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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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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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Zaeske C, Zopfs D, Laukamp K, Lennartz S, Kottlors J, Goertz L, Stetefeld H, Hof M, Abdullayev N, Kabbasch C, Schlamann M, Schönfeld M. Immediate angiographic control after intra-arterial nimodipine administration underestimates the vasodilatory effect. Sci Rep 2024; 14:6154. [PMID: 38486099 PMCID: PMC10940303 DOI: 10.1038/s41598-024-56807-7] [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: 06/15/2023] [Accepted: 03/11/2024] [Indexed: 03/18/2024] Open
Abstract
Intra-arterial nimodipine administration is a widely used rescue therapy for cerebral vasospasm. Although it is known that its effect sets in with delay, there is little evidence in current literature. Our aim was to prove that the maximal vasodilatory effect is underestimated in direct angiographic controls. We reviewed all cases of intra-arterial nimodipine treatment for subarachnoid hemorrhage-related cerebral vasospasm between January 2021 and December 2022. Inclusion criteria were availability of digital subtraction angiography runs before and after nimodipine administration and a delayed run for the most affected vessel at the end of the procedure to decide on further escalation of therapy. We evaluated nimodipine dose, timing of administration and vessel diameters. Delayed runs were performed in 32 cases (19 patients) with a mean delay of 37.6 (± 16.6) min after nimodipine administration and a mean total nimodipine dose of 4.7 (± 1.2) mg. Vessel dilation was more pronounced in delayed vs. immediate controls, with greater changes in spastic vessel segments (n = 31: 113.5 (± 78.5%) vs. 32.2% (± 27.9%), p < 0.0001) vs. non-spastic vessel segments (n = 32: 23.1% (± 13.5%) vs. 13.3% (± 10.7%), p < 0.0001). In conclusion intra-arterially administered nimodipine seems to exert a delayed vasodilatory effect, which should be considered before escalation of therapy.
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Affiliation(s)
- Charlotte Zaeske
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany.
| | - David Zopfs
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Kai Laukamp
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Simon Lennartz
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Jonathan Kottlors
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Lukas Goertz
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Marion Hof
- Department of Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Nuran Abdullayev
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Christoph Kabbasch
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Marc Schlamann
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | - Michael Schönfeld
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
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Gotesman RD, Niznick N, Dewar B, Fergusson DA, Mallick R, Shorr R, Shamy M, Dowlatshahi D. The prevalence of non-contrast CT imaging abnormalities in reversible cerebral vasoconstriction syndrome: A systematic review and meta-analysis. PLoS One 2024; 19:e0295558. [PMID: 38466700 PMCID: PMC10927111 DOI: 10.1371/journal.pone.0295558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/24/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a syndrome of recurrent thunderclap headaches and reversible vasoconstriction of the cerebral arteries on neuroimaging within 3 months of onset. Initial non-contrast computed tomography (CT) can reveal abnormalities such as ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage (SAH) can be present in patients with RCVS and may delay diagnosis. AIMS We conducted a systematic review and meta-analysis in accordance with the PRISMA guidelines. We aimed to estimate the prevalence of imaging abnormalities on initial non-contrast CT head in adult patients with RCVS. DATA SOURCES & ELIGIBILITY CRITERIA We searched electronic databases including MEDLINE, EMBASE, and the Cochrane Register of Clinical Trials from inception to August 2, 2022. Eligible studies included articles reporting the prevalence of non-contrast CT abnormalities on initial neuroimaging in patients with RCVS, aged 18 and older. Case series, observational studies and clinical trials were included. Data was extracted directly from included papers using a standardized data charting form. RESULTS The search yielded 722 titles with duplicates removed. Twenty studies that included 379 patients with RCVS met inclusion criteria. We classified non-contrast CT abnormalities as either ischemic stroke, ICH, or SAH. We pooled prevalence data using a random effects model with the inverse-variance weighted method. The most common imaging finding was SAH with a pooled prevalence of 24% (95% CI:17%-33%), followed by ICH at 14% (95% CI:8%-22%), and ischemic stroke at 10% (95% CI:7%-14%). The pooled prevalence of any of these imaging abnormalities on initial non-contrast CT was 31% (95% CI:23%-40%). Risk of bias was moderate to very-high-risk for case-series and low-risk for observational studies. CONCLUSION Our review demonstrates that one-third of patients with RCVS will have an abnormality on initial non-contrast CT head, including either an ischemic stroke, ICH, or SAH. These findings highlight the diagnostic challenges of RCVS imaging and contribute to our understanding of this disease.
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Affiliation(s)
| | - Naomi Niznick
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dean A. Fergusson
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Risa Shorr
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
- The Ottawa Hospital, Ottawa, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
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Heitkamp C, Geest V, Tokareva B, Winkelmeier L, Faizy TD, Meyer L, Kyselyova AA, Meyer HS, Wentz R, Fiehler J, Bester M, Thaler C. CTA Supplemented by CTP Increases Interrater Reliability and Endovascular Treatment Use in Patients with Aneurysmal SAH. AJNR Am J Neuroradiol 2024; 45:284-290. [PMID: 38238090 DOI: 10.3174/ajnr.a8110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/02/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Cerebral vasospasm is a common complication of aneurysmal SAH and remains a risk factor for delayed cerebral ischemia and poor outcome. The interrater reliability of CTA in combination with CTP has not been sufficiently studied. We aimed to investigate the reliability of CTA alone and in combination with CTP in the detection of cerebral vasospasm and the decision to initiate endovascular treatment. MATERIALS AND METHODS This is a retrospective single-center study including patients treated for aneurysmal SAH. Inclusion criteria were a baseline CTA and follow-up imaging including CTP due to suspected vasospasm. Three neuroradiologists were asked to grade 15 intracranial arterial segments in 71 cases using a tripartite scale (no, mild <50%, or severe >50% vasospasm). Raters further evaluated whether endovascular treatment should be indicated. The ratings were performed in 2 stages with a minimum interval of 6 weeks. The first rating included only CTA images, whereas the second rating additionally encompassed CTP images. All raters were blinded to any clinical information of the patients. RESULTS Interrater reliability for per-segment analysis of vessels was highly variable (κ = 0.16-0.61). We observed a tendency toward higher interrater reliability in proximal vessel segments, except for the ICA. CTP did not improve the reliability for the per-segment analysis. When focusing on senior raters, the addition of CTP images resulted in higher interrater reliability for severe vasospasm (κ = 0.28; 95% CI, 0.10-0.46 versus κ = 0.46; 95% CI, 0.26-0.66) and subsequently higher concordance (κ = 0.23; 95% CI, -0.01-0.46 versus κ = 0.73; 95% CI, 0.55-0.91) for the decision of whether endovascular treatment was indicated. CONCLUSIONS CTA alone offers only low interrater reliability in the graduation of cerebral vasospasm. However, using CTA in combination with CTP might help, especially senior neuroradiologists, to increase the interrater reliability to identify severe vasospasm following aneurysmal SAH and to increase the reliability regarding endovascular treatment decisions.
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Affiliation(s)
- Christian Heitkamp
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Geest
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bogdana Tokareva
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna A Kyselyova
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno S Meyer
- Department of Neurosurgery (H.S.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rabea Wentz
- Department of Diagnostic and Interventional Radiology (R.W.), Katholisches Marienkrankenhaus, Hamburg, Germany
| | - Jens Fiehler
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- From the Department of Neuroradiology (C.H., V.G., B.T., L.W., T.D.F., L.M., A.A.K., J.F., M.B., C.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Tokareva B, Meyer L, Heitkamp C, Wentz R, Faizy TD, Meyer HS, Bester M, Fiehler J, Thaler C. Early and recurrent cerebral vasospasms after aneurysmal subarachnoid hemorrhage: The impact of age. Eur Stroke J 2024; 9:172-179. [PMID: 37910182 PMCID: PMC10916818 DOI: 10.1177/23969873231209819] [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: 07/03/2023] [Accepted: 10/07/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Cerebral vasospasms remain a strong predictor of poor outcome after aneurysmal SAH. The aim of this study was to describe the time course of relevant vasospasms after aneurysmal SAH and to determine the variables associated with early-onset or prolonged and recurrent vasospasms. PATIENTS AND METHODS We conducted a retrospective, single-center study of consecutive adult patients with aneurysmal SAH admitted between 2016 and 2022 at our tertiary stroke center. Relevant vasospasms, defined as vessel narrowing detected in DSA in combination with clinical deterioration or new perfusion deficit, were detected according to our in-house algorithm and eventually treated endovascularly. The primary endpoint was the diagnosis of relevant vasospasms. As secondary endpoints, the time from hemorrhage to the onset of vasospasms and the time from the first to the last endovascular intervention were measured. RESULTS Of 368 patients with aneurysmal SAH, 135 (41.0%) developed relevant vasospasms. The median time between ictus and detection of vasospasms was 8 days (IQR: 6-10). Patients with early-onset vasospasms were significantly younger (mean 52.7 ± 11.2 years vs 58.7 ± 11.5 years, p = 0.003) and presented more frequently vasospasm-related infarctions at discharge (58.8% vs 38.7%, p = 0.03). In 74 patients (54.8%), recurrent relevant vasospasms were observed despite endovascular treatment. Younger age and early onset were significantly associated with longer duration of relevant vasospasms (both p < 0.05). DISCUSSION AND CONCLUSION Younger age was associated with early-onset and longer duration of relevant vasospasms in this study. More frequent clinical and diagnostic follow-up should be considered in this subgroup of patients that are at risk for poor outcomes.
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Affiliation(s)
- Bogdana Tokareva
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rabea Wentz
- Department of Diagnostic and Interventional Radiology, Katholisches Marienkrankenhaus, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno S Meyer
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Sowanou A, Ungureanu A, Aguesse C. Recurrent reversible cerebral vasoconstriction syndrome and antiphospholipid syndrome. Acta Neurol Belg 2024; 124:329-334. [PMID: 37392321 DOI: 10.1007/s13760-023-02324-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Arlos Sowanou
- Neurology Department, Centre Hospitalier Alpes-Léman, Contamine Sur Arve, France
| | - Aurelian Ungureanu
- Neurology Department, Centre Hospitalier Alpes-Léman, Contamine Sur Arve, France.
| | - Claire Aguesse
- Neurology Department, Centre Hospitalier Alpes-Léman, Contamine Sur Arve, France
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Connor-Schuler R, Phillips S, Kuo E, Kandiah P, Sadan O. Feasibility and Reliability of Transcranial POCUS Color-Coded Duplex Sonography Performed by Physicians of Varied Ultrasound Experience in Diagnosing Vasospasm in Aneurysmal Subarachnoid Hemorrhage. J Ultrasound Med 2024; 43:315-322. [PMID: 37902179 DOI: 10.1002/jum.16364] [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] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023]
Abstract
PURPOSE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality, which is largely attributable to secondary complications such as vasospasm and subsequent delayed cerebral ischemia. Transcranial Doppler (TCD) is recommended for the screening of vasospasm; however, technicians are not always available. We aimed to see how feasible and reliable bedside transcranial point-of-care ultrasound (POCUS) color-coded duplex sonography was compared with formal non-imaging TCD in measuring velocities and in diagnosing vasospasm. METHODS This was a prospective observational study that took place in the neuroscience intensive care unit at a single academic medical center. Patients with aSAH who were undergoing formal TCDs were scanned on days 2-10 of their admission by physicians of ranging ultrasound experience. Absolute velocities were compared as well as the diagnosis of vasospasm via POCUS and formal TCDs. RESULTS A total of 226 bedside ultrasound exams were performed and compared with 126 formal TCD studies. Sonographic windows were obtained in 89.4% of patients. Scans took 6.6 minutes to complete on average by the advanced group versus 14.5 minutes in the beginner. Correlation ranged from .52 in the beginner group to .65 in the advanced. When good quality of images obtained at a depth of 4-5 cm were reviewed, correlation of mean velocities increased to .96. Overall sensitivity for diagnosing vasospasm was 75%, with a specificity of 99% and negative predictive value of 99%. CONCLUSION Overall, POCUS TCD cannot replace a formal study performed by expert sonographers. An abbreviated POCUS scan can be performed quickly, however, particularly with more experienced operators. POCUS TCD can also feasibly detect vasospasm, and accurate velocities can be obtained by those with all levels of ultrasound experience. Care must be taken on image interpretation that velocities are obtained at an appropriate depth to ensure appropriate insonation of the MCA as well as in optimal alignment with the vessel to obtain the most accurate velocities.
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Affiliation(s)
- Randi Connor-Schuler
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Steven Phillips
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Emory Kuo
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Prem Kandiah
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
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Abbuehl LS, Lippert J, Hakim A. Split-brain syndrome after subarachnoid haemorrhage. BMJ Case Rep 2024; 17:e258538. [PMID: 38272506 PMCID: PMC10826499 DOI: 10.1136/bcr-2023-258538] [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: 01/27/2024] Open
Abstract
We present the case of a patient with extensive ischaemia of the corpus callosum (CC) including all its anatomical subdivisions, caused by a ruptured aneurysm of the anterior cerebral artery (ACA). This resulted in subarachnoid haemorrhage (SAH) and subsequently in cerebral vasospasm. The aneurysm was coiled, the vasospasm treated with repetitive intra-arterial spasmolysis and the patient then received intensive neurorehabilitative care. The case is an example of ischaemic infarction, which happens rarely in the CC after SAH, and even more rarely affects the CC along its entire length. The case is further remarkable for the resulting nearly complete and isolated split-brain syndrome: CC disconnection syndromes are only exceptionally seen after vascular callosal damage because they are most often overshadowed by symptoms resulting from coaffected adjacent brain areas.
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Affiliation(s)
- Lena Simone Abbuehl
- Department of Neurology, University Hospital of Bern, Spital Netz Bern AG, Bern, Bern, Switzerland
| | - Julian Lippert
- Department of Neurology, University Hospital of Bern, Spital Netz Bern AG, Bern, Bern, Switzerland
| | - Arsany Hakim
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, Spital Netz Bern AG, Bern, Bern, Switzerland
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Seok HY, Eun MY, Kim S, Lee JJ, Oh GR, Kim GY, Sohn SI. Reversible cerebral vasoconstriction syndrome in Guillain-Barre syndrome: a case report and literature review. Neurol Sci 2024; 45:101-107. [PMID: 37676373 DOI: 10.1007/s10072-023-07061-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/02/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by transient constriction of cerebral arteries, leading to severe headache and potential complications. The association between RCVS and Guillain-Barre syndrome (GBS) is rare and poorly understood and warrants further investigation. METHODS A detailed case of RCVS in a patient with GBS was presented, followed by a comprehensive literature review. PubMed, Embase, and Google Scholar were searched for relevant cases and studies. RESULTS The case involved a 62-year-old woman with GBS who developed RCVS. The literature review identified three additional reported cases. RCVS in GBS primarily affected middle-aged women and presented with a variety of neurological symptoms. Neuroimaging showed reversible vasoconstriction in the cerebral arteries, along with other complications such as posterior reversible encephalopathy syndrome, subarachnoid hemorrhage, and infarcts. While the treatment for GBS consisted mainly of intravenous immunoglobulin, specific treatments for RCVS remain unclear. CONCLUSIONS The coexistence of RCVS and GBS is a rare occurrence. RCVS in GBS may result from the disruption of cerebral vascular tone regulation, possibly influenced by GBS-related dysautonomia and consequent high blood pressure. Recognizing RCVS in GBS patients is critical for appropriate management.
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Affiliation(s)
- Hung Youl Seok
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Mi-Yeon Eun
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea.
| | - Sohyeon Kim
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jae-Joon Lee
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Gi Ryeong Oh
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Geun Yeong Kim
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sung-Il Sohn
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
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11
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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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12
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Valaparla VL, Banerjee P, Elnaeem A, Sharma T, Bhatt S, Memon Z, Shaltoni H, Dabi A, Rodríguez-Fernández JM. Cerebral vasospasm due to Fusarium solani meningitis: A complication from medical tourism. Case report and literature review. J Stroke Cerebrovasc Dis 2024; 33:107432. [PMID: 37966093 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107432] [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: 08/07/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 11/16/2023] Open
Abstract
OBJECTIVES Medical tourism is expanding globally, with patients seeking cosmetic procedures abroad. To date, little information is known regarding the risks and outcomes of cosmetic tourism, especially potential stroke complications. Here, we present a case of fungal meningitis in the setting of medical tourism leading to ischemic strokes and vasospasm. MATERIAL AND METHODS We describe an immunocompetent 29-year-old female patient who initially presented with intractable headaches and an abnormal cerebrospinal fluid (CSF) profile who was eventually diagnosed with Fusarium solani meningitis as a part of a common source outbreak in Matamoros, Mexico. These patients were part of a cohort who underwent cosmetic procedures requiring spinal anesthesia. This report also highlights the unusual clinical course leading to poor outcomes in such conditions. RESULTS The patient initially presented with headaches, papilledema, elevated opening pressure on the spinal tap, abnormal CSF studies, and eventually developed ischemic strokes and hydrocephalus. CSF showed positive beta D-Glucan with repeated negative CSF fungal cultures. A cerebral angiogram revealed extensive basilar artery vasospasm that led to ischemic strokes. Continued clinical worsening and lack of response to antifungal treatment prompted further imaging that revealed significant non-obstructive hydrocephalus subsequently complicated by spontaneous intracranial hemorrhage. CSF PCR for Fusarium solani species was positive days after her passing. CONCLUSION This novel case highlights fungal meningitis caused by Fusarium solani complicated by bilateral ischemic strokes stemming from basilar artery vasospasm. Complications from medical tourism impact not only individual patients but also the health systems of both countries. Professional and regulatory entities for cosmetic surgeries must highlight and educate patients on the risks and complications of cosmetic surgeries happening abroad. Physicians should be aware of ongoing outbreaks and possible complications of these procedures.
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Affiliation(s)
| | - Pankhuri Banerjee
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Awab Elnaeem
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Tripti Sharma
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Sandeep Bhatt
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Zeeshan Memon
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Hashem Shaltoni
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Alok Dabi
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
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13
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Haedo MG, Grille P, Burghi G, Barbato M. Correlation between tomographic scales and vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. Crit Care Sci 2023; 35:311-319. [PMID: 38133161 PMCID: PMC10734814 DOI: 10.5935/2965-2774.20230119-en] [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] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/07/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To determine the prevalence of sonographic vasospasm and delayed ischemic deficit in patients with aneurysmal subarachnoid hemorrhage, to evaluate the correlation between different tomographic scales and these complications, and to study prognostic factors in this group of patients. METHODS This was a prospective study of patients admitted to the intensive care unit with a diagnosis of aneurysmal subarachnoid hemorrhage. The prevalence of sonographic vasospasm and radiological delayed cerebral ischemia was analyzed, as was the correlation between different tomographic scales and these complications. RESULTS A total of 57 patients were studied. Sixty percent of the patients developed sonographic vasospasm, which was significantly associated with delayed cerebral ischemia and mortality. The Claassen and Hijdra scales were better correlated with the development of cerebral vasospasm (areas under the curve of 0.78 and 0.68) than was Fisher's scale (0.62). Thirty-two patients (56.1%) developed cerebral infarction on CT; the significantly associated factors were poor clinical grade at admission (p = 0.04), sonographic vasospasm (p = 0.008) and severity of vasospasm (p = 0.015). Only the semiquantitative Hijdra scale was significantly correlated with the development of radiological delayed cerebral ischemia (p = 0.009). The patients who presented cerebral infarction had worse neurological evolution and higher mortality. CONCLUSION This is the first study in our environment on the subject. The Claassen and Hijdra tomographic scales showed better prognostic performance than the Fisher scale for the development of cerebral vasospasm. The finding of sonographic vasospasm could be a noninvasive criterion for the early detection of delayed cerebral ischemia and neurological deterioration in patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
| | - Pedro Grille
- Intensive Care Unit, Hospital Maciel, ASSE - Montevideo, Uruguay
| | - Gastón Burghi
- Intensive Care Unit, Hospital Maciel, ASSE - Montevideo, Uruguay
| | - Marcelo Barbato
- Intensive Care Unit, Hospital Maciel, ASSE - Montevideo, Uruguay
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14
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Perez Herrero M, Yamak Altinpulluk E, Galluccio F, Espinoza Morrales K, Pacheco RLJ, Fajardo M. Correspondence on 'Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence' by Bombardieri et al. J Neurointerv Surg 2023; 16:108-109. [PMID: 37137690 DOI: 10.1136/jnis-2023-020449] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Maria Perez Herrero
- Anesthesiology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain, UltraDissection Spain EchoTraining School, Madrid, Spain
| | - Ece Yamak Altinpulluk
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain, UltraDissection Spain EchoTraining School, Madrid, Spain
- Outcomes Research Consortium, Cleveland, Ohio, USA
- Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Felice Galluccio
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain, UltraDissection Spain EchoTraining School, Madrid, Spain
- Fisiotech Lab Studio, Firenze, Italy
| | - Karla Espinoza Morrales
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain, UltraDissection Spain EchoTraining School, Madrid, Spain
- Anesthesia, CAIS of Puriscal, San Jose, Costa Rica
| | - Ruth Liceth Jara Pacheco
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain, UltraDissection Spain EchoTraining School, Madrid, Spain
- Resident of 3 year of Anesthesia, Member of ultradissection, Spain, Madrid
| | - Mario Fajardo
- Director of Morphological Madrid Research Center (MoMaRC), MoMarc, Madrid, Spain
- Director of UltraDissection Group, UltraDissection Spain EchoTraining School, Madrid, Spain
- Anesthesia, Nisa Hospital, Madrid, Spain
- Intertionational school of PhD program, Rey Juan Carlos University, Mostoles, Madrid
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15
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Wang L, Chen L, Jin Y, Cao X, Xue L, Cheng Q. Clinical value of the low-grade inflammation score in aneurysmal subarachnoid hemorrhage. BMC Neurol 2023; 23:436. [PMID: 38082254 PMCID: PMC10712030 DOI: 10.1186/s12883-023-03490-2] [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: 08/07/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND AND PURPOSE Multiple inflammatory biomarkers have been shown to predict symptomatic cerebral vasospasm (SCVS) and poor functional outcome in patients with aneurysmal subarachnoid hemorrhage. However, the impact of the low-grade inflammation (LGI) score, which can reflect the synergistic effects of five individual inflammatory biomarkers on SCVS and poor functional outcome on aneurysmal subarachnoid hemorrhage (aSAH), has not yet been well established. The aim of this study was to evaluate the impact of the LGI score on SCVS and poor functional outcome in aSAH patients. METHODS The LGI score was calculated as the sum of 10 quantiles of each individual inflammatory biomarker. The association of the LGI score with the risk of SCVS and poor functional outcome was analyzed with multivariate logistical regression. RESULTS A total of 270 eligible aSAH patients were included in this study: 74 (27.4%) had SCVS, and 79 (29.3%) had poor functional outcomes. After adjusting for confounders, a higher LGI score was revealed to independently predict SCVS (OR, 1.083; 95% CI, 1.011-1.161; P = 0.024) and poor functional outcome (OR, 1.132; 95% CI, 1.023-1.252; P = 0.016), and the second and third tertile group had higher risk of SCVS than lowest tertile group (OR, 2.826; 95% CI, 1.090-7.327; P = 0.033) (OR, 3.243; 95% CI, 1.258-8.358; P = 0.015). The receiver operating characteristic (ROC) curve uncovered the ability of the LGI score to distinguish patients with and without SCVS (area under the curve [AUC] = 0.746; 95% CI, 0.690-0.797; P < 0.001) and poor functional outcomes (area under the curve [AUC] = 0.799; 95% CI, 0.746-0.845; P < 0.001), the predictive value of LGI on SCVS and poor functional outcome is superior than PLT, NLR and WBC, but there was no statistical difference between LGI and CRP for predicting SCVS (P = 0.567) and poor functional outcome (P = 0.171). CONCLUSIONS A higher LGI which represents severe low grade inflammation status is associated with SCVS and poor functional outcome at 3 months after aSAH.
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Affiliation(s)
- Ling Wang
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ling Chen
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yang Jin
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huaian, Jiangsu, 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 Huai'an No.1 People's Hospital of Nanjing Medical University, Huaian, Jiangsu, China
| | - Qiantao Cheng
- Department of Neurology, Huai' an 82 hospital, Huaian, Jiangsu, China.
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16
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Bombardieri AM, Heit JJ. Response to Correspondence on "Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence" by AL McLean. J Neurointerv Surg 2023; 15:1288. [PMID: 36889916 DOI: 10.1136/jnis-2023-020232] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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17
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Lawson McLean A. Correspondence on 'Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence' by Bombardieri et al. J Neurointerv Surg 2023; 15:1287. [PMID: 36889915 DOI: 10.1136/jnis-2023-020154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Aaron Lawson McLean
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
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18
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Andersen S, Western E, Sorteberg W, Sorteberg A. The impact of pre-ictal statin use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3325-3338. [PMID: 37792050 PMCID: PMC10624707 DOI: 10.1007/s00701-023-05812-2] [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: 05/29/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Pleiotropic effects of statins may be beneficial in alleviating cerebral vasospasm (VS) and improving outcome after aneurysmal subarachnoid hemorrhage (aSAH). Initiation of statin treatment at aSAH is not recommended; however, the effect of pre-ictal and continued statin use is not fully investigated. METHODS Retrospective study comparing aSAH patients admitted in 2012 to 2021 with pre-ictal statin use versus those not using statins. Patient entry variables, radiological/sonological VS, symptomatic VS, and radiologically documented delayed cerebral ischemia (DCI) were registered. Outcome was scored in terms of mortality, modified Rankin score, Glasgow outcome score extended, and levels of fatigue. Patients were compared on group level and in a case-control design. RESULTS We included 961 patients, with 204 (21.2%) statin users. Statin users were older and had more often hypertension. Severe radiological/sonological VS, symptomatic VS, and DCI were less frequent in statin users, and their length of stay was shorter. Mortality, functional outcome, and levels of fatigue were similar in both groups. When analyzing 89 pairs of statin users and non-statin users matched for age, aSAH severity, gender, and hypertension, we confirmed decreased radiological/sonological and symptomatic VS as well as shorter length of stay in statin users. They also had more often a favorable functional outcome and lower levels of fatigue. CONCLUSIONS Patients with pre-ictal and continued use of statins have a reduced occurrence of radiological/sonological and symptomatic VS, shorter length of stay, and more often favorable functional outcome, whereas mortality is similar to non-statin users. Even though larger multicenter studies with common, strict protocols for prevention, diagnosis, and treatment of vasospasm are needed to finally establish the value of statins in aSAH, continuation of pre-ictal statin use seems worthwhile.
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Affiliation(s)
- S Andersen
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway
| | - E Western
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Nydalen, P.B. 4950, 0424, Oslo, Norway
| | - W Sorteberg
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway
| | - A Sorteberg
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway.
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19
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Senger M, Dziedzic TA, Góralska M, Gotlib T, Kunert P. Delayed symptomatic cerebral vasospasm after transsphenoidal resection of pituitary adenoma. Endokrynol Pol 2023; 74:561-562. [PMID: 37779376 DOI: 10.5603/ep.95790] [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] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/12/2023] [Indexed: 10/03/2023]
Abstract
Not required for Clinical Vignette.
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Affiliation(s)
- Michał Senger
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland.
| | | | - Magdalena Góralska
- Department of Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Gotlib
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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20
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Bombardieri AM, Heifets BD, Treggiari M, Albers GW, Steinberg GK, Heit JJ. Cervical sympathectomy to treat cerebral vasospasm: a scoping review. Reg Anesth Pain Med 2023; 48:513-519. [PMID: 36424089 DOI: 10.1136/rapm-2022-103999] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND/IMPORTANCE Delayed cerebral ischemia (DCI) is the second-leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (aSAH), and is associated with cerebral arterial vasospasm (CAV). Current treatments for CAV are expensive, invasive, and have limited efficacy. Cervical sympathetic block (CSB) is an underappreciated, but potentially highly effective therapy for CAV. OBJECTIVE To provide a comprehensive review of the preclinical and human literature pertinent to CSB in the context of CAV. EVIDENCE REVIEW This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a literature search using Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science until February 2022, to identify abstracts, conference proceedings, and full-text papers pertinent to cervical sympathectomy and CAV in animal/adult patients. FINDINGS We included six human and six experimental studies. Human studies were mostly prospective observational, except one retrospective and one randomized clinical trial, and used various imaging modalities to measure changes in arterial diameter after the block. Studies that used digital subtraction angiography showed an improvement in cerebral perfusion without change in vessel diameter. Transcranial Doppler studies found an approximately 15% statistically significant decrease in velocities consistent with arterial vasodilatation. Overall, the results suggest an increase in cerebral arterial diameter and neurological improvement in patients receiving a CSB. Animal studies demonstrate that sympathetic system ablation vasodilates cerebral vasculature and decreases the incidence of symptomatic vasospasm. CONCLUSIONS This scoping review suggests that CSB may be a viable option for treatment and prevention of CAV/DCI in patients with aSAH, although the included studies were heterogeneous, mostly observational, and with a small sample size. Further research is needed to standardize the technique and prove its effectiveness to treat patients suffering of CAV/DCI after aSAH.
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Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Boris D Heifets
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Treggiari
- Anesthesiology and Perioperative Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregory W Albers
- Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Stanford University School of Medicine, Stanford, California, USA
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21
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Yassin A, Al-Mistarehi AH, Tremont-Lukats IW, El-Salem K, Shawagfeh A, Al-Hafez B, Levine N. Acute diffuse cerebral vasospasm as a complication of endoscopic resection of a colloid cyst: a case report. Br J Neurosurg 2023; 37:1362-1366. [PMID: 32955376 DOI: 10.1080/02688697.2020.1820946] [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: 05/03/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endoscopic resection can be used for removing colloid cysts as a substitute for open craniotomy. Cerebral vasospasm, a possible complication of the craniotomy procedure, has not been reported as a complication of endoscopic removal of colloid cysts. CASE DESCRIPTION A 58-year-old man developed the worst headache of his life. The CT and MRI showed a 1.3 cm midline third ventricular cyst at the level of the foramen of Monro, consistent with a colloid cyst. The patient elected to undergo an endoscopic resection of the colloid cyst. The image-guided frameless stereotactic endoscopic colloid cyst resection proceeded without events. Postoperative MRI showed a gross total resection. The patient continued to improve until post-operative day #9 when he experienced an episode of slurred speech and several episodes of legs buckling. An MRI did not show a stroke. A CT angiogram showed diffuse vasospasm, including the basilar artery and bilateral middle cerebral arteries, when compared to the patient's preoperative MRA. The patient's antihypertensive medications were stopped. The patient was started on Nimodipine, 60 mg every 4 hours, and triple H therapy (Hypertension, Hypervolemia, and Hemodilution) was applied. His blood pressure rose and his neurologic exam improved over several days. The patient returned to his baseline in 14 days without any neurological deficits. To our knowledge, this is the first case report of a patient undergoing endoscopic colloid cyst resection that was complicated by diffuse cerebral vasospasm. CONCLUSIONS We report the first case of acute, transient cerebral vasospasm following endoscopic resection of a colloid cyst.
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Affiliation(s)
- Ahmed Yassin
- Division of Neurology, Department of Neurosciences, Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Abdel-Hameed Al-Mistarehi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Ivo W Tremont-Lukats
- Department of Neurosurgery and the Kenneth R. Peak Brain and Pituitary Treatment Center, Houston Methodist Hospital, Houston, TX, USA
| | - Khalid El-Salem
- Division of Neurology, Department of Neurosciences, Faculty of Medicine, Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Ahmad Shawagfeh
- Plummer Movement Disorders Center, Baylor Scott and White Clinics, Temple, TX, USA
| | - Baraa Al-Hafez
- Department of Neurosurgery, University of Texas, Memorial Hermann Southeast Hospital, 18955 Memorial N, Humble, TX, USA
| | - Nicholas Levine
- Department of Neurosurgery, University of California San Francisco, 155 N Fresno St, Fresno, CA, USA
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Qoorchi Moheb Seraj F, Mirbolouk MH, Vaezi M, Ebrahimnia F, Gorji R, Najafi S, Pahlavan Shamsi H, Sadeghian Shahi A, Sasannejad P, Zabihyan S, Mowla A, Kheradmand D, Baharvahdat H. Safety of dual antiplatelet therapy in the acute phase of aneurysmal subarachnoid hemorrhage: a propensity score-matched study. Neurosurg Focus 2023; 55:E10. [PMID: 37778032 DOI: 10.3171/2023.7.focus23376] [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: 06/01/2023] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE With the evolution of neuroendovascular treatments, there is a great trend to treat acutely ruptured wide-necked aneurysms with stent-assisted coiling (SAC) and flow diverters (FDs), which inevitably requires dual antiplatelet therapy (DAPT). This therapy can increase the rate of hemorrhagic complications following other neurosurgical maneuvers, such as external ventricular drain (EVD) placement or removal. In this study, the authors aimed to evaluate the safety of DAPT in patients with aneurysmal subarachnoid hemorrhage (SAH) treated with SAC or FDs and the therapy's potential benefit in reducing cerebral ischemia and cerebral vasospasm. METHODS In this retrospective study, the authors reviewed the records of patients who had been admitted to their hospital with acute aneurysmal SAH and treated with SAC, FDs, and/or coiling between 2012 and 2022. Patients were classified into two groups: a DAPT group, including patients who had received DAPT for SAC or FDs, and a non-DAPT group, including patients who had not received any antiplatelet regimen and had been treated with coiling. Perioperative hemorrhagic and ischemic complications and clinical outcomes were compared between the two groups. RESULTS From among 938 cases of acute ruptured aneurysms treated during 10 years of study, 192 patients were included in this analysis, with 96 patients in each treatment group, after propensity score matching. All basic clinical and imaging characteristics were equivalent between the two groups except for the neck size of aneurysms (p < 0.001). EVD-related hemorrhage was significantly higher in the DAPT group than in the non-DAPT group (p = 0.035). In most patients, however, the EVD-related hemorrhage was insignificant. Parent artery or stent-induced thrombosis was higher in the DAPT group than in the non-DAPT group (p = 0.003). The rate of cerebral ischemia was slightly lower in the DAPT group than in the non-DAPT group (11.5% vs 15.6%, p = 0.399). In the multivariate analysis, cerebral ischemia, rebleeding before securing the aneurysm, extracranial hemorrhage, and cerebral vasospasm were the predictive factors of a poor clinical outcome (p < 0.001, p < 0.001, p = 0.038, and p = 0.038, respectively). CONCLUSIONS The DAPT regimen may be safe in the setting of acute aneurysmal SAH. Although EVD-related hemorrhage is more common in the DAPT group than the non-DAPT group, it is usually insignificant without any neurological deficit.
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Affiliation(s)
- Farid Qoorchi Moheb Seraj
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Hossein Mirbolouk
- 2Department of Neurosurgery, Firouzgar Hospital, Iran University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Marjan Vaezi
- 2Department of Neurosurgery, Firouzgar Hospital, Iran University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Feizollah Ebrahimnia
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Gorji
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajjad Najafi
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- 3Department of Neurosurgery, Emam Hospital, Mazandaran University of Medical Sciences, School of Medicine, Sari, Iran
| | - Hashem Pahlavan Shamsi
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Sadeghian Shahi
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Payam Sasannejad
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Zabihyan
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ashkan Mowla
- 4Department of Neurological Surgery, Division of Stroke and Endovascular Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Daniel Kheradmand
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Humain Baharvahdat
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- 1Neurosurgical Department, Neurovascular Section, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- 5Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
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Pinto MJ, Schon M, Sousa JA, Filipe J, Costa A, Azevedo E, Sargento-Freitas J, Silva F, Fonseca AC, Castro P. Ultrasonographic Vasospasm and Outcome of Posterior Reversible Encephalopathy and Cerebral Vasoconstriction Syndromes. Ultraschall Med 2023; 44:487-494. [PMID: 37832534 DOI: 10.1055/a-2127-9459] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are often complicated by vasospasm and ischemia. Monitoring with transcranial color-coded Doppler (TCCD) could be useful, but its role is not established. We studied the incidence of ultrasonographic vasospasm (uVSP) in PRES/RCVS and its relationship with ischemic lesions and clinical outcome. MATERIALS AND METHODS We conducted a multicenter retrospective study of all patients with PRES/RCVS from 2008 to 2020 who underwent TCCD and magnetic resonance imaging (MRI). TCCD exams were analyzed for uVSP. Diffusion-weighted MRI was analyzed for positive lesions (DWI-positive). Functional outcome was assessed by modified Rankin scale (mRS) at 90 days. The associations with outcomes were determined by logistic regression. RESULTS We included 80 patients (mean age of 46 (standard deviation, 17) years; 66% females; 41 with PRES, 28 with RCVS and 11 with overlap phenotype). uVSP was detected in 25 (31%) patients. DWI-positive lesions were more often detected in uVSP-positive than uVSP-negative patients (36% vs. 15%; adjusted odds ratio [aOR] 4.05 [95% CI 1.06 - 15.5], P=0.04). DWI-positive lesions were independently associated with worse functional prognosis (mRS 2-6, 43% vs. 10%; aOR, 10 [95% CI 2.6 - 43], P<0.01). Having additional uVSP further increased the odds of a worse outcome (P interaction=0.03). CONCLUSION Ultrasonographic vasospasm was detected in a third of patients with PRES/RCVS and was associated with brain ischemic lesions. TCCD bedside monitoring can help to stratify patients at risk for cerebral ischemia, a strong predictor of functional outcome.
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Affiliation(s)
- Maria João Pinto
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Miguel Schon
- Department of Neurology, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
| | - João André Sousa
- Department of Neurology, Universidade de Coimbra Faculdade de Medicina, Coimbra, Portugal
| | - João Filipe
- Neuroradiology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Andreia Costa
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, University of Porto Faculty of Medicine, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, University of Porto Faculty of Medicine, Porto, Portugal
- Cardiovascular Research and Development Unit, University of Porto Faculty of Medicine, Porto, Portugal
| | - João Sargento-Freitas
- Department of Neurology, Universidade de Coimbra Faculdade de Medicina, Coimbra, Portugal
| | - Fernando Silva
- Department of Neurology, Universidade de Coimbra Faculdade de Medicina, Coimbra, Portugal
| | - Ana Catarina Fonseca
- Department of Neurology, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
- IMM, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
| | - Pedro Castro
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, University of Porto Faculty of Medicine, Porto, Portugal
- Cardiovascular Research and Development Unit, University of Porto Faculty of Medicine, Porto, Portugal
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Abdulazim A, Heilig M, Rinkel G, Etminan N. Diagnosis of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage and Triggers for Intervention. Neurocrit Care 2023; 39:311-319. [PMID: 37537496 PMCID: PMC10542310 DOI: 10.1007/s12028-023-01812-3] [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: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a major determinant for poor neurological outcome after aneurysmal subarachnoid hemorrhage (aSAH). Detection and treatment of DCI is a key component in the neurocritical care of patients with aSAH after initial aneurysm repair. METHODS Narrative review of the literature. RESULTS Over the past 2 decades, there has been a paradigm shift away from macrovascular (angiographic) vasospasm as a main diagnostic and therapeutic target. Instead, the pathophysiology of DCI is hypothesized to derive from several proischemic pathomechanisms. Clinical examination remains the most reliable means for monitoring and treatment of DCI, but its value is limited in comatose patients. In such patients, monitoring of DCI is usually based on numerous neurophysiological and/or radiological diagnostic modalities. Catheter angiography remains the gold standard for the detection of macrovascular spasm. Computed tomography (CT) angiography is increasingly used instead of catheter angiography because it is less invasive and may be combined with CT perfusion imaging. CT perfusion permits semiquantitative cerebral blood flow measurements, including the evaluation of the microcirculation. It may be used for prediction, early detection, and diagnosis of DCI, with yet-to-prove benefit on clinical outcome when used as a screening modality. Transcranial Doppler may be considered as an additional noninvasive screening tool for flow velocities in the middle cerebral artery, with limited accuracy in other cerebral arteries. Continuous electroencephalography enables detection of early signs of ischemia at a reversible stage prior to clinical manifestation. However, its widespread use is still limited because of the required infrastructure and expertise in data interpretation. Near-infrared spectroscopy, a noninvasive and continuous modality for evaluation of cerebral blood flow dynamics, has shown conflicting results and needs further validation. Monitoring techniques beyond neurological examinations may help in the detection of DCI, especially in comatose patients. However, these techniques are limited because of their invasive nature and/or restriction of measurements to focal brain areas. CONCLUSION The current literature review underscores the need for incorporating existing modalities and developing new methods to evaluate brain perfusion, brain metabolism, and overall brain function more accurately and more globally.
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Affiliation(s)
- Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Marina Heilig
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Gabriel Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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25
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Kim Y, Mehta A, Nair R, Felbaum DR, Mai JC, Armonda RA, Chang JJ. The TCD hyperemia index to detect vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neuroimaging 2023; 33:725-730. [PMID: 37291461 DOI: 10.1111/jon.13132] [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: 11/30/2022] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND PURPOSE Elevated mean flow velocity (MFV) on transcranial Doppler (TCD) is used to predict vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Hyperemia should be considered when observing elevated MFV. Lindegaard ratio (LR) is commonly used but does not enhance predictive values. We introduce a new marker, the hyperemia index (HI), calculated as bilateral extracranial internal carotid artery MFV divided by initial flow velocity. METHODS We evaluated SAH patients hospitalized ≥7 days between December 1, 2016 and June 30, 2022. We excluded patients with nonaneurysmal SAH, inadequate TCD windows, and baseline TCD obtained after 96 hours from onset. Logistic regression was conducted to assess the significant associations of HI, LR, and maximal MFV with vasospasm and delayed cerebral ischemia (DCI). Receiver operating characteristic analyses were employed to find the optimal cutoff value for HI. RESULTS Lower HI (odds ratio [OR] 0.10, 95% confidence interval [CI] 0.01-0.68), higher MFV (OR 1.03, 95% CI 1.01-1.05), and LR (OR 2.02, 95% CI 1.44-2.85) were associated with vasospasm and DCI. Area under the curve (AUC) for predicting vasospasm was 0.70 (95% CI 0.58-0.82) for HI, 0.87 (95% CI 0.81-0.94) for maximal MFV, and 0.87 (95% CI 0.79-0.94) for LR. The optimal cutoff value for HI was 1.2. Combining HI <1.2 with MFV improved positive predictive value without altering the AUC value. CONCLUSIONS Lower HI was associated with a higher likelihood of vasospasm and DCI. HI <1.2 may serve as a useful TCD parameter to indicate vasospasm and DCI when elevated MFV is observed, or when transtemporal windows are inadequate.
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Affiliation(s)
- Yongwoo Kim
- Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amit Mehta
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Reshmi Nair
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jason J Chang
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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26
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Youm JY, Park B, Park KH, Il Won Y, Byoun HS, Lim J. Vasodilatory effects of tadalafil in an animal model of cerebral vasospasm: Comparative analysis with oral nimodipine. Clin Neurol Neurosurg 2023; 232:107857. [PMID: 37423086 DOI: 10.1016/j.clineuro.2023.107857] [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: 04/19/2023] [Revised: 06/04/2023] [Accepted: 06/24/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the most fatal complications after spontaneous aneurysmal subarachnoid hemorrhage. Although various treatments have been tried for the treatment of cerebral vasospasm so far, the effect is insignificant or temporary except for oral nimodipine. Phosphodiesterase isozyme type 5 inhibitor, which is used to treat erection dysfunction, recently has been known to have a cerebrovascular vasodilation. It is thought that this will be effective in cerebral vasospasm, and the effect will be compared and analyzed with oral nimodipine through an animal model of cerebral vasospasm. MATERIAL AND METHODS A total of 40 rabbits were used to make subarachnoid hemorrhage model and were divided into three groups - a control group, nimodipine group, and tadalafil group. The cerebral vessels were angiographically measured before and on the third day of subarachnoid hemorrhage. Then vertebrobasilar arteries were harvested and evaluated. Under the microscope, lumen area and media area were measured for each group and were compared. RESULTS Angiographically, tadalafil group showed significant vasodilation compared with the control group (p < 0.01). Histologically, tadalafil showed a similar effect on lumen and on media area to that of nimodipine group compared with the control group. CONCLUSIONS Cerebral vasospasm could leave neurologic deficit or sequelae even after proper treatment. Therefore, prevention is important. Tadalafil showed preventive effect against cerebral vasospasm and vasodilative effect similar to that of nimodipine. Therefore, tadalafil could be considered an alternative preventive treatment of cerebral vasospasm.
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Affiliation(s)
- Jin-Young Youm
- Department of Neurosurgery, Chungnam National University Hospital, 640, Munwharo 282, Daejeon 35015, South Korea.
| | - Bumsoo Park
- Department of Neurosurgery, Chungnam National University Sejong Hospital, 20, Bodeum 7Ro, Sejong, 30099, South Korea.
| | - Kwang Hyon Park
- Department of Neurosurgery, Chungnam National University Sejong Hospital, 20, Bodeum 7Ro, Sejong, 30099, South Korea.
| | - Young Il Won
- Department of Neurosurgery, Chungnam National University Sejong Hospital, 20, Bodeum 7Ro, Sejong, 30099, South Korea.
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Sejong Hospital, 20, Bodeum 7Ro, Sejong, 30099, South Korea.
| | - Jeongwook Lim
- Department of Neurosurgery, Chungnam National University Sejong Hospital, 20, Bodeum 7Ro, Sejong, 30099, South Korea.
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27
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Goto J, Abe Y, Watanabe S. Sudden-onset headache due to reversible cerebral vasoconstriction syndrome. Neurol Sci 2023; 44:3355-3356. [PMID: 37217744 PMCID: PMC10415423 DOI: 10.1007/s10072-023-06863-0] [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: 03/10/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by reversible segmental vasoconstriction of the cerebral arteries that spontaneously resolve within 3 months. Occurrence of RCVS peaks at around 40 years and the syndrome is common in women. Here, we report an adolescent boy case of RCVS.
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Affiliation(s)
- Jion Goto
- Showa University School of Medicine, Tokyo, Japan
| | - Yoshifusa Abe
- Children's Medical Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.
| | - Shuichiro Watanabe
- Children's Medical Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
- Watanabe Children's Clinic, Tokyo, Japan
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28
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Salem MM, Khalife J, Desai S, Sharashidze V, Badger C, Kuhn AL, Monteiro A, Salahuddin H, Siddiqui AH, Singh J, Levy EI, Lang M, Grandhi R, Thomas AJ, Lin LM, Tanweer O, Burkhardt JK, Puri AS, Gross BA, Nossek E, Hassan AE, Shaikh HA, Jankowitz BT. COManeci MechANical Dilation for vasospasm (COMMAND): multicenter experience. J Neurointerv Surg 2023; 15:864-870. [PMID: 36002289 DOI: 10.1136/jnis-2022-019272] [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: 06/13/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND We report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm. METHODS Consecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020-2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up. RESULTS A total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3-4) to post-treatment (0-2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0-2) was noted in 51.5% of patients (median follow-up 6 months). CONCLUSIONS The Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Sohum Desai
- Department of Neuroscience, Valley Baptist Medical Center, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas, USA
| | - Vera Sharashidze
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
| | - Clint Badger
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Anna L Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Andre Monteiro
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Medical Center, Lancaster, California, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jasmeet Singh
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Li-Mei Lin
- Carondelet Neurological Institute, Carondelet Health Network, Tucson, Arizona, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erez Nossek
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
| | - Ameer E Hassan
- Department of Neuroscience, Valley Baptist Medical Center, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas, USA
| | - Hamza A Shaikh
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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Sawamura M, Ogawa M. Lomerizine Improved Bath-related Headache Presenting as Reversible Cerebral Vasoconstriction Syndrome. Intern Med 2023; 62:2445. [PMID: 36631090 PMCID: PMC10484761 DOI: 10.2169/internalmedicine.0545-22] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/24/2022] [Indexed: 01/13/2023] Open
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30
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Wolfert C, Maurer CJ, Sommer B, Steininger K, Motov S, Bonk MN, Krauss P, Berlis A, Shiban E. Management of perimesencephalic nonaneurysmal subarachnoid hemorrhage: a national survey. Sci Rep 2023; 13:12805. [PMID: 37550334 PMCID: PMC10406943 DOI: 10.1038/s41598-023-39195-2] [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: 01/14/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023] Open
Abstract
Perimesencephalic nonaneurysmal subarachnoid hemorrhage (NASAH) is a rare type of subarachnoid hemorrhage (SAH), usually associated with minor complications compared to aneurysmal SAH. Up to date, data is scarce and consensus on therapeutic management and follow-up diagnostics of NASAH is often missing. This survey aims to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding.
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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
| | - Björn Sommer
- Department of Neurosurgery, 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
| | - Maximilian-Niklas Bonk
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Philipp Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Ansgar Berlis
- Department of Neuroradiology, 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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Merli N, Padroni M, Azzini C, Bernardoni A, Marcialis C, Tugnoli V, Inchingolo V, Pugliatti M. Reversible cerebral vasoconstriction syndrome: strategies to early diagnosis and the role of transcranial color-coded doppler ultrasonography (TCCD). Neurol Sci 2023; 44:2541-2545. [PMID: 37014565 PMCID: PMC10257625 DOI: 10.1007/s10072-023-06755-3] [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: 02/15/2023] [Accepted: 03/08/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular transitory condition characterized by severe headache, possible concomitant acute neurological symptoms, evidence of diffuse multifocal segmental constriction of cerebral arteries, and usually spontaneously resolving within 3 months. Putative causes and/or precipitating factors are vasoactive drugs-e.g., antidepressants, α-sympathomimetics, triptans-post-partum, and immunosuppressants. CASE PRESENTATION We report the case of a middle-aged woman referred to the emergency room (ER) with a 7-day long intense headache and vomit. Cerebral non-contrast computed tomography (CT) was negative for acute ischemic lesions or intracranial bleedings. She was again referred to ER 7 days later with additional fluctuating episodes of weakness in left arm and both lower limbs. A new brain CT was negative. Due to worsening headache, a transcranial color-coded Doppler (TCCD) was performed, which showed diffuse multifocal blood flow acceleration in all principal intracranial vessels, and particularly on the right hemisphere. These findings were subsequently confirmed at MR angiogram and digital subtraction angiography. CONCLUSION TCCD imaging is a non-invasive and relatively inexpensive tool which provides real-time information on cerebrovascular function, blood flow velocities, and hemodynamic changes. TCCD may be a powerful tool in the early detection of acute infrequent cerebrovascular conditions, as well as in monitoring their course and the therapeutic response.
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Affiliation(s)
- Nicola Merli
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Marina Padroni
- Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
| | - Cristiano Azzini
- Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
| | - Andrea Bernardoni
- Department of Radiology, S. Anna University Hospital, Ferrara, Italy
| | - Carla Marcialis
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Valeria Tugnoli
- Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy
- Interdepartmental Research Center for Multiple Sclerosis and Other Inflammatory and Degenerative Disorders of the Nervous System, University of Ferrara, Ferrara, Italy
| | - Vincenzo Inchingolo
- Neurology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Interdepartmental Research Center for Multiple Sclerosis and Other Inflammatory and Degenerative Disorders of the Nervous System, University of Ferrara, Ferrara, Italy
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32
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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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Kumar N, Kumar S, Rocha E, Lioutas VA. Vasoconstriction and long-term headache in reversible cerebral vasoconstriction syndrome. J Neurol 2023; 270:1647-1653. [PMID: 36471097 DOI: 10.1007/s00415-022-11511-2] [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: 09/15/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiographic vasoconstriction in reversible cerebral vasoconstriction syndrome (RCVS) is often undetectable at symptom onset and the diagnosis relies on clinical presentation. Although thunderclap headache is a hallmark feature of RCVS, the incidence and predictors of long-term headaches (LTH) are incompletely understood. Our study aims were twofold: to examine the sensitivity and specificity of a recently developed score (RCVS2) for vasoconstriction detection in a real-world clinical context and describe the incidence and predictors of LTH beyond the acute phase of RCVS. METHODS Retrospective analysis of consecutive patients with clinical diagnosis of RCVS in a tertiary hospital between 2017 and 2021. We examined associations between demographic factors, comorbidities, medications, imaging characteristics, and LTH (defined as at least one episode present at greater than 6-months follow-up necessitating medication). We separately examined the association between RCVS2 score and angiographic vasoconstriction and computed its sensitivity, specificity, and negative and positive predictive value based on established cutoffs (certain ≥ 5, negative ≤ 2). RESULTS We included 55 patients, 50.5 (± 13.7) years; 41 (75%) female. 25 (49%) patients had LTH; only prior history of headache was significantly associated with LTH [OR 4.3, 95% CI (1.1-16.2), p = 0.03]. We found a significant association between RCVS2 score and angiographic vasoconstriction [OR 1.49, 95% CI (1.18-1.88), p = 0.001]; sensitivity, specificity, and positive and negative predictive value were 64%, 94%, 95% and 58% respectively. CONCLUSIONS Approximately 50% of RCVS patients experienced LTH; only prior headache history was associated with its incidence. The RCVS2 score had a significant association with high specificity and positive predictive value for angiographic vasoconstriction in our cohort, validating its utility in improving the accuracy of diagnosis in the clinical setting.
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Affiliation(s)
- Neha Kumar
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Eva Rocha
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
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Morishita M, Endo H, Asayama B, Kamiyama K, Nakamura H. Hyperintense vessel sign on magnetic resonance imaging at the time of presentation in reversible cerebral vasoconstriction syndrome. Clin Neurol Neurosurg 2023; 228:107705. [PMID: 37004476 DOI: 10.1016/j.clineuro.2023.107705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Masahiro Morishita
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan.
| | - Hideki Endo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan.
| | - Bunsho Asayama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan.
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan.
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan.
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Khawaja AM, McNulty J, Thakur UV, Chawla S, Devi S, Liew A, Mirshahi S, Du R, Mekary RA, Gormley W. Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 46:3. [PMID: 36471088 DOI: 10.1007/s10143-022-01913-1] [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] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18 years with aSAH for radiographic vasospasm detection. The DerSimonian-Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR -). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68-91%) and a specificity of 97% (95%CI, 93-98%), while TCD had lower sensitivity 38% (95%CI, 19-62%) and specificity of 91% (95%CI, 87-94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR - for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR - than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR - , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, Wayne State University, Detroit, MI, 48201, USA
| | - Jack McNulty
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
| | | | - Shreya Chawla
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Sharmila Devi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shervin Mirshahi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA.
- School of Pharmacy, MCPHS University, Boston, MA, USA.
| | - William Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Hernández-Hernández MA, Cherchi MS, Torres-Díez E, Orizaola P, Martín-Láez R, Fernández-Torre JL. Bispectral index monitoring to detect delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2022; 72:154154. [PMID: 36152563 DOI: 10.1016/j.jcrc.2022.154154] [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: 03/11/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Evaluate the bispectral index (BIS) monitoring to detect delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). MATERIALS AND METHODS A single-center prospective study in patients with aSAH. BIS monitoring was recorded during 25-120 min in two periods, within the initial 72 h (BIS1) and between days 4 and 6 (BIS2) from admission. The median for each exported BIS parameter was analyzed. Transcranial Doppler (TCD) sonography was simultaneously performed with BIS1 (TCD1) and BIS2 (TCD2) monitoring. A multivariate logistic regression model was built to identify the variables associated with DCI. RESULTS Sixty-four patients were included and 16 (25%) developed DCI. During BIS2 monitoring, significant differences were found in BIS value (left, p = 0.01; right, p = 0.009), 95% spectral edge frequency (left and right, p = 0.04), and total power (left and right, p = 0.04). In multivariable analysis, vasospasm on TCD2 (OR 42.8 [95% CI 3.1-573]; p = 0.005), a median BIS2 value <85 in one or both sides (OR 6.2 [95% CI 1.28-30]; p = 0.023), and age (OR 1.08 [95% CI 1.00-1.17]; p = 0.04) were associated with the development of DCI. CONCLUSIONS BIS value is the most useful BIS parameter for detecting DCI after aSAH. Pending further validation, BIS monitoring might be even more accurate than TCD.
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Affiliation(s)
- Miguel A Hernández-Hernández
- Department of Intensive Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Marina S Cherchi
- Department of Intensive Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Biomedical Research Institute (IDIVAL), Santander, Spain.
| | - Eduardo Torres-Díez
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Pedro Orizaola
- Department of Clinical Neurophysiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Rubén Martín-Láez
- Biomedical Research Institute (IDIVAL), Santander, Spain; Department of Neurosurgery and Surgical Spine Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José L Fernández-Torre
- Biomedical Research Institute (IDIVAL), Santander, Spain; Department of Clinical Neurophysiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Department of Physiology and Pharmacology, University of Cantabria (UNICAN), Santander, Spain
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Ikuta G, Makino K, Takamatsu K, Takada A, Wada K, Hashimoto Y. [Subdural hematoma with reversible cerebral vasoconstriction syndrome: a case report]. Rinsho Shinkeigaku 2022; 62:732-735. [PMID: 36031380 DOI: 10.5692/clinicalneurol.cn-001766] [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: 06/15/2023]
Abstract
A 71-year-old man had persistent cervical pain secondary to thunderclap headache during sleep. MRI conducted the next morning revealed subdural hematoma and convexity subdural hemorrhage on the right occipital region, and the patient was hospitalized. MRA showed vascular narrowing in the bilateral PCA. Follow-up MRA on day 8 of admission showed aggravated vascular narrowing of PCA, indicative of reversible cerebral vasoconstriction syndrome (RCVS). The patient was treated with a calcium-channel antagonist. Post-discharge MRA showed improvement of PCA narrowing, and the diagnosis of RCVS was confirmed.
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Affiliation(s)
- Genki Ikuta
- Department of Neurosurgery, Kumamoto City Hospital
| | | | | | - Akira Takada
- Department of Neurosurgery, Kumamoto City Hospital
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Li J, Zhou K, Wang L, Cao Q. Predictive Model of Cerebral Vasospasm in Subarachnoid Hemorrhage Based on Regression Equation. Scanning 2022; 2022:3397967. [PMID: 35581969 PMCID: PMC9064499 DOI: 10.1155/2022/3397967] [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] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/26/2022] [Accepted: 04/01/2022] [Indexed: 06/15/2023]
Abstract
In order to explore the regression equation for the prediction model of subarachnoid hemorrhage and cerebral vasospasm, the nomogram prediction model of SCVS occurrence was established. This study is a retrospective analysis of 125 cases of aSAH admitted to a hospital; the patients were divided into SCVS group and non-SCVS group. Select SIRI as a simple and reliable marker of inflammation, analyze its correlation with SCVS and its predictive value, and analyze the predictive value of SIRI to SCVS through ROC curve. Based on the SIRI inflammation level and other related risk factors, a nomogram prediction model for the occurrence of SCVS was built. The experimental results show that the SIRI level of patients in the SCVS group was significantly higher than that of the non-SCVS group, and logistic regression analysis found that SIRI is an independent risk factor for SCVS. SIRI = 3.63 × 109/L is the best cutoff value for diagnosing the occurrence of SCVS. When TC = 2.24 mmol/L and SIRI = 3.63 × 10%/L, its Youden Index is the largest (0.312, 0.296) and is the best cutoff value for predicting the occurrence of SCVS; at the same time, its prediction accuracy (area under the ROC curve (AUC)), sensitivity, specificity, the positive predictive value, and negative predictive value are 0.743, 72.70%, 80.10%, 77.53%, and 94.24% and 0.725, 70.60%, 76.90%, 73.49%, and 93.59%. Nomogram prediction model establishment and evaluation combined with the results of multifactor analysis are used to build an individual nomogram prediction model. The model has good prediction consistency (C-index = 0.685, P < 0.01). ROC analysis results showed that the model that combined SIRI and other standard variables (AUC = 0.896, 95% CI was 0.803-0.929, P < 0.001) was better than the model that did not combine SIRI (AUC = 0.859, 95% CI was 0.759-0.912, P < 0.001) and the model based only on SIRI (AUC = 0.725, 95% CI was 0.586-0.793, P = 0.001) has better predictive value for SCVS. Joint SIRI will optimize the prediction performance of the nomogram model and improve the early recognition and screening capabilities of SCVS.
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Affiliation(s)
- Jianzhong Li
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, 100176, China
| | - Kaiguo Zhou
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, 100176, China
| | - Lei Wang
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, 100176, China
| | - Qiumei Cao
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, 100176, China
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Roelz R, Scheiwe C, Grauvogel J, Csok I, Coenen VA, Beck J, Reinacher PC. Early cisternal fibrinolysis is more effective than rescue spasmolysis for the prevention of delayed infarction after subarachnoid haemorrhage. Stroke Vasc Neurol 2022; 7:108-113. [PMID: 34750281 PMCID: PMC9067274 DOI: 10.1136/svn-2021-001146] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/03/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND To compare the efficacy of two different concepts of cisternal therapy-PREVENTIVE fibrinolysis plus on-demand spasmolysis versus RESCUE spasmolysis-for the prevention of cerebral vasospasm (CVS) and delayed cerebral infarction (DCI) in patients with aneurysmal subarachnoid haemorrhage (aSAH). METHODS Retrospective analysis of 84 aSAH patients selected for cisternal therapy for DCI prevention. 66 high-risk patients received PREVENTIVE cisternal therapy to enhance blood clearance. Either stereotactic catheter ventriculocisternostomy (STX-VCS) or intraoperative placement of a cisterno-ventriculostomy catheter (CVC), followed by fibrinolytic cisternal lavage using urokinase was performed. In case of vasospasm, nimodipine was applied intrathecally. 22 low-risk patients who developed CVS against expectations were selected for STX-VCS as RESCUE intervention for cisternal spasmolysis with nimodipine. Rates of DCI and mean flow velocities of daily transcranial Doppler (TCD) ultrasonographies were evaluated. RESULTS Despite a higher prespecified DCI risk, patients selected for PREVENTIVE intervention primarily aiming at blood clearance had a lower DCI rate compared with patients selected for intrathecal spasmolysis as a RESCUE therapy (11.3% vs 18.2%). After intrathecal treatment onset, CVS (TCD>160 cm/s) occurred in 45% of patients with PREVENTIVE and 77% of patients with RESCUE therapy (p=0.013). A stronger response of CVS to intrathecal nimodipine was observed in patients with PREVENTIVE intervention as the mean CVS duration after start of intrathecal nimodipine was 3.2 days compared with 5.8 days in patients with RESCUE therapy (p=0.026). CONCLUSIONS PREVENTIVE cisternal therapy directed at blood clearance is more effective for the prevention of CVS and delayed infarction compared with cisternal RESCUE spasmolysis. TRIAL REGISTRATION NUMBER DRKS00016532.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Istvan Csok
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Volker Arnd Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
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Vo HK, Le VT, Nguyen VL, Dao XC, Duong DH, Trinh TL, Nguyen VT, Vo HL, Nguyen CH, Tran VL, Nguyen AT, Hoang VT, Truong TA, Nguyen TB, Chu BC, Le TM, Dao TTH, Duong TH, Ha HQ, Trinh TPL, Truong TT, Phan VD, Pham TNL, Phuong TH, Le QC. Diagnostic value of cerebral vasospasm by transcranial doppler ultrasound in Vietnamese patients with subarachnoid hemorrhage. Eur Rev Med Pharmacol Sci 2022; 26:1939-1944. [PMID: 35363343 DOI: 10.26355/eurrev_202203_28341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Although the application of transcranial Doppler (TCD) ultrasonography in clinical diagnosis of cerebral vasospasm is popular in clinical practice in Vietnam, available evidence of the predictive value of vasospasm on TCD in the literature was mostly reported from large institutions in developed countries. Hence, this study was conducted to evaluate the value of TCD ultrasonography in the diagnosis of vasospasm in patients with subarachnoid hemorrhage (SAH) in Vietnam. PATIENTS AND METHODS This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between 2008 and December 2011. TCD and 64-slice computed tomographic angiography (CTA) were used to cerebral vasospasm in SAH patients. RESULTS 316 patients were analyzed (mean age = 52.97±12.27 years, 52.2% males). There were statistically significant difference rates of the cerebral vasospasm by Hunt and Hess Classification and Fisher classification (p <0.01). The proportion of the patients with cerebral vasospasm who were diagnosed exactly by TCD was 95.2%, while the proportion of the patients without cerebral vasospasm diagnosed exactly was 91.5%. TCD predictive diagnostic value was the highest, with the sensitivity of 0.95 (95% CI: 0.91-0.98), specificity of 0.91 (95% CI: 0.85-0.96), positive predictive value of 0.94 (5% CI: 0.90-0.97) and negative predictive value of 0.93 (95 CI: 0.87-0.97). Hemiplegia was the clinical symptom with the highest diagnostic value with the sensitivity of 0.34 (95% CI: 0.27-0.41), specificity of 0.92 (95% CI: 0.86-0.96), positive predictive value of 0.86 (95% CI: 0.76-0.93) and negative predictive value of 0.49 (95% CI: 0.41-0.54). CONCLUSIONS Evidence of vasospasm diagnosis on TCD ultrasonography was found with high accuracy. Current study enables to suggest the wide application of TCD in Vietnam health facilities from central to grassroots levels instead of the CTA use.
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Affiliation(s)
- H-K Vo
- Neurology Center, Bach Mai Hospital, Hanoi, Vietnam.
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Steiger HJ, Ensner R, Andereggen L, Remonda L, Berberat J, Marbacher S. Hemodynamic response and clinical outcome following intravenous milrinone plus norepinephrine-based hyperdynamic hypertensive therapy in patients suffering secondary cerebral ischemia after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:811-821. [PMID: 35138488 PMCID: PMC8913475 DOI: 10.1007/s00701-022-05145-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/29/2022] [Indexed: 12/12/2022]
Abstract
Purpose Intravenous and intra-arterial milrinone as a rescue measure for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) has been adopted by several groups, but so far, evidence for the clinical benefit is unclear and effect on brain perfusion is unknown. The aim of the actual analysis was to define cerebral hemodynamic effects and outcome of intravenous milrinone plus norepinephrine supplemented by intra-arterial nimodipine as a rescue strategy for DCI following aneurysmal SAH. Methods Of 176 patients with aneurysmal SAH treated at our neurosurgical department between April 2016 and March 2021, 98 suffered from DCI and were submitted to rescue therapy. For the current analysis, characteristics of these patients and clinical response to rescue therapy were correlated with hemodynamic parameters, as assessed by CT angiography (CTA) and perfusion CT. Time to peak (TTP) delay in the ischemic focus and the volume with a TTP delay of more than 4 s (T4 volume) were used as hemodynamic parameters. Results The median delay to neurological deterioration following SAH was 5 days. Perfusion CT at that time showed median T4 volumes of 40 cc and mean focal TTP delays of 2.5 ± 2.1 s in these patients. Following rescue therapy, median T4 volume decreased to 10 cc and mean focal TTP delay to 1.7 ± 1.9 s. Seventeen patients (17% of patients with DCI) underwent additional intra-arterial spasmolysis using nimodipine. Visible resolution of macroscopic vasospasm on CTA was observed in 43% patients with DCI and verified vasospasm on CTA, including those managed with additional intra-arterial spasmolysis. Initial WFNS grade, occurrence of secondary infarction, ischemic volumes and TTP delays at the time of decline, the time to clinical decline, and the necessity for additional intra-arterial spasmolysis were identified as the most important features determining neurological outcome at 6 months. Conclusion The current analysis shows that cerebral perfusion in the setting of secondary cerebral ischemia following SAH is measurably improved by milrinone and norepinephrine–based hyperdynamic therapy. A long-term clinical benefit by the addition of milrinone appears likely. Separation of the direct effect of milrinone from the effect of induced hypertension is not possible based on the present dataset.
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Affiliation(s)
- Hans-Jakob Steiger
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland.
- Klinik Für Neurochirurgie, Neurozentrum, Kantonsspital Aarau, Tellstr. 25, CH-5001, Aarau, Switzerland.
| | - Rolf Ensner
- Surgical Intensive Care Unit, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Jatta Berberat
- Division of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland
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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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Yan Z, Zou Y, Deng Y, Liu S, Li K, Yang J, Guo X, He R, Zheng W, Xie H. Analysis of role of rat cerebral pericytes in cerebral vasospasm after subarachnoid hemorrhage and molecular mechanism of neurovascular injury. Bioengineered 2021; 12:3957-3967. [PMID: 34288796 PMCID: PMC8806491 DOI: 10.1080/21655979.2021.1947630] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
To investigate mechanism of pericytes in the early stage of subarachnoid haemorrhage (SAH) and its associated microvascular spasm and neurovascular injury, 100 healthy 8-week-old Sprague-Dawley male rats were taken as subjects and divided into four groups: group A (sham operation, control group), group B (SAH operation group), group C (SAH operation group treated with scutellarin), and group D (SAH operation group treated with L-nitro-arginine). 72 hours after the operation, the rats were conducted assessment of neurological impairment, observation of microangiography, detection of blood-brain barrier permeability, observation of skull base haemorrhage, identification of pericyte culture, and measurement of blood nitric oxide. The results showed that neurological impairment score, degree of micro-vasoconstriction, and BBB permeability of group C were significantly better than those of group B and D (P<0.05), there was no significant difference between group C and group A (P>0.05). There were significantly fewer blood clots in the brain of group C, and the order of expression levels of α-smooth muscle actin (α-SMA) in perioperative cells of the four groups from highest to lowest were D, B, C, and A. Nitric oxide concentration inhibited expression of α-SMA in pericytes after SAH at both protein and mRNA levels. The detection results of nitric oxide in the blood of four groups of rats confirmed that pericyte phenotype conversion and actin α-SMA expression could be prevented by upregulation of nitric oxide in serum, so as to relieve pathological symptoms after SAH operation.
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Affiliation(s)
- Zhenxing Yan
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Zou
- Department of Neurology, Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yiting Deng
- Department of Neurology, Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Siqin Liu
- Department of Neurology, Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Kaifeng Li
- Department of Neurology, Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Juan Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xihua Guo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Rongni He
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Wenxia Zheng
- Department of Neurology, Shunde Hospital, Southern Medical University, Foshan, China
| | - Huifang Xie
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Buono A, Pero G, Bettari L, Pezzotti E, Cortinovis S, Gentili L, Mor D, Cuccia C, Maffeo D. Recurrent idiopathic carotid and coronary artery vasospasm treated by stent implantations. J Cardiovasc Med (Hagerstown) 2021; 22:e37-e40. [PMID: 34482326 DOI: 10.2459/jcm.0000000000001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Arterial vasospasm is a well known cause of ischemia and, if prolonged, of parenchymal infarction. The clinical presentation varies according to the involved arterial district. We describe a rare case, which occurred in a young lady, of recurrent and multisystem vasospasm, resulting in multiple cerebral and myocardial infarctions. Our patient was resistant to medical therapy, requiring stent implantation of the involved vessels.
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Affiliation(s)
| | | | | | - Elena Pezzotti
- Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Sarah Cortinovis
- Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Luisa Gentili
- Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Donata Mor
- Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Claudio Cuccia
- Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
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Geraghty JR, Lung TJ, Hirsch Y, Katz EA, Cheng T, Saini NS, Pandey DK, Testai FD. Systemic Immune-Inflammation Index Predicts Delayed Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 89:1071-1079. [PMID: 34560777 PMCID: PMC8600162 DOI: 10.1093/neuros/nyab354] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [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: 02/24/2021] [Accepted: 07/31/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Delayed cerebral vasospasm is a feared complication of aneurysmal subarachnoid hemorrhage (SAH). OBJECTIVE To investigate the relationship of systemic inflammation, measured using the systemic immune-inflammation (SII) index, with delayed angiographic or sonographic vasospasm. We hypothesize that early elevations in SII index serve as an independent predictor of vasospasm. METHODS We retrospectively reviewed the medical records of 289 SAH patients for angiographic or sonographic evidence of delayed cerebral vasospasm. SII index [(neutrophils × platelets/lymphocytes)/1000] was calculated from laboratory data at admission and dichotomized based on whether or not the patient developed vasospasm. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to determine the ability of SII index to predict the development of vasospasm. RESULTS A total of 246 patients were included in our study, of which 166 (67.5%) developed angiographic or sonographic evidence of cerebral vasospasm. Admission SII index was elevated for SAH in patients with vasospasm compared to those without (P < .001). In univariate logistic regression, leukocytes, neutrophils, lymphocytes, neutrophil-lymphocyte ratio (NLR), and SII index were associated with vasospasm. After adjustment for age, aneurysm location, diabetes mellitus, hyperlipidemia, and modified Fisher scale, SII index remained an independent predictor of vasospasm (odds ratio 1.386, P = .003). ROC analysis revealed that SII index accurately distinguished between patients who develop vasospasm vs those who do not (area under the curve = 0.767, P < .001). CONCLUSION Early elevation in SII index can independently predict the development of delayed cerebral vasospasm in aneurysmal SAH.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tyler J Lung
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Yonatan Hirsch
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Eitan A Katz
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tiffany Cheng
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Neil S Saini
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Dilip K Pandey
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
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Croci DM, Wanderer S, Strange F, Grüter BE, Sivanrupan S, Andereggen L, Casoni D, von Gunten M, Widmer HR, Di Santo S, Fandino J, Mariani L, Marbacher S. Tocilizumab Reduces Vasospasms, Neuronal Cell Death, and Microclot Formation in a Rabbit Model of Subarachnoid Hemorrhage. Transl Stroke Res 2021; 12:894-904. [PMID: 33409731 DOI: 10.1007/s12975-020-00880-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 09/09/2020] [Revised: 11/29/2020] [Accepted: 12/20/2020] [Indexed: 02/07/2023]
Abstract
Early brain injury (EBI), delayed cerebral vasospasm (DCVS), and delayed cerebral ischemia (DCI) are common complications of subarachnoid hemorrhage (SAH). Inflammatory processes in the cerebrospinal fluid (CSF) are one of the causes for such complications. Our aim to study the effects of an IL-6 receptor antagonist (Tocilizumab) examines the occurrence of DCVS, neuronal cell death, and microclot formation in an acute SAH rabbit model. Twenty-nine New Zealand white rabbits were randomized into one of three groups as the SAH, SAH + Tocilizumab, and sham groups. In SAH groups, hemorrhage was induced by extracranial-intracranial arterial blood shunting from the subclavian artery into the cisterna magna under intracranial pressure (ICP) monitoring. In the second group, Tocilizumab was given once intravenously 1 h after SAH induction. Digital subtraction angiography was performed, and CSF and blood were sampled before and after (day 3) SAH induction. IL-6 plasma and CSF levels were measured. TUNEL, FJB, NeuN, and caspase-3 immunostaining were used to assess cell apoptosis, neurodegeneration, and neuronal cell death, respectively. Microclot formation was detected by fibrinogen immunostaining. Between baseline and follow-up, there was a significant reduction of angiographic DCVS (p < 0.0001) in the Tocilizumab compared with the SAH group. Tocilizumab treatment resulted in decreased neuronal cell death in the hippocampus (p = 0.006), basal cortex (p = 0.001), and decreased microclot formation (p = 0.02). Tocilizumab reduced DCVS, neuronal cell death, and microclot formation in a rabbit SAH model, and could be a potential treatment to prevent DCVS and DCI in SAH patients.
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Affiliation(s)
- Davide M Croci
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland.
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Basil E Grüter
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Sivani Sivanrupan
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Daniela Casoni
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | | | - Hans Rudolf Widmer
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefano Di Santo
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland
- Cerebrovascular Research Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
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Wang T, Richard SA, Li J, Jiao H, Zhang C, Wang C, Lin S, Xie X, You C. Cerebral vasospasm resulted in "stent shortening" after pipeline assisted coil embolization for blood blister aneurysms. Medicine (Baltimore) 2021; 100:e26971. [PMID: 34414968 PMCID: PMC8376338 DOI: 10.1097/md.0000000000026971] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/01/2021] [Indexed: 02/05/2023] Open
Abstract
Blood blister aneurysms (BBAs) are intracranial arterial lesions appearing in nonbranching sites of the supraclinoid internal carotid artery as well as the basilar artery. Endovascular treatment of BBAs is still not well established because of the rarity of these lesions. We report incidences of BBAs with associated vasospasms. Treatment of the BBAs and associate vasospasms with single Pipeline Flex embolization device (PLED) assisted coiling resulted in seemly shorting of the PLEDs in 3 patients.A retrospective analysis of patients with BBAs who were treated with single PLED assisted coiling from July 2018 to October 2019 was conducted. Patients' ethnic and medical records, aneurysmal characteristics, intraoperative-rupture, cerebral vasospasm (CVS), postprocedure contrast filling, follow-up imaging, and results were analyzed. Neurological examination at baseline and outcome based on modified Rankin scale (mRS) at discharge as well as follow-ups were also documented.Six patients consisting of 5 females and 1 male, with a mean age of 48.3 years (range from 34-67) were identified during our analysis. All the BBAs were located in nonbranching site of supra-clinoidal segment of internal carotid artery with a mean neck width of 4.5 mm and mean aneurysm size of 4.23 mm. PLED assisted coiling's were performed in all of them. CVS was observed in 3 patients while 1 patient had an intraoperative-rupture of the BBA. Postprocedure contrast filling was still present in 1 patient. All the patients had good outcomes with discharge and follow-up mRS scores ≤ 2 except 1 patient with mRS score = 3 with aphasia.PLED assisted endovascular coiling is very safe and efficient in treating patients with BBAs. Resolution of CVSs after treatment made the PLEDs seemly shorter. Furthermore, a combination of arterial lengthening after gaining their tensile strength back and radical expansion of the PLED could account for the shortening.
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Affiliation(s)
- Ting Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
- Department of Medicine, Princefield University, P. O. Box MA 128, Ho-Volta Region, Ghana
| | - Junrao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - He Jiao
- Department of Radiology, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
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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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Matsubayashi T, Oniki A, Furuki M, Obayashi M. Reversible Cerebral Vasoconstriction Syndrome without Headache That Was Initially Suspected of Being Primary Angiitis of the Central Nervous System. Intern Med 2021; 60:2321-2326. [PMID: 33612678 PMCID: PMC8355395 DOI: 10.2169/internalmedicine.6560-20] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 48-year-old man had convulsions, and magnetic resonance angiography (MRA) showed diffuse constriction of the cerebral arteries. He was suspected of having primary angiitis of the central nervous system (PACNS) and treated with steroid for three days. The MRA abnormality disappeared after a week. After 69 days, he developed dizziness, and MRA revealed recurrence of cerebral artery stenosis. Nevertheless, the symptoms and abnormal MRA findings recovered promptly without treatment. He was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) without headache. This case suggests that RCVS should be a differential diagnosis in patients without headache whose MRA findings show multiple cerebral artery stenosis.
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Affiliation(s)
- Taiki Matsubayashi
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
| | - Ayako Oniki
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
| | - Misako Furuki
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
| | - Masato Obayashi
- Department of Neurology, National Hospital Organization Disaster Medical Center, Japan
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50
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Rabinstein AA, Braksick SA, Wijdicks EF. Subarachnoid hemorrhage from sudden gravitational changes. Neuroradiol J 2021; 35:240-242. [PMID: 34235989 DOI: 10.1177/19714009211030540] [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: 11/15/2022] Open
Abstract
Diffuse subarachnoid hemorrhage is commonly attributed to the rupture of intracranial aneurysms or other vascular malformations. Non-aneurysmal hemorrhages often have a characteristic pattern or clear mechanism (e.g. trauma) with an often more benign clinical course. We report the case of a diffuse non-aneurysmal subarachnoid hemorrhage due to sudden gravitational changes encountered during complex airflight maneuvers, complicated by hydrocephalus and cerebral vasospasm. This case illustrates a rare phenomenon that may again be encountered in the future with the advent and advancement of civilian spaceflight.
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