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Fung C, Heiland DH, Reitmeir R, Niesen WD, Raabe A, Eyding J, Schnell O, Rölz R, Z Graggen WJ, Beck J. Ultrasound Perfusion Imaging for the Detection of Cerebral Hypoperfusion After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:149-159. [PMID: 35211837 PMCID: PMC9283360 DOI: 10.1007/s12028-022-01460-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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/27/2022] [Indexed: 11/24/2022]
Abstract
Background Delayed cerebral ischemia increases mortality and morbidity after aneurysmal subarachnoid hemorrhage (aSAH). Various techniques are applied to detect cerebral vasospasm and hypoperfusion. Contrast-enhanced ultrasound perfusion imaging (UPI) is able to detect cerebral hypoperfusion in acute ischemic stroke. This prospective study aimed to evaluate the use of UPI to enable detection of cerebral hypoperfusion after aSAH. Methods We prospectively enrolled patients with aSAH and performed UPI examinations every second day after aneurysm closure. Perfusion of the basal ganglia was outlined to normalize the perfusion records of the anterior and posterior middle cerebral artery territory. We applied various models to characterize longitudinal perfusion alterations in patients with delayed ischemic neurologic deficit (DIND) across the cohort and predict DIND by using a multilayer classification model. Results Between August 2013 and December 2015, we included 30 patients into this prospective study. The left–right difference of time to peak (TTP) values showed a significant increase at day 10–12. Patients with DIND demonstrated a significant, 4.86 times increase of the left–right TTP ratio compared with a mean fold change in patients without DIND of 0.9 times (p = 0.032). Conclusions UPI is feasible to enable detection of cerebral tissue hypoperfusion after aSAH, and the left–right difference of TTP values is the most indicative result of this finding.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany. .,Medical Faculty, University of Freiburg, Freiburg, Germany.
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Raluca Reitmeir
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Wolf-Dirk Niesen
- Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jens Eyding
- Department of Neurology, Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke, Herdecke, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Roland Rölz
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Werner J Z Graggen
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
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Lakhal K, Hivert A, Alexandre PL, Fresco M, Robert-Edan V, Rodie-Talbere PA, Ambrosi X, Bourcier R, Rozec B, Cadiet J. Intravenous Milrinone for Cerebral Vasospasm in Subarachnoid Hemorrhage: The MILRISPASM Controlled Before-After Study. Neurocrit Care 2021; 35:669-679. [PMID: 34478028 DOI: 10.1007/s12028-021-01331-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 05/24/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intravenous (IV) milrinone, in combination with induced hypertension, has been proposed as a treatment option for cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, data on its safety and efficacy are scarce. METHODS This was a controlled observational study conducted in an academic hospital with prospectively and retrospectively collected data. Consecutive patients with cerebral vasospasm following aSAH and treated with both IV milrinone (0.5 µg/kg/min-1, as part of a strict protocol) and induced hypertension were compared with a historical control group receiving hypertension alone. Multivariable analyses aimed at minimizing potential biases. We assessed (1) 6-month functional disability (defined as a score between 2 and 6 on the modified Rankin Scale) and vasospasm-related brain infarction, (2) the rate of first-line or rescue endovascular angioplasty for vasospasm, and (3) immediate tolerance to IV milrinone. RESULTS Ninety-four patients were included (41 and 53 in the IV milrinone and the control group, respectively). IV milrinone infusion was independently associated with a lower likelihood of 6-month functional disability (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.10-0.77]) and vasospasm-related brain infarction (aOR = 0.19, 95% CI 0.04-0.94). Endovascular angioplasty was less frequent in the IV milrinone group (6 [15%] vs. 28 [53%] patients, p = 0.0001, aOR = 0.12, 95% CI 0.04-0.38). IV milrinone (median duration of infusion, 5 [2-8] days) was prematurely discontinued owing to poor tolerance in 12 patients, mostly (n = 10) for "non/hardly-attained induced hypertension" (mean arterial blood pressure < 100 mmHg despite 1.5 µg/kg/min-1 of norepinephrine). However, this event was similarly observed in IV milrinone and control patients (n = 10 [24%] vs. n = 11 [21%], respectively, p = 0.68). IV milrinone was associated with a higher incidence of polyuria (IV milrinone patients had creatinine clearance of 191 [153-238] ml/min-1) and hyponatremia or hypokalemia, whereas arrhythmia, myocardial ischemia, and thrombocytopenia were infrequent. CONCLUSIONS Despite its premature discontinuation in 29% of patients as a result of its poor tolerance, IV milrinone was associated with a lower rate of endovascular angioplasty and a positive impact on long-term neurological and radiological outcomes. These preliminary findings encourage the conduction of confirmatory randomized trials.
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Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.
| | - Antoine Hivert
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-Louis Alexandre
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Marion Fresco
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-André Rodie-Talbere
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Xavier Ambrosi
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Julien Cadiet
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
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Frase S, Steimer M, Selzner L, Kaiser S, Foit NA, Niesen WD, Schallner N. Temporal Expression Pattern of Hemoxygenase-1 Expression and Its Association with Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:279-291. [PMID: 34312792 PMCID: PMC8813853 DOI: 10.1007/s12028-021-01299-w] [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] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 06/11/2021] [Indexed: 12/01/2022]
Abstract
Background Red blood cell-induced cerebral inflammation and toxicity has been shown to be attenuated by induction of the heme-catalyzing enzyme, hemoxygenase-1 (HO-1), in animal models of subarachnoid hemorrhage (SAH). Although inflammatory mechanisms leading to secondary neuronal injury in SAH are becoming increasingly well understood, markers of cerebral inflammation have so far not been implemented in clinical prediction models of SAH. Methods In this biomarker observational study, HO-1 messenger ribonucleic acid (mRNA) expression levels were determined in cerebrospinal fluid (CSF) and blood of 66 patients with aneurysmal SAH on days 1, 7, and 14 after the SAH event. HO-1 mRNA expression was determined via real time polymerase chain reaction (PCR), and relative expression changes were quantified in comparison with expression levels in nonhemorrhagic control CSF. Subarachnoid blood burden, as well as presence of vasospasm and delayed cerebral ischemia (DCI), were recorded. Short and long-term clinical outcomes were assessed using the Modified Rankin Scale at discharge and 1 year after the SAH event. Results CSF HO-1 expression levels showed a significant increase over the 14-day observation period (p < 0.001, F = 22.53) and correlated with intracranial hematoma burden (ρ = 0.349, p = 0.025). In multivariate analyses, CSF HO-1 expression levels did not reach significance as independent predictors of outcome. Vasospasm on computed tomographic angiography was associated with lower CSF HO-1 expression levels on day 7 after SAH (n = 53, p = 0.010), whereas patients with DCI showed higher CSF HO-1 expression levels on day 14 after SAH (n = 21, p = 0.009). Conclusions HO-1 expression in CSF in patients with SAH follows a distinct temporal induction pattern and is dependent on intracranial hematoma burden. CSF HO-1 expression was unable to predict functional outcome. Associations of early low HO-1 expression with vasospasm and late elevated HO-1 expression with DCI may point to detrimental effects of late HO-1 induction, warranting the need for further investigation in a larger study population.
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Affiliation(s)
- Sibylle Frase
- Department of Neurology and Neuroscience, Medical Center - University of Freiburg, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Matti Steimer
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Lisa Selzner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Sandra Kaiser
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Niels Alexander Foit
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neuroscience, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Schallner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
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