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Wijdicks EFM. The Laboratory Origins of Nimodipine in Cerebral Vasospasm. Neurocrit Care 2024:10.1007/s12028-023-01914-y. [PMID: 38243149 DOI: 10.1007/s12028-023-01914-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 01/21/2024]
Affiliation(s)
- Eelco F M Wijdicks
- Neurocritical Care Services, Saint Marys Hospital, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
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Kramer A, Selbach M, Kerz T, Neulen A, Brockmann MA, Ringel F, Brockmann C. Continuous Intraarterial Nimodipine Infusion for the Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Retrospective, Single-Center Cohort Trial. Front Neurol 2022; 13:829938. [PMID: 35370871 PMCID: PMC8964957 DOI: 10.3389/fneur.2022.829938] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/04/2022] [Indexed: 11/14/2022] Open
Abstract
Background Delayed cerebral ischemia (DCI) occurs after aneurysmal subarachnoid hemorrhage (aSAH). Continuous intraarterial nimodipine infusion (CIAN) is a promising approach in patients with intracranial large vessel vasospasm (LVV). The objective of this retrospective single-center cohort study was to evaluate the outcome in aSAH-patients treated with CIAN. Methods CIAN was initiated and ended based on the clinical evaluation and transcranial Doppler (TCD), CT-angiography, CT-perfusion (PCT), and digital subtraction angiography (DSA). Nimodipine (0.5–2.0 mg/h) was administered continuously through microcatheters placed in the extracranial internal carotid and/or vertebral artery. Primary outcome measures were Glasgow Outcome Scale (GOS) at discharge and within 1 year after aSAH, and the occurrence of minor and major (<⅓ and >⅓ of LVV-affected territory) DCI-related infarctions in subsequent CT/MRI-scans. Secondary outcome measures were CIAN-associated complications. Results A total of 17 patients underwent CIAN. Median onset of CIAN was 9 (3–13) days after aSAH, median duration was 5 (1–13) days. A favorable outcome (GOS 4–5) was achieved in 9 patients (53%) at discharge and in 13 patients within 1 year (76%). One patient died of posthemorrhagic cerebral edema. Minor cerebral infarctions occurred in five and major infarctions in three patients. One patient developed cerebral edema possibly due to CIAN. Normalization of PCT-parameters within 2 days was observed in 9/17 patients. Six patients showed clinical response and thus did not require PCT imaging. Conclusion The favorable outcome in 76% of patients after 1 year is in line with previous studies. CIAN thus may be used to treat patients with severe therapy-refractory DCI.
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Affiliation(s)
- Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Moritz Selbach
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
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Kapapa T, König R, Mayer B, Braun M, Schmitz B, Müller S, Schick J, Wirtz CR, Pala A. Adverse Events and Complications in Continuous Intra-arterial Nimodipine Infusion Therapy After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 12:812898. [PMID: 35250795 PMCID: PMC8895039 DOI: 10.3389/fneur.2021.812898] [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: 11/10/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo determine the frequency and severity of complications associated with the continuous intra-arterial infusion of nimodipine (CIANI) as a new treatment of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH).MethodsPatients from two centers (n = 718) treated for SAH between 2008 and 2016 were included. Demographic and SAH-related parameters were evaluated, and also the frequency of adverse events (AEs) and complications including their severity (mild, moderate, and severe). Clinical outcome was analyzed using Glasgow Outcome Scale (GOS). The unfavorable outcome was defined as GOS 1 to 3, and favorable outcome as GOS 4 to 5. The Short-Form 36 (SF-36) health-related quality-of-life (QoL) questionnaire served as a QoL measurement.ResultsOf 718 patients, 65 (9%) were treated by CIANI and had a higher clinical or imaging grade of bleeding severity. Clinical deterioration while on treatment happened more often in patients who were treated with CIANI than in others. In patients with CIANI, 67% had AEs and/or complications during the treatment. Nimodipine-associated hypotension was seen in 8% (mild). Catheter-associated thrombus occurred in 9% (moderate). New intracerebral hemorrhage was found in 14% (moderate). A total of 6% treated by CIANI died during the treatment period (severe). More than one-third (39%) of patients of CIANI reached at least moderate disability, and 23% showed good recovery. Patients who received CIANI showed reduced QoL, but differences in mental and general health, and also pain were minimal.ConclusionPatients who received CIANI had higher rates of AEs and complications. However, this does not exclude the possibility that the use of CIANI might be helpful in patients with severe and therapy-refractory CV and DCI. Controlled and randomized studies would be helpful to clarify this question but they are methodologically and ethically challenging.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Michael Braun
- Section Neuroradiology, University Hospital Ulm, Günzburg, Germany
| | - Bernd Schmitz
- Section Neuroradiology, University Hospital Ulm, Günzburg, Germany
| | - Silwia Müller
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Julia Schick
- Section Interdisciplinary Operative Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
- *Correspondence: Andrej Pala
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Anthofer J, Bele S, Wendl C, Kieninger M, Zeman F, Bruendl E, Schmidt NO, Schebesch KM. Continuous intra-arterial nimodipine infusion as rescue treatment of severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2021; 96:163-171. [PMID: 34789415 DOI: 10.1016/j.jocn.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 08/30/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
Severe refractory cerebral vasospasm (CV) is a major cause of disability and death in patients with aneurysmal subarachnoid hemorrhage (SAH). One rescue therapy in selected patients is intra-arterial nimodipine, either given as a single shot or as continuous infusion. To evaluate treatment efficacy, we analyzed outcome factors such as the incidence of craniectomy, ventriculo-peritonial (VP) shunting, and tracheotomy after intra-arterial nimodipine infusion. We retrospectively analyzed the rates of cerebral infarction, decompressive craniectomy, VP shunting, and tracheotomy in patients with severe CV after SAH. Three different patient groups were compared: group 1 had only been treated with oral nimodipine and hypervolemic hypertensive therapy (HHT) (2006-2010), group 2 with a single shot of intra-arterial nimodipine (SSN) in addition to oral conservative treatment (2006-2010), and group 3 with continuous intra-arterial nimodipine (CIAN) (2011-2017). The incidence of cerebral infarction was significantly lower in CIAN group (p = 0.005) than in conservative and SSN group. The indication for consecutive decompressive craniectomy was significantly lower in CIAN group in comparison with the conservative group (p = 0.018). The rates of VP shunting and tracheotomy were significantly higher in the CIAN group than in the conservative group (p = 0.028 for VP, and p = 0.003 for tracheotomy). The significantly lower rate of craniectomy in the CIAN group was most probably attributable to the significantly lower rate of CV-induced infarction. The higher rate of tracheotomy reflects more extensive sedation and the need of longer stays on the intensive care unit. Thus, the effect on long-term neurological outcome and quality of life has to be evaluated separately.
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Affiliation(s)
- Judith Anthofer
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany.
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Christina Wendl
- Department of Neuroradiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Elisabeth Bruendl
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
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Hosmann A, Wang WT, Dodier P, Bavinzski G, Engel A, Herta J, Plöchl W, Reinprecht A, Gruber A. The Impact of Intra-Arterial Papaverine-Hydrochloride on Cerebral Metabolism and Oxygenation for Treatment of Delayed-Onset Post-Subarachnoid Hemorrhage Vasospasm. Neurosurgery 2021; 87:712-719. [PMID: 31792510 DOI: 10.1093/neuros/nyz500] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delayed posthemorrhagic vasospasm remains among the major complications after aneurysmal subarachnoid hemorrhage (SAH) and can result in devastating ischemic strokes. As rescue therapy, neurointerventional procedures are used for selective vasodilatation. OBJECTIVE To investigate the effects of intra-arterial papaverine-hydrochloride on cerebral metabolism and oxygenation. METHODS A total of 10 consecutive patients, suffering from severe aneurysmal SAH were prospectively included. Patients were under continuous multimodality neuromonitoring and required intra-arterial papaverine-hydrochloride for vasospasm unresponsive to hypertensive therapy. Cerebral metabolism (microdialysis), brain tissue oxygen tension (ptiO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were analyzed for a period of 12 h following intervention. RESULTS A median dose of 125 mg papaverine-hydrochloride was administered ipsilateral to the multimodality probe. Angiographic improvement of cerebral vasospasm was observed in 80% of patients. During intervention, a significant elevation of ICP (13.7 ± 5.2 mmHg) and the lactate-pyruvate ratio (LPR) (54.2 ± 15.5) was observed, whereas a decrease in cerebral glucose (0.9 ± 0.5 mmol/L) occurred. Within an hour, an increase of cerebral lactate (5.0 ± 2.0 mmol/L) and glycerol (104.4 ± 89.8 μmol/L) as well as a decrease of glucose (0.9 ± 0.4 mmol/L) were measured. In 2 to 5 h after treatment, the LPR significantly decreased (pretreatment: 39.3 ± 15.3, to lowest 30.5 ± 6.7). Cerebral pyruvate levels increased in 1 to 10 h (pretreatment: 100.1 ± 33.1 μmol/L, to highest 141.4 ± 33.7 μmol/L) after intervention. No significant changes in ptiO2 or CPP occurred. CONCLUSION The initial detrimental effects of the endovascular procedure itself were outweighed by an improved cerebral metabolism within 10 h thereafter. As the effect was very limited, repeated interventions or continuous application should be considered.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Adrian Engel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Herta
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Walter Plöchl
- Department of Anesthesia, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler Universitätsklinikum, Johannes Kepler University Linz, Linz, Austria
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Continuous intra-arterial infusion of verapamil for treatment of severe vasospasm after subarachnoid hemorrhage. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Side Effects of Long-Term Continuous Intra-arterial Nimodipine Infusion in Patients with Severe Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage. Neurocrit Care 2019; 28:65-76. [PMID: 28685393 DOI: 10.1007/s12028-017-0428-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Long-term continuous intra-arterial nimodipine infusion (CIAN) is a rescue therapy option in cases of severe refractory cerebral vasospasm (CV) following acute non-traumatic subarachnoid hemorrhage (SAH). However, CIAN therapy can be associated with relevant side effects. Available studies focus on intracerebral complications, whereas extracerebral side effects are rarely examined. Aim of the present study was to generate descriptive data on the clinical course during CIAN therapy and expectable extracerebral side effects. METHODS All patients treated with CIAN therapy for at least 5 days between May 2011 and December 2015 were included. We retrospectively extracted data from the patient data management system regarding the period between 2 days before the beginning and 5 days after the termination of CIAN therapy to analyze the course of ventilation parameters and pulmonary gas exchange, hemodynamic support, renal and liver function, integrity of the gastrointestinal tract, and the occurrence of infectious complications. In addition, we recorded the mean daily values of intracranial pressure (ICP) and intracerebral problems associated with CIAN therapy. RESULTS Data from 28 patients meeting inclusion criteria were analyzed. The mean duration of long-term CIAN therapy was 10.5 ± 4.5 days. Seventeen patients (60.7%) reached a good outcome level (Glasgow Outcome Scale [GOS] 4-5) 6 months after SAH. An impairment of the pulmonary gas exchange occurred only at the very beginning of CIAN therapy. The required vasopressor support with norepinephrine was significantly higher on all days during and the first day after CIAN therapy compared to the situation before starting CIAN therapy. Two patients required short-time resuscitation due to cardiac arrest during CIAN therapy. Acute kidney injury was observed in four patients, and one of them required renal replacement therapy with sustained low-efficiency daily dialysis. During CIAN therapy, 23 patients (82.1%) needed the escalation of a previous antiinfective therapy or the onset of antibiotics which was in line with a significant increase of C-reactive protein and white blood cell count. Obstipation was observed in 22 patients (78.6%). Ten patients (35.7%) even showed insufficient defecation on at least seven consecutive days. Compared to the situation before, ICP was significantly higher during the whole period of CIAN therapy. CONCLUSIONS Long-term CIAN therapy is associated with diverse side effects. The leading problems are an impairment of the hemodynamic situation and cardiac problems, an increase in infectious complications, a worsening of the motility of the gastrointestinal tract, and rising ICP values. Teams on neurointensive care units must be aware of these side effects to avoid that the beneficial effects of CIAN therapy on CV reported elsewhere are foiled by the problems this technique can be associated with.
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Mindt S, Tokhi U, Hedtke M, Groß HJ, Hänggi D. Mass spectrometry-based method for quantification of nimodipine and glutamate in cerebrospinal fluid. Pilot study with patients after aneurysmal subarachnoid haemorrhage. J Clin Pharm Ther 2019; 45:81-87. [PMID: 31421063 DOI: 10.1111/jcpt.13028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/01/2019] [Accepted: 07/17/2019] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Delayed cerebral ischaemia is an important cause of morbidity and mortality after aneurysmal subarachnoid haemorrhage (aSAH). Nimodipine is the only drug approved by the FDA for improving outcome after aSAH. Clinically, however, there are no specific values of this drug in cerebrospinal fluid (CSF) during aSAH treatment that could be associated to outcome improvement. Furthermore, the neurotransmitter glutamate acts as a secondary marker for brain injury. The aim was to establish a method to measure nimodipine and glutamate concentrations simultaneously in CSF of patients after aSAH. METHODS From June 2017 to June 2018, we prospectively collected clinical data of patients with aSAH admitted to our neurointensive care unit. All included patients received nimodipine orally (60 mg every 4 hours). Patients, who developed clinical vasospasm during their in-hospital stay, underwent intra-arterial application of nimodipine (IAN), followed by angiographic control. A method using high-performance liquid chromatography coupled with mass spectrometric analysis (LC-MS/MS) was established for quantification of both analytes in CSF. RESULTS AND DISCUSSION In 15 (60%) of 25 patients, nimodipine and glutamate concentrations were measured. After IAN for treatment of vasospasms, CSF nimodipine concentrations were slightly higher than in patients who received nimodipine only orally (0.60 ± 0.27 ng/mL vs 0.48 ± 0.18 ng/mL). Patients developing vasospasm exhibited higher glutamate concentrations than patients without vasospasm (188.84 ng/mL vs136.07 ng/mL). WHAT IS NEW AND CONCLUSION The developed method allowed the simultaneous quantification of nimodipine and glutamate in CSF. Furthermore, we demonstrated that IAN resulted in higher concentrations in CSF, when compared to oral application only.
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Affiliation(s)
- Sonani Mindt
- Institute for Clinical Chemistry, Medical Faculty Mannheim of the University of Heidelberg, University Hospital Mannheim, Mannheim, Germany
| | - Ursala Tokhi
- Department of Neurosurgery, Medical Faculty Mannheim of the University of Heidelberg University Hospital Mannheim, Mannheim, Germany
| | - Maren Hedtke
- Institute for Clinical Chemistry, Medical Faculty Mannheim of the University of Heidelberg, University Hospital Mannheim, Mannheim, Germany
| | - Hans-Jürgen Groß
- Institute for Clinical Chemistry, Medical Faculty Ulm, University Hospital Ulm, Ulm, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty Mannheim of the University of Heidelberg University Hospital Mannheim, Mannheim, Germany
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Paľa A, Schick J, Klein M, Mayer B, Schmitz B, Wirtz CR, König R, Kapapa T. The influence of nimodipine and vasopressors on outcome in patients with delayed cerebral ischemia after spontaneous subarachnoid hemorrhage. J Neurosurg 2019; 132:1096-1104. [PMID: 30849754 DOI: 10.3171/2018.11.jns182891] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a major factor contributing to the inferior outcome of patients with spontaneous subarachnoid hemorrhage (SAH). Nimodipine and induced hypertension using vasopressors are an integral part of standard therapy. Consequences of the opposite effect of nimodipine and vasopressors on blood pressure on patient outcome remain unclear. The authors report the detailed general characteristics and influence of nimodipine and vasopressors on outcome in patients with SAH. METHODS The authors performed a 2-center, retrospective, clinical database analysis of 732 SAH patients treated between 2008 and 2016. Demographic and clinical data such as age, sex, World Federation of Neurosurgical Societies (WFNS) grade, BMI, Fisher grade, history of arterial hypertension and smoking, aneurysm location, C-reactive protein (CRP) level, and detailed dosage of vasopressors and nimodipine during the treatment period were evaluated. Clinical outcome was analyzed using the modified Rankin Scale (mRS) 6 months after treatment. Univariate and multivariate regression analyses were performed. Additionally, mean arterial pressure (MAP), age, nimodipine, and vasopressor dose cutoff were evaluated with regard to outcome. The level of significance was set at ≤ 0.05. RESULTS Follow-up was assessed for 397 patients, 260 (65.5%) of whom achieved a good outcome (defined as an mRS score of 0-3). Univariate and multivariate analyses confirmed that nimodipine (p = 0.049), age (p = 0.049), and CRP level (p = 0.002) are independent predictors of good outcome. WFNS grade, Fisher score, hypertension, initial hydrocephalus, and total vasopressor dose showed significant influence on outcome in univariate analysis, and patient sex, smoking status, BMI, and MAP showed no significant association with outcome. A subgroup analysis of patients with milder initial SAH (WFNS grades I-III) revealed that initial hydrocephalus (p = 0.003) and CRP levels (p = 0.001) had significant influence on further outcome. When evaluating only patients with WFNS grade IV or V, age, CRP level (p = 0.011), vasopressor dose (p = 0.030), and nimodipine dose (p = 0.049) were independent predictors of patient outcome. Patients with an MAP < 93 mm Hg, a nimodipine cutoff dose of 241.8 mg, and cutoff total vasopressor dose of 523 mg had better outcomes. CONCLUSIONS According to the authors' results, higher doses of vasopressors can safely provide a situation in which the maximum dose of nimodipine could be administered. Cutoff values of the total vasopressor dose were more than 3 times higher in patients with severe SAH (WFNS grade IV or V), while the nimodipine cutoff remained similar in patients with mild and severe SAH. Hence, it seems encouraging that a maximum nimodipine dosage can be achieved despite the need for a higher vasopressor dose in patients with SAH.
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Affiliation(s)
- Andrej Paľa
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | | | - Moritz Klein
- 2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Benjamin Mayer
- 3Institute of Epidemiology and Medical Biometry, University of Ulm; and
| | - Bernd Schmitz
- 4Section of Neuroradiology, University of Ulm, Günzburg, Germany
| | - Christian Rainer Wirtz
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Ralph König
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Thomas Kapapa
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
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Kieninger M, Gruber M, Knott I, Dettmer K, Oefner PJ, Bele S, Wendl C, Tuemmler S, Graf B, Eissnert C. Incidence of Arterial Hypotension in Patients Receiving Peroral or Continuous Intra-arterial Nimodipine After Aneurysmal or Perimesencephalic Subarachnoid Hemorrhage. Neurocrit Care 2019; 31:32-39. [DOI: 10.1007/s12028-019-00676-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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12
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Effect of Intra-arterial Nimodipine on Cerebral Oxygen Saturation and Systemic Hemodynamic Indices in Patients With Cerebral Vasospasm: A Prospective Cohort Study. J Neurosurg Anesthesiol 2019; 32:177-181. [DOI: 10.1097/ana.0000000000000570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Paľa A, Schneider M, Brand C, Pedro MT, Özpeynirci Y, Schmitz B, Wirtz CR, Kapapa T, König R, Braun M. The evolution of invasive cerebral vasospasm treatment in patients with spontaneous subarachnoid hemorrhage and delayed cerebral ischemia—continuous selective intracarotid nimodipine therapy in awake patients without sedation. Neurosurg Rev 2018; 42:463-469. [DOI: 10.1007/s10143-018-0986-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/01/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
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14
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Joshi S, Ellis JA, Emala CW. Revisiting intra-arterial drug delivery for treating brain diseases or is it "déjà-vu, all over again"? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2018; 1:108-115. [PMID: 25478580 DOI: 10.4103/2348-0548.130386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
For over six decades intra-arterial (IA) drugs have been sporadically used for the treatment of lethal brain diseases. In recent years considerable advance has been made in the IA treatment of retinoblastomas, liver and locally invasive breast cancers, but relatively little progress has been made in the treatment of brain cancers. High resting blood flow and the presence of the blood-brain barrier (BBB), makes IA delivery to the brain tissue far more challenging, compared to other organs. The lack of advance in the field is also partly due to the inability to understand the complex pharmacokinetics of IA drugs as it is difficult to track drug concentrations in sub-second time frame by conventional chemical methods. The advances in optical imaging now provide unprecedented insights into the pharmacokinetics of IA drug and optical tracer delivery. Novel delivery methods, improved IA drug formulations, and optical pharmacokinetics, present us with untested paradigms in pharmacology that could lead to new therapeutic interventions for brain cancers and stroke. The object of this review is to bring into focus the current practice, problems, and the potential of IA drug delivery for treating brain diseases. A concerted effort is needed at basic sciences (pharmacology and drug imaging), and translational (drug delivery techniques and protocol development) levels by the interventional neuroradiology community to advance the field.
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Affiliation(s)
- Shailendra Joshi
- Departments of Anesthesiology, and Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, NY
| | - Jason A Ellis
- Departments of Anesthesiology, and Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, NY
| | - Charles W Emala
- Departments of Anesthesiology, and Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, NY
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15
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Mogollon JP, Smoll NR, Panwar R. Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology. World Neurosurg 2018; 113:e29-e37. [PMID: 29410100 DOI: 10.1016/j.wneu.2018.01.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service. METHODS This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital. RESULTS The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period. CONCLUSIONS Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV. STUDY REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616000201471.
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MESH Headings
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Brain Damage, Chronic/epidemiology
- Brain Damage, Chronic/etiology
- Brain Damage, Chronic/prevention & control
- Computed Tomography Angiography
- Embolization, Therapeutic
- Endovascular Procedures/statistics & numerical data
- Female
- Humans
- Incidence
- Intensive Care Units/statistics & numerical data
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Length of Stay/statistics & numerical data
- Ligation
- Male
- Middle Aged
- Radiography, Interventional/statistics & numerical data
- Recurrence
- Severity of Illness Index
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/surgery
- Tertiary Care Centers/statistics & numerical data
- Treatment Outcome
- Vasospasm, Intracranial/epidemiology
- Vasospasm, Intracranial/etiology
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Affiliation(s)
| | - Nicolas Roydon Smoll
- Melbourne School of Population Health, University of Melbourne, Melbourne, Australia
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
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16
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Hockel K, Diedler J, Steiner J, Birkenhauer U, Ernemann U, Schuhmann MU. Effect of Intra-Arterial and Intravenous Nimodipine Therapy of Cerebral Vasospasm After Subarachnoid Hemorrhage on Cerebrovascular Reactivity and Oxygenation. World Neurosurg 2017; 101:372-378. [DOI: 10.1016/j.wneu.2017.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/31/2017] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
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17
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von der Brelie C, Doukas A, Stopfer A, Larsen N, Mehdorn M, Synowitz M, Jansen O. Clinical Course and Monitoring Parameters After Continuous Interventional Intra-Arterial Treatment in Patients with Refractory Cerebral Vasospasm. World Neurosurg 2017; 100:504-513. [DOI: 10.1016/j.wneu.2016.12.110] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 11/16/2022]
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18
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Andereggen L, Beck J, Z'Graggen WJ, Schroth G, Andres RH, Murek M, Haenggi M, Reinert M, Raabe A, Gralla J. Feasibility and Safety of Repeat Instant Endovascular Interventions in Patients with Refractory Cerebral Vasospasms. AJNR Am J Neuroradiol 2016; 38:561-567. [PMID: 27979797 DOI: 10.3174/ajnr.a5024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 10/11/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions. MATERIALS AND METHODS This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions. RESULTS During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions (P = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; P = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; P = .004). CONCLUSIONS Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.
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Affiliation(s)
- L Andereggen
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.).,Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.)
| | - J Beck
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - W J Z'Graggen
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.).,Departments of Neurology (W.J.Z.)
| | - G Schroth
- Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.)
| | - R H Andres
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - M Murek
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - M Haenggi
- Intensive Care Medicine (M.H.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - M Reinert
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - A Raabe
- From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.)
| | - J Gralla
- Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.)
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19
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Helbok R, Zangerle A, Chemelli A, Beer R, Benke T, Ehling R, Fischer M, Sojer M, Pfausler B, Thome C, Schmutzhard E. Continuous intra-arterial nimodipine infusion in refractory symptomatic vasospasm after subarachnoid hemorrhage. SPRINGERPLUS 2016; 5:1807. [PMID: 27812447 PMCID: PMC5069241 DOI: 10.1186/s40064-016-3495-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 10/07/2016] [Indexed: 11/10/2022]
Abstract
Introduction Vasospasm still is a major cause of morbidity after aneurysmal subarachnoid hemorrhage. The purpose of this report is to describe the successful management of severe refractory vasospasm with continuous intra-arterial nimodipine (IAN) treatment. Case description A 72-year old right handed woman was admitted with non-traumatic SAH WFNS grade 1. Cerebral computed tomography demonstrated thick blood filling of the basal cisterns, and intraventricular hemorrhage. Cerebral angiogram failed to detect a vascular abnormality. After an uneventful initial course the patient developed symptomatic left middle cerebral artery vasospasm with aphasia and corresponding restriction in diffusion weighted images in the left frontal lobe. Bolus IAN only transiently improved cerebral circulation and clinical signs and symptoms. Continuous-IAN was started and led to full clinical recovery and normalisation of MRI diffusion restrictions. Discussion and conclusions Continuous selective intra-arterial infusion of nimodipine may be an option in selected patients with symptomatic vasospasm refractory to conventional treatment after careful consideration of benefits and procedure-related risks.
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Affiliation(s)
- Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Alexandra Zangerle
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Andreas Chemelli
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Thomas Benke
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Rainer Ehling
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Marlene Fischer
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Martin Sojer
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
| | - Claudius Thome
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck , Anichstrasse 35, 6020 Innsbruck, Austria
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20
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Hänggi D, Etminan N, Macdonald RL, Steiger HJ, Mayer SA, Aldrich F, Diringer MN, Hoh BL, Mocco J, Strange P, Faleck HJ, Miller M. NEWTON: Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage. Neurocrit Care 2016; 23:274-84. [PMID: 25678453 DOI: 10.1007/s12028-015-0112-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. EG-1962 is a sustained-release microparticle formulation of nimodipine that has shown preclinical efficacy when administered intraventricularly or intracisternally to dogs with SAH, without evidence of toxicity at doses in the anticipated therapeutic range. Thus, we propose to administer EG-1962 to humans in order to assess safety and tolerability and determine a dose to investigate efficacy in subsequent clinical studies. METHODS We describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the maximum tolerated dose (MTD) and assess the safety and tolerability of EG-1962 in patients with aSAH. The study will comprise two parts: a dose escalation period (Part 1) to determine the MTD of EG-1962 and a treatment period (Part 2) to assess the safety and tolerability of the selected dose of EG-1962. Patients with a ruptured saccular aneurysm treated by neurosurgical clipping or endovascular coiling will be considered for enrollment. Patients will be randomized to receive either EG-1962 (study drug: nimodipine microparticles) or oral nimodipine in the approved dose regimen (active control) within 60 h of aSAH. RESULTS Primary objectives are to determine the MTD and the safety and tolerability of the selected dose of intraventricular EG-1962 as compared to enteral nimodipine. The secondary objective is to determine release and distribution by measuring plasma and CSF concentrations of nimodipine. Exploratory objectives are to determine the incidence of delayed cerebral infarction on computed tomography, clinical features of delayed cerebral ischemia, angiographic vasospasm, and incidence of rescue therapy and clinical outcome. Clinical outcome will be determined at 90 days after aSAH using the extended Glasgow outcome scale, modified Rankin scale, Montreal cognitive assessment, telephone interview of cognitive status, and Barthel index. CONCLUSION Here, we describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the MTD and assess the safety and tolerability of EG-1962 in patients with aSAH.
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Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany,
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21
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Bashir A, Andresen M, Bartek J, Cortsen M, Eskesen V, Wagner A. Intra-arterial nimodipine for cerebral vasospasm after subarachnoid haemorrhage: Influence on clinical course and predictors of clinical outcome. Neuroradiol J 2016; 29:72-81. [PMID: 26825134 DOI: 10.1177/1971400915626429] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intra-arterial nimodipine (IAN) has shown a promising effect on cerebral vasospasm (CV) after aneurysmal subarachnoid haemorrhage. At our institution, Rigshospitalet, IAN treatment has been used since 2009, but the short- and long-term clinical efficacy of IAN has not yet been assessed. The purpose was to evaluate the efficacy and clinical outcome of IAN treatment of symptomatic CV, and to assess the predictors of clinical outcome. Medical records of 25 patients undergoing a total of 41 IAN treatment sessions were retrospectively reviewed. Data on angiographic results, blood-flow velocities and the clinical condition before and after the IAN treatment were recorded. Predictors of the clinical outcome were assessed with a linear regression model. Positive angiographic response was achieved in 95.1% of 41 IAN treatment sessions. Flow-velocity measurements showed no relationship with angiographic responses of IAN. The immediate clinical improvement was observed in three patients (12%). Five patients (20%) had a favourable outcome at discharge and at three-month follow-up; 10 patients (40%) had a moderate to poor outcome; and the rest (40%) died. Increased number of affected vessels and number of procedures carried out per patient, and a trend toward an increased delay time from symptomatic CV to confirming angiographic CV and thus instituting IAN treatment predicted the poor clinical outcome. IAN treatment appears to be effective in reversing angiographic CV. However, it is not always effective in reversing clinical deterioration, as several other factors including treatment delay affect the clinical course.
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Affiliation(s)
- Asma Bashir
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jiri Bartek
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Cortsen
- Department of Radiology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Aase Wagner
- Department of Radiology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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22
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Hockel K, Diedler J, Steiner J, Birkenhauer U, Danz S, Ernemann U, Schuhmann MU. Long-Term, Continuous Intra-Arterial Nimodipine Treatment of Severe Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2015; 88:104-112. [PMID: 26732964 DOI: 10.1016/j.wneu.2015.11.081] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary vasospasm and disturbances in cerebrovascular autoregulation are associated with the development of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. An intra-arterial application of nimodipine has been shown to increase the vessel diameter, although this effect is transient. The feasibility of long-term, continuous, intra-arterial nimodipine treatment and its effects on macrovasospasm, autoregulation parameters, and outcome were evaluated in patients with refractory severe macrovasospasm. METHODS Ten patients were included with refractory macrovasospasm despite bolus nimodipine application (n = 4) or with primary severe vasospasm (n = 6). The patients were assessed with continuous multimodal neuromonitoring (mean arterial pressure, intraceranial pressure, cerebral perfusion pressure, brain tissue oxygen tension probe), daily transcranial Doppler examinations, and computed tomography angiography/perfusion. Autoregulation indices, the pressure reactivity index, and oxygen reactivity index were calculated. Indwelling microcatheters were placed in the extracranial internal carotid arteries and 0.4 mg nimodipine was continuously infused at 50 mL/hour. RESULTS The duration of continuous, intra-arterial nimodipine ranged from 9 to 15 days. During treatment intracranial pressure remained stable, transcranial Doppler flow velocity decreased, and brain tissue oxygen tension improved by 37%. Macrovasospasm, as assessed via computed tomography angiography, had improved (n = 5) or disappeared (n = 5) at the end of treatment. Cerebrovascular autoregulation according to the pressure reactivity index and oxygen reactivity index significantly worsened during treatment. All patients showed a favorable outcome (median Glasgow Outcome Scale 5) at 3 months. CONCLUSIONS In well-selected patients with prolonged severe macrovasospasm, continuous intra-arterial nimodipine treatment can be applied as a rescue therapy with relative safety for more than 2 weeks to prevent secondary cerebral ischemia. The induced impairment of cerebrovascular autoregulation during treatment seems to have no negative effects.
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Affiliation(s)
- Konstantin Hockel
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany.
| | - Jennifer Diedler
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Jochen Steiner
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Ulrich Birkenhauer
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Sören Danz
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, University of Tübingen, Germany
| | - Ulrike Ernemann
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, University of Tübingen, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
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23
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Continuous intra-arterial nimodipine infusion in patients with severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a feasibility study and outcome results. Acta Neurochir (Wien) 2015; 157:2041-50. [PMID: 26439105 DOI: 10.1007/s00701-015-2597-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Severe cerebral vasospasm is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. No causative treatment is yet available and hypertensive hypervolemic therapy (HHT) is often insufficient to avoid delayed cerebral ischemia and neurological deficits. We compared patients receiving continuous intra-arterial infusion of the calcium-antagonist nimodipine with a historical group treated with HHT and oral nimodipine alone. METHODS Between 0.5 and 1.2 mg/h of nimodipine were continuously administered by intra-arterial infusion via microcatheters either into the internal carotid or vertebral artery or both, depending on the areas of vasospasm. The effect was controlled via multimodal neuromonitoring and transcranial Doppler sonography. Outcome was determined by means of the Glasgow Outcome Scale at discharge and 6 months after the hemorrhage and compared to a historical control group. RESULTS Twenty-one patients received 28 intra-arterial nimodipine infusions. Six months after discharge, the occurrence of cerebral infarctions was significantly lower (42.6 %) in the nimodipine group than in the control group (75.0 %). This result was reflected by a significantly higher proportion (76.0 %) of patients with good outcome in the nimodipine-treated group, when compared to 10.0 % good outcome in the control group. Median GOS was 4 in the nimodipine group and 2 in the control group (p = 0.001). CONCLUSIONS Continuous intra-arterial nimodipine infusion is an effective treatment for patients with severe cerebral vasospasm who fail to respond to HHT and oral nimodipine alone. Key to the effective administration of continuous intra-arterial nimodipine is multimodal neuromonitoring and the individual adaptation of dosage and time of infusion for each patient.
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24
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Basalious EB, Shamma RN. Novel self-assembled nano-tubular mixed micelles of Pluronics P123, Pluronic F127 and phosphatidylcholine for oral delivery of nimodipine: In vitro characterization, ex vivo transport and in vivo pharmacokinetic studies. Int J Pharm 2015; 493:347-56. [DOI: 10.1016/j.ijpharm.2015.07.075] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/25/2015] [Accepted: 07/28/2015] [Indexed: 01/08/2023]
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25
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Logallo N, Bøthun ML, Guttormsen AB, Holmaas G, Kråkenes J, Thomassen L, Svendsen F, Helland CA. Continuous Local Intra-Arterial Nimodipine for the Treatment of Cerebral Vasospasm. J Neurol Surg Rep 2015; 76:e75-8. [PMID: 26251816 PMCID: PMC4520965 DOI: 10.1055/s-0034-1543976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 11/15/2014] [Indexed: 11/26/2022] Open
Abstract
Vasospasm (VSP) is one of the major causes for prolonged neurologic deficit in patients with aneurysmal subarachnoid hemorrhage. Few case series have reported about continuous local intra-arterial nimodipine administration (CLINA) in refractory VSP. We report our experience with CLINA in a patient with refractory cerebral VSP.
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Affiliation(s)
- Nicola Logallo
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway ; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Marianne Lundervik Bøthun
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway ; Department of Clinical Medicine, University of Bergen, Bergen, Norway ; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | | | - Gunhild Holmaas
- Intensive Care Unit, Haukeland University Hospital, Bergen, Norway
| | - Jostein Kråkenes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway ; Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Lars Thomassen
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway ; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frode Svendsen
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christian A Helland
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway ; Department of Clinical Medicine, University of Bergen, Bergen, Norway ; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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26
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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Huang S, Yu X, Yang L, Song F, Chen G, Lv Z, Li T, Chen D, Zhu W, Yu A, Zhang Y, Yang F. The efficacy of nimodipine drug delivery using mPEG-PLA micelles and mPEG-PLA/TPGS mixed micelles. Eur J Pharm Sci 2014; 63:187-98. [DOI: 10.1016/j.ejps.2014.07.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/18/2014] [Accepted: 07/14/2014] [Indexed: 02/05/2023]
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Milrinone Via Lumbar Subarachnoid Catheter for Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2014; 21:470-5. [DOI: 10.1007/s12028-014-9996-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Esposito E, Ebner M, Ziemann U, Poli S. In cold blood: intraarteral cold infusions for selective brain cooling in stroke. J Cereb Blood Flow Metab 2014; 34:743-52. [PMID: 24517972 PMCID: PMC4013766 DOI: 10.1038/jcbfm.2014.29] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/19/2013] [Accepted: 01/19/2014] [Indexed: 12/29/2022]
Abstract
Hypothermia is a promising therapeutic option for stroke patients and an established neuroprotective treatment for global cerebral ischemia after cardiac arrest. While whole body cooling is a feasible approach in intubated and sedated patients, its application in awake stroke patients is limited by severe side effects: Strong shivering rewarms the body and potentially worsens ischemic conditions because of increased O2 consumption. Drugs used for shivering control frequently cause sedation that increases the risk of aspiration and pneumonia. Selective brain cooling by intraarterial cold infusions (IACIs) has been proposed as an alternative strategy for patients suffering from acute ischemic stroke. Preclinical studies and early clinical experience indicate that IACI induce a highly selective brain temperature decrease within minutes and reach targeted hypothermia 10 to 30 times faster than conventional cooling methods. At the same time, body core temperature remains largely unaffected, thus systemic side effects are potentially diminished. This review critically discusses the limitations and side effects of current cooling techniques for neuroprotection from ischemic brain damage and summarizes the available evidence regarding advantages and potential risks of IACI.
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Affiliation(s)
- Elga Esposito
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Matthias Ebner
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Continuous selective intra-arterial application of nimodipine in refractory cerebral vasospasm due to aneurysmal subarachnoid hemorrhage. BIOMED RESEARCH INTERNATIONAL 2014; 2014:970741. [PMID: 24527461 PMCID: PMC3914346 DOI: 10.1155/2014/970741] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 12/08/2013] [Accepted: 12/11/2013] [Indexed: 11/17/2022]
Abstract
Background. Cerebral vasospasm is one of the leading courses for disability in aneurysmal subarachnoid hemorrhage. Effective treatment of vasospasm is therefore one of the main priorities for these patients. We report about a case series of continuous intra-arterial infusion of the calcium channel antagonist nimodipine for 1–5 days on the intensive care unit. Methods. In thirty patients with aneurysmal subarachnoid hemorrhage and refractory vasospasm continuous infusion of nimodipine was started on the neurosurgical intensive care unit. The effect of nimodipine on brain perfusion, cerebral blood flow, brain tissue oxygenation, and blood flow velocity in cerebral arteries was monitored. Results. Based on Hunt & Hess grades on admission, 83% survived in a good clinical condition and 23% recovered without an apparent neurological deficit. Persistent ischemic areas were seen in 100% of patients with GOS 1–3 and in 69% of GOS 4-5 patients. Regional cerebral blood flow and computed tomography perfusion scanning showed adequate correlation with nimodipine application and angiographic vasospasm. Transcranial Doppler turned out to be unreliable with interexaminer variance and failure of detecting vasospasm or missing the improvement. Conclusion. Local continuous intra-arterial nimodipine treatment for refractory cerebral vasospasm after aSAH can be recommended as a low-risk treatment in addition to established endovascular therapies.
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Intra-arterial dantrolene for refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2013; 17:245-9. [PMID: 22815125 DOI: 10.1007/s12028-012-9737-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Intravenous dantrolene has been used to prevent and treat cerebral vasospasm. We report a case of refractory cerebral vasospasm treated with intra-arterial dantrolene after aneurysmal subarachnoid hemorrhage. METHODS A 56-year-old woman suffered a diffuse subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm which was successfully treated with coil embolization. She subsequently developed bilateral severe angiographic vasospasm which was treated with intra-arterial vasodilators. However, owing to the recurrence of vasospasm, intra-arterial dantrolene followed by balloon angioplasty was used. RESULTS There was moderate improvement of the severe vasospasm in bilateral A1 segments of the anterior cerebral arteries after microcatheter-based intra-arterial infusion of 30 ml (1 mg/ml) dantrolene. Patient's hemodynamic parameters were monitored during and after the procedure and no significant changes were seen after dantrolene infusion. A follow up cerebral angiogram after 1 day demonstrated the persistence of therapeutic effect. CONCLUSION Intra-arterial dantrolene induced a sustained improvement in cerebral vasospasm secondary to ruptured aneurysm. No significant side effects were observed during or after the infusion of the drug.
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Kerz T, Boor S, Beyer C, Welschehold S, Schuessler A, Oertel J. Effect of intraarterial papaverine or nimodipine on vessel diameter in patients with cerebral vasospasm after subarachnoid hemorrhage. Br J Neurosurg 2012; 26:517-24. [DOI: 10.3109/02688697.2011.650737] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wolf S, Vajkoczy P, Dengler J, Schürer L, Horn P. Drift of the Bowman Hemedex® cerebral blood flow monitor between calibration cycles. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012; 114:187-90. [PMID: 22327690 DOI: 10.1007/978-3-7091-0956-4_36] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Since its introduction into clinical practice, the Bowman Hemedex® regional cerebral blood flow (CBF) monitor has provided a valuable tool for the bedside assessment of CBF in neurointensive care. The purpose of our study was to estimate the accuracy of CBF measurements between automatically performed self-calibration cycles at regular intervals. METHODS We analyzed data from 75 CBF probes, predominantly implanted into patients after severe subarachnoid hemorrhage. Automatic recalibration of the regional CBF device was performed every 30 min. CBF data were averaged once per minute and the measurement cycles pooled. Statistical analysis was performed with generalized additive modeling and bootstrapping methods. RESULTS Mean regional CBF was 24 mL/100 g/min after calibration and showed a mean drift of 2.3 mL/100 g/min per measurement cycle (p < 0.001). In every patient, the drift over the measurement cycle followed an exponential trend, with large heterogeneity between patients (-3.67 to 12.0 mL/100 g/min). A highly significant difference in drift was found for the internal software versions of the monitoring devices (p < 0.001). CONCLUSIONS Data from the Bowman Hemedex® regional CBF monitor shows an upward measurement drift of clinically relevant magnitude. As the drift follows a stable exponential function over time, recalculation of drift-corrected data is possible after termination of the measurement.
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Affiliation(s)
- Stefan Wolf
- Department of Neurosurgery, Charité University, Berlin, Germany.
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Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N. Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic Vasospasm After Subarachnoid Hemorrhage. Neurosurgery 2011; 68:1541-7; discussion 1547. [DOI: 10.1227/neu.0b013e31820edd46] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm (CV) is a potentially disastrous consequence of subarachnoid hemorrhage despite medical treatment. Nimodipine is a potent drug for vessel relaxation, but side effects may preclude a sufficient dose.
OBJECTIVE:
To explore whether continuous local intra-arterial nimodipine administration (CLINA) can reverse vasospasm and prevent delayed ischemic neurological deficit.
METHODS:
Six consecutive subarachnoid hemorrhage patients (5 women; mean age, 47.2 years) with severe CV despite maximum medical therapy underwent CLINA within 2 hours after the onset of clinical symptoms. After anticoagulation, microcatheters were inserted distally in the concerning supra-aortic vessels. Glyceryl trinitrate injection (2 mg) was followed by CLINA (nimodipine 0.4 mg/h for 70-147 hours). Duration of CLINA was determined by neurological status, transcranial Doppler sonography, and partial tissue oxygen pressure values.
RESULTS:
In all patients, neurological deficits improved or partial tissue oxygen pressure values returned to normal and transcranial Doppler sonography confirmed a reduced blood flow velocity within 12 hours. Magnetic resonance imaging showed no ischemic lesion caused by CV. Neurological outcome was good (modified Rankin Scale score, 0–2) in 3 patients, whereas 1 patient had a moderate clinical outcome (modified Rankin Scale score, 3–4) and 2 patients had a poor outcome (modified Rankin Scale score, 5) because of the SAH.
CONCLUSION:
Preliminary data show that CLINA is a straightforward, effective, and safe option for patients with severe CV refractory to medical therapy. Dilation of spastic arteries starts within a few hours and is lasting. Indication for CLINA is peripheral and diffuse CV at any location.
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Affiliation(s)
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen
| | - Zsolt Vajda
- Department of Neuroradiology, Klinikum Stuttgart, Germany
| | - Jan Coburger
- Department of Neurosurgery, Klinikum Stuttgart, Germany
| | - Nikolai Hopf
- Department of Neurosurgery, Klinikum Stuttgart, Germany
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