1
|
Luzzi S, Bektaşoğlu PK, Doğruel Y, Güngor A. Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia. Neurosurg Rev 2024; 47:305. [PMID: 38967704 PMCID: PMC11226492 DOI: 10.1007/s10143-024-02543-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/15/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.
Collapse
Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Türkiye
| | - Yücel Doğruel
- Department of Neurosurgery, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Abuzer Güngor
- Faculty of Medicine, Department of Neurosurgery, Istinye University, İstanbul, Türkiye
| |
Collapse
|
2
|
Luzzi S, Giotta Lucifero A, Baldoncini M, Campero A, Galzio R, Lawton MT. Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation. World Neurosurg 2023; 170:e612-e621. [PMID: 36410704 DOI: 10.1016/j.wneu.2022.11.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Optic foraminotomy (OF) has been recently proposed as an alternative to anterior clinoidectomy (AC) for selected types of paraclinoid aneurysms. In this study, OF and AC were compared for small superior-projecting paraclinoid aneurysms assuming visual and angiographic results as outcome measures. Indications for OF are also discussed. METHODS Data of patients who underwent surgery for a paraclinoid aneurysm in the last 10 years were collected across 3 tertiary hospitals. Small to regular-size and superior projecting aneurysms were sorted. Multiple and complex aneurysms were excluded. Records of patients who went through OF were compared with those of patients who underwent AC. Neurologic outcome was reported as a modified Rankin Scale. Aneurysm complete occlusion rate and rate of approach-related worsened vision were selected as outcome measures of efficacy and safety, respectively, of the OF versus AC. Unpaired t test and χ2 test were used for numerical and categorical variables, respectively. A P value less than 0.05 was considered statistically significant. RESULTS OF and AC groups involved 18 and 25 patients, respectively. Complication rate, overall neurologic outcome, rate of approach-related worsened vision, and complete occlusion rate did not differ between the groups. The average follow-up was 51 ± 34 and 60 ± 41 months in the OF and AC groups, respectively. CONCLUSIONS Compared to AC, OF did not show either a higher rate of approach-related worsened vision or a lower aneurysm complete occlusion rate. OF can be considered a valid alternative to the AC for small superior-projecting dorsal ICA wall paraclinoid aneurysms.
Collapse
Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina; Laboratory of Microsurgical Neuroanatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Alvaro Campero
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| |
Collapse
|
3
|
Campero A, Baldoncini M, Martinez J, Villalonga JF, Lucifero AG, Luzzi S. Microneurosurgical management of aneurysms of the A1 segment of the anterior cerebral artery: Anatomy and surgical technique. Surg Neurol Int 2022; 13:310. [PMID: 35928319 PMCID: PMC9345093 DOI: 10.25259/sni_68_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare and have characteristics differentiating them from other intracranial aneurysms. Their microsurgical management is challenging and requires different strategies. In this article, we review the surgical anatomy of the A1 segment of the ACA with cadaveric dissections and describe the microsurgical management of complex A1 aneurysms with illustrative cases. Methods: A right pterional craniotomy and Sylvian dissection were performed on a formalin-fixed and silicone-injected cadaver head to depict the key anatomic structures and surgical corridors for microsurgical clipping of A1 segment aneurysms. The microneurosurgical management of ruptured and unruptured aneurysms of the A1 segment of the ACA is described with case illustrations. Results: The A1 segment of the ACA can be subdivided into proximal, middle, and distal subsegments, the former having abundant perforating branches. Both patients treated with microsurgical clipping had excellent and durable outcomes and postoperative cerebral angiograms showed complete aneurysm occlusion. Conclusion: Small A1 aneurysms may require early treatment as their rupture risk appears to be higher. A1 aneurysms are usually embedded in perforators, especially those arising from the proximal A1 subsegment, and require careful distal to proximal microdissection and strategic placement of the aneurysm clip blades. The approach, arachnoid dissection, and angles of attack are carefully planned after accounting for the aneurysm dome projection, precise location of the aneurysm neck and perforators, and the presence or absence of subarachnoid hemorrhage.
Collapse
Affiliation(s)
- Alvaro Campero
- Department of Neurosurgery, LINT, Facultad de Medicina, Universidad Nacional de Tucumán,
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Matías Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Argentina
- Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina,
| | - Jaime Martinez
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA,
| | - Juan F. Villalonga
- Department of Neurosurgery, LINT, Facultad de Medicina, Universidad Nacional de Tucumán,
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
4
|
Luzzi S, Giotta Lucifero A, Spina A, Baldoncini M, Campero A, Elbabaa SK, Galzio R. Cranio-Orbito-Zygomatic Approach: Core Techniques for Tailoring Target Exposure and Surgical Freedom. Brain Sci 2022; 12:brainsci12030405. [PMID: 35326360 PMCID: PMC8946068 DOI: 10.3390/brainsci12030405] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/13/2022] [Accepted: 03/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The cranio-orbito-zygomatic (COZ) approach is a workhorse of skull base surgery, and each of its steps has a precise effect on target exposure and surgical freedom. The present study overviews the key techniques for execution and tailoring of the COZ approach, focusing on the quantitative effects resulting from removal of the orbitozygomatic (OZ) bar, orbital rim, and zygomatic arch. Methods: A PRISMA-based literature review was performed on the PubMed/Medline and Web of Science databases using the main keywords associated with the COZ approach. Articles in English without temporal restriction were included. Eligibility was limited to neurosurgical relevance. Results: A total of 78 articles were selected. The range of variants of the COZ approach involves a one-piece, two-piece, and three-piece technique, with a decreasing level of complexity and risk of complications. The two-piece technique includes an OZ and orbitopterional variant. Superolateral orbitotomy expands the subfrontal and transsylvian corridors, increasing surgical freedom to the basal forebrain, hypothalamic region, interpeduncular fossa, and basilar apex. Zygomatic osteotomy shortens the working distance of the pretemporal and subtemporal routes. Conclusion: Subtraction of the OZ bar causes a tremendous increase in angular exposure of the subfrontal, transsylvian, pretemporal, and subtemporal perspectives avoiding brain retraction, allowing for multiangled trajectories, and shortening the working distance. The COZ approach can be tailored based on the location of the lesion, thus optimizing the target exposure and surgical freedom and decreasing the risk of complications.
Collapse
Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Correspondence:
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Matías Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Buenos Aires 1646, Argentina;
- Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires 1053, Argentina
| | - Alvaro Campero
- Laboratorio de Innovaciones Neuroquirúrgicas de Tucuman (LINT), Facultad de Medicina, Universidad Nacional de Tucumán, Tucuman 4000, Argentina;
- Department of Neurosurgery, Hospital Padilla, San Miguel de Tucumán, Tucuman 4000, Argentina
| | - Samer K. Elbabaa
- Department of Pediatric Neurosurgery, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, FL 32806, USA;
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, 48033 Cotignola, Italy;
| |
Collapse
|
5
|
Baldoncini M, Luzzi S, Giotta Lucifero A, Flores-Justa A, González-López P, Campero A, Villalonga JF, Lawton MT. Optic Foraminotomy for Clipping of Superior Carotid-Ophthalmic Aneurysms. Front Surg 2021; 8:681115. [PMID: 34957196 PMCID: PMC8695686 DOI: 10.3389/fsurg.2021.681115] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Carotid-ophthalmic aneurysms usually cause visual problems. Its surgical treatment is challenging because of its anatomically close relations to the optic nerve, carotid artery, ophthalmic artery, anterior clinoid process, and cavernous sinus, which hinder direct access. Despite recent technical advancements enabling risk reduction of this complication, postoperative deterioration of visual function remains a significant problem. Therefore, the goal of preserving and/or improving the visual outcome persists as a paramount concern. Objective: We propose optic foraminotomy as an alternative microsurgical technique for dorsal carotid-ophthalmic aneurysms clipping. As a secondary objective, the step by step of that technique and its benefits are compared to the current approach of anterior clinoidectomy. Methods: We present as an example two patients with superior carotid-ophthalmic aneurysms in which the standard pterional craniotomy, transsylvian approach, and optic foraminotomy were performed. Surgical techniques are presented and discussed in detail with the use of skull base dissections, microsurgical images, and original drawings. Results: Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all patients allowing a working angle with the carotid artery for correct visualization of the aneurysm and further clipping. Significant visual acuity improvement occurred in both patients because of decompression of the optic nerve. Conclusion: Optic foraminotomy is an easy and recommended technique for exposing and treating superior carotid-ophthalmic aneurysms and allowing optic nerve decompression during the first stages of the procedure. It shows several advantages over the current anterior clinoidectomy technique regarding surgical exposure and facilitating visual improvement.
Collapse
Affiliation(s)
- Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina.,Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Ana Flores-Justa
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Pablo González-López
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Alvaro Campero
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Juan F Villalonga
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| |
Collapse
|