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Santos Neto EPD, Sousa ÍAD, Ricarte IF, Pontes-Neto OM. Reversible Cerebral Vasoconstriction Syndrome And Fibromuscular Dysplasia: An Epiphenomenon Or A Causal Relationship? Acta Neurol Taiwan 2024; 33(3):122-126. [PMID: 37968850] [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: 11/17/2023]
Abstract
Fibromuscular dysplasia (FMD) is a rare non-atherosclerotic arterial disease that primarily affects middle-aged Caucasian women. Carotid web (CW) is a variant of FMD characterized by a nonatheromatous, membrane-like tissue protrusion into the carotid bulb. Reversible cerebral vasoconstriction syndrome (RCVS) is defined by severe headaches and reversible narrowing of cerebral arteries, which typically resolves within three months. While most RCVS cases have identifiable triggers, a significant portion occurs without known causes. Recent studies have reported a high prevalence of neurovascular abnormalities in RCVS patients. We present a case of a thirty-year-old woman with a sudden-onset severe headache, diagnosed with RCVS associated with carotid web. The patient had no ischemic involvement and responded well to flunarizine treatment. Follow-up imaging showed no stenosis. This case highlights a potential association between carotid web and RCVS, suggesting that FMD may contribute to vascular hyperreactivity and presents as a risk factor for RCVS. Further investigations are needed to understand the underlying mechanisms connecting these two vascular disorders. Keywords: reversible vasoconstriction syndrome; fibromuscular dysplasia; carotid web; structural abnormalities; vascular hyperreactivity.
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Affiliation(s)
- Elizeu Pereira Dos Santos Neto
- Institute of Radiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo SP, Brazil; Neurologist and Interventional Neuroradiologist, Department of Neurology, Hospital Getúlio Vargas, Teresina PI, Brazil
| | - Ícaro Araújo de Sousa
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Irapuá Ferreira Ricarte
- Department of Neurology and Neurosurgery, São Paulo Federal University, São Paulo, SP, Brazil
| | - Octávio Marques Pontes-Neto
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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Revilla-González G, Varela LM, Ruiz de Azua-López Z, Amaya-Villar R, Pezzotti MR, Castro MJ, Ureña J, González-Montelongo MDC, Castellano A. Changes in Adhesion and the Expression of Adhesion Molecules in PBMCs after Aneurysmal Subarachnoid Hemorrhage: Relation to Cerebral Vasospasm. Transl Stroke Res 2024; 15:378-387. [PMID: 36814009 PMCID: PMC10891186 DOI: 10.1007/s12975-023-01136-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/17/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a neurovascular disease produced by extravasation of blood to the subarachnoid space after rupture of the cerebral vessels. After bleeding, the immune response is activated. The role of peripheral blood mononuclear cells (PBMCs) in this response is a current subject of research. We have analysed the changes in PBMCs of patients with aSAH and their interaction with the endothelium, focusing on their adhesion and the expression of adhesion molecules. Using an in vitro adhesion assay, we observed that the adhesion of PBMCs of patients with aSAH is increased. Flow cytometry analysis shows that monocytes increased significantly in patients, especially in those who developed vasospasm (VSP). In aSAH patients, the expression of CD162, CD49d, CD62L and CD11a in T lymphocytes and of CD62L in monocytes increased. However, the expression of CD162, CD43, and CD11a decreased in monocytes. Furthermore, monocytes from patients who developed arteriographic VSP had lower expression of CD62L. In conclusion, our results confirm that after aSAH, monocyte count and adhesion of PBMCs increase, especially in patients with VSP, and that the expression of several adhesion molecules is altered. These observations can help predict VSP and to improve the treatment of this pathology.
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Affiliation(s)
- Gonzalo Revilla-González
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Lourdes María Varela
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Zaida Ruiz de Azua-López
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- UGC de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rosario Amaya-Villar
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- UGC de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Rosa Pezzotti
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - María José Castro
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Juan Ureña
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - María Del Carmen González-Montelongo
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain.
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain.
- Unidad de Investigación, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Hospital Universitario Puerta del Mar, Cádiz, Spain.
| | - Antonio Castellano
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain.
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain.
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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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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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Hyperglycemia Aggravates Cerebral Vasospasm after Subarachnoid Hemorrhage in a Rat Model: Corrigendum. Neurosurgery 2023; 94:e45. [PMID: 38117074 DOI: 10.1227/neu.0000000000002806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
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Pugazenthi S, Norris AJ, Lauzier DC, Lele AV, Huguenard A, Dhar R, Zipfel GJ, Athiraman U. Conditioning-based therapeutics for aneurysmal subarachnoid hemorrhage - A critical review. J Cereb Blood Flow Metab 2024; 44:317-332. [PMID: 38017387 PMCID: PMC10870969 DOI: 10.1177/0271678x231218908] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) carries significant mortality and morbidity, with nearly half of SAH survivors having major cognitive dysfunction that impairs their functional status, emotional health, and quality of life. Apart from the initial hemorrhage severity, secondary brain injury due to early brain injury and delayed cerebral ischemia plays a leading role in patient outcome after SAH. While many strategies to combat secondary brain injury have been developed in preclinical studies and tested in late phase clinical trials, only one (nimodipine) has proven efficacious for improving long-term functional outcome. The causes of these failures are likely multitude, but include use of therapies targeting only one element of what has proven to be multifactorial brain injury process. Conditioning is a therapeutic strategy that leverages endogenous protective mechanisms to exert powerful and remarkably pleiotropic protective effects against injury to all major cell types of the CNS. The aim of this article is to review the current body of evidence for the use of conditioning agents in SAH, summarize the underlying neuroprotective mechanisms, and identify gaps in the current literature to guide future investigation with the long-term goal of identifying a conditioning-based therapeutic that significantly improves functional and cognitive outcomes for SAH patients.
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Affiliation(s)
- Sangami Pugazenthi
- Department of Neurological Surgery, Washington University, St. Louis MO, USA
| | - Aaron J Norris
- Department of Anesthesiology, Washington University, St. Louis MO, USA
| | - David C Lauzier
- Department of Neurological Surgery, University of California, Los Angeles, CA, USA
| | - Abhijit V Lele
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Anna Huguenard
- Department of Neurological Surgery, Washington University, St. Louis MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Gregory J Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology and Neurological Surgery, Washington University, St. Louis, MO, USA
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Ghazanfar S, Farooq M, Chaurasia B. Letter to the Editor Regarding Stellate Ganglion Block in Subarachnoid Hemorrhage: A Promising Protective Measure Against Vasospasm? World Neurosurg 2024; 183:278-279. [PMID: 38468178 DOI: 10.1016/j.wneu.2023.12.049] [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: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 03/13/2024]
Affiliation(s)
- Shamas Ghazanfar
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Minaam Farooq
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA; Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal.
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Mutoh T, Aono H, Seto W, Kimoto T, Tochinai R, Moroi J, Ishikawa T. Factors Influencing Discontinuation of Clazosentan Therapy in Elderly Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study from a Japanese Single Center. Med Sci Monit 2024; 30:e943303. [PMID: 38361355 PMCID: PMC10877966 DOI: 10.12659/msm.943303] [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: 11/26/2023] [Accepted: 12/28/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Clazosentan is an endothelin receptor antagonist approved in Japan for preventing cerebral vasospasm and vasospasm-associated cerebral ischemia and infarction. This study included elderly patients aged ≥75 years with aneurysmal subarachnoid hemorrhage (SAH) and aimed to evaluate the factors associated with discontinuing anti-vasospasm therapy with clazosentan. MATERIAL AND METHODS In this single-center retrospective observational study, we extracted diagnostic and therapeutic work-up data of consecutive 40 patients with SAH treated with clazosentan infusion (10 mg/h) as first-line anti-vasospasm therapy between May 2022 and August 2023. Patient data were compared between the discontinued and completed groups, and related factors for the discontinuation were further analyzed. RESULTS Clazosentan was discontinued in 22% (n=9) of patients due to intolerable dyspnea accompanied by hypoxemia at 5±3 days after therapy initiation, in which 44% (n=4) were elderly (≥75 years). Patients who discontinued clazosentan therapy showed significantly lower urine volumes compared with those who completed the therapy (P<0.05). Multivariate regression analysis revealed that day-to-day urine volume variance and older age were independent risk factors for drug cessation (P<0.05). The cut-off value for predicting clazosentan discontinuation was -0.7 mL/kg/h with sensitivity of 86% and specificity of 75% (area under the curve: 0.76±0.10; 95% confidence interval: 0.56-0.96; P=0.035). CONCLUSIONS Our results suggest that approximately 20% of SAH patients suffered from intolerable respiratory symptoms attributable to hypoxemia. We found that both reduced day-to-day urine volume variation and older age are independent risk factors for drug discontinuation.
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Affiliation(s)
- Tatsushi Mutoh
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Hiroaki Aono
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Wataru Seto
- Department of Pharmaceutics, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Takehiro Kimoto
- Department of Pharmaceutics, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Ryota Tochinai
- Department of Veterinary Pathophysiology and Animal Health, Graduate School of Agriculture and Life Sciences, the University of Tokyo, Tokyo, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
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Caylor MM, Macdonald RL. Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:159-169. [PMID: 37740138 DOI: 10.1007/s12028-023-01847-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/23/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries. METHODS Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan. RESULTS The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad. CONCLUSIONS We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.
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Affiliation(s)
- Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - R Loch Macdonald
- Community Neurosciences Institute, Community Health Partners, 7257 North Fresno Street, Fresno, CA, 93720, USA.
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Lei Z, You G, Qi X, Liu Z, Shuai P, Zheng N. Treatment and clinical analysis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Minerva Med 2024; 115:102-104. [PMID: 37439765 DOI: 10.23736/s0026-4806.23.08750-5] [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] [Indexed: 07/14/2023]
Affiliation(s)
- Zhen Lei
- Department of Neurosurgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Neurosurgery, Seventh People's Hospital of Chengdu, Chengdu, China
| | - Guoliang You
- Department of Cerebrovascular Disease, Leshan People's Hospital, Leshan, China
| | - Xinwei Qi
- Department of Neurosurgery, Seventh People's Hospital of Chengdu, Chengdu, China
| | - Zhiye Liu
- Department of Cerebrovascular Disease, Leshan People's Hospital, Leshan, China
| | - Peiyu Shuai
- Department of Anesthesiology, Leshan Shizhong District People's Hospital, Leshan, China
| | - Niandong Zheng
- Department of Neurosurgery, Affiliated Hospital of Southwest Medical University, Luzhou, China -
- Department of Cerebrovascular Disease, Leshan People's Hospital, Leshan, China
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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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12
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Oliveira LDB, Batista S, Prestes MZ, Bocanegra-Becerra JE, Rabelo NN, Bertani R, Welling LC, Figueiredo EG. Stellate Ganglion Block in Subarachnoid Hemorrhage: A Promising Protective Measure Against Vasospasm? World Neurosurg 2024; 182:124-131. [PMID: 38042290 DOI: 10.1016/j.wneu.2023.11.122] [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: 06/22/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Stellate ganglion block (SGB) may have protective effects in patients at risk of vasospasm following subarachnoid hemorrhage (SAH) due to reduced sympathetic activity. However, the safety and clinical outcomes of SGB in this scenario are not definitively known. The objective was to evaluate the safety, clinical outcomes, and cerebral blood flow velocity in patients submitted to SGB or cervical sympathectomy with SAH. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review and meta-analysis of studies investigating SGB or cervical sympathectomy use in SAH were conducted. PubMed, Cochrane Library, and Embase were evaluated. Patients with mRS from 0 to 2, GOS from 4 to 5, or symptom resolution were considered favorable clinical outcomes. Related mortality was defined as death by vasospasm or delayed cerebral ischemia. RESULTS The analysis included 8 studies comprising 182 patients. Only 2 studies employed SGB prophylactically. The results revealed favorable outcomes in 52% of patients (95% CI: 37%-65%). The overall incidence of complications was 2% (95% CI: 0% -26%). The mortality rate was 13% (95% CI: 7%-21%), with a vasospasm-related mortality rate of 11% (95% CI: 2%-20%). A decrease of cerebral blood flow velocity was reported in 4 studies. CONCLUSIONS The notable reduction in cerebral blood flow velocity following SGB, alongside positive outcomes and a low occurrence of mortality and complications, highlights its significance as a therapeutic intervention for vasospasm following SAH. While the number of studies evaluating SGB as a preventive measure is limited, the promising results emphasize the importance of future research.
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Affiliation(s)
| | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
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13
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Dabbagh Ohadi MA, Maroufi SF, Mohammadi MR, Hosseini Siyanaki MR, Khorasanizadeh M, Kellner CP. Ferroptosis as a Therapeutic Target in Subarachnoid Hemorrhage. World Neurosurg 2024; 182:52-57. [PMID: 37979679 DOI: 10.1016/j.wneu.2023.11.049] [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: 08/24/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a cerebrovascular disorder with significant mortality and morbidity. Neural injury in SAH is mediated through a variety of pathophysiological processes. Currently available treatments are either nonspecific in targeting the basic pathophysiological mechanisms that result in neural damage in SAH, or merely focus on vasospasm. Ferroptosis is a type of programmed iron dependent cell death, which has received attention due to its possible role in neural injury in SAH. Herein, we review how intracellular iron overload mediates the production of reactive free radicals and lipid peroxidation through a variety of biochemical pathways in SAH. This in turn results in induction of ferroptosis, as well as exacerbation of vasospasm. We also discuss several therapeutic agents that have been shown to inhibit ferroptosis through targeting different steps of the process. Such agents have proven effective in ameliorating vasospasm, neural damage, and neurobehavioral outcomes in animal models of SAH. Human studies to test the safety and efficacy of intrathecal or parenteral administration of the inhibitors of ferroptosis in improving outcomes of SAH patients are warranted. There are currently a few ongoing clinical trials pursuing this therapeutic concept, the results of which will be critical to determine the value of ferroptosis as a novel therapeutic target in SAH.
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Affiliation(s)
- Mohammad Amin Dabbagh Ohadi
- Departments of Pediatric Neurosurgery Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City, New York, USA.
| | - Christopher P Kellner
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City, New York, USA
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14
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Ditz C, Matone MV, Schwachenwald B, Küchler J. Risks of nimodipine dose reduction during the high-risk period for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2024; 47:37. [PMID: 38191859 DOI: 10.1007/s10143-023-02273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/12/2023] [Accepted: 12/31/2023] [Indexed: 01/10/2024]
Abstract
Nimodipine dose reduction is recommended in case of high vasopressor demand after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess potential adverse effects of nimodipine reduction during the high-risk period for delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) between days 5 and 10 after hemorrhage. Demographic and clinical data as well as daily nimodipine dose of aSAH patients admitted between 2010 and 2019 were retrospectively analyzed. Univariable and multivariable regression analyses were performed to identify factors associated with DCI, angiographic CVS, DCI-related infarction, and unfavorable outcome. A total of 205 patients were included. Nimodipine dose reduction occurred in 108 (53%) patients ('nimodipine reduction group'), while 97 patients (47%) received the full dose ('no nimodipine reduction group'), Patients in the 'nimodipine reduction group' had significant worse WFNS and Fisher grades and developed significantly more often DCI and angiographic CVS. DCI-related infarction and unfavorable outcome were also significantly increased in the 'nimodipine reduction group.' 'Reduced nimodipine dose' was the only independent predictor for the occurrence of DCI and angiographic CVS in multivariable regression analysis. 'Poor WFNS grade' and 'reduced nimodipine dose' were identified as independent risk factors for DCI-related infarction while 'older age,' 'poor WFNS grade,' and 'reduced nimodipine dose' were associated with unfavorable outcome at 3 months after discharge. Nimodipine dose reduction during the high-risk period of DCI and CVS between days 5 and 10 after hemorrhage might abrogate the positive prognostic effects of nimodipine and should be critically evaluated.
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Affiliation(s)
- Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Maria V Matone
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Bram Schwachenwald
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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15
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Yokota M, Okada T, Asaeda M, Iida T, Tanada S, Tuji S, Nigami T. Effect of Intrathecal Urokinase Infusion on Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2024; 181:e678-e684. [PMID: 37898263 DOI: 10.1016/j.wneu.2023.10.113] [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: 07/28/2023] [Revised: 10/22/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) causes serious neurological complications, despite surgical clipping of the aneurysm. Intrathecal urokinase (UK) infusion has been shown to effectively prevent symptomatic vasospasm in patients who have undergone endovascular obliteration of the ruptured aneurysms. OBJECTIVE To investigate whether intrathecal UK infusion can prevent symptomatic vasospasm in patients undergoing surgical or endovascular treatment. METHODS A total of 90 patients with severe aneurysmal SAH were enrolled and assigned to a surgical neck clipping (n = 56) or an endovascular coil embolization (n = 34) groups. After treatment, UK infusion from the lumbar drain was repeated in 32 patients in the surgical neck clipping group (group B) and all in the endovascular coil embolization group (group C) until complete resolution of the SAH was observed on computed tomography. The remaining 24 of the surgical neck clipping group, without UK infusion, were assigned to group A. RESULTS Symptomatic vasospasm occurred in 7 (29.2%) patients in group A, 2 (6.3%) in group B, and none in group C (group A vs. group B [P = 0.02]; group B vs. group C [P = 0.14]). Excellent clinical outcomes (modified Rankin score, 0 or 1) were observed in 37.5%, 59.4%, and 76.5% of patients in group A, B, and C, respectively (group A vs. group B [P = 0.11]). CONCLUSION Clearance of SAH via intrathecal UK infusion significantly reduced symptomatic vasospasm in patients in both UK groups, resulting in better clinical outcomes.
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Affiliation(s)
- Masayuki Yokota
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan.
| | - Takuya Okada
- Department of Anesthesiology, School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Masahiro Asaeda
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Tomoko Iida
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Shuichi Tanada
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Shoichiro Tuji
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Taishi Nigami
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
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16
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Bozdag S, Sucu HK, Altun ZS, Akkalp AK, Yilmaz O, Celikkaya D. Dexamethasone Addition Impairs the Therapeutic Effects of Nimodipine for Subarachnoid Hemorrhage: An Experimental Animal Study. Turk Neurosurg 2024; 34:148-159. [PMID: 38282594 DOI: 10.5137/1019-5149.jtn.43427-23.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
AIM To evaluate the effects of the combination of nimodipine and dexamethasone in subarachnoid hemorrhage (SAH). MATERIAL AND METHODS In this study, 35 female adult Wistar Albino rats were randomly assigned to four groups: Sham (n=8), SAH with no treatment (n=9), SAH with nimodipine (n=9, oral gavage, 12 mg/kg, BID) treatment, and SAH with combined therapy with nimodipine and dexamethasone (n=9, intraperitoneally, 1mg/kg, BID). The "cisterna magna double injection of autologous blood" model was used. The animals were euthanized 5 days after the first injection. RESULTS Of the total, five rats died before euthanasia. The SAH+Nontreatment group showed the worst score in neurological examinations, and the most severe histopathological findings were noted in terms of vasospasm. The SAH+Nimodipine group showed the best neurological score and the closest histopathological results to those of the Sham group, whereas adding dexamethasone to nimodipine treatment (the SAH+Nimodipine+Dexamethasone group) worsened the neurological and histopathological outcomes. CONCLUSION We thus concluded that the therapeutic effects of nimodipine were impaired when combined with dexamethasone. We thus hypothesized that dexamethasone possibly induces the CYP3A4-enzyme that metabolizes nimodipine. However, it should be noted that our results are based on laboratory findings obtained on a small sample, therefore further studies with drug-drug interaction on a larger sample size through CYP3A4-enzyme and clinical confirmation are warranted.
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Affiliation(s)
- Selin Bozdag
- Kastamonu Training and Research Hospital, Department of Neurosurgery, Kastamonu, Türkiye
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17
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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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18
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Nakajima H, Okada T, Kawakita F, Oinaka H, Suzuki Y, Nampei M, Kitano Y, Nishikawa H, Fujimoto M, Miura Y, Yasuda R, Toma N, Suzuki H. Cilostazol May Improve Outcomes Even in Patients with Aneurysmal Subarachnoid Hemorrhage Aged 75 Years and Older: Multicenter Cohort Study and Propensity Score-Matched Analyses. World Neurosurg 2024; 181:e273-e290. [PMID: 37839574 DOI: 10.1016/j.wneu.2023.10.039] [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: 08/25/2023] [Revised: 10/07/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The opportunities to treat elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) are increasing globally, but the outcome remains poor. This study seeks to investigate treatment-related factors that can modify functional outcomes in patients with aSAH aged ≥75 years. METHODS A total of 202 patients with aSAH aged ≥75 years prospectively enrolled in 9 primary stroke centers from 2013 to 2021 were retrospectively analyzed. Clinical variables including treatments for hydrocephalus, angiographic vasospasm, and delayed cerebral ischemia were compared between patients with good (modified Rankin Scale [mRS] score 0-2) and poor (mRS score 3-6) outcomes at 90 days from onset, followed by multivariate analyses to find independent outcome determinants. A modifiable treatment-related variable was evaluated after propensity score matching with adjustments for age, sex, pre-onset mRS score, aSAH severity, and treatment modality. RESULTS More than half of patients showed World Federation of Neurological Societies grades IV-V on admission. Univariate analyses showed that advanced age, worse pre-onset mRS score, more severe neurologic status on admission, higher modified Fisher grade on admission computed tomography scans, and acute and chronic hydrocephalus were associated with poor outcomes. In contrast, administration of a phosphodiesterase type III inhibitor, cilostazol, was associated with good outcomes in both univariate (P = 0.036) and multivariate analyses (adjusted odds ratio, 0.305; 95% confidence interval, 0.097-0.955; P = 0.042). Propensity score matching analyses showed that patients treated with cilostazol had better outcomes (P = 0.016) with fewer incidences of delayed cerebral infarction (P = 0.008). CONCLUSIONS Even in patients with aSAH aged ≥75 years, cilostazol administration may lead to better outcomes by suppressing the development of delayed cerebral infarction.
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Affiliation(s)
- Hideki Nakajima
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Takeshi Okada
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Fumihiro Kawakita
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroki Oinaka
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yume Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mai Nampei
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yotaro Kitano
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hirofumi Nishikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
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Resitoglu G, Akgun MY, Ates O, Oztanir MN. Investigation of the effect of carnitine on cerebral vasospasm in experimental subarachnoid hemorrhage model. Sci Rep 2023; 13:23033. [PMID: 38155210 PMCID: PMC10754841 DOI: 10.1038/s41598-023-50025-3] [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: 08/19/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023] Open
Abstract
The vasospasm, which develops after subarachnoid hemorrhage (SAH), is an unenlightened table in terms of etiology and results. It is usually associated with decreased perfusion, which is associated with decreased blood flow distal to the affected artery and can be demonstrated radiologically. Acetyl-L-carnitine (ALCAR) can be found in brain tissue and easily crosses the blood-brain barrier. Therefore, in this study, we aimed to investigate the therapeutic efficacy of ALCAR, which is an effective antioxidant amine, on vasospasm development after experimental SAH. In our study, 35 adults male Wistar RATs weighing between 235-250 g were used. These RATs were divided into five groups with n = 7. Group 1 Control group, Group 2 SAH + SF (carrier solution), Group 3 SAH + ALCAR 50 mg\kg intraperitoneally, Group 4 SAH + ALCAR 100 mg\kg intraperitoneally and Group 5 SAH. Subarachnoid hemorrhage was induced by giving autologous arterial blood to the cisterna magna of the animals in groups 2, 3, 4, and 5. At 0.-12.- 24.- 36.- 48.- 60. and 72. h, Group 2 was injected with SF, Group 3 with intraperitoneally ALCAR 50 mg\kg, and Group 4 with intraperitoneally ALCAR 100 mg\kg, respectively. Following perfusion and fixation, the animals were subjected to a wide craniectomy, and the brain, cerebellum, and brain stems were removed globally. Then, sections were taken from the basilar arteries of all animals and photographed at 40X magnification. Basilar artery lumen cross-sectional areas, basilar artery areas, and wall thicknesses were measured from these sections. The basilar artery lumen cross-sectional area was found to be significantly larger in the groups in which SAH was formed and ALCAR 50 mg\kg and ALCAR 100 mg\kg were given compared to the group with only SAH and SAH + SF (p = 0.0408). Basilar artery wall thickness increased in all groups except the control group (p < 0.05). In light of all these findings, it was concluded in our study that Carnitine was effective in the resolution of vasospasm in the experimental SAH model.
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Affiliation(s)
- Gokhan Resitoglu
- Department of Neurosurgery, Karaman Research and Education Hospital, Karaman, Turkey
| | | | - Ozkan Ates
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
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20
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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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21
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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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22
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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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23
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Singhal AB. Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment. Int J Stroke 2023; 18:1151-1160. [PMID: 37246916 DOI: 10.1177/17474930231181250] [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: 05/30/2023]
Abstract
Reversible segmental narrowing of the intracranial arteries has been described since several decades in numerous clinical settings, using variable nosology. Twenty-one years ago, we tentatively proposed the unifying concept that these entities, based on similar clinical-imaging features, represented a single cerebrovascular syndrome. This "reversible cerebral vasoconstriction syndrome" or RCVS has now come of age. A new International Classification of Diseases code, (ICD-10, I67.841) has been established, enabling larger-scale studies. The RCVS2 scoring system provides high accuracy in confirming RCVS diagnosis and excluding mimics such as primary angiitis of the central nervous system. Several groups have characterized its clinical-imaging features. RCVS predominantly affects women. Recurrent worst-ever (thunderclap) headaches are typical at onset. While initial brain imaging is often normal, approximately one-third to half develop complications such as convexity subarachnoid hemorrhages, lobar hemorrhages, ischemic strokes located in arterial "watershed" territories and reversible edema, alone or in combination. Vasoconstriction evolves over hours to days, first affecting distal and then the more proximal arteries. An overlap between RCVS and primary thunderclap headache, posterior reversible encephalopathy syndrome, Takotsubo cardiomyopathy, transient global amnesia, and other conditions has been recognized. The pathophysiology remains largely unknown. Management is mostly symptomatic: headache relief with analgesics and oral calcium-channel blockers, removal of vasoconstrictive factors, and avoidance of glucocorticoids that can significantly worsen outcome. Intra-arterial vasodilator infusions provide variable success. Overall, 90-95% of admitted patients achieve complete or major resolution of symptoms and clinical deficits within days to weeks. Recurrence is exceptional, although 5% can later develop isolated thunderclap headaches with or without mild cerebral vasoconstriction.
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Affiliation(s)
- Aneesh B Singhal
- Neurology Department, Massachusetts General Hospital, Boston, MA, USA
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24
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Solou M, Ydreos I, Papadopoulos EK, Demetriades AK, Boviatsis EJ. Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms. Surgeon 2023; 21:e328-e345. [PMID: 37451887 DOI: 10.1016/j.surge.2023.06.006] [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: 02/17/2023] [Revised: 04/09/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes. METHODS A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed. RESULTS Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation. CONCLUSIONS A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.
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Affiliation(s)
- Mary Solou
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece.
| | - Ioannis Ydreos
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| | - Evangelos K Papadopoulos
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| | - Andreas K Demetriades
- Department of Neurosurgery, Royal Infirmary Edinburgh, UK; Department of Neurosurgery, Leiden University Medical Centre, the Netherlands
| | - Efstathios J Boviatsis
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
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25
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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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26
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Pontes JPM, Santos MDC, Gibram FC, Rodrigues NMV, Cavalcante-Neto JF, Barros ADM, Solla DJF. Efficacy and Safety of Clazosentan After Aneurysmal Subarachnoid Hemorrhage: An Updated Meta-Analysis. Neurosurgery 2023; 93:1208-1219. [PMID: 37462365 DOI: 10.1227/neu.0000000000002601] [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: 09/04/2022] [Accepted: 05/18/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Clazosentan has been studied to treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH).This meta-analysis of randomized controlled trials updates the current knowledge regarding the efficacy and safety of clazosentan compared with placebo after aSAH. METHODS Databases were systematically searched for randomized controlled trials directly comparing the use of clazosentan and placebo for the treatment of cerebral vasospasm after aSAH. Additional eligibility criteria were the report of any of the outcomes of interest (vasospasm, morbidity, functional outcome, or mortality). The primary outcome was vasospasm-related delayed cerebral ischemia (DCI). The analyses were stratified by clazosentan dosage (low or high dose) and aneurysm treatment modality (clipping or coiling). The Cochrane RoB-2 tool was used for studies quality assessment. RESULTS Six studies comprising 7 clinical trials were included, involving 2778 patients. Clazosentan decreased the risk of vasospasm-related DCI (risk ratio [RR] 0.56, 95% CI 0.38-0.81) and delayed ischemic neurological deficit (RR 0.63, 95% 0.50-0.80). Angiographic vasospasm (RR 0.54, 95% CI 0.47-0.61) was also decreased. Functional outcomes (favorable Glasgow Outcome Scale, RR 0.99, 95% CI 0.79-1.24) and death (RR 1.03, 95% CI 0.71-1.49) did not change. Meanwhile, adverse events were increased by clazosentan (RR 1.54, 95% CI 1.35-1.76). CONCLUSION Clazosentan decreased vasospasm-related DCI and angiographic vasospasm but did not improve functional outcomes or mortality. Adverse events were increased by clazosentan.
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Affiliation(s)
- Julia Pereira Muniz Pontes
- Department of Surgical Specialties, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro , Rio de Janeiro , Brazil
| | | | - Franceliny Couto Gibram
- Department of Neurosurgery, University of Vale do Sapucai, Pouso Alegre , Minas Gerais , Brazil
| | | | | | | | - Davi J Fontoura Solla
- Division of Neurosurgery, Department of Neurology, Hospital das Clínicas da Faculdade de Medicina, University of São Paulo, São Paulo , Brazil
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27
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Bombardieri AM, Albers GW, Rodriguez S, Pileggi M, Steinberg GK, Heit JJ. Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence. J Neurointerv Surg 2023; 15:1212-1217. [PMID: 36597947 DOI: 10.1136/jnis-2022-019838] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 11/04/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022]
Abstract
Delayed cerebral ischemia (DCI) affects 30% of patients following aneurysmal subarachnoid hemorrhage (aSAH) and is a major driver of morbidity, mortality, and intensive care unit length of stay for these patients. DCI is strongly associated with cerebral arterial vasospasm, reduced cerebral blood flow and cerebral infarction. The current standard treatment with intravenous or intra-arterial calcium channel antagonist and balloon angioplasty or stent has limited efficacy. A simple treatment such as a cervical sympathetic block (CSB) may be an effective therapy but is not routinely performed to treat vasospasm/DCI. CSB consists of injecting local anesthetic at the level of the cervical sympathetic trunk, which temporarily blocks the innervation of the cerebral arteries to cause arterial vasodilatation. CSB is a local, minimally invasive, low cost and safe technique that can be performed at the bedside and may offer significant advantages as complementary treatment in combination with more conventional neurointerventional surgery interventions. We reviewed the literature that describes CSB for vasospasm/DCI prevention or treatment in humans after aSAH. The studies outlined in this review show promising results for a CSB as a treatment for vasospasm/DCI. Further research is required to standardize the technique, to explore how to integrate a CSB with conventional neurointerventional surgery treatments of vasospasm and DCI, and to study its long-term effect on neurological outcomes.
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Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Samuel Rodriguez
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marco Pileggi
- Neuroradiology, Lugano Regional Hospital Civico and Italiano Sites, Lugano, Switzerland
| | | | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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28
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Ohta T, Matsumoto S, Fukumitsu R, Imamura H, Adachi H, Hara Y, Hosoda K, Kimura H, Kuwayama K, Mizowaki T, Motooka Y, Miyata S, Shinoda N, Ueno Y, Yamaura I, Yoshida Y, Sakai C, Sakai N. Incidence and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Registry-based Descriptive Trial in Kobe City. Neurol Med Chir (Tokyo) 2023; 63:519-525. [PMID: 37648538 PMCID: PMC10725825 DOI: 10.2176/jns-nmc.2023-0090] [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: 04/24/2023] [Accepted: 07/03/2023] [Indexed: 09/01/2023] Open
Abstract
The current study aims to evaluate the incidence and results of aneurysmal subarachnoid hemorrhage (aSAH) throughout Kobe City. Based on a multicenter retrospective registry-based descriptive trial involving all 13 primary stroke centers in Kobe City, patients with aSAH treated between October 2017 and September 2019 were studied. A total of 334 patients were included, with an estimated age-adjusted incidence of 11.12 per 100,000 person-years. Curative treatment was given to 94% of patients, with endovascular treatment (51%) preferred over surgical treatment (43%). Of the patients, 12% were treated by shunt surgery for sequential hydrocephalus with a worse outcome at 30 days or discharge (14% vs. 46%, odds ratio (OR): 0.19, 95% confidence interval (CI): 0.088-0.39, p-value <0.001). As for vasospasm and delayed cerebral ischemia, most patients were given intravenous fasudil infusion (73%), with endovascular treatment for vasospasm in 24 cases (7.2%). The fasudil group had more good outcomes (42% vs. 30%, OR: 1.64, 95% CI: 0.95-2.87, p-value = 0.075) and significantly less death (3.3% vs. 35%, OR: 0.064, 95% CI: 0.024-0.15, p-value <0.001) at 30 days or discharge. Mortality rose from 12% at 30 days or discharge to 17% at 1 year, but neurological function distribution improved over time (modified Rankin Scale 0-2 was 39% at 30 days or discharge, 53% at 60 days, and 63% at 1 year). Our retrospective registered trial presented various statistics on aSAH, summarizing the current treatment status and prognosis.
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Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Shirabe Matsumoto
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center West Hospital
| | - Yoshie Hara
- Department of Neurosurgery, Hyogo Emergency Medical Center and Kobe Red Cross Hospital
| | - Kohkichi Hosoda
- Department of Neurosurgery, Kobe City Nishi-Kobe Medical Center
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | - Kazuyuki Kuwayama
- Department of Neurosurgery, Japan Community Health Care Organization Kobe Central Hospital
| | | | | | - Shiro Miyata
- Department of Neurosurgery, Kobe Ekisaikai Hospital
| | | | - Yasushi Ueno
- Department of Neurosurgery, Shinko Memorial Hospital
| | - Ikuya Yamaura
- Department of Neurosurgery, Cerebrovascular Research Institute, Yoshida Hospital
| | - Yasuhisa Yoshida
- Department of Neurosurgery, Cerebrovascular Research Institute, Yoshida Hospital
| | - Chiaki Sakai
- Department of Neurovascular Research, Kobe City Medical Center General Hospital
| | - Nobuyuki Sakai
- Department of Neurovascular Research, Kobe City Medical Center General Hospital
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29
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Pavelka M, Necarsulmer J, Ho J, Sasaki-Adams D. Vasospasm risk following aneurysmal subarachnoid hemorrhage in older adults. J Neurosurg 2023; 139:1302-1310. [PMID: 37119113 DOI: 10.3171/2023.3.jns222720] [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: 12/03/2022] [Accepted: 03/09/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Cerebral arterial vasospasm is a dreaded sequela of aneurysm rupture and can result in significant narrowing of the surrounding vasculature and subsequent cerebral ischemia. Treatment interventions are associated with distinct side effect profiles, including the risk of thrombosis and worsened ischemia, which may be associated with increased mortality-especially in older adults. An improved understanding of the likelihood of vasospasm in elderly patients would enable clinicians and patients to better consider the risks and benefits of vasospasm prophylaxis in this vulnerable population. This retrospective chart review aimed to assess the relationship between age at onset and the incidence of cerebral vasospasm among patients treated at the University of North Carolina Medical Center with spontaneous aneurysmal subarachnoid hemorrhage (aSAH). METHODS Electronic health record data from the Epic Systems Corp. database, compiled by the Carolina Data Warehouse for Health, were analyzed for patients older than 18 years who were previously treated for an SAH secondary to aneurysm at the University of North Carolina Medical Center within the past 10 years, ranging from June 2011 through June 2021. Logistic regression was used to calculate odds ratios and to determine the association of age with the occurrence of vasospasm following aSAH. RESULTS Of the 386 cases analyzed, 149 patients (38.6%) were older than 65 years at the time of aSAH. A total of 192 of the 386 patients (49.7%) developed vasospasm within the first 3-21 days following aSAH. Among the patients who developed vasospasm, only 31 of 192 patients (16.1%) were older than 65 years at the time of aneurysm rupture. Odds ratio calculations revealed that older adults (> 65 years) were 8 times less likely to develop vasospasm compared to their younger counterparts (p < 0.0001; 95% CI 5.0-13.0). CONCLUSIONS This study found that older patients are less likely to develop cerebral vasospasm following aSAH than are younger individuals. Age-associated changes in arteriosclerosis, inflammatory responses, and CSF dynamics may mitigate vascular narrowing in response to aSAH. This finding suggests that the aSAH treatment and vasospasm prevention paradigms should be revised to minimize potentially unnecessary interventions and avoid adverse outcomes for older adults.
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Affiliation(s)
| | | | - James Ho
- 2Neurology, and
- 3Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina; and
| | - Deanna Sasaki-Adams
- Departments of1Neurosurgery
- 4Department of Neurosurgery, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
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30
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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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31
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Wu Y, Lin F, Bai Y, Liang F, Wang X, Wang B, Jian M, Wang Y, Liu H, Wang A, Chen X, Han R. Early stellate ganglion block for improvement of postoperative cerebral blood flow velocity after aneurysmal subarachnoid hemorrhage: results of a pilot randomized controlled trial. J Neurosurg 2023; 139:1339-1347. [PMID: 37119094 DOI: 10.3171/2023.3.jns222567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/01/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Stellate ganglion block (SGB) is a commonly used sympathetic nerve block technique that may have benefits for patients with aneurysmal subarachnoid hemorrhage (aSAH) in the early stage. Cerebral vasospasm (CVS), one of the most common complications of aSAH, is accompanied by an abnormal increase in cerebral blood flow velocity (CBFV) and neurological dysfunction. In this pilot study the authors sought to determine the feasibility of early SGB for CVS in aSAH patients by observing the incidence of symptomatic CVS. METHODS Prior to receiving surgical treatment, patients with aSAH were randomly assigned to the SGB group or the non-SGB group. The primary outcome was the incidence of symptomatic CVS within 14 ± 2 days after the onset of aSAH. As a higher CBFV is often associated with CVS and a poor prognosis, the mean CBFV of the middle cerebral artery was observed immediately after surgery and on postoperative days 1, 2, 3, 5, and 7. Other secondary outcomes included transcranial Doppler (TCD)/CTA-type CVS, delayed cerebral ischemia during hospitalization, new cerebral infarction within 3 months, adverse events (AEs), and clinical prognosis. RESULTS Symptomatic CVS occurred in 40% of patients in the non-SGB group and in 20% in the SGB group (RR 0.50, 95% CI 0.22-1.16). Continuous TCD sonography revealed that the postoperative mean CBFV was lower in the SGB group than in the non-SGB group (F = 3.608, p = 0.02). In addition, the percentages of patients with CVS evaluated by TCD (TCD-CVS) and total new infarctions within 3 months were also significantly lower than those in patients with CVS (TCD-CVS 36.7% vs 70%, RR 0.52, 95% CI 0.31-0.89, and total new infarctions 26.7% vs 53.3%, RR 0.50, 95% CI 0.25-0.99). In terms of AEs and mortality, there were no significant differences between the two groups. CONCLUSIONS This pilot study demonstrated for the first time, to the authors' knowledge, that early SGB is feasible and has the potential to reduce the risk of CVS and improve the prognosis of aSAH. This method may be a new treatment for patients with aSAH that may have more advantages than traditional therapeutic drugs and is worth further study. Clinical trial registration no.: NCT04691271 (ClinicalTrials.gov).
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Affiliation(s)
| | - Fa Lin
- 2Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Yang Bai
- Departments of1Anesthesiology and
| | - Fa Liang
- Departments of1Anesthesiology and
| | | | - Bo Wang
- Departments of1Anesthesiology and
| | | | | | | | - Anxin Wang
- 3Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- 2Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
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32
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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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33
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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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Tarkiainen J, Hovi V, Pyysalo L, Ronkainen A, Frösen J. The clinical course and outcomes of non-aneurysmal subarachnoid hemorrhages in a single-center retrospective study. Acta Neurochir (Wien) 2023; 165:2843-2853. [PMID: 37659045 PMCID: PMC10542109 DOI: 10.1007/s00701-023-05767-4] [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: 05/09/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Non-aneurysmal subarachnoid hemorrhages (SAHs) are thought to have a benign clinical course compared to aneurysmal SAHs. The aim of this study is to report the clinical course and outcomes of non-aneurysmal SAHs in a large single-center study. METHODS The patients with non-aneurysmal SAHs were screened from Tampere University Hospital from 2005 to 2020. The clinical data were collected from the patient's medical records and from the imaging studies. The primary interest was the neurological outcome assessed by dichotomized GOS at 2 months. Multivariable logistic regression was used to study the factors associated with unfavorable outcome. RESULTS We found 216 non-aneurysmal SAHs in 214 patients (2 patients with > 1 bleed). Ninety-seven percent of patients with a typical perimesencephalic bleeding pattern SAH (PSAH) (75/77) had a favorable outcome, while 86% of patients with non-perimesencephalic SAH (NPSAH) had a favorable outcome (84/98). In a multivariable logistic regression analysis, loss of consciousness (LOC) (aOR 214.67, 95% CI 17.62-2615.89) and Fisher grade 4 bleeding pattern (aOR 23.32, 95% CI 1.40-387.98) were associated with increased risk for unfavorable outcome (GOS 1-3). Vasospasm was seen in 20% of non-aneurysmal SAH patients, hydrocephalus in 17%, and 13% needed ventriculostomy. CONCLUSIONS Non-aneurysmal SAH seems to have a good prognosis for majority of patients, especially for patients with a PSAH. Non-aneurysmal SAH patients are however affected by vasospasm and hydrocephalus and have similar risk factors for poor outcome as patients with aneurysmal SAH. This suggests that it is the severity of the bleed rather than the etiology that associates with poor outcome.
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Affiliation(s)
- Jeremias Tarkiainen
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland.
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland.
| | - Valtteri Hovi
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland
| | - Liisa Pyysalo
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland
- Department of Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Antti Ronkainen
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Juhana Frösen
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland
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Cole TS, Rudy RF, Faridmoayer E, Gandhi S, Cavallo C, Catapano JS, Jadhav AP, Lawton MT, Albuquerque FC, Ducruet AF. Relationship between cerebral vasospasm vascular territory and functional outcome after aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2023; 15:958-963. [PMID: 36379702 DOI: 10.1136/jnis-2022-019016] [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: 04/06/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) contributes significant morbidity and mortality after brain aneurysm rupture. However, the association between vascular territory of vasospasm and clinical outcome has not been studied. We present a hypothesis-generating study to determine whether the location of vasospasm within the intracranial circulation is associated with functional outcome after SAH. METHODS A retrospective analysis of a prospective, intention-to-treat trial for aneurysmal SAH was performed to supplement trial outcomes with in-hospital angiographic imaging and treatment variables regarding vasospasm. The location of vasospasm and the position on the vessel (distal vs proximal) were evaluated. Modified Rankin scale (mRS) outcomes were assessed at discharge and 6 months, and predictive models were constructed. RESULTS A total of 406 patients were included, 341 with follow-up data at 6 months. At discharge, left-sided vasospasm was associated with poor outcome (odds ratio (OR), 2.37; 95% CI, 1.25 to 4.66; P=0.01). At 6 months, anterior cerebral artery (ACA) vasospasm (OR, 3.87; 95% CI, 1.29 to 11.88; P=0.02) and basilar artery (BA) vasospasm (OR, 6.22; 95% CI, 1.54 to 27.11; P=0.01) were associated with poor outcome after adjustment. A model predicting 6-month mRS score and incorporating vasospasm variables achieved an area under the curve of 0.85 and a net improvement in reclassification of 13.2% (P<0.01) compared with a previously validated predictive model for aneurysmal SAH. CONCLUSIONS In aneurysmal SAH, left-sided vasospasm is associated with worse discharge functional status. At 6 months, both ACA and BA vasospasm are associated with unfavorable functional status.
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Affiliation(s)
- Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Erfan Faridmoayer
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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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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Carrera DA, Marsh LM, Roach JJ, Sarangarm P, Cole CD, Torbey MT, Carlson AP. HummingFlow: novel single twist-drill access for ventricular drainage, irrigation, monitoring, and automated local drug delivery in subarachnoid hemorrhage. J Neurosurg 2023; 139:1036-1041. [PMID: 37856891 DOI: 10.3171/2023.2.jns23295] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/08/2023] [Accepted: 02/17/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) remains one of the most important targets for neurocritical care. Advances in monitoring technology have facilitated a more thorough understanding of the pathophysiology and therapeutic approaches, but interventions are generally limited to either systemic therapies or passive CSF drainage. The authors present a novel approach that combines a multimodal monitoring bolt-based system with an irrigating ventricular drain capable of delivering intrathecal medications and describe their early experience in patients with aSAH. METHODS The authors performed a retrospective review of cases treated with the combined Hummingbird multimodal bolt system and the IRRAflow irrigating ventriculostomy. RESULTS Nine patients were treated with the combined multimodal bolt system with irrigating ventriculostomy approach. The median number of days to clearance of the third and fourth ventricles was 3 days in patients with obstructive intraventricular hemorrhage. Two patients received intrathecal alteplase for intraventricular hemorrhage clearance, and 2 patients received intrathecal nicardipine as rescue therapy for severe symptomatic angiographic vasospasm. CONCLUSIONS Combined CSF drainage, irrigation, multimodality monitoring, and automated local drug delivery are feasible using a single twist-drill hole device. Further investigation of irrigation settings and treatment approaches in high-risk cases is warranted.
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Affiliation(s)
| | - Laura M Marsh
- 2Neurosurgery, University of New Mexico, Albuquerque; and
| | | | - Preeyaporn Sarangarm
- 4Department of Pharmacy, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Chad D Cole
- 2Neurosurgery, University of New Mexico, Albuquerque; and
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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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Robert-Edan V, Lakhal K. Treating Vasospasm with IV Milrinone: Relax (The Vessel) or Don't Do It! Neurocrit Care 2023; 39:547-548. [PMID: 37434104 DOI: 10.1007/s12028-023-01789-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France
| | - Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France.
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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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Joos GS, Gottschalk A, Ewelt C, Holling M, Stummer W, Englbrecht JS. Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients. J Neurosurg Sci 2023; 67:576-584. [PMID: 35416450 DOI: 10.23736/s0390-5616.22.05497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS. METHODS Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale. RESULTS We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS. CONCLUSIONS Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.
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Affiliation(s)
- Gunther S Joos
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Antje Gottschalk
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Clinic Hamm-Heessen, Hamm, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Jan S Englbrecht
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany -
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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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Bokhari R, Elkaim LM, Shlobin NA, Alotaibi NM, Sabbagh AJ, Weil AG, Baeesa S, Dudley RWR, Atkinson J, Farmer JP. Vasospasm following brain tumor resection in children: institutional experience and systematic review. J Neurosurg Pediatr 2023; 32:343-350. [PMID: 37327188 DOI: 10.3171/2023.3.peds22373] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 03/28/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) associated with vasospasm is well described in the setting of aneurysmal subarachnoid hemorrhage (SAH). In addition, DCI is very infrequently encountered in patients who have undergone resection of a brain tumor with unclear pathophysiology. The occurrence of DCI in the pediatric population is exceedingly rare, and outcomes in this population have, to the authors' knowledge, never been systematically reviewed. Therefore, the authors present what is to their knowledge the largest series of pediatric patients with this complication and systematically reviewed the literature for individual participant data. METHODS The authors conducted a retrospective review of 172 sellar and suprasellar tumors in pediatric patients who underwent surgery at the Montreal Children's Hospital between 1999 and 2017 to identify cases of vasospasm occurring after tumor resection. Descriptive statistics, including patient characteristics, intraoperative and postoperative findings, and outcome status, were collected. A systematic review was also conducted using three databases (PubMed, Web of Science, Embase) to identify reported cases available in the literature of vasospasm after tumor resection in children and collect individual participant data on these patients for further analysis. RESULTS Six patients treated at Montreal Children's Hospital were identified, with an average age of 9.5 years (range 6-15 years). The prevalence of vasospasm after tumor resection was 3.5% (6/172). Vasospasm in all 6 patients occurred after craniotomy was performed to treat a suprasellar tumor. The average interval from surgery to symptoms was 3.25 days (range 12 hours-10 days). The most common tumor etiology was craniopharyngioma, seen in 4 cases. Extensive tumor encasement of blood vessels requiring significant operative manipulation was described in all 6 patients. A rapid decrease in serum sodium (exceeding 12 mEq/L/24 hrs or below 135 mEq/L) was seen in 4 patients. On final follow-up, 3 patients were left with significant disability, and all patients had persistent deficits. A systematic review of the literature revealed a total of 10 other patients whose characteristics and treatment were compared with those of the 6 patients treated at Montreal Children's Hospital. CONCLUSIONS Vasospasm after tumor resection in children and youth is likely a rare entity, with a prevalence of 3.5% in this case series. Suprasellar tumor location (particularly craniopharyngioma tumor etiology), significant encasement of blood vessels by the tumor, and postoperative hyponatremia may be predictive factors. Outcome is poor, with most patients having significant persistent neurological deficits.
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Affiliation(s)
- Rakan Bokhari
- 1Division of Neurosurgery, Department of Surgery, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- 2Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
| | - Lior M Elkaim
- 2Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
| | - Nathan A Shlobin
- 3Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Naif M Alotaibi
- 4Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman J Sabbagh
- 1Division of Neurosurgery, Department of Surgery, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Alexander G Weil
- 5Division of Surgery, St-Justine University Hospital, Montréal, Québec, Canada
| | - Saleh Baeesa
- 6Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; and
| | - Roy W R Dudley
- 2Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
- 7Department of Paediatric Surgery, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Jeffrey Atkinson
- 2Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
- 7Department of Paediatric Surgery, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Jean-Pierre Farmer
- 2Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
- 7Department of Paediatric Surgery, McGill University Health Centre, McGill University, Montréal, Québec, Canada
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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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Jesser J, Awounvo S, Vey JA, Vollherbst DF, Hilgenfeld T, Chen M, Nguyen TN, Schönenberger S, Bendszus M, Möhlenbruch MA, Weyland CS. Prediction and outcomes of cerebral vasospasm in ischemic stroke patients receiving anterior circulation endovascular stroke treatment. Eur Stroke J 2023; 8:684-691. [PMID: 37254510 PMCID: PMC10472964 DOI: 10.1177/23969873231177766] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/07/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Vasospasm is a common complication of endovascular therapy (EVT). There is a lack of understanding of risk factors for periprocedural vasospasm. Here, we aimed to identify factors associated with vasospasm in patients with acute ischemic stroke who undergo EVT. METHODS We conducted a retrospective single-center analysis of patients receiving EVT for anterior circulation vessel occlusion between January 2015 and December 2021. Patients were excluded if they showed signs of intracranial atherosclerotic disease (ICAD) or if they underwent intra-arterial thrombolysis. Study groups were defined as patients developing vasospasm during EVT (V+) and patients who did not (V-). The study groups were compared in univariable analysis. Multivariable regression models were developed to predict the patient's risk for developing vasospasm based on pre-identified potential prognostic factors. The secondary endpoint was clinical outcome defined as the modified Rankin Scale (mRS) difference between pre-stroke mRS and discharge mRS (delta mRS) and likelihood of successful reperfusion (TICI 2b/3). RESULTS In total, 132/1768 patients (7.5%) developed vasospasm during EVT. Vasospasm was more likely to occur in EVT with multiple thrombectomy attempts and after several stent retriever maneuvers. Factors associated with developing vasospasm were younger age (OR = 0.967, 95% CI = 0.96-0.98) and lower pre-stroke mRS (OR = 0.759, 95% CI = 0.63-0.91). The prediction model incorporating patient age, pre-stroke mRS, stent retriever thrombectomy attempts, and total attempts as prognostic factors was found to predict vasospasm with good accuracy (AUC = 0.714, 95% CI = 0.709-0.720). V+ patients showed higher median (IQR) delta mRS (2 (1-4) vs 2 (1-3); p = 0.014). There was no difference in successful reperfusion (TICI 2b-3) between those with or without vasospasm. CONCLUSION Vasospasm was a common complication in EVT affecting younger and previously healthy patients. Presence of vasospasm did not reduce the likelihood of successful reperfusion. As independent predictors, patient age, pre-stroke mRS, thrombectomy maneuvers, and stent retriever attempts predict the occurrence of vasospasm during EVT with good accuracy.
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Affiliation(s)
- Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sinclair Awounvo
- Department of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes A Vey
- Department of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Tim Hilgenfeld
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thanh N Nguyen
- Department of Neurology and Department of Radiology, Boston Medical Center, Boston, MA, USA
| | | | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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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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Muraoka S, Asai T, Fukui T, Ota S, Shimato S, Koketsu N, Nishizawa T, Araki Y, Saito R. Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study. Neurosurg Rev 2023; 46:195. [PMID: 37555872 DOI: 10.1007/s10143-023-02104-2] [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: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/10/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.
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Affiliation(s)
- Shinsuke Muraoka
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan.
| | - Takumi Asai
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takahiko Fukui
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shinji Ota
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Shinji Shimato
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Naoki Koketsu
- Department of Neurosurgery, Tosei General Hospital, Seto, Aichi, Japan
| | - Toshihisa Nishizawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Takao K, Matsuta H, Murata K, Fujiki M. Reversible cerebral vasospasm and cerebral infarction secondary to meningitis following penetrating head trauma with bamboo. BMJ Case Rep 2023; 16:e254676. [PMID: 37553171 PMCID: PMC10414058 DOI: 10.1136/bcr-2023-254676] [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: 08/10/2023] Open
Abstract
A man in the 70s fell on a bamboo and punctured his left upper eyelid. CT of the head showed fractures of the medial and superior walls of the left orbit, intracranial traumatic subarachnoid haemorrhage, intraventricular haematoma and left frontal cerebral contusion. He was treated conservatively. Despite prophylactic antibiotic therapy, he had prolonged loss of consciousness. A cerebrospinal fluid examination revealed bacterial meningitis. Imaging studies on day 15 showed extensive subacute cerebral infarction in the bilateral parieto-occipital lobes and main trunk artery stenosis. On day 31, MRA showed improvement of the main arteries, and cerebral vasospasm-induced cerebral infarction was diagnosed. He was transferred to rehabilitation with full assistance. The prognosis of bamboo perforation trauma is critical. Thus, preventing and treating central nervous system infection are considered the key to the prognosis. However, given the lack of established treatment for meningitis-associated cerebral vasospasm, case-specific treatment must be considered.
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Affiliation(s)
- Kunpei Takao
- Department of Neurosurgery, Oita University Hospital, Yufu, Oita, Japan
| | - Hiroyuki Matsuta
- Department of Neurosurgery, Oita University School of Medicine Graduate School of Medicine, Yufu, Japan
| | - Kumi Murata
- Department of Forensic Medicine, Oita University School of Medicine Graduate School of Medicine, Yufu, Japan
| | - Minoru Fujiki
- Department of Neurosurgery, Oita University School of Medicine Graduate School of Medicine, Yufu, Japan
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Deem S, Diringer M, Livesay S, Treggiari MM. Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:81-90. [PMID: 37160848 DOI: 10.1007/s12028-023-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023]
Abstract
One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. Hypovolemia and hypotension were favored prior to the era of early aneurysmal surgery but were subsequently replaced by the use of hypervolemia and hypertension. More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.
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Affiliation(s)
- Steven Deem
- Neurocritical Care Unit, Swedish Medical Center, Seattle, WA, USA.
| | - Michael Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- College of Nursing, Rush University, Chicago, IL, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical School, Durham, NC, USA
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