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Galijasevic M, Steiger R, Treichl SA, Ho WM, Mangesius S, Ladenhauf V, Deeg J, Gruber L, Ouaret M, Regodic M, Lenhart L, Pfausler B, Grams AE, Petr O, Thomé C, Gizewski ER. Could Phosphorous MR Spectroscopy Help Predict the Severity of Vasospasm? A Pilot Study. Diagnostics (Basel) 2024; 14:841. [PMID: 38667486 PMCID: PMC11049300 DOI: 10.3390/diagnostics14080841] [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: 02/22/2024] [Revised: 04/02/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
One of the main causes of the dismal prognosis in patients who survive the initial bleeding after aneurysmal subarachnoidal hemorrhage is the delayed cerebral ischaemia caused by vasospasm. Studies suggest that cerebral magnesium and pH may potentially play a role in the pathophysiology of this adverse event. Using phosphorous magnetic resonance spectrocopy (31P-MRS), we calculated the cerebral magnesium (Mg) and pH levels in 13 patients who suffered from aSAH. The values between the group that developed clinically significant vasospasm (n = 7) and the group that did not (n = 6) were compared. The results of this study show significantly lower cerebral Mg levels (p = 0.019) and higher pH levels (p < 0.001) in the cumulative group (all brain voxels together) in patients who developed clinically significant vasospasm. Further clinical studies on a larger group of carefully selected patients are needed in order to predict clinically significant vasospasm.
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Affiliation(s)
- Malik Galijasevic
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Ruth Steiger
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Stephanie Alice Treichl
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.A.T.); (W.M.H.); (O.P.); (C.T.)
| | - Wing Man Ho
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.A.T.); (W.M.H.); (O.P.); (C.T.)
| | - Stephanie Mangesius
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Valentin Ladenhauf
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Johannes Deeg
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Leonhard Gruber
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Miar Ouaret
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Milovan Regodic
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Lukas Lenhart
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Astrid Ellen Grams
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Ondra Petr
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.A.T.); (W.M.H.); (O.P.); (C.T.)
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.A.T.); (W.M.H.); (O.P.); (C.T.)
| | - Elke Ruth Gizewski
- Department of Radiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (M.G.); (S.M.); (V.L.); (J.D.); (L.G.); (M.O.); (M.R.); (L.L.); (A.E.G.); (E.R.G.)
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Deem S, Diringer M, Livesay S, Treggiari MM. Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:81-90. [PMID: 37160848 DOI: 10.1007/s12028-023-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023]
Abstract
One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. Hypovolemia and hypotension were favored prior to the era of early aneurysmal surgery but were subsequently replaced by the use of hypervolemia and hypertension. More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.
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Affiliation(s)
- Steven Deem
- Neurocritical Care Unit, Swedish Medical Center, Seattle, WA, USA.
| | - Michael Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- College of Nursing, Rush University, Chicago, IL, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical School, Durham, NC, USA
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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Lannon M, Martyniuk A, Sharma S. Intravenous milrinone for delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage: a systematic review. Br J Neurosurg 2022:1-6. [PMID: 36154769 DOI: 10.1080/02688697.2022.2125160] [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: 06/09/2022] [Accepted: 09/10/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a major contributor to mortality worldwide, with delayed cerebral ischaemia (DCI) contributing significantly to morbidity in these patients. There are limited evidence-based therapies for DCI. A 2012 case series first recommended the use of intravenous (IV) milrinone in this patient population, stating the need for formal prospective trials. However, uptake of this therapy into clinical practice has proceeded without adequate studies for efficacy and safety. METHODS We sought to determine the effect of IV milrinone on DCI in patients with aSAH in terms of functional outcome through a systematic review using Embase, MEDLINE, and Cochrane Library databases. Quality assessment was performed using MINORS criteria. RESULTS A total of 2429 studies were screened, with ten studies included in the review. Of these, no randomized trials were identified. Three observational comparative studies were included, and the remaining seven studies were non-comparative in nature, and mainly retrospective. Overall, the quality of evidence for non-comparative studies was poor. CONCLUSIONS This study reveals a paucity of evidence in the literature and highlights the need for high-quality randomized trials to investigate the safety and efficacy of IV milrinone, a commonly utilized treatment in critically ill aSAH patients with DCI. Ultimately, without evidence of efficacy and absence of harm, we caution continued use of intravenous milrinone for the treatment of DCI.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
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Baulier C, Lessert M, Chauvet JL, Garel P, Bergis A, Burdeau J, Clavier T. Left Ventricular Outflow Tract Obstruction in Patients Treated With Milrinone for Cerebral Vasospasm: Case Report and Literature Review. JMIRX MED 2022; 3:e31019. [PMID: 37463041 PMCID: PMC10337478 DOI: 10.2196/31019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/05/2021] [Accepted: 01/27/2022] [Indexed: 07/20/2023]
Abstract
Subarachnoid hemorrhage is associated with high morbidity and mortality, and cerebral arterial vasospasm is one of its main complications that determines neurological prognosis. The use of intravenous milrinone is becoming more common in the treatment of vasospasm. This molecule has positive inotropic and vasodilating properties by inhibiting phosphodiesterase-3. Its most described side effects are cardiac arrhythmias and arterial hypotension. In this paper, we raise a new issue concerning milrinone and discuss an undescribed side effect of this treatment, left ventricular outflow tract obstruction (LVOTO). Dynamic LVOTO is a clinical situation favored by hypovolemia, decreased left ventricular afterload, and excessive inotropism that can lead to severe hemodynamic failure and pulmonary edema. To our knowledge, this is the first study describing milrinone-induced LVOTO. This could compromise cerebral perfusion and therefore the neurological prognosis of patients. While it is known that catecholamines may induce LVOTO, milrinone-induced LVOTO appears to be a new pathophysiological entity of which neurosurgical intensivists should be aware.
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Affiliation(s)
- Charles Baulier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Marc Lessert
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | | | - Pauline Garel
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Alexandre Bergis
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Julie Burdeau
- Cardiology Department Rouen University Hospital Rouen France
| | - Thomas Clavier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
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Steiger HJ, Ensner R, Andereggen L, Remonda L, Berberat J, Marbacher S. Hemodynamic response and clinical outcome following intravenous milrinone plus norepinephrine-based hyperdynamic hypertensive therapy in patients suffering secondary cerebral ischemia after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:811-821. [PMID: 35138488 PMCID: PMC8913475 DOI: 10.1007/s00701-022-05145-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/29/2022] [Indexed: 12/12/2022]
Abstract
Purpose Intravenous and intra-arterial milrinone as a rescue measure for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) has been adopted by several groups, but so far, evidence for the clinical benefit is unclear and effect on brain perfusion is unknown. The aim of the actual analysis was to define cerebral hemodynamic effects and outcome of intravenous milrinone plus norepinephrine supplemented by intra-arterial nimodipine as a rescue strategy for DCI following aneurysmal SAH. Methods Of 176 patients with aneurysmal SAH treated at our neurosurgical department between April 2016 and March 2021, 98 suffered from DCI and were submitted to rescue therapy. For the current analysis, characteristics of these patients and clinical response to rescue therapy were correlated with hemodynamic parameters, as assessed by CT angiography (CTA) and perfusion CT. Time to peak (TTP) delay in the ischemic focus and the volume with a TTP delay of more than 4 s (T4 volume) were used as hemodynamic parameters. Results The median delay to neurological deterioration following SAH was 5 days. Perfusion CT at that time showed median T4 volumes of 40 cc and mean focal TTP delays of 2.5 ± 2.1 s in these patients. Following rescue therapy, median T4 volume decreased to 10 cc and mean focal TTP delay to 1.7 ± 1.9 s. Seventeen patients (17% of patients with DCI) underwent additional intra-arterial spasmolysis using nimodipine. Visible resolution of macroscopic vasospasm on CTA was observed in 43% patients with DCI and verified vasospasm on CTA, including those managed with additional intra-arterial spasmolysis. Initial WFNS grade, occurrence of secondary infarction, ischemic volumes and TTP delays at the time of decline, the time to clinical decline, and the necessity for additional intra-arterial spasmolysis were identified as the most important features determining neurological outcome at 6 months. Conclusion The current analysis shows that cerebral perfusion in the setting of secondary cerebral ischemia following SAH is measurably improved by milrinone and norepinephrine–based hyperdynamic therapy. A long-term clinical benefit by the addition of milrinone appears likely. Separation of the direct effect of milrinone from the effect of induced hypertension is not possible based on the present dataset.
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Affiliation(s)
- Hans-Jakob Steiger
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland.
- Klinik Für Neurochirurgie, Neurozentrum, Kantonsspital Aarau, Tellstr. 25, CH-5001, Aarau, Switzerland.
| | - Rolf Ensner
- Surgical Intensive Care Unit, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Jatta Berberat
- Division of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Neurozentrum, Kantonsspital Aarau, Aarau, Switzerland
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Rouanet C, Chaddad F, Freitas F, Miranda M, Vasconcellos N, Valiente R, Muehlschlegel S, Silva GS. Kinetics of cerebral blood flow velocities during treatment for delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. Neurocrit Care 2021; 36:226-239. [PMID: 34286467 DOI: 10.1007/s12028-021-01288-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 05/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In aneurysmal subarachnoid hemorrhage (aSAH), one of the main determinants of prognosis is delayed cerebral ischemia (DCI). Transcranial Doppler (TCD) is used to monitor vasospasm and DCI. We aimed to better understand cerebral hemodynamics response to hypertension induction (HI) with norepinephrine (NE) and inotropic therapy with milrinone so that TCD can be a bedside tool in helping to guide DCI therapies. Our primary objective was to determine TCD blood flow velocity (BFV) kinetics during HI and inotropic therapy for DCI treatment. Secondly, we performed an analysis by treatment subgroups and evaluated clinical response to therapies. METHODS We performed a prospective observational cohort study in a Brazilian high-volume center for aSAH. Patients with aSAH admitted between 2016 and 2018 who received NE or milrinone for DCI treatment were included. TCDs were performed before therapy initiation (t0) and 45 (t1) and 90 min (t2) from the onset of therapy. For each DCI event, we analyzed the highest mean flow velocity (MFV) and the mean MFV and compared their kinetics over time. The National Institutes of Health Stroke Scale was determined at t0, t1, and t2. RESULTS Ninety-eight patients with aSAH were admitted during the study period. Twenty-one (21.4%) developed DCI, of whom six had DCI twice, leading to a total of 27 analyzed DCI events (12 treated with HI and 15 with milrinone). Patients treated with NE had their mean arterial pressure raised (85 mm Hg in t0, 112 mm Hg in t2 [p < 0.001]), whereas those treated with milrinone had a significant decrease in mean arterial pressure over treatment (94 mm Hg in t0, 88 mm Hg in t2 [p = 0.004]). Among all treated patients, there was a significant drop from t0 to t2 but not to t1 in the highest MFV and in the highest mean MFV. Among those treated with HI, there were no significant changes from t0 to t1 or t2 (highest MFV in t0 163.2 cm/s, in t1 172.9 cm/s [p = 0.27], and in t2 164 cm/s [p = 0.936]). Conversely, in those treated with milrinone, there was a significant decrease from t0 to t1 and to t2 (highest MFV in t0 197.1 cm/s, in t1 172.8 cm/s [p = 0.012], in t2 159 cm/s [p = 0.002]). Regarding clinical outcomes, we observed a significant improvement in mean National Institutes of Health Stroke Scale scores from 17 to 16 in t1 (p < 0.001) and to 15 in t2 (p = 0.002). CONCLUSIONS BFV analyzed by TCD in patients with aSAH who developed DCI and were treated with milrinone or NE significantly decreased in a time-dependent way. Milrinone effectively decrease cerebral BFV, whereas NE do not. Clinical improvement was achieved with both treatment strategies.
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Affiliation(s)
- Carolina Rouanet
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil.
| | - Feres Chaddad
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | - Flavio Freitas
- Anesthesiology, Pain, and Critical Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Maramelia Miranda
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | - Natalia Vasconcellos
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | - Raul Valiente
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | - Susanne Muehlschlegel
- Division of Neurocritical Care, Departments of Neurology, Anesthesia/Critical Care, and Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
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Intravenous milrinone for treatment of delayed cerebral ischaemia following subarachnoid haemorrhage: a pooled systematic review. Neurosurg Rev 2021; 44:3107-3124. [PMID: 33682040 DOI: 10.1007/s10143-021-01509-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
Small trials have demonstrated promising results utilising intravenous milrinone for the treatment of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Here we summarise and contextualise the literature and discuss the future directions of intravenous milrinone for DCI. A systematic, pooled analysis of literature was performed in accordance with the PRISMA statement. Methodological rigour was analysed using the MINORS criteria. Extracted data included patient population; treatment protocol; and clinical, radiological, and functional outcome. The primary outcome was clinical resolution of DCI. Eight hundred eighteen patients from 10 single-centre, observational studies were identified. Half (n = 5) of the studies were prospective and all were at high risk of bias. Mean age was 52 years, and females (69%) outnumbered males. There was a similar proportion of low-grade (WFNS 1-2) (49.7%) and high-grade (WFNS 3-5) (50.3%) SAH. Intravenous milrinone was administered to 523/818 (63.9%) participants. Clinical resolution of DCI was achieved in 375/424 (88%), with similar rates demonstrated with intravenous (291/330, 88%) and combined intra-arterial-intravenous (84/94, 89%) therapy. Angiographic response was seen in 165/234 (71%) receiving intravenous milrinone. Hypotension (70/303, 23%) and hypokalaemia (31/287, 11%) were common drug effects. Four cases (0.5%) of drug intolerance occurred. Good functional outcome was achieved in 271/364 (74%) patients. Cerebral infarction attributable to DCI occurred in 47/250 (19%), with lower rates in asymptomatic spasm. Intravenous milrinone is a safe and feasible therapy for DCI. A signal for efficacy is demonstrated in small, low-quality trials. Future research should endeavour to establish the optimal protocol and dose, prior to a phase-3 study.
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Santos-Teles AG, Ramalho C, Ramos JGR, Passos RDH, Gobatto A, Farias S, Batista PBP, Caldas JR. Efficacy and safety of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage: a systematic review. Rev Bras Ter Intensiva 2020; 32:592-602. [PMID: 33470361 PMCID: PMC7853682 DOI: 10.5935/0103-507x.20200097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 03/17/2020] [Indexed: 12/30/2022] Open
Abstract
Objective To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage. Methods The Pubmed®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies. Results Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm. Conclusion The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.
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Affiliation(s)
- Alex Goes Santos-Teles
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil
| | - Clara Ramalho
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | | | - André Gobatto
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | - Suzete Farias
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil
| | | | - Juliana Ribeiro Caldas
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Escola Bahiana de Medicina e Saúde Pública - Salvador (BA), Brasil.,Universidade de Salvador - Salvador (BA), Brasil
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