analysis was performed on a cohort of 96 patients who met the inclusion criteria out of a total of 139 patients admitted Trakya University Hospital with a confirmed diagnosis of aSAH between January 2013 and December 2021. Diagnostic procedures, neurological examinations, and laboratory tests were performed to assess the patients' condition. The Student's t-test compared age variables, while the chi-square test compared categorical variables between the non-vasospasm (NVS) and vasospasm (VS) groups. Receiver operating characteristic (ROC) curve analyses were used to evaluate the diagnostic accuracy of laboratory parameters, calculating the area under the ROC curve, cut-off values, sensitivity, and specificity. A significance level of p<0.05 was considered statistically significant. RESULTS The study included 96 patients divided into two groups : NVS and VS. Various laboratory parameters, such as NLR, SII, and dNLR, were measured daily for 15 days, and statistically significant differences were found in NLR on 7 days, with specific cut-off values identified for each day. SII showed a significant difference on day 9, while dNLR had significant differences on days 2, 4, and 9. Graphs depicting the values of these markers for each day are provided. CONCLUSION Neuroinflammatory biomarkers, when used alongside radiology and scoring scales, can aid in predicting prognosis, determining severity and treatment decisions for aSAH, and further studies with larger patient groups are needed to gain more insights.
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Affiliation(s)
- Osman Kula
- Department of Radiology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Burak Günay
- Department of Radiology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Merve Yaren Kayabaş
- Department of Radiology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Yener Aktürk
- Department of Neurosurgery, Edirne Sultan 1.Murat State Hospital, Edirne, Turkey
| | - Ezgi Kula
- Department of Electroneurophysiology, Trakya University of Health Services Vocational College, Edirne, Turkey
| | - Banu Tütüncüler
- Department of Neurosurgery, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Necdet Süt
- Department of Bioistatistics, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Serdar Solak
- Department of Radiology, Trakya University Faculty of Medicine, Edirne, Turkey
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12
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Busse TL, Munthe S, Ketharanathan B, Bülow K, Jóhannsson B, Diaz A, Nielsen TH. Perfusion Computed Tomography as a Screening Tool for Pending Delayed Cerebral Ischemia in Comatose Patients After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2023:10.1007/s12028-023-01855-6. [PMID: 37821720 DOI: 10.1007/s12028-023-01855-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is frequently complicated by delayed cerebral ischemia (DCI), leading to poor outcomes. Early diagnosis of DCI is crucial for improving survival and outcomes but remains challenging in comatose patients. In this study, we aimed to evaluate computed tomography with angiography and perfusion (P-CT) as a screening modality on postictal days four and eight for impending DCI after aSAH in comatose patients using vasospasm with hypoperfusion (hVS) as a surrogate and DCI-related infarction as an outcome measure. Two objectives were set: (1) to evaluate the screening's ability to accurately risk stratify patients and (2) to assess the validity of P-CT screening. METHODS We conducted a retrospective review of the records of comatose patients with aSAH from January 2019 to December 2021 who were monitored with P-CT scans on days four and eight. The event rates of DCI-related infarction, hVS, and endovascular rescue therapy (ERT) were analyzed, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for DCI were calculated. DCI-related infarction was defined as new secondary cerebral infarction > 48 h < 6 weeks post aSAH not attributable to other causes, and hVS was defined as arterial narrowing with corresponding hypoperfusion on P-CT. RESULTS Fifty-six comatose patients were included, and 98 P-CT scans were performed. The incidence of DCI-related infarction was 40%. Screening P-CT on days four and eight found vasospasm in 23% of all patients, including 11% with hVS. A positive hVS on day four or eight revealed a relative risk of 2.4 [95% confidence interval (CI) 1.13-5.11, p = 0.03], sensitivity of 23% (95% CI 8-45, p = 0.03), specificity of 95% (95% CI 36-100, p = 0.03), PPV of 0.83 (95% CI 0.36-1.00, p = 0.03), and NPV of 0.65 (95% CI 0.50-0.78). Six positive P-CT scans led to digital subtraction angiography in five patients, three of whom received ERT. All ERT-intervened patients developed DCI-related infarction. CONCLUSIONS P-CT resulted in few interventions and often resulted in late detection of DCI at an irreversible stage. Although a positive P-CT result accurately predicts impending DCI-related infarction, screening on days four and eight alone in comatose patients with aSAH often fails to timely detect impending DCI. Based on our analysis, we cannot recommend P-CT as a screening modality. P-CT is likely best used as a confirmatory test prior to invasive interventions when guided by continuous multimodal monitoring; however, prospective studies with comparison groups are warranted. The need for a reliable continuous screening modality is evident because of the high rate of deterioration and narrow treatment window.
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Affiliation(s)
- Thor Löwe Busse
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.
| | - Sune Munthe
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | - Karsten Bülow
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Bjarni Jóhannsson
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Anabel Diaz
- Department of Radiology, Odense University Hospital, Odense, Denmark
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13
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Johansson C, Aineskog H, Koskinen LOD, Gunnarsson A, Lindvall P. Serum neurofilament light as a predictor of outcome in subarachnoid haemorrhage. Acta Neurochir (Wien) 2023; 165:2793-2800. [PMID: 37351672 PMCID: PMC10542720 DOI: 10.1007/s00701-023-05673-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Prognostication of clinical outcome in patients suffering from aneurysmal subarachnoid haemorrhage (SAH) is a challenge. There are no biochemical markers in routine use that can aid in prognostication. Neurofilament light (NFL) measured in cerebrospinal fluid (CSF) has been associated with clinical outcome in previous studies. OBJECTIVE To investigate if serum levels of NFL correlate with CSF levels and long-term clinical outcome in patients suffering from SAH. METHODS We conducted an observational cohort study of 88 patients treated for SAH at Umeå University Hospital in 2014-2018. Serum and CSF samples were analysed using an enzyme-linked immunosorbent assay to quantify NFL levels. Outcome was assessed using Glasgow Outcome Scale Extended and dichotomised as favourable or unfavourable. Differences in NFL levels between outcome groups were analysed using repeated measurements ANOVA. Relationship between CSF and serum NFL levels was analysed using Pearson's correlation. A multivariate binary logistic regression model and a receiver operation characteristic curve were used to assess the predictive value of serum NFL. RESULTS A significant correlation between serum and CSF-NFL levels could be seen (Pearson's correlation coefficient = 0.7, p < .0001). Mean level of serum NFL was higher in the unfavourable outcome group than the favourable outcome group (p < .0001), in all epochs of SAH, and correlated with initial disease severity on the World Federation of Neurosurgical Societies scale. Serum NFL in the late phase displayed the best predictive potential in a receiver operation characteristic curve analysis (AUC=0.845, p < .0001). CONCLUSION Levels of NFL in serum and CSF are correlated. Early serum NFL levels seem to reflect initial tissue damage and serum NFL levels in the late phase may reflect secondary events such as vasospasm or delayed cerebral ischemia. Serum NFL may be used as a prognostic marker of clinical outcome in SAH.
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Affiliation(s)
- Conny Johansson
- Department of Clinical Science, Neurosciences, Umeå University, SE-901 87, Umea, Sweden.
| | - Helena Aineskog
- Department of Clinical Science, Neurosciences, Umeå University, SE-901 87, Umea, Sweden
| | - Lars-Owe D Koskinen
- Department of Clinical Science, Neurosciences, Umeå University, SE-901 87, Umea, Sweden
| | | | - Peter Lindvall
- Department of Clinical Science, Neurosciences, Umeå University, SE-901 87, Umea, Sweden
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14
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Ali A, Rajeswaran AB, Shaikh N, Al-Rumaihi G, Al-Sulaiti G. Role of albumin-induced volume expansion therapy for cerebral vasospasm in aneurysmal subarachnoid hemorrhage: A systematic review. J Neurosci Rural Pract 2023; 14:582-590. [PMID: 38059246 PMCID: PMC10696353 DOI: 10.25259/jnrp_372_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/04/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives This study reviews the effect of albumin-induced volume expansion therapy on symptomatic vasospasm and clinical outcome in aneurysmal subarachnoid hemorrhage (aSAH). Materials and Methods Computer searches carried out from the Scopus, Medline, Embase, Web of Science, the Cochrane Library, and Internet documents; hand searching of medical journals; and review of reference lists. Randomized controlled trials (RCT) and observational studies (OSs) comparing albumin therapy in combination or alone with crystalloid therapy for the treatment of cerebral vasospasm in aSAH were included in the study. Risk-of-bias assessment was conducted using ROB2.0 and ROBINS-I tools for RCTs and Oss, respectively. Results Out of a total of 1078 searches, one RCT (published in two articles) and one observational (retrospective) study were included for final analysis. In RCT, albumin was used for volume expansion therapy with a baseline crystalloid regime and comparison made between hypervolemic and normovolemic groups and it showed no beneficial effects on symptomatic vasospasm and clinical outcomes based on the Glasgow outcome scale. Furthermore, the use of albumin showed a tendency for sodium retention with lowering of glomerular filtration rate, limiting the amount of total fluid required for targeted central venous pressure values, and thereby avoiding fluid overload manifestations. The retrospective study results between albumin versus non-albumin groups (crystalloids only) supported improved outcomes in the former group with lower in-hospital mortality. Cardiorespiratory complications were equivocal in RCT and increased in non-albumin group in the retrospective study. Risk-of-bias assessment analyses revealed "some concerns" in RCT and "serious" limitation in OS due to its retrospective design. Conclusion Albumin-induced volume expansion therapy for cerebral vasospasm does not have substantiative evidence to improve cerebral vasospasm and clinical outcomes in aSAH. Studies with well-designed RCTs are required to compare the use of albumin for volume expansion therapy versus standard fluid management using crystalloids to mitigate the scarcity of published data.
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Affiliation(s)
- Arshad Ali
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Arun Babu Rajeswaran
- Department of Neurosurgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Nisar Shaikh
- Surgical Intensive Care Unit, Hamad Medical Corporation, Doha, Qatar
| | - Ghaya Al-Rumaihi
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ghanem Al-Sulaiti
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
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15
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Kerschbaumer J, Freyschlag CF, Petr O, Adage T, Breitenbach J J, Wessels L, Wolf S, Hecht N, Gempt J, Wostrack M, Gmeiner M, Gollwitzer M, Stefanits H, Bendszus M M, Gruber A, Meyer B, Vajkoczy P, Thomé C. A randomized, single ascending dose safety, tolerability and pharmacokinetics study of NicaPlant® in aneurysmal subarachnoid hemorrhage patients undergoing clipping. Brain Spine 2023; 3:102673. [PMID: 38021019 PMCID: PMC10668089 DOI: 10.1016/j.bas.2023.102673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Post-hemorrhagic vasospasm with neurological deterioration is a major concern in this context. NicaPlant®, a modified release formulation of the calcium channel blocker nicardipine, has shown vasodilator efficacy preclinically and a similar formulation known as NPRI has shown anti-vasospasm activity in aSAH patients under compassionate use. Research question The study aimed to assess pharmacokinetics and pharmacodynamics of NicaPlant® pellets to prevent vasospasm after clip ligation in aSAH. Material and methods In this multicenter, controlled, randomized, dose escalation trial we assessed the safety and tolerability of NicaPlant®. aSAH patients treated by clipping were randomized to receive up to 13 NicaPlant® implants, similarly to the dose of NPRIs previous used, or standard of care treatment. Results Ten patients across four dose groups were treated with NicaPlant® (3-13 implants) while four patients received standard of care. 45 non-serious and 13 serious adverse events were reported, 4 non-serious adverse events and 5 serious adverse events assessed a probable or possible causal relationship to the investigational medical product. Across the NicaPlant® groups there was 1 case of moderate vasospasm, while in the standard of care group there were 2 cases of severe vasospasm. Discussion and conclusion The placement of NicaPlant® during clip ligation of a ruptured cerebral aneurysm raised no safety concern. The dose of 10 NicaPlant® implants was selected for further clinical studies.
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Affiliation(s)
| | | | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Lars Wessels
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Maria Gollwitzer
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Martin Bendszus M
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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16
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Salvagno M, Gouvea Bogossian E, Halenarova K, Ego A, Taccone FS. Cervical Ganglion Sympathectomy to Treat Cerebral Vasospasm in Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:241-249. [PMID: 36828982 DOI: 10.1007/s12028-023-01694-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
Delayed cerebral ischemia (DCI) is still a significant cause of death and disability after aneurysmal subarachnoid hemorrhage. Cerebral vasospasm represents one of the most reported mechanisms associated with DCI. The management of DCI-related vasospasm remains a significant challenge for clinicians; induced hypertension, intraarterial vasodilators, and/or intracranial vessel angioplasty-particularly in refractory or recurrent cases-are the most used therapies. Because an essential role in the pathophysiology of cerebral vasospasm has been attributed to the adrenergic sympathetic nerves, a "sympatholytic" intervention, consisting of a temporary interruption of the sympathetic pathways using local anesthetics, has been advocated to minimize the vascular narrowing and reverse the consequences of cerebral vasospasm on tissue perfusion. In this review, we have analyzed the existing literature on the block of the cervical ganglions, particularly the stellate ganglion, in managing refractory cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. These findings could help clinicians to understand the potential role of such intervention and to develop future interventional trials in this setting.
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Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium.
| | | | - Katarina Halenarova
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Amedée Ego
- Department of Intensive Care, Hôpitaux Iris Sud, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
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17
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Deem S, Diringer M, Livesay S, Treggiari MM. Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:81-90. [PMID: 37160848 DOI: 10.1007/s12028-023-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023]
Abstract
One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. Hypovolemia and hypotension were favored prior to the era of early aneurysmal surgery but were subsequently replaced by the use of hypervolemia and hypertension. More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.
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Affiliation(s)
- Steven Deem
- Neurocritical Care Unit, Swedish Medical Center, Seattle, WA, USA.
| | - Michael Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- College of Nursing, Rush University, Chicago, IL, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical School, Durham, NC, USA
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18
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Hamzah A, Alharbi AS, Abdulhamid AS, Turkistani AN, Aref MH. Management of postoperative cerebral vasospasm in skull base surgeries: A systematic review of case reports and series. Surg Neurol Int 2023; 14:214. [PMID: 37404488 PMCID: PMC10316141 DOI: 10.25259/sni_441_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/03/2023] [Indexed: 07/06/2023] Open
Abstract
Background This study provides a comprehensive overview of the management of postoperative vasospasm after skull base surgeries. This phenomenon is rare but can be of serious sequelae. Methods Medline, Embase, and PubMed Central were searched, along with examining the references of the included studies. Only case reports and series that reported vasospasm following a skull base pathology were incorporated. Cases with pathologies other than skull base, subarachnoid hemorrhage, aneurysm, and reversible cerebral vasoconstriction syndrome were excluded from the study. Quantitative data were presented as mean (Standard Deviation) or median (range), accordingly, while qualitative data were presented as frequency (percentage). Chi- square test and one-way analysis of variance were used to assess for any association between the different factors and patient outcomes. Results We had a total of 42 cases extracted from the literature. The mean age was 40.1 (±16.1) with approximately equal males and females (19 [45.2%] and 23 [54.8%], respectively). The time to develop vasospasm after the surgery was 7 days (±3.7). Most of the cases were diagnosed by either angiogram or magnetic resonance angiography. Seventeen of the 42 patients had pituitary adenoma as the pathology. Anterior circulation was nearly affected in all patients. For management, most patients received pharmacological with supportive management. Twenty-three patients had an incomplete recovery as a result of vasospasm. Conclusion Vasospasm following skull base operations can affect males and females, and most patients in this review were middle-aged adults. The outcome of patients varies; however, most patients did not achieve a full recovery. There was no correlation between any factors and the outcome.
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Affiliation(s)
- Abdulaziz Hamzah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah S. Alharbi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed S. Abdulhamid
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Alaa Nabil Turkistani
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mohmmed Hani Aref
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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19
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Liu S, Gan N, Xie J, Zhang Y, Su F, Jia T. Clinical evaluation of Alprostadil combined with Nimodipine in treatment of Cerebral Vasospasm after Subarachnoid Hemorrhage in elderly patients. Pak J Med Sci 2023; 39:682-686. [PMID: 37250544 PMCID: PMC10214805 DOI: 10.12669/pjms.39.3.6753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/18/2022] [Accepted: 02/26/2023] [Indexed: 05/31/2023] Open
Abstract
Objective To analyze the clinical efficacy of alprostadil combined with nimodipine in the treatment of cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) in elderly patients. Methods This is a retrospective study. According to different treatment methods, the elderly 100 patients with CVS after SAH hospitalized in Baoding First Central Hospital from March 2020 to May 2021 were randomly divided into control group and observation group, with 50 patients in each group. The control group was treated with nimodipine, while the observation group was additionally combined with alprostadil. The levels of inflammatory factors and hemorheological indexes were measured before and after treatment. The clinical efficacy was compared and the adverse reactions were observed of the two groups. Results The overall clinical efficacy in the observation group (95.00%) was significantly higher than that in the control group (74.00%) (p<0.05). After treatment, serum tumor necrosis factor-α (TNF-α), interleukin-8 (IL-8), high-sensitivity C-reactive protein (hs-CRP) and hemorheological indexes such as plasma viscosity, whole blood viscosity at high shear, whole blood viscosity at low shear, hematocrit and platelet adhesion decreased significantly compared with those before treatment (p<0.05), which were more obvious in the observation group (p<0.05). During treatment, the rate of adverse reactions in the observation group was 12.00%, and that in the control group was 8.00%, without statistically significant difference between the two groups (p> 0.05). Conclusion Alprostadil combined with nimodipine is markedly effective in the treatment of CVS after SAH in elderly patients. It can effectively reduce inflammatory factor levels and improve hemorheological indexes in patients, which is conducive to the repair of neurological function.
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Affiliation(s)
- Sisi Liu
- Sisi Liu, Department of Neuroscience Critical Care Unit, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
| | - Ning Gan
- Ning Gan, Department of Neurosurgery, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
| | - Jing Xie
- Jing Xie, Department of Neurosurgery, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
| | - Yu Zhang
- Yu Zhang, Department of Neurosurgery, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
| | - Fei Su
- Fei Su, Department of Neurosurgery, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
| | - Tongle Jia
- Tongle Jia, Department of Neurosurgery, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
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Hossain I, Younsi A, Castaño Leon AM, Lippa L, Tóth P, Terpolilli N, Tobieson L, Latini F, Raabe A, Depreitere B, Rostami E. Huge variability in restrictions of mobilization for patients with aneurysmal subarachnoid hemorrhage - A European survey of practice. Brain Spine 2023; 3:101731. [PMID: 37383447 PMCID: PMC10293289 DOI: 10.1016/j.bas.2023.101731] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 06/30/2023]
Abstract
Introduction One of the major goals of neurointensive care is to prevent secondary injuries following aSAH. Bed rest and patient immobilization are practiced in order to decrease the risk of DCI. Research question To explore the current practices in place concerning the management of patients with aSAH, specifically, protocols and habits regarding restrictions of mobilization and HOB positioning. Material and methods A survey was designed, modified, and approved by the panel of the Trauma & Critical Care section of the EANS to cover the practice of restrictions of patient mobilization and HOB positioning in patients with aSAH. Results Twenty-nine physicians from 17 countries completed the questionnaire. The majority (79.3%) stated that non-secured aneurysm and the presence of an EVD were the factors related to the establishment of restriction of mobilization. The average duration of the restriction varied widely ranging between 1 and 21 days. The presence of an EVD (13.8%) was found to be the main reason to recommend restriction of HOB elevation. The average duration of restriction of HOB positioning ranged between 3 and 14 days. Rebleeding or complications related to CSF over-drainage were found to be related to these restrictions. Discussion and conclusion Restriction of patient mobilization regimens vary widely in Europe. Current limited evidence does not support an increased risk of DCI rather the early mobilization might be beneficial. Large prospective studies and/or the initiative of a RCT are needed to understand the significance of early mobilization on the outcome of patients with aSAH.
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Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ana Maria Castaño Leon
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Laura Lippa
- Department of Neurosurgery, Ospedale Niguarda, Milano, Italy
| | - Péter Tóth
- Department of Neurosurgery, University of Pecs, Hungary
| | - Nicole Terpolilli
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Lovisa Tobieson
- Department of Neurosurgery of Linköping, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Francesco Latini
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
- Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
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21
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Wang RL, Gingrich KJ, Vance A, Johnson MD, Welch BG, McDonagh DL. The effects of aneurysmal subarachnoid hemorrhage on cerebral vessel diameter and flow velocity. J Stroke Cerebrovasc Dis 2023; 32:107056. [PMID: 36933521 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Transcranial Doppler flow velocity is used to monitor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Generally, blood flow velocities appear inversely related to the square of vessel diameter representing local fluid dynamics. However, studies of flow velocity-diameter relationships are few, and may identify vessels for which diameter changes are better correlated with Doppler velocity. We therefore studied a large retrospective cohort with concurrent transcranial Doppler velocities and angiographic vessel diameters. METHODS This is a single-site, retrospective, cohort study of adult patients with aneurysmal subarachnoid hemorrhage, approved by the UT Southwestern Medical Center Institutional Review Board. Study inclusion required transcranial Doppler measurements within </= 24 hours of vessel imaging. Vessels assessed were: bilateral anterior, middle, posterior cerebral arteries; internal carotid siphons; vertebral arteries; and basilar artery. Flow velocity-diameter relationships were constructed and fitted with a simple inverse power function. A greater influence of local fluid dynamics is suggested as power factors approach two. RESULTS 98 patients were included. Velocity-diameter relationships are curvilinear, and well fit by a simple inverse power function. Middle cerebral arteries showed the highest power factors (>1.1, R2>0.9). Furthermore, velocity and diameter changed (P<0.033) consistent with the signature time course of cerebral vasospasm. CONCLUSIONS These results suggest that middle cerebral artery velocity-diameter relationships are most influenced by local fluid dynamics, which supports these vessels as preferred endpoints in Doppler detection of cerebral vasospasm. Other vessels showed less influence of local fluid dynamics, pointing to greater role of factors outside the local vessel segment in determining flow velocity.
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Affiliation(s)
- Richard L Wang
- Department of Anesthesiology and Pain Management; The University of Texas Southwestern, Dallas, Texas, USA; Department of Radiology, University of Miami Miller School of Medicine.
| | - Kevin J Gingrich
- Department of Anesthesiology and Pain Management; The University of Texas Southwestern, Dallas, Texas, USA; Department of Anesthesiology and Pain Management, Univ. of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, Texas 75390 USA.
| | - Awais Vance
- Department of Neurological Surgery; The University of Texas Southwestern, Dallas, Texas, USA; Departments of Radiology; The University of Texas Southwestern, Dallas, Texas, USA; Department of Neurosurgery, Baylor Scott & White Medical Center.
| | - Mark D Johnson
- Department of Neurology; The University of Texas Southwestern, Dallas, Texas, USA; Department of Neurology, Univ. of Texas Southwestern Medical Center.
| | - Babu G Welch
- Department of Neurological Surgery; The University of Texas Southwestern, Dallas, Texas, USA; Departments of Radiology; The University of Texas Southwestern, Dallas, Texas, USA; Departments of Neurological Surgery & Radiology, Univ. of Texas Southwestern Medical Center.
| | - David L McDonagh
- Department of Anesthesiology and Pain Management; The University of Texas Southwestern, Dallas, Texas, USA; Department of Neurological Surgery; The University of Texas Southwestern, Dallas, Texas, USA; Department of Neurology; The University of Texas Southwestern, Dallas, Texas, USA; Departments of Anesthesiology and Pain Management, Neurology, and Neurological Surgery; Univ. of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, Texas 75390 USA.
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22
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Gan N, Jia TL, Tian N, Liu SS, Cao S. Effect of nimodipine combined with atorvastatin calcium on microinflammation and oxidative stress levels in patients with cerebral vasospasm after subarachnoid hemorrhage. Pak J Med Sci 2023; 39:434-438. [PMID: 36950409 PMCID: PMC10025739 DOI: 10.12669/pjms.39.2.6721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/23/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
Objective To evaluate the effect of nimodipine combined with atorvastatin calcium on the micro inflammation and oxidative stress levels in patients with cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) and its clinical implications. Methods A total of 80 patients with CVS caused by SAH who had been admitted to Baoding First Central Hospital from August 2021 to August 2022 were selected and randomly divided into two groups. The control group underwent conventional symptomatic treatment, while the experimental group was administered nimodipine combined with atorvastatin calcium on the basis of conventional treatment. The changes in the micro inflammatory cytokines and oxidative stress factors in the two groups were compared, as well as the differences in clinical efficacy and incidence of adverse drug reactions. Result After treatment, the levels of inflammatory cytokines in the experimental group decreased more significantly than those in the control group (p=0.00). After treatment, the serum levels of oxidative stress factors were obviously higher in the experimental group than in the control group (p=0.00). After treatment, the total efficacy was 77.5% in the experimental group and 55% in the control group, and the difference was statistically significant (p=0.04). Conclusions Nimodipine combined with atorvastatin calcium could significantly improve the clinical symptoms in patients with CVS after SAH, which would be beneficial, safe, and effective for the patient's recovery.
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Affiliation(s)
- Ning Gan
- Ning Gan, Department of Neurosurgery, Baoding First Central Hospital, Baoding, Hebei, 071000, China
| | - Tong-le Jia
- Tong-le Jia, Department of Neurosurgery, Baoding First Central Hospital, Baoding, Hebei, 071000, China
| | - Nan Tian
- Nan Tian, Department of Neurosurgery, Baoding First Central Hospital, Baoding, Hebei, 071000, China
| | - Si-si Liu
- Si-si Liu. Department of Neurology and Intensive Care, Baoding First Central Hospital, Baoding, Hebei, 071000, China
| | - Shan Cao
- Shan Cao, Department of Neurology, Baoding First Central Hospital, Baoding, Hebei, 071000, China
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23
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Kaliuzhka V, Tkachenko A, Myasoedov V, Markevych M, Onishchenko A, Babalyan I, Piatykop V. The Prognostic Value of Eryptosis Parameters in the Cerebrospinal Fluid for Cerebral Vasospasm and Delayed Cerebral Ischemia Formation. World Neurosurg 2023; 173:e578-e585. [PMID: 36842532 DOI: 10.1016/j.wneu.2023.02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) and cerebral vasospasm (VS.) contribute to poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). The pathophysiology of DCI is not fully understood, and this has hindered the adoption of a uniform definition. Reliable diagnostic tests and effective evidence-based treatment are lacking. This study explored the possibility of using eryptosis parameters in the cerebrospinal fluid (CSF) as a marker for early detection of VS and DCI. METHODS Twenty-one SAH patients were recruited and treated at Kharkiv Regional Hospital. The occurrences of DCI and VS were also recorded. Flow cytometry was used to assess eryptosis indices in the CSF by analyzing phosphatidylserine externalization in erythrocytes using annexin V staining and evaluating reactive oxygen species generation using 2,7-dichlorodihydrofluorescein (DCF) diacetate staining. RESULTS The percentage of annexin-positive red blood cells (RBCs) in the VS group was significantly higher than that in the non-VS group (P = 0.0017). Furthermore, higher values of this index were significantly associated with DCI formation (P < 0.0001). Patients with VS had higher mean fluorescence intensity values of DCF in RBCs compared to patients without VS (P = 0.0258). Patients with DCI also had higher mean fluorescence intensity values of DCF in RBCs (P = 0.0282). A higher percentage of annexin-positive RBCs following 3 days of aSAH was correlated with poor 3-month neurological outcomes (r = 0.7). CONCLUSIONS Our findings indicate a strong correlation between eryptosis level and DCI in a sizable series of patients with aSAH. Correlations between eryptosis indicators in the CSF and clinical and radiological manifestations suggest that eryptosis parameters are promising diagnostic biomarkers for DCI.
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Affiliation(s)
- Vladyslav Kaliuzhka
- Department of Neurosurgery, Kharkiv National Medical University, Kharkiv, Ukraine; Communal Non-Commercial Enterprise of Kharkiv Regional Council "Regional Clinical Hospital", Kharkiv, Ukraine.
| | - Anton Tkachenko
- Research Institute of Experimental and Clinical Medicine, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Valeriy Myasoedov
- Department of Medical Biology, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Mykyta Markevych
- Department of Internal Medicine and Endocrinology, Kharkiv National Medical University, Kharkiv, Ukraine; Communal Non-Commercial Enterprise of Kharkiv Regional Council "Regional Clinical Hospital", Kharkiv, Ukraine
| | - Anatolii Onishchenko
- Research Institute of Experimental and Clinical Medicine, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Iurii Babalyan
- Department of Neurosurgery, Kharkiv National Medical University, Kharkiv, Ukraine; Communal Non-Commercial Enterprise of Kharkiv Regional Council "Regional Clinical Hospital", Kharkiv, Ukraine
| | - Volodymyr Piatykop
- Department of Neurosurgery, Kharkiv National Medical University, Kharkiv, Ukraine; Communal Non-Commercial Enterprise of Kharkiv Regional Council "Regional Clinical Hospital", Kharkiv, Ukraine
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Ozono I, Ikawa F, Hidaka T, Matsuda S, Oku S, Horie N, Date I, Suzuki M, Kobata H, Murayama Y, Sato A, Kato Y, Sano H. Different Risk Factors Between Cerebral Infarction and Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 173:e487-e497. [PMID: 36841530 DOI: 10.1016/j.wneu.2023.02.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE Cerebral infarction due to cerebral vasospasm (IVS) after aneurysmal subarachnoid hemorrhage is associated with poor outcomes and symptomatic cerebral vasospasm (SVS). However, the difference of risk factors between SVS and IVS was unclear to date. In this study, we aimed to elucidate the risk factors for SVS and IVS based on the registry study. METHODS The modified World Federation of Neurosurgical Societies scale study comprises 1863 cases. Patients with aneurysmal subarachnoid hemorrhage who underwent radical treatment within 72 hours with a premorbid modified Rankin Scale score 0-2 as the inclusion criteria were retrospectively examined. The risk factors for SVS and IVS were analyzed using multivariable logistic regression analysis. RESULTS Among them, 1090 patients who met the inclusion criteria were divided into 2 groups according to SVS and IVS; 273 (25%) patients with SVS and 92 (8.4%) with IVS. Age was not a risk factor for SVS, but for IVS, and Fisher scale was a risk factor for SVS, but not for IVS. CONCLUSIONS The prevalence of IVS was not associated with the Fisher scale but with older age, suggesting possible factors other than SVS. Different associated factors between SVS and IVS were confirmed in this study.
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Affiliation(s)
- Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shingo Matsuda
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shinnichiro Oku
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiyasu Suzuki
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Osaka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Sato
- Department of Rehabilitation, Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
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Kuwano A, Ishiguro T, Nomura S, Omura Y, Hodotsuka K, Tanaka Y, Murakami M, Kawamata T, Kawashima A. Predictive factors for improvement of symptomatic cerebral vasospasm following subarachnoid hemorrhage by selective intra-arterial administration of fasudil hydrochloride. Interv Neuroradiol 2023:15910199231155037. [PMID: 36740915 DOI: 10.1177/15910199231155037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Symptomatic cerebral vasospasm after subarachnoid hemorrhage (SAH) is a significant cause of delayed cerebral ischemia that leads to poor outcomes. Selective intra-arterial administration of fasudil hydrochloride (IAF) has been adopted for its vasodilatory effect on spasm arteries to prevent delayed cerebral ischemia. However, its effect on clinical outcomes and predictive factors for good recovery are not fully understood. This study aimed to investigate the outcomes of selective IAF and identify predictive factors for good outcomes in patients with cerebral vasospasm after SAH. METHODS A retrospective study of 36 patients with cerebral vasospasm following SAH who underwent selective IAF at our institution between January 2014 and May 2022 was conducted. We evaluated the improvements in neurological findings before and after selective IAF. Statistical analyses were performed to determine factors associated with good outcomes. RESULTS Selective IAF improved the neurological findings in 26 patients (72.2%). Pre-therapeutic absence of cerebral infarction in more than 1/3 of the spasm artery perfusion area was significantly associated with an improvement in neurological findings (p < 0.0001). Furthermore, there was a tendency for a good outcome when the age was younger (p = 0.093), and the spasm was limited to peripheral vessels (p = 0.065). CONCLUSION Our study indicates that selective IAF has a promising effect in improving symptomatic vasospasm, except when a large cerebral infarction exists in the spasm artery perfusion area. Early consideration of selective IAF could be recommended once patients experience symptomatic cerebral vasospasm after SAH.
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Affiliation(s)
- Atsushi Kuwano
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Taichi Ishiguro
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Shunsuke Nomura
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Yoshihiro Omura
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Kenichi Hodotsuka
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Yukiko Tanaka
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Masato Murakami
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Japan
| | - Akitsugu Kawashima
- Department of Neurosurgery, 428677Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo-city, Japan
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Messina R, de Gennaro L, De Robertis M, Pop R, Chibbaro S, Severac F, Blagia M, Balducci MT, Bozzi MT, Signorelli F. Cerebrospinal Fluid Lactate and Glucose Levels as Predictors of Symptomatic Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 170:e596-e602. [PMID: 36403937 DOI: 10.1016/j.wneu.2022.11.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a complex neurovascular syndrome with profound systemic effects associated with high rates of disability and mortality. Delayed cerebral ischemia (DCI), which encompasses all neurobiological events occurring in the subacute-late stage after aSAH, has a complex pathogenesis and can occur in the absence of instrumental vasospasm. Our aim was to assess the correlation between cerebrospinal fluid (CSF) lactate and glucose levels measured on the second or third day after aSAH with clinical deterioration caused by DCI and with 3-month functional outcome. METHODS This prospective study included all aSAH patients admitted between January 2020 and December 2021 who underwent external ventricular drain placement and CSF lactate and glucose measurement. RESULTS Among 133 aSAH patients, 48 had an external ventricular drain placed and early CSF lactate and glucose assessment. Independent predictors of symptomatic DCI were World Federation of Neurosurgical Societies grade IV-V (adjusted odds ratio [aOR] 25.8, 95% confidence interval [CI] 2.9-649.2, P = 0.012), elevated CSF glucose (aOR 28.8, 95% CI 3.3-775.2, P = 0.010), and elevated CSF lactate (aOR 14.7, 95% CI 1.9-205.7, P = 0.018). The only independent predictor of 3-month functional outcome was occurrence of symptomatic DCI (aOR 0.02, 95% CI 0.0-0.2, P = 0.01). CONCLUSIONS Elevated CSF lactate and glucose levels in the first 3 days following aSAH were independent predictors of subsequent DCI-related neurological impairment; the presence of instrumental vasospasm was not significantly correlated with DCI after multivariate adjustment. CSF lactate and glucose monitoring may represent a point-of-care test, which could potentially improve prediction of subacute neurological worsening and guide therapeutic choices. Further research with larger prospective cohorts is warranted.
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Affiliation(s)
- Raffaella Messina
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Luigi de Gennaro
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Mario De Robertis
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France; Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France
| | - Salvatore Chibbaro
- Neurosurgery Department, Strasbourg University Hospitals, Strasbourg, France
| | - François Severac
- Public Healthcare Department, Strasbourg University Hospitals, Strasbourg, France
| | - Maria Blagia
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | | | - Maria Teresa Bozzi
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Translational Biomedicine and Neurosciences (DiBraiN), University "Aldo Moro" of Bari, Bari, Italy.
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Yuan JY, Chen Y, Jayaraman K, Kumar A, Zlepper Z, Allen ML, Athiraman U, Osbun J, Zipfel G, Dhar R. Automated Quantification of Compartmental Blood Volumes Enables Prediction of Delayed Cerebral Ischemia and Outcomes After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 170:e214-e222. [PMID: 36323345 PMCID: PMC10995956 DOI: 10.1016/j.wneu.2022.10.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of hemorrhage volume in risk of vasospasm, delayed cerebral ischemia (DCI), and poor outcomes after aneurysmal subarachnoid hemorrhage (SAH) is well established. However, the relative contribution of blood within individual compartments is unclear. We present an automated technique for measuring not only total but also volumes of blood in each major compartment after SAH. METHODS We trained convolutional neural networks to identify compartmental blood (cisterns, sulci, and ventricles) from baseline computed tomography scans of patients with SAH. We compared automated blood volumes against traditional markers of bleeding (modified Fisher score [mFS], Hijdra sum score [HSS]) in 190 SAH patients for prediction of vasospasm, DCI, and functional status (modified Rankin Scale) at hospital discharge. RESULTS Combined cisternal and sulcal volume was better correlated with mFS and HSS than cisternal volume alone (ρ = 0.63 vs. 0.58 and 0.75 vs. 0.70, P < 0.001). Only blood volume in combined cisternal plus sulcal compartments was independently associated with DCI (OR 1.023 per mL, 95% CI 1.002-1.048), after adjusting for clinical factors while ventricular blood volume was not. Total and specifically sulcal blood volume was strongly associated with poor outcome (OR 1.03 per mL, 1.01-1.06, P = 0.006 and OR 1.04, 1.00-1.08 for sulcal) as was HSS (OR 1.06 per point, 1.00-1.12, P = 0.04), while mFS was not (P = 0.24). CONCLUSIONS An automated imaging algorithm can measure the volume of bleeding after SAH within individual compartments, demonstrating cisternal plus sulcal (and not ventricular) blood contributes to risk of DCI/vasospasm. Automated blood volume was independently associated with outcome, while qualitative grading was not.
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Affiliation(s)
- Jane Y Yuan
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Keshav Jayaraman
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Zach Zlepper
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michelle L Allen
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Joshua Osbun
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Gregory Zipfel
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.
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Wolfert C, Maurer CJ, Berlis A, Schneider H, Steininger K, Motov S, Krauss P, Sommer B, Shiban E. Hydrocephalus, cerebral vasospasm, and delayed cerebral ischemia following non-aneurysmatic spontaneous subarachnoid hemorrhages: an underestimated problem. Neurosurg Rev 2022; 46:23. [PMID: 36547720 PMCID: PMC9780132 DOI: 10.1007/s10143-022-01919-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/13/2022] [Accepted: 11/27/2022] [Indexed: 12/24/2022]
Abstract
Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27-84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications.
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Affiliation(s)
- Christina Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Christoph J Maurer
- Department of Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Ansgar Berlis
- Department of Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kathrin Steininger
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Motov
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Philipp Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Björn Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Bruder N, Higashida R, Santin-Janin H, Dubois C, Aldrich EF, Marr A, Roux S, Mayer SA. The REACT study: design of a randomized phase 3 trial to assess the efficacy and safety of clazosentan for preventing deterioration due to delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. BMC Neurol 2022; 22:492. [PMID: 36539711 PMCID: PMC9763815 DOI: 10.1186/s12883-022-03002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND For patients presenting with an aneurysmal subarachnoid hemorrhage (aSAH), delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality. The REACT study is designed to assess the safety and efficacy of clazosentan in preventing clinical deterioration due to DCI in patients with aSAH. METHODS REACT is a prospective, multicenter, randomized phase 3 study that is planned to enroll 400 patients with documented aSAH from a ruptured cerebral aneurysm, randomized 1:1 to 15 mg/hour intravenous clazosentan vs. placebo, in approximately 100 sites and 15 countries. Eligible patients are required to present at hospital admission with CT evidence of significant subarachnoid blood, defined as a thick and diffuse clot that is more than 4 mm in thickness and involves 3 or more basal cisterns. The primary efficacy endpoint is the occurrence of clinical deterioration due to DCI up to 14 days post-study drug initiation. The main secondary endpoint is the occurrence of clinically relevant cerebral infarction at Day 16 post-study drug initiation. Other secondary endpoints include the modified Rankin Scale (mRS) and the Glasgow Outcome Scale-Extended (GOSE) score at Week 12 post-aSAH, dichotomized into poor and good outcome. Radiological results and clinical endpoints are centrally evaluated by independent committees, blinded to treatment allocation. Exploratory efficacy endpoints comprise the assessment of cognition status at 12 weeks and quality of life at 12 and 24 weeks post aSAH. DISCUSSION In the REACT study, clazosentan is evaluated on top of standard of care to determine if it reduces the risk of clinical deterioration due to DCI after aSAH. The selection of patients with thick and diffuse clots is intended to assess the benefit/risk profile of clazosentan in a population at high risk of vasospasm-related ischemic complications post-aSAH. TRIAL REGISTRATION (ADDITIONAL FILE 1): ClinicalTrials.gov (NCT03585270). EU Clinical Trial Register (EudraCT Number: 2018-000241-39).
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Affiliation(s)
- Nicolas Bruder
- grid.5399.60000 0001 2176 4817Department of Anesthesia and Critical Care, Hôpital de la Timone, Aix-Marseille Université, 264 rue St-Pierre, 13005 Marseille, France
| | - Randall Higashida
- grid.413077.60000 0004 0434 9023Department of Neuro Interventional Radiology, University of California San Francisco Medical Center, San Francisco, USA
| | - Hugues Santin-Janin
- grid.508389.f0000 0004 6414 2411Biometry, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Cécile Dubois
- grid.508389.f0000 0004 6414 2411Biometry, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - E. François Aldrich
- grid.411024.20000 0001 2175 4264Department of Neurosurgery, University of Maryland, Baltimore, USA
| | - Angelina Marr
- grid.508389.f0000 0004 6414 2411Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Sébastien Roux
- grid.508389.f0000 0004 6414 2411Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Stephan A. Mayer
- grid.417052.50000 0004 0476 8324Neurocritical Care and Emergency Neurology Services, Westchester Medical Center Health Network, Valhalla, USA ,grid.260917.b0000 0001 0728 151XDepartment of Neurology and Neurosurgery, New York Medical College, New York, USA
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Shah KA, White TG, Teron I, Turpin J, Dehdashti AR, Temes RE, Black K, Woo HH. Quantitative magnetic resonance angiography as an alternative imaging technique in the assessment of cerebral vasospasm after subarachnoid hemorrhage. Interv Neuroradiol 2022:15910199221138167. [PMID: 36357992 DOI: 10.1177/15910199221138167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION The major mechanism of morbidity of delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is considered to be severe vasospasm. Quantitative MRA (QMRA) provides direct measurements of vessel-specific volumetric blood flow and may permit a clinically relevant assessment of the risk of ischemia secondary to cerebral vasospasm. PURPOSE To evaluate the utility of QMRA as an alternative imaging technique for the assessment of cerebral vasospasm after SAH. METHODS QMRA volumetric flow rates of the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) were compared with vessel diameters on catheter-based angiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of QMRA for detecting cerebral vasospasm was determined by receiver-operating characteristic curves. Spearman correlation coefficients were calculated for QMRA flow versus angiographic vessel diameter. RESULTS Sixty-six vessels (10 patients) were evaluated with QMRA and catheter-based angiography. The median percent QMRA flow of all vessels with angiographic vasospasm (55.0%, IQR 34.3-71.6%) was significantly lower than the median percent QMRA flow of vessels without vasospasm (91.4%, IQR 81.4-100.4%) (p < 0.001). Angiographic vasospasm reduced QMRA-assessed flow by 23 ± 5 (p = 0.018), 95 ± 12 (p = 0.042), and 16 ± 4 mL/min (p = 0.153) in the ACA, MCA, and PCA, respectively, compared to vessels without angiographic vasospasm. The sensitivity, specificity, PPV, and NPV of QMRA for the discrimination of cerebral vasospasm was 84%, 72%, 84%, and 72%, respectively, for angiographic vasospasm >25% and 91%, 60%, 87%, and 69%, respectively, for angiographic vasospasm >50%. The Spearman correlation indicated a significant association between QMRA flows and vessel diameters (rs = 0.71, p < 0.001). CONCLUSION Reduction in QMRA flow correlates with angiographic vessel narrowing and may be useful as a non-invasive imaging modality for the detection of cerebral vasospasm after SAH.
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Affiliation(s)
- Kevin A Shah
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Ina Teron
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Richard E Temes
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Karen Black
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Slavin KV, Vannemreddy P. Cervical spinal cord stimulation for prevention and treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: clinical and radiographic outcomes of a prospective single-center clinical pilot study. Acta Neurochir (Wien) 2022; 164:2927-2937. [PMID: 35920945 DOI: 10.1007/s00701-022-05325-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/21/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of high morbidity and mortality, for which there is no consistently effective treatment. Cervical spinal cord stimulation (cSCS) has been shown to induce vasodilatation and improve peripheral and cerebral blood flow in both animal and human studies. This pilot study was performed to assess the clinical effect and long-term results of cSCS treatment in aSAH patients. METHODS This was the first IRB- and US FDA-approved prospective non-randomized non-controlled study comprising of 12 aSAH patients (8 women, 4 men, age range 34-62 years) treated between May and November 2008. All patients underwent up to 2 weeks of cSCS with a single percutaneously implanted 8-contact electrode. Neurological outcomes at discharge and follow-up of up to 13 years and mortality/complications rates were analyzed. RESULTS All 12 aSAH patients underwent cSCS electrode implantation immediately after securing the aneurysm. Patients were stimulated for 10-14 consecutive days starting within 3 days of aneurysm rupture. Angiographic vasospasm occurred in six patients; two patients developed new vasospasm-related neurological symptoms; both recovered completely by discharge time. One patient died from unrelated multi-system failure; the rest were followed up clinically (average, 7.5 years; range, 12-151 months) and angiographically (average, 6.5 years; range, 36-125 months). No delayed ischemic neurological deficits/strokes and no cSCS-related adverse effects were observed. CONCLUSIONS Our short- and long-term data suggest that cSCS is feasible and safe for patients in the acute aSAH settings. Small size of the patient cohort and lack of control do not allow us to conclude whether cSCS is able to prevent cerebral vasospasm, decrease its severity, and improve clinical outcomes in aSAH patients. However, our findings support further clinical trials and development of cSCS as a new concept to prevent and treat cerebral vasospasm. TRIAL REGISTRATION CLINICALTRIALS gov NCT00766844, posted on 10/06/2008.
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Affiliation(s)
- Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA. .,Neurology Service, Jesse Brown Veterans Administration Hospital, Chicago, IL, USA.
| | - Prasad Vannemreddy
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Narotam PK, Garton A, Morrison J, Nathoo N, Narotam N. Brain Oxygen-Directed Management of Aneurysmal Subarachnoid Hemorrhage. Temporal Patterns of Cerebral Ischemia During Acute Brain Attack, Early Brain Injury, and Territorial Sonographic Vasospasm. World Neurosurg 2022; 166:e215-36. [PMID: 35803565 DOI: 10.1016/j.wneu.2022.06.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. METHODS This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40). RESULTS The brain oxygen-directed protocol reduced Lbo2 (Pbto2 [partial pressure of brain tissue oxygen] <20 mm Hg) from 67% to 15% during acute brain attack (<24 hours of ictus), by increasing Pbto2 from 11.31 ± 9.34 to 27.85 ± 6.76 (P < 0.0001) and then to 29.09 ± 17.88 within 72 hours. Day-after-bleed, Fio2 change, ICP, hemoglobin, and oxygen saturation were predictors for Pbto2 during early brain injury. Transcranial Doppler ultrasonography velocities (>20 cm/second) increased at day 2. During DCI caused by territorial sonographic vasospasm (TSV), middle cerebral artery mean velocity (Vm) increased from 45.00 ± 15.12 to 80.37 ± 38.33/second by day 4 with concomitant Pbto2 reduction from 29.09 ± 17.88 to 22.66 ± 8.19. Peak TSV (days 7-12) coincided with decline in Pbto2. Nicardipine mitigated Lbo2 during peak TSV, in contrast to nimodipine, with survival benefit (P < 0.01). Intravenous and cisternal nicardipine combination had survival benefit (Cramer Φ = 0.43 and 0.327; G2 = 28.32; P < 0.001). This study identifies 4 zones of Lbo2 during survival benefit (Cramer Φ = 0.43 and 0.3) TSV, uncompensated; global cerebral ischemia, compensated, and normal Pbto2. Admission Glasgow Coma Scale score (not increased ICP) was predictive of low Pbto2 (β = 0.812, R2 = 0.661, F1,30 = 58.41; P < 0.0001) during early brain injury. Coma was the only credible predictor for mortality (odds ratio, 7.33/>4.8∗; χ2 = 7.556; confidence interval, 1.70-31.54; P < 0.01) followed by basilar aneurysm, poor grade, high ICP and Lbo2 during TSV. Global cerebral ischemia occurs immediately after the ictus, persisting in 30% of patients despite the high therapeutic intensity level, superimposed by DCI during TSV. CONCLUSIONS We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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Shi M, Zhang TB, Li XF, Zhang ZY, Li ZJ, Wang XL, Zhao WY. The prognostic value of hyperglycemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:3717-3728. [PMID: 36169785 DOI: 10.1007/s10143-022-01870-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 11/27/2022]
Abstract
Recent studies have demonstrated that hyperglycemia may result in a poor prognosis following aneurysmal subarachnoid hemorrhage (aSAH). However, the association between hyperglycemia and the clinical outcome of aSAH has not been clearly established thus far. Therefore, we performed a systematic review and meta-analysis to investigate the association between hyperglycemia and the development of aSAH. We completed a literature search in four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) up to November 1, 2021, including all eligible studies investigating the prognostic value of hyperglycemia in patients with aSAH. We performed a quality assessment of included studies using the Newcastle-Ottawa Quality Assessment Scale. The pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to assess the association of hyperglycemia in aneurysmal subarachnoid hemorrhage. A total of 35 studies with 11,519 patients were finally included in the meta-analysis. Nineteen studies reported the association between hyperglycemia and poor outcome, 12 studies reported the association between hyperglycemia and all-cause mortality, 7 studies reported the association between hyperglycemia and cerebral vasospasm, and 9 studies reported the association between hyperglycemia and cerebral infarction. The pooled data of these studies suggested that hyperglycemia was significantly associated with poor functional outcomes (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.17-1.42; P < 0.00001; I2 = 83%), all-cause mortality (OR, 1.02; 95% CI, 1.01-1.04; P = 0.0006; I2 = 89%), cerebral vasospasm (OR, 1.02; 95% CI, 1.01-1.02; P = 0.0002; I2 = 35%), and cerebral infarction (OR, 1.16; 95% CI, 1.09-1.23; P < 0.00001; I2 = 10%) in aSAH patients. These findings suggested that assessing for hyperglycemia at admission may help clinicians to identify critically ill patients and complete patient stratification early, which may achieve better management and improve the prognosis of patients with aSAH.
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Affiliation(s)
- Min Shi
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ting-Bao Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiao-Feng Li
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zong-Yong Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ze-Jin Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xue-Lou Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen-Yuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China.
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Hostettler IC, Kreiser K, Lange N, Schwendinger N, Trost D, Frangoulis S, Hirle T, Gempt J, Wostrack M, Meyer B. Treatment during cerebral vasospasm phase-complication association and outcome in aneurysmal subarachnoid haemorrhage. J Neurol 2022; 269:5553-5560. [PMID: 35729347 PMCID: PMC9468043 DOI: 10.1007/s00415-022-11212-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/27/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
Background Aneurysm treatment during cerebral vasospasm (CVS) phase is frequently considered as particularly dangerous, mainly because of the risk of cerebral infarct. Objective We aimed to evaluate the risk of aneurysmal subarachnoid haemorrhage (aSAH)-specific complications and functional outcome in patients treated during CVS phase. Methods We retrospectively analysed a large, retro- and prospectively collected database of aSAH patients admitted to our department between March 2006 and March 2020. We conducted a uni- and multivariable logistic regression analysis to evaluate influencing factors on rebleeding, cerebral infarct, Glasgow Outcome Score (GOS) at discharge and mortality and assessed the rate of angiographic vasospasm on admission. Results We included 853 patients. The majority of patients were female (66.6%), mean age was 57.3 years. Out of 853 included patients, 92 (10.8%) were treated during CVS phase, 312 (36.6%) underwent clipping and 541 (63.4%) endovascular treatment. Treatment during CVS phase was significantly associated with cerebral infarct in the multivariable logistic regression analysis, unrelated to the nature of intervention (OR 2.42, 1.29–4.54 95% CI p-value = 0.006). However, patients treated during CVS phase did not have increased risk of unfavourable outcome by GOS on discharge. In addition, they did not have a higher rate of rebleeding or mortality. Conclusions Treatment during CVS phase was significantly associated with a higher rate of cerebral infarct as confirmed by imaging. This did not reflect on GOS on discharge, rebleeding, or mortality. Aneurysm treatment during CVS phase is relatively safe and should not be postponed due to the risk of rebleeding and subsequent devastating deterioration. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11212-w.
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Affiliation(s)
- Isabel C Hostettler
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany. .,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
| | - Kornelia Kreiser
- Department of Neuroradiology, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Nicole Lange
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Nina Schwendinger
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Dominik Trost
- Department of Neuroradiology, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Samira Frangoulis
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Theresa Hirle
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
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Asada R, Suzuki H. Osteopontin in post-subarachnoid hemorrhage pathologies. J Integr Neurosci 2022; 21:62. [PMID: 35364650 DOI: 10.31083/j.jin2102062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 11/06/2022] Open
Abstract
Rupture of intracranial aneurysms causes subarachnoid hemorrhage (SAH), of which the treatment remains the most difficult among cerebrovascular disorders even in this modern medical era. Following successful surgical ablation of ruptured intracranial aneurysms, other conditions may be encountered including delayed cerebral ischemia and chronic hydrocephalus, in addition to early brain injury. Osteopontin (OPN) is one of matricellular proteins that have cytokine-like effect on various cells and act as secretory extracellular matrix proteins between cells. The complexity of OPN functions is attributed to its several isoforms, cleavage sites and functional changes determined by its differing isoforms following various cleavages or other post-translational modifications. Notably, OPN functions beneficially or harmfully in accordance with the context of OPN upregulation. In the field of aneurysmal SAH, OPN has exerted neuroprotective effects against early brain injury and delayed cerebral ischemia by suppressing apoptosis of neurons, disruption of blood-brain barrier, and/or cerebrovascular constriction, while excessive and prolonged secretion of OPN can be harmful through the occurrence of chronic hydrocephalus requiring shunt surgery. This is a review article that is focused on OPN's potential roles in post-SAH pathologies.
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Affiliation(s)
- Reona Asada
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, 514-8507 Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, 514-8507 Mie, Japan
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Li L, Fu X, Qiu H, Shi P. Effects of cilostazol treatment for patients with aneurysmal subarachnoid hemorrhage: A meta-analysis of 14 studies. J Clin Neurosci 2022; 99:190-203. [PMID: 35286971 DOI: 10.1016/j.jocn.2021.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/04/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To perform an updated meta-analysis to comprehensively assess the efficacy and safety of cilostazol in preventing aneurysmal subarachnoid hemorrhage (SAH)-related secondary complications. METHODS Electronic databases of PubMed, the Cochrane library, CNKI and Wanfang were searched on August 2021. Pooled odds ratio (OR) and standardized mean difference (SMD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of 14 studies [comprising 18,726 aneurysmal SAH patients (6654 in the cilostazol group and 12,072 in the control group)] performed in Japan or China were included. Compared with the control group, cilostazol treatment significantly reduced the median cerebral artery (SMD = -0.49; p < 0.001), improved the therapeutic efficacy (OR = 2.37; p = 0.009), decreased the incidence of symptomatic vasospasm/delayed cerebral ischemia (OR = 0.42; p < 0.001), severe angiographic vasospasm (OR = 0.54; p < 0.001), new cerebral infarction (OR = 0.33; p < 0.001), poor outcomes (OR = 0.86; p = 0.001), mortality (OR = 0.62; p < 0.001) and increased the incidence of no or mild angiographic vasospasm (OR = 1.94; p = 0.004), but did not induce more adverse events (OR = 1.08; p = 0.871). The mechanism of cilostazol treatment was to inhibit the production of tenascin-C (SMD = -1.46; p < 0.001). These results were hardly changed by subgroup analysis. CONCLUSION This meta-analysis indicates cilostazol may be an effective and safe drug for aneurysmal SAH patients. However, further trials involving other world populations are required to demonstrate the generalization of treatment effects of cilostazol.
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Affiliation(s)
- Lian Li
- Emergency Department, Hongqiao Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200052, China
| | - Xiaofeng Fu
- Emergency Department, Hongqiao Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200052, China
| | - Huiming Qiu
- 80w Ward, Pudong Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200120, China.
| | - Peihong Shi
- Emergency Department, Hongqiao Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200052, China
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Powell K, White TG, Nash C, Rebeiz T, Woo HH, Narayan RK, Li C. The Potential Role of Neuromodulation in Subarachnoid Hemorrhage. Neuromodulation 2022; 25:1215-1226. [PMID: 35088724 DOI: 10.1016/j.neurom.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Aneurysmal subarachnoid hemorrhage (SAH) continues to be a difficult cerebrovascular disease with limited pharmacologic treatment options. Cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) are leading causes of morbidity and mortality after SAH. Despite the advances in the understanding of its pathophysiology and tremendous efforts to date, nimodipine is currently the sole Food and Drug Administration-approved treatment for patients with SAH, with benefits that are marginal at best. The neuromodulation therapies are promising, especially those that target CV and DCI to improve functional outcomes. The aim of this review is therefore to summarize the available evidence for each type of neuromodulation for CV and DCI, with a special focus on its pathophysiological mechanisms, in addition to their clinical utility and drawbacks, which we hope will lead to future translational therapy options after SAH. MATERIALS AND METHODS We conducted a comprehensive review of preclinical and clinical studies demonstrating the use of neuromodulation for SAH. The literature search was performed using PubMed, Embase, and ClinicalTrials.gov. A total of 21 articles published from 1992 to 2021 and eight clinical trials were chosen. RESULTS The studies reviewed provide a compelling demonstration that neuromodulation is a potentially useful strategy to target multiple mechanisms of DCI and thus to potentially improve functional outcomes from SAH. There are several types of neuromodulation that have been tested to treat CV and DCI, including the trigeminal/vagus/facial nerve stimulation, sphenopalatine ganglion and spinal cord stimulation, transcranial direct electrical stimulation, transcutaneous electrical neurostimulation, and electroacupuncture. Most of them are in the preclinical or early phases of clinical application; however, they show promising results. CONCLUSIONS DCI has a complex pathogenesis, making the unique anatomical distribution and pleiotropic capabilities of various types of neuromodulation a promising field of study. We may be at the cusp of a breakthrough in the use of these techniques for the treatment of this stubbornly difficult disease.
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Affiliation(s)
- Keren Powell
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Timothy G White
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, NY, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Christine Nash
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Tania Rebeiz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Raj K Narayan
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, NY, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Chunyan Li
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, NY, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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Samagh N, Panda NB, Gupta V, Bharti N, Tripathi M, Bhagat H, Chhabra RK, Jangra K, Luthra A. Impact of Stellate Ganglion Block in the Management of Cerebral Vasospasm: A Prospective Interventional Study. Neurol India 2022; 70:289-295. [PMID: 35263898 DOI: 10.4103/0028-3886.338735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters. MATERIALS AND METHODS We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated. RESULTS After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients. CONCLUSION SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.
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Affiliation(s)
- Navneh Samagh
- Department of Anaesthesiology and Critical Care, AIIMS, Bathinda, India
| | - Nidhi B Panda
- Professor Neuroanesthesia, Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Vivek Gupta
- Additional Director Interventional Neuroradiology, Fortis Healthcare, Chandigarh, India
| | - Neerja Bharti
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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Bissolo M, Scheiwe C, Csók I, Grauvogel J, Beck J, Reinacher PC, Roelz R. Introduction of cisternal lavage leads to avoidance of induced hypertension and reduced cardiovascular complications in patients with subarachnoid hemorrhage. J Clin Neurosci 2021; 94:286-291. [PMID: 34863452 DOI: 10.1016/j.jocn.2021.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Marco Bissolo
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany.
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany
| | - Istvan Csók
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany; Fraunhofer Institute for Laser Technology (ILT), Steinbachstraße 15, Aachen 52074, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany
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Raymond J, Létourneau-Guillon L, Darsaut TE. Angiographic vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage: Moving from theoretical to practical research pertinent to neurosurgical care. Neurochirurgie 2021:S0028-3770(21)00232-0. [PMID: 34844761 DOI: 10.1016/j.neuchi.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) and angiographic vasospasm following subarachnoid hemorrhage (SAH) have been associated for more than 50years. We aimed to examine whether the knowledge gained by theoretical research on vasospasm has actually translated into better patient outcomes in practice. METHODS This is a narrative review of the concept of vasospasm as a cause of DCI after SAH. We discuss recent studies that have assessed the accuracy and reliability of the diagnostic tests (transcranial Doppler ultrasound [TCD], CT angiography, and catheter angiography), which are used to identify SAH patients at-risk of DCI. RESULTS Both the diagnostic accuracy of TCD and the reliability of CT angiography to identify patients in severe vasospasm are poor. For the gold standard catheter angiography, the repeatability of the diagnosis of vasospasm, made by multiple raters, is only fair. Interventions on angiographic vasospasm have never been proven to improve patient outcomes. A pragmatic trial integrating the meaning of the diagnosis of vasospasm into a study protocol that assesses the value of endovascular interventions in the prevention of DCI after SAH seems to be in order. Such a trial could provide a pragmatic definition of clinically meaningful vasospasm. CONCLUSION We must move beyond research conceived as an enterprise aiming to acquire theoretical knowledge to one where research is integrated into clinical practice to improve clinical outcomes in real time.
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Isola C, Evain JN, Francony G, Baud C, Millet A, Desrumaux A, Wroblewski I, Payen JF, Mortamet G. Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management. Neurocrit Care 2021; 36:868-875. [PMID: 34791595 DOI: 10.1007/s12028-021-01388-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). METHODS This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). RESULTS Eighty patients aged 8.6 years (3.3-14.8 years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). CONCLUSIONS These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.
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Affiliation(s)
- Clément Isola
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Jean-Noel Evain
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France
| | - Gilles Francony
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France
| | - Caroline Baud
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Anne Millet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Amélie Desrumaux
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Jean-Francois Payen
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France.,Grenoble Institute Neurosciences, Grenoble Alpes University, Grenoble, 3800, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France. .,INSERM U1042, Grenoble-Alpes University,, Grenoble, 3800, France.
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Trinh-Duc A, Labeyrie MA, Caillard A, Ben Hassen W, Mebazaa A, Chousterman BG. Effects of levosimendan on occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a case-control study. Crit Care 2021; 25:396. [PMID: 34784938 PMCID: PMC8597255 DOI: 10.1186/s13054-021-03824-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/11/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Antoine Trinh-Duc
- Department of Anesthesiology and Critical Care, DMU Parabol, FHU PROMICE, APHP.Nord, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France.,INSERM U942 MASCOT, Université de Paris, Paris, France
| | - Marc-Antoine Labeyrie
- Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France.,EA 7334 REMES, Université de Paris, Paris, France
| | - Anaïs Caillard
- Department of Anesthesiology and Critical Care, DMU Parabol, FHU PROMICE, APHP.Nord, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France.,INSERM U942 MASCOT, Université de Paris, Paris, France
| | - Wagih Ben Hassen
- UMR 1266, Department of Neuroradiology, GHU Paris, Université de Paris, INSERM, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, DMU Parabol, FHU PROMICE, APHP.Nord, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France.,INSERM U942 MASCOT, Université de Paris, Paris, France
| | - Benjamin Glenn Chousterman
- Department of Anesthesiology and Critical Care, DMU Parabol, FHU PROMICE, APHP.Nord, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France. .,INSERM U942 MASCOT, Université de Paris, Paris, France.
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Esmael A, Flifel ME, Elmarakby F, Belal T. Predictive value of the transcranial Doppler and mean arterial flow velocity for early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. Ultrasound 2021; 29:218-228. [PMID: 34777542 DOI: 10.1177/1742271x20976965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/27/2020] [Indexed: 01/15/2023]
Abstract
Objectives We aimed to predict cerebral vasospasm in acute aneurysmal subarachnoid hemorrhage and to determine the cut-off values of the mean flow velocity by the use of transcranial Doppler. Methods A total of 40 patients with acute aneurysmal subarachnoid hemorrhage were included in this study and classified into two groups. The first group was 26 patients (65%) with cerebral vasospasm and the second group was 14 patients (35%) without vasospasm. Initial evaluation using the Glasgow Coma Scale and the severity of aneurysmal subarachnoid hemorrhage was detected by using both the clinical Hunt and Hess and radiological Fisher grading scales. All patients underwent transcranial Doppler evaluations five times in 10 days measuring the mean flow velocities (MFV) of cerebral arteries. Results Patients with cerebral vasospasm were associated with significantly higher mean Glasgow Coma Scale score (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), with significantly higher mean diabetes mellitus (p = 0.03), significantly higher mean systolic blood pressure and diastolic blood pressure (p = 0.02 and p = 0.005 respectively) and significantly higher MFVs measured within the first 10 days. Logistic regression analysis demonstrated that MFV ≥81 cm/s in the middle cerebral artery is accompanied by an almost five-fold increased risk of vasospasm (OR 4.92, p < 0.01), while MFV ≥63 cm/s in the anterior cerebral artery is accompanied by a three-fold increased risk of vasospasm (OR 3.12, p < 0.01), and MFV ≥42 cm/s in the posterior cerebral artery is accompanied by a two-fold increased risk of vasospasm (OR 2.11, p < 0.05). Conclusion Transcranial Doppler is a useful tool for early detection, monitoring, and prediction of post subarachnoid vasospasm and valuable for early therapeutic intervention before irreversible ischemic neurological deficits take place.
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Affiliation(s)
- Ahmed Esmael
- Neurology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed E Flifel
- Neurology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Farid Elmarakby
- Neuropsychiatry Department, Mataria Teaching Hospital, Egypt
| | - Tamer Belal
- Neurology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Anthofer J, Bele S, Wendl C, Kieninger M, Zeman F, Bruendl E, Schmidt NO, Schebesch KM. Continuous intra-arterial nimodipine infusion as rescue treatment of severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2021; 96:163-171. [PMID: 34789415 DOI: 10.1016/j.jocn.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 08/30/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
Severe refractory cerebral vasospasm (CV) is a major cause of disability and death in patients with aneurysmal subarachnoid hemorrhage (SAH). One rescue therapy in selected patients is intra-arterial nimodipine, either given as a single shot or as continuous infusion. To evaluate treatment efficacy, we analyzed outcome factors such as the incidence of craniectomy, ventriculo-peritonial (VP) shunting, and tracheotomy after intra-arterial nimodipine infusion. We retrospectively analyzed the rates of cerebral infarction, decompressive craniectomy, VP shunting, and tracheotomy in patients with severe CV after SAH. Three different patient groups were compared: group 1 had only been treated with oral nimodipine and hypervolemic hypertensive therapy (HHT) (2006-2010), group 2 with a single shot of intra-arterial nimodipine (SSN) in addition to oral conservative treatment (2006-2010), and group 3 with continuous intra-arterial nimodipine (CIAN) (2011-2017). The incidence of cerebral infarction was significantly lower in CIAN group (p = 0.005) than in conservative and SSN group. The indication for consecutive decompressive craniectomy was significantly lower in CIAN group in comparison with the conservative group (p = 0.018). The rates of VP shunting and tracheotomy were significantly higher in the CIAN group than in the conservative group (p = 0.028 for VP, and p = 0.003 for tracheotomy). The significantly lower rate of craniectomy in the CIAN group was most probably attributable to the significantly lower rate of CV-induced infarction. The higher rate of tracheotomy reflects more extensive sedation and the need of longer stays on the intensive care unit. Thus, the effect on long-term neurological outcome and quality of life has to be evaluated separately.
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Affiliation(s)
- Judith Anthofer
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany.
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Christina Wendl
- Department of Neuroradiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Elisabeth Bruendl
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
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Tsukagoshi E, Sato H, Kohyama S. A case of subdural hemorrhage due to ruptured cerebral aneurysm presenting with atypical imaging features. Radiol Case Rep 2021; 16:3911-3914. [PMID: 34703517 PMCID: PMC8526494 DOI: 10.1016/j.radcr.2021.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/27/2022] Open
Abstract
Acute subdural hemorrhage caused by ruptured cerebral aneurysms is rare. Herein, we report an atypical case of subdural hemorrhage caused by ruptured anterior communicating artery aneurysm in a 49-year-old woman. Computed tomography revealed subarachnoid, intracerebral, and subdural hemorrhages. After the treatment with endovascular coiling significantly decreased the patient's subdural hemorrhage. However, the subdural hemorrhage revealed and became iso-attenuation compared with the white matter on the 11th day, and hypo-attenuation on the 19th day. On the 33rd day, this subdural hemorrhage completely resolved after discontinuation of dual antiplatelet therapy. Due to rapid changes in the radiologic features of SDH, frequent computed tomography scans at least once a week may be needed especially in patients who receive antiplatelet therapy during the vasospasm phase.
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Affiliation(s)
- Eisuke Tsukagoshi
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, Japan
| | - Hiroki Sato
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, Japan
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, Japan
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Majewska P, Hara S, Gulati S, Solheim O. Association between transcranial Doppler vasospasm and functional outcome after subarachnoid hemorrhage. Brain Circ 2021; 7:271-276. [PMID: 35071844 PMCID: PMC8757509 DOI: 10.4103/bc.bc_63_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/18/2021] [Accepted: 11/11/2021] [Indexed: 12/02/2022] Open
Abstract
AIM OF THE STUDY: This study aimed to investigate the association between transcranial Doppler (TCD) vasospasm and patient outcome and to assess the predictive factors for developing TCD vasospasm after subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: This retrospective observational study included adult patients with nontraumatic SAH. Patient characteristics and TCD values were recorded retrospectively from patient records. Data on maxTCD (maximal TCD value recorded on any side between day 1 and day 14) as well as Δ TCD (maximal difference between mean velocity measured on days 1–3 and days 4–14 on any side) were calculated. The modified Rankin Score was recorded from electronic patient notes at discharge and 3, 6, and 12 months after ictus. The effect of TCD vasospasm, maxTCD, and Δ TCD on the clinical outcome was investigated. Potential predictive factors for developing TCD vasospasm were assessed. The association between the same factors and maxTCD and Δ TCD were explored. RESULTS: One hundred and thirty-eight patients were included in the study. Higher age was associated with a lower risk of developing TCD vasospasm (odds ratio: 0.952, 95% confidence interval: 0.924–0.982, P = 0.002). Fisher grade was a predictor of developing TCD vasospasm (P = 0.05). Age was negatively correlated with maxTCD (R = −0.47, P = 0.01). There was no statistically significant difference in patient outcome at hospital discharge and at 3, 6, and 12 months between patients with and without TCD vasospasm. Higher maxTCD and Δ TCD were associated with a worse clinical outcome at 3 months after SAH ictus. CONCLUSIONS: The clinical benefit of routine TCD assessments in SAH patients remains uncertain.
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Affiliation(s)
- Paulina Majewska
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | - Sozaburo Hara
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Sasha Gulati
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
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Labeyrie MA, Simonato D, Gargalas S, Morisson L, Cortese J, Ganau M, Fuschi M, Patel J, Froelich S, Gaugain S, Chousterman B, Houdart E. Intensive therapies of delayed cerebral ischemia after subarachnoid hemorrhage: a propensity-matched comparison of different center-driven strategies. Acta Neurochir (Wien) 2021; 163:2723-2731. [PMID: 34302553 DOI: 10.1007/s00701-021-04935-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intensive therapies of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) have still controversial and unproven benefit. We aimed to compare the overall efficacy of two different center-driven strategies for the treatment of DCI respectively with and without vasospasm angioplasty. METHODS Two hundred consecutive patients with aSAH were enrolled in each of two northern European centers. In an interventional center, vasospasm angioplasty was indicated as first line rather than rescue treatment of DCI using distal percutaneous balloon angioplasty technique combined with intravenous milrinone. In non-interventional center, induced hypertension was the only intensive therapy of DCI. Radiological DCI (new cerebral infarcts not visible on immediate post-treatment imaging), death at 1 month, and favorable outcome at 6 months (modified Rankin scale score ≤ 2) were retrospectively analyzed by independent observers and compared between two centers before and after propensity score (PS) matching for baseline characteristics. RESULTS Baseline characteristics only differed between centers for age and rate of smokers and patients with chronic high blood pressure. In the interventional center, vasospasm angioplasty was performed in 38% of patients with median time from bleeding of 8 days (Q1 = 6.5;Q3 = 10). There was no significant difference of incidence of radiological DCI (9% vs.14%, P = 0.11), death (8% vs. 9%, P = 0.4), and favorable outcome 74% vs. 72% (P = 0.4) between interventional and non-interventional centers before and after PS matching. CONCLUSIONS Our results suggest either that there is no benefit, or might be minimal, of one between two different center-driven strategies for intensive treatment of DCI. Despite potential lack of power or unknown confounders in our study, these results question the use of such intensive therapies in daily practice without further optimization and validation.
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Affiliation(s)
- Marc-Antoine Labeyrie
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France.
| | - Davide Simonato
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Sergios Gargalas
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Louis Morisson
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Jonathan Cortese
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France
| | - Mario Ganau
- Neurosurgery Unit, John Radcliffe Hospital, Oxford, UK
| | - Maurizio Fuschi
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Jash Patel
- Neurosurgery Unit, John Radcliffe Hospital, Oxford, UK
| | - Sébastien Froelich
- Neurosurgery Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Samuel Gaugain
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Benjamin Chousterman
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
- UMR 1123, Université de Paris, INSERM, Paris, France
| | - Emmanuel Houdart
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France
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Bruder M, Kashefiolasl S, Brawanski N, Keil F, Won SY, Seifert V, Konczalla J. Vitamin K Antagonist (Phenprocoumon) and Subarachnoid Hemorrhage: A Single-Center, Matched-Pair Analysis. Neurocrit Care 2021; 33:105-114. [PMID: 31659679 DOI: 10.1007/s12028-019-00868-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Demographic changes are leading to an aging society with a growing number of patients relying on anticoagulation, and vitamin K antagonists (VKA) are still widely used. As mortality and functional outcomes are worse in case of VKA-associated hemorrhagic stroke, phenprocoumon treatment seems to be a negative prognostic factor in case of subarachnoid hemorrhage (SAH). The purpose of this study was to analyze whether phenprocoumon treatment does worsen the outcome after non-traumatic SAH. METHODS All patients treated for non-traumatic SAH between January 2007 and December 2016 in our institution were retrospectively analyzed. After exclusion of patients with anticoagulant or antiplatelet treatment other than phenprocoumon, we analyzed 1040 patients. Thirty-three patients (3%) of those were treated with continuous phenprocoumon. In total, 132 out of all 1007 patients without anticoagulant treatment of the remaining patients were matched as control group (ratio = 1:4). RESULTS Patients with phenprocoumon treatment were significantly older (66.5 years vs. 53.9 years; p < .0001), and admission status was significantly more often poor (66.7% vs. 41.8%, p = .007) compared to all patients without anticoagulant treatment. Further, bleeding pattern and rates of early hydrocephalus did not differ. Matched-pair analysis revealed a significant higher rate of angio-negative SAH in the study group (p = .001). Overall rates of hemorrhagic or thromboembolic complications did not differ (21.4% vs. 18.8%; NS) but were more often fatal, and 30-day mortality rate was significantly higher in the phenprocoumon group than in patients of the matched-pair control group (33% vs. 24%; p < .001). 30% of the phenprocoumon group and 37% of the matched-pair control group reached favorable outcome. However, poor outcome was strong associated with the reason for phenprocoumon treatment. CONCLUSION Patients with phenprocoumon treatment at the time of SAH are significantly older, admission status is worse, and 30-day mortality rates are significantly higher compared to patients without anticoagulant treatment. However, outcome at 6 months did not differ to the matched-pair control group but seems to be strongly associated with the underlying cardiovascular disease. Treatment of these patients is challenging and should be performed on an interdisciplinary base in each individual case. Careful decision-making regarding discontinuation and bridging of anticoagulation and close observation is mandatory.
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Affiliation(s)
- Markus Bruder
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
| | | | - Nina Brawanski
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Fee Keil
- Department of Neuroradiology, Goethe University, Frankfurt am Main, Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
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49
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Akbik F, Waddel H, Jaja BNR, Macdonald RL, Moore R, Samuels OB, Sadan O. Nicardipine Prolonged Release Implants for Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:106020. [PMID: 34365121 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/12/2021] [Accepted: 07/18/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES A paucity of treatments to prevent delayed cerebral ischemia (DCI) has stymied recovery after aneurysmal subarachnoid hemorrhage (aSAH). Nicardipine has long been recognized as a potent cerebrovascular vasodilator with a history off-label use to prevent vasospasm and DCI. Multiple centers have developed nicardipine prolonged release implants (NPRI) that are directly applied during clip ligation to locally deliver nicardipine throughout the vasospasm window. Here we perform a systematic review and meta-analysis to assess whether NPRI confers protection against DCI and improves functional outcomes after aSAH. MATERIALS AND METHODS A systematic search of PubMed, Ovid Embase, and Cochrane databases was performed for studies reporting the use of NPRI after aSAH published after January 1, 1980. We included all studies assessing the association of NPRI with DCI and or functional outcomes. Findings from studies with control arms were analyzed using a random effects model. A separate network meta-analysis was performed, including controlled NPRI studies, single-arm NPRI reports, and the control-arms of modern aSAH randomized clinical trials as additional comparators. RESULTS The search identified 214 unique citations. Three studies with 284 patients met criteria for the random effects model. The pooled summary odds ratio for the association of NPRI and DCI was 0.21 (95% CI 0.09-0.49, p = 0.0002) with no difference in functional outcomes (OR 1.80, 95% CI 0.63 - 5.16, p = 0.28). 10 studies of 866 patients met criteria for the network meta-analysis. The pooled summary odds ratio for the association of NPRI and DCI was 0.30 (95% CI 0.13-0.89,p = 0.017) with a trend towards improved functional outcomes (OR 1.68, 0.63 - 4.13 95% CI, p = 0.101). CONCLUSIONS In these meta-analyses, NPRI decreases the incidence of DCI with a non-significant trend towards improvement in functional outcomes. Randomized trials on the role of intrathecal calcium channel blockers are warranted to evaluate these observations in a prospective manner.
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Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
| | - Hannah Waddel
- Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, GA, USA.
| | | | - R Loch Macdonald
- Department of Neurosurgery, University of California, San Francisco, Fresno, CA, USA.
| | - Renee Moore
- Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, GA, USA.
| | - Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA
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50
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Samuelsson J, Sunila M, Rentzos A, Nilsson D. Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid haemorrhage - neurological and radiological outcome. Neuroradiol J 2021; 35:213-219. [PMID: 34350797 PMCID: PMC8958555 DOI: 10.1177/19714009211036695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives Cerebral vasospasm is a known complication to aneurysmal subarachnoid
haemorrhage, which can lead to severe morbidity. Intra-arterial vasodilation
therapy is widely used as a last resort treatment in patients with
symptomatic refractory cerebral vasospasm but there is limited data about
the outcome. The purpose of this study is to evaluate the neurological and
radiological outcome in patients treated with intra-arterial nimodipine in
relation to cerebral infarction, procedure-related complications and
clinical outcome. Methods Patients with refractory cerebral vasospasm treated with intra-arterial
nimodipine during 2009–2020 at Sahlgrenska University Hospital were
retrospectively reviewed. Neurological outcome (modified Rankin Scale) at 30
days and 6 months, development of cerebral infarction after intra-arterial
nimodipine treatment and procedure-related complications were studied. Results Forty-eight patients were treated with intra-arterial nimodipine. A good
outcome (modified Rankin Scale 0–2) was seen in 25%
(n = 12) of the patients after 30 days and in 47%
(n = 22) of the patients after six months. Infarction
related to the vasospastic vessel after treatment with intra-arterial
nimodipine was seen in 60% (n = 29) of the patients. A
total of 124 procedures with intra-arterial nimodipine were performed where
complications were seen in 10 (21%) patients in 10 (8%) procedures. Four
(8%) patients died within 30 days. Conclusions A majority of patients developed an ischaemic cerebral infarction in spite of
intra-arterial nimodipine treatment. However, a good clinical recovery was
seen in almost half of the patients after 6 months. Minor complications
occurred in one out of five patients.
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Affiliation(s)
- Jennifer Samuelsson
- Institute of Neurosciences and Physiology, Gothenburg University, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Sweden
| | - Merete Sunila
- Institute of Neurosciences and Physiology, Gothenburg University, Sweden
| | - Alexandros Rentzos
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Sweden.,Department of Radiology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Nilsson
- Institute of Neurosciences and Physiology, Gothenburg University, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Sweden
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