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Moncur EM, Craven CL, Al-Ahmad S, Jones B, Robertson F, Reddy U, Toma AK. Chemical angioplasty vs. balloon plus chemical angioplasty for delayed cerebral ischemia: a pilot study of PbtO 2 outcomes. Acta Neurochir (Wien) 2024; 166:179. [PMID: 38627273 PMCID: PMC11021294 DOI: 10.1007/s00701-024-06066-2] [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: 10/31/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Delayed cerebral ischaemia (DCI) is a major cause of morbidity and mortality after aneurysmal subarachnoid haemorrhage (aSAH). Chemical angioplasty (CA) and transluminal balloon angioplasty (TBA) are used to treat patients with refractory vasospasm causing DCI. Multi-modal monitoring including brain tissue oxygenation (PbtO2) is routinely used at this centre for early detection and management of DCI following aSAH. In this single-centre pilot study, we are comparing these two treatment modalities and their effects on PbtO2. METHODS Retrospective case series of patients with DCI who had PbtO2 monitoring as part of their multimodality monitoring and underwent either CA or TBA combined with CA. PbtO2 values were recorded from intra-parenchymal Raumedic NEUROVENT-PTO® probes. Data were continuously collected and downloaded as second-by-second data. Comparisons were made between pre-angioplasty PbtO2 and post-angioplasty PbtO2 median values (4 h before angioplasty, 4 h after and 12 h after). RESULTS There were immediate significant improvements in PbtO2 at the start of intervention in both groups. PbtO2 then increased by 13 mmHg in the CA group and 15 mmHg in the TBA plus CA group in the first 4 h post-intervention. This improvement in PbtO2 was sustained for the TBA plus CA group but not the CA group. CONCLUSION Combined balloon plus chemical angioplasty results in more sustained improvement in brain tissue oxygenation compared with chemical angioplasty alone. Our findings suggest that PbtO2 is a useful tool for monitoring the response to angioplasty in vasospasm.
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Affiliation(s)
- Eleanor M Moncur
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK.
| | - Claudia L Craven
- Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Selma Al-Ahmad
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Bethany Jones
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Fergus Robertson
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ugan Reddy
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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Jia Y, He E, Lu C, Zhao C. A Case of Pregnancy-Induced Hereditary Thrombotic Thrombocytopenic Purpura Complicated by Cerebral Vasospasm. Clin Lab 2024; 70. [PMID: 38623670 DOI: 10.7754/clin.lab.2023.231010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND The aim was to explore the treatment of a case of congenital thrombotic thrombocytopenic purpura induced by pregnancy complicated with cerebral vasospasm. METHODS We present a case study of congenital TTP where disease onset occurred during two separate pregnancies. Interestingly, the disease course exhibited distinct differences on each occasion. Additionally, following plasma transfusion therapy, there was a transient occurrence of cerebral vasospasm. RESULTS In this case, ADAMTS13 levels reached their lowest point three days after delivery during the first pregnancy, triggering morbidity. Remarkably, a single plasma transfusion of 400 mL sufficed for the patient's recovery. Nonetheless, a recurrence of symptoms transpired during her second pregnancy at 24 weeks of gestation. Plasma transfusions were administered during and after delivery. Sudden convulsions developed. ADAMTS13 ac-tivity returned to normal, but cranial MRA revealed constrictions in the intracranial segments of both vertebral arteries, the basilar artery, and the lumen of the anterior, middle, and posterior cerebral arteries. A subsequent cranial MRA conducted a month later showed no lumen stenosis, indicating spontaneous recovery. CONCLUSIONS These findings highlight the importance of careful consideration when administering plasma transfusions in congenital TTP during pregnancy. Moreover, the development of novel therapeutic approaches such as recombinant ADAMTS13 is crucial for minimizing complications and optimizing patient care.
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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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Sorrentino ZA, Lucke-Wold BP, Laurent D, Quintin SS, Hoh BL. Interventional Treatment of Symptomatic Vasospasm in the Setting of Traumatic Brain Injury: A Systematic Review of Reported Cases. World Neurosurg 2024; 183:45-55. [PMID: 38043741 DOI: 10.1016/j.wneu.2023.11.135] [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] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies.
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Affiliation(s)
- Zachary A Sorrentino
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Brandon P Lucke-Wold
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dimitri Laurent
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Stephan S Quintin
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brian L Hoh
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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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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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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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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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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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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Neumann A, Weber W, Küchler J, Schacht H, Jensen-Kondering U, Berlis A, Schramm P. Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018-2021: an overview of the current care situation. ROFO-FORTSCHR RONTG 2023; 195:1018-1026. [PMID: 37467777 DOI: 10.1055/a-2102-0129] [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: 07/21/2023]
Abstract
BACKGROUND Evaluation of endovascular therapies for cerebral vasospasm (CVS) documented in the DeGIR registry from 2018-2021 to analyse the current clinical care situation in Germany. METHODS Retrospective analysis of the clinical and procedural data on endovascular spasm therapies (EST) documented anonymously in the DeGIR registry. We analysed: pre-interventional findings of CTP and consciousness; radiation dose applied, interventional-technical parameters (local medication, devices, angiographic result), post-interventional symptoms, complications and mortality. RESULTS 3584 patients received a total of 7628 EST (median age/patient: 53 [range: 13-100, IQR: 44-60], 68.2 % women) in 91 (2018), 92 (2019), 100 (2020) and 98 (2021) centres; 5388 (70.6 %) anterior circulation and 378 (5 %) posterior circulation (both involved in 1862 cases [24.4 %]). EST was performed once in 2125 cases (27.9 %), with a mean of 2.1 EST/patient. In 7476 times, purely medicated EST were carried out (nimodipine: 6835, papaverine: 401, nitroglycerin: 62, other drug not specified: 239; combinations: 90). Microcatheter infusions were documented in 1132 times (14.8 %). Balloon angioplasty (BA) (additional) was performed in 756 EST (9.9 %), other mechanical recanalisations in 154 cases (2 %) and stenting in 176 of the EST (2.3 %). The median dose area product during ET was 4069 cGycm² (drug: 4002/[+]BA: 8003 [p < 0.001]). At least 1 complication occurred in 95 of all procedures (1.2 %) (drug: 1.1 %/[+]BA: 4.2 % [p < 0.001]). Mortality associated with EST was 0.2 % (n = 18). After EST, overall improvement or elimination of CVS was found in 94.2 % of cases (drug: 93.8 %/[+]BA: 98.1 % [p < 0.001]). In a comparison of the locally applied drugs, papaverine eliminated CVS more frequently than nimodipine (p = 0.001). CONCLUSION EST have a moderate radiation exposure and can be performed with few complications. Purely medicated EST are predominantly performed, especially with nimodipine. With (additional) BA, radiation exposure, complication rates and angiographic results are higher or better. When considering drug EST alone, there is evidence for an advantage of papaverine over nimodipine, but a different group size has to be taken into account. In the analysis of EST, the DeGIR registry data are suitable for answering more specific questions, especially due to the large number of cases; for this purpose, further subgroupings should be sought in the data documentation. KEY POINTS · In Germany, there are currently no guidelines for the endovascular treatment of cerebral vasospasm following spontaneous subarachnoid hemorrhage.. · In addition to oral nimodipine administration endovascular therapy is used to treat cerebral vasospasm in most hospitals.. · This is the first systematic evaluation of nationwide registry data on endovascular treatment of cerebral vasopasm in Germany.. · This real-world data shows that endovascular treatment for cerebral vasospasm has a moderate radiation exposure and can be performed with few complications overall. With (additional) balloon angioplasty, radiation exposure, complication rates and angiographic therapy results are higher or better.. CITATION FORMAT · Neumann A, Weber W, Küchler J et al. Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018-2021: an overview of the current care situation. Fortschr Röntgenstr 2023; 195: 1018 - 1026.
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Affiliation(s)
- Alexander Neumann
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Werner Weber
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Ulf Jensen-Kondering
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, 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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12
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Wolfert C, Maurer CJ, Sommer B, Steininger K, Motov S, Bonk MN, Krauss P, Berlis A, Shiban E. Management of perimesencephalic nonaneurysmal subarachnoid hemorrhage: a national survey. Sci Rep 2023; 13:12805. [PMID: 37550334 PMCID: PMC10406943 DOI: 10.1038/s41598-023-39195-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023] Open
Abstract
Perimesencephalic nonaneurysmal subarachnoid hemorrhage (NASAH) is a rare type of subarachnoid hemorrhage (SAH), usually associated with minor complications compared to aneurysmal SAH. Up to date, data is scarce and consensus on therapeutic management and follow-up diagnostics of NASAH is often missing. This survey aims to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding.
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Affiliation(s)
- Christina Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Christoph J Maurer
- Department of Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Björn Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kathrin Steininger
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Motov
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Maximilian-Niklas Bonk
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Philipp Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Ansgar Berlis
- Department of Neuroradiology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Salvagno M, Gouvea Bogossian E, Halenarova K, Ego A, Taccone FS. Cervical Ganglion Sympathectomy to Treat Cerebral Vasospasm in Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:241-249. [PMID: 36828982 DOI: 10.1007/s12028-023-01694-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
Delayed cerebral ischemia (DCI) is still a significant cause of death and disability after aneurysmal subarachnoid hemorrhage. Cerebral vasospasm represents one of the most reported mechanisms associated with DCI. The management of DCI-related vasospasm remains a significant challenge for clinicians; induced hypertension, intraarterial vasodilators, and/or intracranial vessel angioplasty-particularly in refractory or recurrent cases-are the most used therapies. Because an essential role in the pathophysiology of cerebral vasospasm has been attributed to the adrenergic sympathetic nerves, a "sympatholytic" intervention, consisting of a temporary interruption of the sympathetic pathways using local anesthetics, has been advocated to minimize the vascular narrowing and reverse the consequences of cerebral vasospasm on tissue perfusion. In this review, we have analyzed the existing literature on the block of the cervical ganglions, particularly the stellate ganglion, in managing refractory cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. These findings could help clinicians to understand the potential role of such intervention and to develop future interventional trials in this setting.
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Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium.
| | | | - Katarina Halenarova
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Amedée Ego
- Department of Intensive Care, Hôpitaux Iris Sud, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
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14
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Samagh N, Panda NB, Gupta V, Bharti N, Tripathi M, Bhagat H, Chhabra RK, Jangra K, Luthra A. Impact of Stellate Ganglion Block in the Management of Cerebral Vasospasm: A Prospective Interventional Study. Neurol India 2022; 70:289-295. [PMID: 35263898 DOI: 10.4103/0028-3886.338735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters. MATERIALS AND METHODS We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated. RESULTS After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients. CONCLUSION SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.
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Affiliation(s)
- Navneh Samagh
- Department of Anaesthesiology and Critical Care, AIIMS, Bathinda, India
| | - Nidhi B Panda
- Professor Neuroanesthesia, Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Vivek Gupta
- Additional Director Interventional Neuroradiology, Fortis Healthcare, Chandigarh, India
| | - Neerja Bharti
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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Abstract
PURPOSE OF REVIEW Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH. RECENT FINDINGS Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes. SUMMARY Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.
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Labeyrie MA, Simonato D, Gargalas S, Morisson L, Cortese J, Ganau M, Fuschi M, Patel J, Froelich S, Gaugain S, Chousterman B, Houdart E. Intensive therapies of delayed cerebral ischemia after subarachnoid hemorrhage: a propensity-matched comparison of different center-driven strategies. Acta Neurochir (Wien) 2021; 163:2723-2731. [PMID: 34302553 DOI: 10.1007/s00701-021-04935-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intensive therapies of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) have still controversial and unproven benefit. We aimed to compare the overall efficacy of two different center-driven strategies for the treatment of DCI respectively with and without vasospasm angioplasty. METHODS Two hundred consecutive patients with aSAH were enrolled in each of two northern European centers. In an interventional center, vasospasm angioplasty was indicated as first line rather than rescue treatment of DCI using distal percutaneous balloon angioplasty technique combined with intravenous milrinone. In non-interventional center, induced hypertension was the only intensive therapy of DCI. Radiological DCI (new cerebral infarcts not visible on immediate post-treatment imaging), death at 1 month, and favorable outcome at 6 months (modified Rankin scale score ≤ 2) were retrospectively analyzed by independent observers and compared between two centers before and after propensity score (PS) matching for baseline characteristics. RESULTS Baseline characteristics only differed between centers for age and rate of smokers and patients with chronic high blood pressure. In the interventional center, vasospasm angioplasty was performed in 38% of patients with median time from bleeding of 8 days (Q1 = 6.5;Q3 = 10). There was no significant difference of incidence of radiological DCI (9% vs.14%, P = 0.11), death (8% vs. 9%, P = 0.4), and favorable outcome 74% vs. 72% (P = 0.4) between interventional and non-interventional centers before and after PS matching. CONCLUSIONS Our results suggest either that there is no benefit, or might be minimal, of one between two different center-driven strategies for intensive treatment of DCI. Despite potential lack of power or unknown confounders in our study, these results question the use of such intensive therapies in daily practice without further optimization and validation.
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Affiliation(s)
- Marc-Antoine Labeyrie
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France.
| | - Davide Simonato
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Sergios Gargalas
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Louis Morisson
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Jonathan Cortese
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France
| | - Mario Ganau
- Neurosurgery Unit, John Radcliffe Hospital, Oxford, UK
| | - Maurizio Fuschi
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Jash Patel
- Neurosurgery Unit, John Radcliffe Hospital, Oxford, UK
| | - Sébastien Froelich
- Neurosurgery Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Samuel Gaugain
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Benjamin Chousterman
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
- UMR 1123, Université de Paris, INSERM, Paris, France
| | - Emmanuel Houdart
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France
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Wang T, Richard SA, Li J, Jiao H, Zhang C, Wang C, Lin S, Xie X, You C. Cerebral vasospasm resulted in "stent shortening" after pipeline assisted coil embolization for blood blister aneurysms. Medicine (Baltimore) 2021; 100:e26971. [PMID: 34414968 PMCID: PMC8376338 DOI: 10.1097/md.0000000000026971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/01/2021] [Indexed: 02/05/2023] Open
Abstract
Blood blister aneurysms (BBAs) are intracranial arterial lesions appearing in nonbranching sites of the supraclinoid internal carotid artery as well as the basilar artery. Endovascular treatment of BBAs is still not well established because of the rarity of these lesions. We report incidences of BBAs with associated vasospasms. Treatment of the BBAs and associate vasospasms with single Pipeline Flex embolization device (PLED) assisted coiling resulted in seemly shorting of the PLEDs in 3 patients.A retrospective analysis of patients with BBAs who were treated with single PLED assisted coiling from July 2018 to October 2019 was conducted. Patients' ethnic and medical records, aneurysmal characteristics, intraoperative-rupture, cerebral vasospasm (CVS), postprocedure contrast filling, follow-up imaging, and results were analyzed. Neurological examination at baseline and outcome based on modified Rankin scale (mRS) at discharge as well as follow-ups were also documented.Six patients consisting of 5 females and 1 male, with a mean age of 48.3 years (range from 34-67) were identified during our analysis. All the BBAs were located in nonbranching site of supra-clinoidal segment of internal carotid artery with a mean neck width of 4.5 mm and mean aneurysm size of 4.23 mm. PLED assisted coiling's were performed in all of them. CVS was observed in 3 patients while 1 patient had an intraoperative-rupture of the BBA. Postprocedure contrast filling was still present in 1 patient. All the patients had good outcomes with discharge and follow-up mRS scores ≤ 2 except 1 patient with mRS score = 3 with aphasia.PLED assisted endovascular coiling is very safe and efficient in treating patients with BBAs. Resolution of CVSs after treatment made the PLEDs seemly shorter. Furthermore, a combination of arterial lengthening after gaining their tensile strength back and radical expansion of the PLED could account for the shortening.
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Affiliation(s)
- Ting Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
- Department of Medicine, Princefield University, P. O. Box MA 128, Ho-Volta Region, Ghana
| | - Junrao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - He Jiao
- Department of Radiology, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
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Neumann A, Küchler J, Ditz C, Krajewski K, Leppert J, Schramm P, Schacht H. Non-compliant and compliant balloons for endovascular rescue therapy of cerebral vasospasm after spontaneous subarachnoid haemorrhage: experiences of a single-centre institution with radiological follow-up of the treated vessel segments. Stroke Vasc Neurol 2021; 6:16-24. [PMID: 32709603 PMCID: PMC8005899 DOI: 10.1136/svn-2020-000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/06/2020] [Accepted: 06/24/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND For endovascular rescue therapy (ERT) of cerebral vasospasm (CVS) due to spontaneous subarachnoid haemorrhage (sSAH), non-compliant (NCB) and compliant (CB) balloons are used with both balloon types bearing the risk of vessel injury due to specific mechanical properties. Although severe delayed arterial narrowing after transluminal balloon angioplasty (TBA) for CVS has sporadically been described, valid data concerning incidence and relevance are missing. Our aim was to analyse the radiological follow-up (RFU) of differently TBA-treated arteries (CB or NCB). METHODS Twelve patients with utilisation of either NCB or CB for CVS were retrospectively analysed for clinical characteristics, ERT, functional outcome after 3 months and RFU. Compared with the initial angiogram, we classified delayed arterial narrowing as mild, moderate and severe (<30%, 30%-60%, respectively >60% calibre reduction). RESULTS Twenty-three arteries were treated with CB, seven with NCB. The median first RFU was 11 months after TBA with CB and 10 after NCB. RFU was performed with catheter angiography in 18 arteries (78%) treated with CB and in five (71%) after NCB; magnetic resonance angiography was acquired in five vessels (22%) treated with CB and in two (29%) after NCB. Mild arterial narrowing was detected in three arteries (13%) after CB and in one (14%) after NCB. Moderate or severe findings were neither detected after use of CB nor NCB. CONCLUSION We found no relevant delayed arterial narrowing after TBA for CVS after sSAH. Despite previous assumptions that CB provides for more dilatation in segments adjacent to CVS, we observed no disadvantages concerning long-term adverse effects. Our data support TBA as a low-risk treatment option.
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Affiliation(s)
- Alexander Neumann
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Küchler
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Claudia Ditz
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Kara Krajewski
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Leppert
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Peter Schramm
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Hannes Schacht
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
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20
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Bender M, Richter E, Schwarm FP, Kolodziej MA, Uhl E, Reinges MHT, Stein M. Transcranial Doppler Sonography Defined Vasospasm, Ischemic Brain Lesions, and Delayed Ischemic Neurological Deficit in Younger and Elderly Patients after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 138:e718-e724. [PMID: 32198122 DOI: 10.1016/j.wneu.2020.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 01/07/2020] [Accepted: 03/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Vasospasm, delayed ischemic neurologic deficit (DIND), and ischemic brain lesions after acute subarachnoid hemorrhage (SAH) are associated with increased morbidity and mortality. The purpose of this study was to analyze age cutoffs for vasospasm, DIND, and ischemic brain lesions after SAH. METHODS This study included 292 aneurysmal SAH patients from January 2005 to December 2015. Patients' data were extracted from a prospective database with measurements of transcranial Doppler sonography. Any vasospasm was defined as a maximum mean flow velocity (MMFV) >120 cm/sec. Severe vasospasms were defined as at least 2 measurements of MMFVs >200 cm/sec or an increase of MMFV >50 cm/sec/24 hours over 2 consecutive days or a new neurologic deficit. All MMFVs >120 cm/sec in absence of severe vasospasm criteria were defined as mild vasospasm. Age-related cutoff values were calculated using receiver operating curve analysis. RESULTS Any vasospasms occurred in 142 patients and thereof mild vasospasm in 86/142 (60.6%) patients and severe vasospasm in 56/142 patients (39.4%). Significantly higher incidences of any vasospasm (P = 0.005), severe vasospasm (P = 0.003), DIND (P = 0.031), and ischemic brain lesions (P = 0.04) were observed in patients aged <50 years. According to receiver operating curve analysis, the optimal age cutoff was 50 years for the presence of overall vasospasms, severe vasospasms, DIND, and ischemic brain lesions and 65 years for mild vasospasms. CONCLUSIONS Higher incidences of any vasospasms, severe vasospasms, DIND, and ischemic brain lesions were observed in younger SAH patients.
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Affiliation(s)
- Michael Bender
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany.
| | - Eva Richter
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - Frank P Schwarm
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | | | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - Marcus H T Reinges
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany; Department of Neurosurgery, Bremen-Mitte Hospital, Bremen, Bremen, Germany
| | - Marco Stein
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
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21
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Norby K, Young M, Siddiq F. Use of stent retriever for treatment of iatrogenic intracranial vasospasm. Interv Neuroradiol 2019; 25:511-515. [PMID: 31088245 PMCID: PMC6777108 DOI: 10.1177/1591019919848771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 01/20/2019] [Accepted: 04/03/2019] [Indexed: 12/22/2022] Open
Abstract
Cerebral vasospasm is a source of morbidity and mortality, not only associated with aneurysmal subarachnoid hemorrhage (SAH) but also with endovascular procedures. Treatment of vasospasm associated with SAH include trans-luminal balloon angioplasty and intra-arterial delivery of vasodilator medications. We present a case report of a patient who underwent a mechanical thrombectomy for stroke and suffered from vasospasm. This severe flow-limiting vasospasm was successfully treated with the Trevo stent device. Although stent retrievers have become more widespread for thrombectomy, vasospasm treatment has not been often described in the literature. Further study is needed to determine if this is a viable technique for treating resistant vasospasm.
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Affiliation(s)
- K Norby
- 5024 Preservation Ave, Colleyville,
USA
| | - M Young
- 5128 Chessie Circle, Haltom City,
USA
| | - F Siddiq
- University of Missouri, Columbia,
USA
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22
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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Yamada H, Kikuchi R, Nakamura A, Miyazaki H. Severe Reversible Cerebral Vasoconstriction Syndrome with Large Posterior Cerebral Infarction. J Stroke Cerebrovasc Dis 2018; 27:3043-3045. [PMID: 30087075 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/28/2018] [Accepted: 06/30/2018] [Indexed: 11/20/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome is characterized by thunderclap headache and multifocal cerebral vasoconstriction. Cerebral vasoconstriction is reversible, and most cases have good prognosis. However, clinical outcome is possibly severe when it is complicated by stroke, yet detailed reports on such a case are few. We experienced a case of severe reversible cerebral vasoconstriction syndrome in a 32-year-old woman with medical history of preeclampsia 3years prior. She presented with sudden sharp headache followed by altered mental status and vasoconstriction of the bilateral posterior cerebral arteries. She was treated with intravenous and oral calcium channel blockers, edaravone, and glycerol. However, the cerebral infarction in the posterior circulation subsequently remained, and her impaired consciousness did not recover. Furthermore, although imaging findings of vasoconstriction showed improvement a day after the occurrence of symptom, the same vessels showed poor visualization 7 weeks later, which indicated the recurrence of vasoconstriction, without additional symptom due to the fixed infarction. Although most cases of reversible cerebral vasoconstriction syndrome show good prognosis, neurologists must monitor the possibility of worse clinical course and permanent neurological deficit when associated with stroke, such as cerebral infarction. Strict management and treatment are needed in these cases.
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MESH Headings
- Adult
- Cerebral Angiography/methods
- Diffusion Magnetic Resonance Imaging
- Female
- Headache Disorders, Primary/etiology
- Headache Disorders, Primary/physiopathology
- Humans
- Infarction, Posterior Cerebral Artery/diagnostic imaging
- Infarction, Posterior Cerebral Artery/etiology
- Infarction, Posterior Cerebral Artery/physiopathology
- Infarction, Posterior Cerebral Artery/therapy
- Magnetic Resonance Angiography
- Posterior Cerebral Artery/diagnostic imaging
- Posterior Cerebral Artery/physiopathology
- Syndrome
- Tomography, X-Ray Computed
- Vasoconstriction
- Vasospasm, Intracranial/complications
- Vasospasm, Intracranial/diagnostic imaging
- Vasospasm, Intracranial/physiopathology
- Vasospasm, Intracranial/therapy
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Affiliation(s)
- Hiroki Yamada
- Department of Neurosurgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa 254-0065, Japan.
| | - Ryogo Kikuchi
- Department of Neurosurgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa 254-0065, Japan
| | - Akiyoshi Nakamura
- Department of Neurosurgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa 254-0065, Japan
| | - Hiromichi Miyazaki
- Department of Neurosurgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa 254-0065, Japan
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Takemaru M, Takeshima S, Hara N, Himeno T, Shiga Y, Takeshita J, Takamatsu K, Nomura E, Shimoe Y, Kuriyama M. [Reversible cerebral vasoconstriction syndrome: a clinical study of 11 cases]. Rinsho Shinkeigaku 2018; 58:377-384. [PMID: 29863100 DOI: 10.5692/clinicalneurol.cn-001143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This study reports eleven cases of reversible cerebral vasospasm syndrome (RCVS). Of the 11 patients, two were males and nine were females, with the average age of 47.9 ± 14.1 years. Many of these patients were young. The rates of severe, intractable and pulsative headache, generalized convulsions, and motor hemiparesis were 64%, 27%, and 36%, respectively. As complications of intracerebral lesions in the early stage of disease onset, convexal subarachnoid hemorrhage, lobar intracerebral hemorrhage, and posterior reversible encephalopathy syndrome were observed in 63%, 9%, and 45% of cases, respectively. Cerebral infarction occurred in 45% of cases at around 1-3 weeks after onset. Improvement of cerebral vasoconstriction was recognized in several cases from about the first month of onset. The post-partum period, migraine, transfusion, rapid amelioration for anemia, renal failure, bathing, and cerebrovascular dissection were suspected as disease triggers. Abnormally high blood pressure at onset was confirmed in 55% of cases. It is important to analyze the pathophysiology of RCVS associated with these triggers from the viewpoint of the breakdown of the blood-brain barrier.
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Affiliation(s)
- Makoto Takemaru
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
| | - Shinichi Takeshima
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
- Present address: Showa University School of Medicine
| | - Naoyuki Hara
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
- Present address: Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Takahiro Himeno
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
| | - Yuji Shiga
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
- Present address: Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Jun Takeshita
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
| | | | - Eiichi Nomura
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
| | - Yutaka Shimoe
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
| | - Masaru Kuriyama
- Brain Attack Center, Ota Memorial Hospital, Department of Neurology
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25
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Yao Z, Hu X, You C. Endovascular therapy for vasospasm secondary to subarachnoid hemorrhage: A meta-analysis and systematic review. Clin Neurol Neurosurg 2017; 163:9-14. [PMID: 29031080 DOI: 10.1016/j.clineuro.2017.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 08/17/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 02/05/2023]
Abstract
Endovascular therapy has been used as an alternative treatment for vasospasm following subarachnoid hemorrhage. The effectiveness and safety of endovascular therapy are still controversial. We performed a systematic review and meta-analysis to identify any advantage of endovascular therapy over traditional medical treatment. We systematically reviewed related English publications by searching PubMed, Ovid, Cochrane library, and Web of Science up to May 2017.The risk ratios (RR) and 95% confidence intervals (CI) were synthesized with fixed effect model. Subgroup analyses and sensitivity analyses were conducted to check the robustness the result. Publication bias was measured with funnel plot. Eight cohort studies were included, receiving a mean score of 7 on the Newcastle-Ottawa Scale. The overall effect (RR 1.01, [95% CI 0.80-1.26]) found no significant difference in the outcome between the endovascular treatment and control groups but with heterogeneity (Chi2=18.07, p=0.01, I2=61%). Subgroup analyses stratified by country, year of publication, treatment modality, follow-up time, and sensitivity analysis by excluding the most biased study yielded the same result (RR 1.19, [95% CI 0.94-1.52]), with rare heterogeneity (Chi2=4.21, p=0.65, I2=0). Funnel plot was visually symmetric in sensitivity analysis. Despite good performance in reversing vasospasm in previous studies, endovascular therapy did not show superiority to traditional medical treatment in improving patient outcomes. Further randomized controlled studies are needed to elucidate this issue.
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Affiliation(s)
- Zhong Yao
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China.
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26
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Boulouis G, Labeyrie MA, Raymond J, Rodriguez-Régent C, Lukaszewicz AC, Bresson D, Ben Hassen W, Trystram D, Meder JF, Oppenheim C, Naggara O. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Eur Radiol 2016; 27:3333-3342. [PMID: 28004163 DOI: 10.1007/s00330-016-4702-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [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: 06/28/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To examine the clinical outcome of aneurysmal subarachnoid haemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS)-targeted treatments in a meta-analysis and to evaluate the efficacy of intra-arterial (IA) approaches in patients with severe/refractory vasospasm. METHODS Randomised controlled trials, prospective and retrospective observational studies reporting clinical outcomes of aSAH patients exposed to CVS targeted treatments, published between 2006-2016 were searched using PubMed, EMBASE and the Cochrane Library. The main endpoint was the proportion of unfavourable outcomes, defined as a modified Rankin score of 3-6 at last follow-up. RESULTS Sixty-two studies, including 26 randomised controlled trials, were included (8,976 patients). At last follow-up 2,490 of the 8,976 patients had an unfavourable outcome, including death (random-effect weighted-average, 33.7%; 99% confidence interval [CI], 28.1-39.7%; Q value, 806.0; I 2 = 92.7%). The RR of unfavourable outcome was lower in patients treated with Cilostazol (RR = 0.46; 95% CI, 0.25-0.85; P = 0.001; Q value, 1.5; I 2 = 0); and in refractory CVS patients treated by IA intervention (RR = 0.68; 95% CI, 0.57-0.80; P < 0.0001; number needed to treat with IA intervention, 6.2; 95% CI, 4.3-11.2) when compared with the best available medical treatment. CONCLUSIONS Endovascular treatment may improve the outcome of patients with severe-refractory vasospasm. Further studies are needed to confirm this result. KEY POINTS • 33.7% of patients with cerebral Vasospasm following aneurysmal subarachnoid-hemorrhage have an unfavorable outcome. • Refractory vasospasm patients treated using endovascular interventions have lower relative risk of unfavourable outcome. • Subarachnoid haemorrhage patients with severe vasospasm may benefit from endovascular interventions. • The relative risk of unfavourable outcome is lower in patients treated with Cilostazol.
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Affiliation(s)
- Grégoire Boulouis
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France.
- DHU NeuroVasc Paris Sorbonne, Paris, France.
| | - Marc Antoine Labeyrie
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Christine Rodriguez-Régent
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Anne Claire Lukaszewicz
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Damien Bresson
- DHU NeuroVasc Paris Sorbonne, Paris, France
- Neuroradiology, and Neurosurgery, Université Paris Diderot Paris VII, Paris, France
| | - Wagih Ben Hassen
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Denis Trystram
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Jean Francois Meder
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Catherine Oppenheim
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
| | - Olivier Naggara
- INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Université Paris-Descartes, 1 rue Cabanis, 75014, Paris, France
- DHU NeuroVasc Paris Sorbonne, Paris, France
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27
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Provencio JJ, Swank V, Lu H, Brunet S, Baltan S, Khapre RV, Seerapu H, Kokiko-Cochran ON, Lamb BT, Ransohoff RM. Neutrophil depletion after subarachnoid hemorrhage improves memory via NMDA receptors. Brain Behav Immun 2016; 54:233-242. [PMID: 26872422 PMCID: PMC4828315 DOI: 10.1016/j.bbi.2016.02.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [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: 11/02/2015] [Revised: 01/29/2016] [Accepted: 02/08/2016] [Indexed: 01/17/2023] Open
Abstract
Cognitive deficits after aneurysmal subarachnoid hemorrhage (SAH) are common and disabling. Patients who experience delayed deterioration associated with vasospasm are likely to have cognitive deficits, particularly problems with executive function, verbal and spatial memory. Here, we report neurophysiological and pathological mechanisms underlying behavioral deficits in a murine model of SAH. On tests of spatial memory, animals with SAH performed worse than sham animals in the first week and one month after SAH suggesting a prolonged injury. Between three and six days after experimental hemorrhage, mice demonstrated loss of late long-term potentiation (L-LTP) due to dysfunction of the NMDA receptor. Suppression of innate immune cell activation prevents delayed vasospasm after murine SAH. We therefore explored the role of neutrophil-mediated innate inflammation on memory deficits after SAH. Depletion of neutrophils three days after SAH mitigates tissue inflammation, reverses cerebral vasoconstriction in the middle cerebral artery, and rescues L-LTP dysfunction at day 6. Spatial memory deficits in both the short and long-term are improved and associated with a shift of NMDA receptor subunit composition toward a memory sparing phenotype. This work supports further investigating suppression of innate immunity after SAH as a target for preventative therapies in SAH.
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Affiliation(s)
- Jose Javier Provencio
- Neuroinflammation Research Center, Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA; Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA; Department of Neurology and Neuroscience, Brain Immunology and Glia Center, University of Virginia, PO Box 800394, Charlottesville, VA 22908, USA.
| | - Valerie Swank
- Neuroinflammation Research Center, Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Haiyan Lu
- Neuroinflammation Research Center, Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Sylvain Brunet
- Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Selva Baltan
- Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Rohini V Khapre
- Neuroinflammation Research Center, Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Himabindu Seerapu
- Neuroinflammation Research Center, Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Olga N Kokiko-Cochran
- Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Bruce T Lamb
- Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Richard M Ransohoff
- Neuroinflammation Research Center, Neuroscience, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
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Perrein A, Petry L, Reis A, Baumann A, Mertes P, Audibert G. Cerebral vasospasm after traumatic brain injury: an update. Minerva Anestesiol 2015; 81:1219-1228. [PMID: 26372114] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Post-traumatic vasospasm (PTV) remains a poorly understood entity. Using a systematic review approach, we examined the incidence, mechanisms, risk factors, impact on outcome and potential therapies of PTV. METHODS A search on Medline database up to 2015 performed with "traumatic brain injury" and "vasospasm" key-words retrieved 429 references. This systematic review was reported and analysed following the PRISMA criteria and according to the relevance in human clinical practice. RESULTS The research retrieved 429 references of which 226 were excluded from analysis because of their irrelevance and 87 finally included in the review. CONCLUSION Mechanical stretching, inflammation, calcium dysregulation, endotelin, contractile proteins, products of cerebral metabolism and cortical spreading depolarization have been involved in PTV pathophysiology. PTV occurs in up to 30-40% of the patients after severe traumatic brain injury. Usually, PTV starts within the first 3 days following head trauma and may last 5 to 10 days. Young age, low Glasgow Coma Score at admission and subarachnoid hemorrhage have been identified as risk factors of PTV. Suspected on transcranial Doppler, PTV diagnosis is best confirmed by angiography, CT angiography or MR angiography, and perfusion and ischaemic consequences by perfusion CT or MRI. Early PTV is associated with poor outcome. No PTV prevention strategy has proved efficient up to now. Regarding PTV treatment, only nimodipine and intra-arterial papaverine have been studied up to now. Treatment with milrinone has been described in a few cases reports and may represent a new therapeutic option.
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Affiliation(s)
- A Perrein
- Département d'Anesthésie Réanimation, Hôpital Central, Centre Hospitalier Universitaire de Nancy, Nancy, France -
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29
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Konczalla J, Brawanski N, Bruder M, Senft C, Platz J, Seifert V. Outcome of Patients with Long-Lasting Cerebral Vasospasm After Subarachnoid Hemorrhage: Is Prolonged Treatment for Cerebral Vasospasm Worthwhile? A Matched-Pair Analysis. World Neurosurg 2015; 88:488-496. [PMID: 26498398 DOI: 10.1016/j.wneu.2015.10.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Cerebral vasospasm (CVS) occurs regularly between days 3 and 12 after subarachnoid hemorrhage (SAH). Yet, some patients suffering from SAH have long-lasting cerebral vasospasm (LL-CVS, i.e., longer than 14 days). The outcome of these patients with a very long treatment is unknown. METHODS Patients with SAH were entered into a prospectively collected database. In unconscious patients, CVS was treated until a reversal of CVS was confirmed by imaging. Outcome was assessed with the modified Rankin Scale (mRS; favorable [mRS 0-2] and unfavorable [mRS 3-6]) 6 months after SAH. Data were compared by matched pair analysis. RESULTS Of 1126 patients, 106 had LL-CVS (9.4%). The mean of treatment was until day 20 (range, 15-42). Of these patients, more than 30% needed treatment longer than 21 days after SAH; 29% had a small intracerebral hematoma (ICH; <50 mL). Hydrocephalus that required external ventricular drainage was present in 81%. Outcomes were favorable in 60%, and 8% died. In the multivariate logistic regression analysis, risk factors for an unfavorable outcome were elderly patients, poor admission status, and the presence of small ICH. Compared with the matched control group, who had "regular-lasting" CVS, patients with LL-CVS had a significant better outcome (60% vs. 49%) and a significant lower mortality rate (8% vs. 27%). CONCLUSION Patients with LL-CVS had a significant better outcome than patients with "regular-lasting" CVS. Risk factors for worse outcome of patients with LL-CVS were a worse admission status, elderly age, and the presence of small ICH. We recommend using an objective method to validate the reversal of CVS in unconscious patients.
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany.
| | - Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
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30
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Tekle WG, Chaudry SA, Hassan AE, Qaiser H, Grigoryan M, Rodriguez GJ, Qureshi AI. High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm. Neurocrit Care 2015; 20:399-405. [PMID: 23463421 DOI: 10.1007/s12028-013-9825-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.
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Affiliation(s)
- Wondwossen G Tekle
- Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, 420 Delaware St. SE. MMC 295, Minneapolis, MN, 55455, USA,
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Chalouhi N, Tjoumakaris S, Thakkar V, Theofanis T, Hammer C, Hasan D, Starke RM, Wu C, Gonzalez LF, Rosenwasser R, Jabbour P. Endovascular management of cerebral vasospasm following aneurysm rupture: outcomes and predictors in 116 patients. Clin Neurol Neurosurg 2014; 118:26-31. [PMID: 24529225 DOI: 10.1016/j.clineuro.2013.12.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [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: 10/12/2013] [Revised: 11/11/2013] [Accepted: 12/25/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To retrospectively assess the safety and efficacy of endovascular treatment of cerebral vasospasm with different modalities and assess predictors of outcome. METHODS Endovascular treatment was indicated in the event of neurological deterioration refractory to medical therapy. Data were collected for 116 patients treated at our institution. RESULTS Vasospasm was treated with balloon angioplasty in 52.6%, intra-arterial nicardipine infusion in 19.8%, or both in 27.6%. Angiographic vasospasm was reversed in all but 4 (96.6%) patients. The complication rate was 0.9%. Twenty patients (17.2%) had incipient pre-procedure hypodensities; 3 (15%) hypodensities were reversed and neurological improvement occurred in 60% of these patients. Retreatment was required in 22 (19%) patients. Higher Hunt and Hess grades and treatment with nicardipine alone predicted retreatment. Neurological improvement was noted in 82%. Male gender, pre-procedure hypodensities, and posterior communicating artery aneurysm location negatively predicted neurological recovery. Favorable outcomes were noted in 73%. Higher Hunt and Hess grades, pre-procedure hypodensities, posterior circulation aneurysms, and no neurological recovery predicted poor outcome. CONCLUSION Endovascular therapy for vasospasm has an excellent safety-efficacy profile. Balloon angioplasty and nicardipine are equally effective but effects of nicardipine are less durable. Patients with incipient pre-procedure hypodensities benefit from endovascular intervention and should probably not be excluded from treatment.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Vismay Thakkar
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Christine Hammer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, USA
| | - Robert M Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Chengyuan Wu
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA.
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Hayashi K, Hirao T, Sakai N, Nagata I. Current Status of Endovascular Treatment for Vasospasm following Subarachnoid Hemorrhage: Analysis of JR-NET2. Neurol Med Chir (Tokyo) 2014; 54 Suppl 2:107-112. [PMID: 26236822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
Endovascular treatments are employed for cerebral vasospasm following subarachnoid hemorrhage, which is not responded to the medical treatments. However, the effect or complication of the treatments is not known well. Here, we analyzed the data of Japanese Registry of Neuroendovascular Therapy 2 (JR-NET2) and revealed current status of the endovascular treatment for the cerebral vasospasm. JR-NET2 is conducted from January 1, 2007 to December 31, 2009. Information on the clinical status, imaging studies, treatment methods, the results of treatment, and status 30 days later were recorded. Totally 645 treatments for 480 patients (mean age, 59.4 years; 72.7% woman) were included. Factors related to the neurological improvement and treatment related complications were statistically analyzed. Treatments for ruptured cerebral aneurysm were direct surgery for 366 cases and endovascular treatment for 253 cases. The timing of the endovascular treatment for the cerebral vasospasm was within 3 hours in 209 cases, 3–6 hours in 158 cases, and more than 6 hours in 158 cases. Intra-arterial vasodilator was employed for the 495 cases and percutaneous transluminal angioplasty for 140 cases. Neurological improvement was observed in 372 cases and radiological improvement was seen in 623 cases. The treatment related complication occurred in 20 cases (3.1%), including 6 cases of intracranial hemorrhage, 5 cases of cerebral ischemia, a case of puncture site trouble, and 8 cases of others. Statistical analysis showed early treatment was related to the neurological improvement. Current status of endovascular treatment for cerebral vasospasm was revealed. Endovascular treatment was effective for vasospasm especially was performed early.
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Abstract
Compromise of blood flow to the brain leads to cerebral ischemia, which if left untreated may even result in cerebral infarction. This has been the main cause of major morbidity and mortality over the years in the US and around the world. Cerebral ischemia to the posterior fossa is more critical and difficult to treat. This is primarily due to complex anatomy and physiology of the posterior fossa cerebal circulation. There has been multiple modalities tested over the years to treat posterior fossa ischemia which have definitely contributed in the outcome in patients with this complex problem. Improving the blood flow in the areas of brain at risk in properly selected patients could prevent impending cerebral ischemia and infarction. Today, there are mainly three types of treatment offered to patients with posterior cerebral ischemia. These are (a) medical, (b) endovascular and (c) surgical. The recent advances in technology, the diagnosis and mode of therapy, has definitely improved the outcomes of cerebral ischemia. We discuss the multidisciplinary treatment of posterior circulation ischemia. Various pre-operative and operative techniques involved in treating patients with posterior cerebral ischemia are discussed.
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Affiliation(s)
- M Misra
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Brallier JW, Deiner SG. Use of the bilateral BIS monitor as an indicator of cerebral vasospasm in ICU patients. Middle East J Anaesthesiol 2013; 22:161-164. [PMID: 24180164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Earlier diagnosis of cerebral vasospasm and delayed cerebral ischemia (DCI) and treatment has the potential to decrease post-bleed morbidity after subarachnoid hemorrhage (SAH). Previous studies have shown that electroencephalogram (EEG) can detect blood flow changes associated with DCI sooner than other modalities potentially leading to earlier diagnosis. However, continual monitoring with raw EEG requires significant expertise and effort, and may be difficult due to the intermittent need for MRI studies in these patients. Here we describe a series of patients with subarachnoid hemorrhage in the Neurosurgical ICU who underwent monitoring with the Bilateral Bispectral Index (BIS) monitor.
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Affiliation(s)
- Jess W Brallier
- Department of Anesthesiology, Mount Sinai School of Medicine. One Gustave Levy Place, New York, NY 10029, USA
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35
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Abstract
Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors' experience, aimed at providing practical aid to those caring for patients with this disease.
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Affiliation(s)
- Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6007, Baltimore, MD 21287, USA
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36
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Sanelli PC, Anumula N, Gold R, Elias E, Johnson C, Comunale J, Tsiouris AJ, Segal AZ. Outcomes-based assessment of a new reference standard for delayed cerebral ischemia related to vasospasm in aneurysmal subarachnoid hemorrhage. Acad Radiol 2012; 19:1066-74. [PMID: 22727622 PMCID: PMC3416968 DOI: 10.1016/j.acra.2012.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/02/2012] [Accepted: 04/04/2012] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose is to perform outcomes-based assessment of a new reference standard for delayed cerebral ischemia (DCI) related to vasospasm. MATERIALS AND METHODS Retrospective study was performed with consecutive aneurysmal subarachnoid hemorrhage (A-SAH) patients between January 2002 and May 2009. A new reference standard for DCI was applied to the study population incorporating clinical and imaging criteria. Diagnostic accuracy was determined by chart diagnosis. Outcome measures for assessment included: permanent neurologic deficits, infarction, functional disability, treatment, and discharge status. Medical record review was performed by two blinded observers. Chi-square test calculated statistical significance between DCI and no DCI groups. RESULTS A total of 137 patients were included; 59% (81/137) classified as DCI and 41% (56/137) as no DCI by the reference standard. Overall accuracy is 96% (95% confidence interval 92-99) with 100% sensitivity, 92% specificity, 94% positive and 100% negative predictive values. Patients classified as DCI had 40% (32/81) permanent neurologic deficits and 57% (46/81) infarction compared to 0% (0/56) classified as no DCI. DCI patients had 33% (27/81) functional disability compared to 13% (7/56) classified as no DCI. Ninety-four percent (76/81) DCI patients received treatment compared to 0% (0/56) classified as no DCI. DCI group had 46% (37/81) discharged to rehabilitation facilities and 11% (9/81) mortality compared to 25% (14/56) and 2% (1/56), respectively, in no DCI group. There are statistically significant differences (P < .0001) between DCI and no DCI groups for all outcome measures. CONCLUSION This new reference standard has high diagnostic accuracy for DCI related to vasospasm. The outcomes-based assessment further supports its accuracy in correctly classifying A-SAH patients.
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Affiliation(s)
- Pina C Sanelli
- Department of Radiology, Weill Cornell Medical College/New York-Presbyterian Hospital, NY 10065, USA.
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37
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Harrer JU, Eyding J, Ritter M, Schminke U, Schulte-Altedorneburg G, Köhrmann M, Nedelmann M, Schlachetzki F. [The potential of neurosonography in neurological emergency and intensive care medicine: basic principles, vascular stroke diagnostics, and monitoring of stroke-specific therapy - Part 1]. Ultraschall Med 2012; 33:218-235. [PMID: 22700165 DOI: 10.1055/s-0031-1299455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- J U Harrer
- Klinik für Neurologie, Caritas Klinik St. Theresie, Saarbrücken und Klinik für Neurologie, Universitätsklinikum Aachen, RWTH Aachen
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Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711-37. [PMID: 22556195 DOI: 10.1161/str.0b013e3182587839] [Citation(s) in RCA: 2184] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
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Jiang YZ, Li C, Xu JY, Lu YZ, Xu R, Han B, Lu WH. [Observation of clinical efficacy of acupuncture for cerebral vasospasm after embolization of ruptured aneurysms]. Zhongguo Zhen Jiu 2012; 32:193-197. [PMID: 22471125] [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: 05/31/2023]
Abstract
OBJECTIVE To observe the improvement of acupuncture in cerebral vasospasm (CVS) after embolization of ruptured aneurysms. METHODS Sixty cases were randomly divided into two groups, an acupuncture-medication group and a conventional treatment group, 30 cases in each one. The cases of CVS in conventional treatment group were treated with Nimodipine. In acupuncture-medication group, on the basis of the treatment as conventional treatment group, Baihui (GV 20) and Fengchi (GB 20) were selected as the main acupoints in the treatment of CVS. The treatment lasted for 3 weeks. Hunt-Hess scale for the standard assessment was adopted to determine the severity of disease before and after treatment and compare the efficacy between two groups. The transcranial Doppler (TCD) was conducted on the 1st, 4th, 7th, 10th, 14th and 21st days successively after operation, and the average flow velocity of 3 pairs of vessels (ACA, MCA, and PCA) was recorded. CT perfusion (CTP) was taken to test cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) on the 1st, 7th, 14th and 21st days successively. RESULTS The improvement of Hunt-Hess scale in acupuncture-medication group was superior to that in conventional treatment group (P < 0.05). The analysis of variance (ANOVA) was adopted in the comparison of ACA, MCA, PCA, CBF, CBV and MTT between two groups. The results showed that the therapy in either group achieved the effect on CVS (all P < 0.05). But, the improvements in the above mentioned indices in acupuncture-medication group were superior to those in conventional treatment group (all P < 0.05). CONCLUSION Acupuncture at Baihui (GV 20) and Fengchi (GB 20) down-regulates the peak values or upregulates the valley values. It releases the peak of CVS effectively, improves the clinical prognosis significantly and is the effective therapy for CVS after subarachnoid hemorrhage.
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Affiliation(s)
- Yun-Zhao Jiang
- Department of Neurosurgery, Wuxi Integrated Chinese and Western Medicine Hospital, Wuxi 214041, Jiangsu Province, China
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40
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Mazzeo AT, Di Pasquale R, Settineri N, Bottari G, Granata F, Faragò G, Pitrone A, Longo M, Santamaria LB. Usefulness and limits of near infrared spectroscopy monitoring during endovascular neuroradiologic procedures. Minerva Anestesiol 2012; 78:34-45. [PMID: 21617599] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Transcranial cerebral oximetry (TCCO) with near-infrared spectroscopy (NIRS) is a non-invasive, bedside technique, which allows the continuous measurement of regional cerebral oxygenation. The aim of this study was to evaluate TCCO monitoring during endovascular neuroradiologic procedures. METHODS Adult patients undergoing elective endovascular embolization of cerebral aneurysms, arteriovenous malformations, dural arteriovenous fistulas and meningiomas under general anesthesia were included in the study, over a period of 12 months. Twenty-eight procedures in 25 patients were analyzed. RESULTS Regional cerebral oxygenation rSO(2) readings were significantly different according to the different phases of the neuroendovascular procedure. An effect of the underlying cerebral pathology on regional cerebral oxygenation rSO(2) recording, in relation to the different stage of the interventional procedure, was also evident, the more invasive the procedure the greater the impact on rSO(2) reading. NIRS monitoring contributed to a prompt diagnosis and management of two adverse intraoperative events and helped in early evaluation of prognosis. CONCLUSION TCCO with NIRS is a promising monitoring tool to assess the balance between oxygen supply and demand during neuroradiologic procedures. Nevertheless, some limits should be acknowledged, such as the study of the posterior circulation and artefacts related to contrast agent injection. A careful understanding of the undergoing step of the procedure as well of the possible influence of intrinsic and extrinsic factors affecting recording is important for interpretation of data.
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Affiliation(s)
- A T Mazzeo
- Anesthesia and Neurointensive Care Unit, Department of Neuroscience, Psychiatric and Anesthesiological Sciences, University of Messina, Italy.
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41
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Abstract
Cerebral vasospasm occurs frequently after aneurysmal subarachnoid and contributes to delayed cerebral ischemia. In this article we address systematic problems with the literature on vasospasm and then review both established and experimental treatment options.
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Affiliation(s)
- M. Kamran Athar
- Department of Neurology, Hospital of the University of Pennsylvania, 3 W Gates, 3400 Spruce Street, Philadelphia, Pennsylvania 19104 USA
| | - Joshua M. Levine
- Department of Neurology, Hospital of the University of Pennsylvania, 3 W Gates, 3400 Spruce Street, Philadelphia, Pennsylvania 19104 USA
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104 USA
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104 USA
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42
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Abstract
Animal models provide a basis for clarifying the complex pathogenesis of delayed cerebral vasospasm (DVCS) and for screening of potential therapeutic approaches. The aim of this work was to identify and analyze the most consistent and feasible models and their characteristics for each animal. An online search of the MEDLINE PubMed and EMBASE medical databases (1969 to week 21 of 2007) was performed using the key words "mice", "rat", "rabbit", "canine", and "primate" in combination with "subarachnoid hemorrhage", "model", and "vasospasm". Seven techniques were mainly used to induce experimental subarachnoid hemorrhage in closed and open cranium approaches. Among the great number of experimental SAH methods and associated parameters only a fistful reliable models can be identified and recommended for experimental work in mice, rats, rabbits, dogs and nonhuman primates.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Cantonal Hospital Aarau, 5000, Aarau, Switzerland.
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43
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Hansen-Schwartz J. Advances in treatment of cerebral vasospasm: an update. Acta Neurochir Suppl 2011; 110:23-26. [PMID: 21116909 DOI: 10.1007/978-3-7091-0353-1_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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
An update of published clinical advances in the treatment of cerebral vasospasm after subarachnoid haemorrhage was provided. Searching MEDLINE using the search terms "cerebral vasospasm" and "clinical trials" 46 papers were identified that had been published since the International Conference on Cerebral Vasospasm in Istanbul, Turkey in 2006. Of these 26 were either safety studies or case reports leaving 20 papers for consideration. The major topics covered were calcium antagonists, magnesium sulphate, statins, and fasudil hydrochloride. The studies published did not reach an impact justified recommended routine use, but certainly as options. Results of the CONSCIOUS trials on endothelin receptor antagonists are awaited.
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Affiliation(s)
- Jacob Hansen-Schwartz
- Department of Neurosurgery, Glostrup University Hospital, DK-2600, Glostrup, Denmark.
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44
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Rama-Maceiras P, Fàbregas Julià N, Ingelmo Ingelmo I, Hernández-Palazón J. [Neurologic complications of subarachnoid hemorrhage due to intracranial aneurysm rupture]. Rev Esp Anestesiol Reanim 2010; 57 Suppl 2:S44-S62. [PMID: 21298909] [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: 05/30/2023]
Abstract
The high rates of morbidity and mortality after subarachnoid hemorrhage due to spontaneous rupture of an intracranial aneurysm are mainly the result of neurologic complications. Sixty years after cerebral vasospasm was first described, this problem remains unsolved in spite of its highly adverse effect on prognosis after aneurysmatic rupture. Treatment is somewhat empirical, given that uncertainties remain in our understanding of the pathophysiology of this vascular complication, which involves structural and biochemical changes in the endothelium and smooth muscle of vessels. Vasospasm that is refractory to treatment leads to cerebral infarction. Prophylaxis, early diagnosis, and adequate treatment of neurologic complications are key elements in the management of vasospasm if neurologic damage, lengthy hospital stays, and increased use of health care resources are to be avoided. New approaches to early treatment of cerebral lesions and cortical ischemia in cases of subarachnoid hemorrhage due to aneurysm rupture should lead to more effective, specific management.
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Affiliation(s)
- P Rama-Maceiras
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario A Coruña.
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45
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Affiliation(s)
- Srijana Zarkou
- Department of Neurology, Mayo Clinic, 5777 Mayo Blvd, Phoenix, AZ 85054, USA.
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46
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Barçin C, Kurşaklioğlu H, Köse S, Amasyali B, Işik E. Resistant radial artery spasm during coronary angiography via radial approach responded to local warm compress. Anadolu Kardiyol Derg 2010; 10:90-91. [PMID: 20150014] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Cem Barçin
- Department of Cardiology, Gülhane Military Medical Academy, Ankara, Turkey.
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47
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Podgorniak MI, Nikitin PI, Pavlov OA. [Embolization of cerebral aneurysms in acute period of hemorrhage complicated by the development of vasospasm]. Vestn Khir Im I I Grek 2010; 169:66-69. [PMID: 20973190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Results of endovascular treatment of cerebral aneurysms in acute period of hemorrhage complicated by the development of vasospasm in 80 patients were analyzed. The results of treatment of patients with vasospasm were worse. The appearance of vasospasm did not depend of the severity of the patient's state, so all the patients independent on their state need prophylactic measures against this complication. Based on the analysis a strategy of embolization of aneurysms in acute period of hemorrhage complicated by the development of vasospasm was worked out.
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48
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Sampson TR, Dhar R, Diringer MN. Factors associated with the development of anemia after subarachnoid hemorrhage. Neurocrit Care 2009; 12:4-9. [PMID: 19777386 DOI: 10.1007/s12028-009-9273-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 08/28/2009] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Anemia is common after subarachnoid hemorrhage (SAH) and may exacerbate the reduction in oxygen delivery that underlies delayed cerebral ischemia. Fall in hemoglobin may relate to blood loss as well as inflammatory suppression of erythropoiesis. Identifying factors associated with anemia may facilitate targeted interventions, such as the use of erythropoiesis-stimulating agents, which could minimize the burden of anemia and reduce red blood cell (RBC) transfusion requirements. METHODS We analyzed a cohort of patients with spontaneous SAH admitted over a 3-year period who survived at least 4 days. All patients had daily hematocrit values drawn while in the ICU. Multivariate regression was performed to determine baseline and early post-admission variables associated with development of anemia (defined as hematocrit < 30%). RESULTS Anemia developed in 47% of 243 patients with SAH after a mean of 3.5 days (median 2 days). Admission variables independently associated with anemia were female gender (OR 3.7, 95% CI 1.8-7.6), baseline hematocrit < 36% (OR 3.9, 1.5-10.1 compared to 36-45%), history of hypertension (OR 2.1, 1.05-4.2), and poor clinical grade (OR 5.9, 2.3-15.0). Surgical aneurysm treatment (OR 13.5, 6.0-30.3) and greater admission SIRS score (OR 5.7, 1.7-19.2 if 3-4 criteria for systemic inflammatory response syndrome were met on day of admission compared to none) were also associated with fall in hematocrit. CONCLUSIONS It may be possible to predict those most likely to develop anemia using simple baseline clinical variables. Anemia was strongly related to surgery, likely through greater blood loss, and greater systemic inflammatory response on admission, possibly explained by cytokine-mediated inhibition of RBC production.
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Affiliation(s)
- Tomoko R Sampson
- Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8111, Saint Louis, MO 63110, USA
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49
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Bederson JB, Connolly ES, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE, Harbaugh RE, Patel AB, Rosenwasser RH. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40:994-1025. [PMID: 19164800 DOI: 10.1161/strokeaha.108.191395] [Citation(s) in RCA: 911] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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50
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Naidech AM, Bendok BR, Tamul P, Bassin SL, Watts CM, Batjer HH, Bleck TP. Medical complications drive length of stay after brain hemorrhage: a cohort study. Neurocrit Care 2008; 10:11-9. [PMID: 18821035 DOI: 10.1007/s12028-008-9148-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [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: 07/16/2008] [Accepted: 09/02/2008] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Longer length of stay (LOS) is associated with higher complications and costs in ICU patients, while hospital protocols may decrease complications and LOS. We hypothesized that medical complications would increase LOS after spontaneous subarachnoid (SAH) and intracerebral (ICH) hemorrhage after accounting for severity of neurologic injury in a cohort of consecutively admitted patients. METHODS We prospectively recorded admission characteristics, hospital complications, and LOS for 122 patients with SAH and 56 patients with ICH from February 2006 through March 2008. A multidisciplinary Neuro-ICU team included a dedicated pharmacist and intensivist on daily rounds. Hospital protocols set glucose control with intravenous insulin, ventilator bundles, pharmacist involvement, and hand hygiene. Associations were explored with univariate statistics (t-tests, ANOVA, or non-parametric statistics as appropriate) and linear regression (repeated after log transformation of ICU and hospital LOS). RESULTS Factors associated with longer LOS after SAH and ICH were similar. In both SAH and ICH the strongest drivers of LOS were infection, fever, and acute lung injury. For SAH, vasospasm and Glasgow Coma Scale were also significant in some models, while in patients with ICH the volume of the initial bleed was significant in some models. CONCLUSION LOS after spontaneous brain hemorrhage is driven by medical complications even after the adoption of dedicated intensive care medical staff, pharmacist involvement, and evidence-based protocols for ICU care. Further alterations in care will be necessary to eliminate "preventable" complications and minimize LOS after brain hemorrhage.
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Affiliation(s)
- Andrew M Naidech
- Department of Neurology, Northwestern University, 710 N Lake Shore Drive, 11th floor, Chicago, IL, 60611, USA.
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