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Riordan K, Mamaril-Davis J, Aguilar-Salinas P, Dumont TM, Weinand ME. Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 232:107877. [PMID: 37441930 DOI: 10.1016/j.clineuro.2023.107877] [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: 04/06/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis. RESULTS Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively. CONCLUSIONS The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.
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Affiliation(s)
- Katherine Riordan
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - James Mamaril-Davis
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Martin E Weinand
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States.
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2
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Yao Z, Hu X, You C. Endovascular therapy for vasospasm secondary to subarachnoid hemorrhage: A meta-analysis and systematic review. Clin Neurol Neurosurg 2017; 163:9-14. [PMID: 29031080 DOI: 10.1016/j.clineuro.2017.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 02/05/2023]
Abstract
Endovascular therapy has been used as an alternative treatment for vasospasm following subarachnoid hemorrhage. The effectiveness and safety of endovascular therapy are still controversial. We performed a systematic review and meta-analysis to identify any advantage of endovascular therapy over traditional medical treatment. We systematically reviewed related English publications by searching PubMed, Ovid, Cochrane library, and Web of Science up to May 2017.The risk ratios (RR) and 95% confidence intervals (CI) were synthesized with fixed effect model. Subgroup analyses and sensitivity analyses were conducted to check the robustness the result. Publication bias was measured with funnel plot. Eight cohort studies were included, receiving a mean score of 7 on the Newcastle-Ottawa Scale. The overall effect (RR 1.01, [95% CI 0.80-1.26]) found no significant difference in the outcome between the endovascular treatment and control groups but with heterogeneity (Chi2=18.07, p=0.01, I2=61%). Subgroup analyses stratified by country, year of publication, treatment modality, follow-up time, and sensitivity analysis by excluding the most biased study yielded the same result (RR 1.19, [95% CI 0.94-1.52]), with rare heterogeneity (Chi2=4.21, p=0.65, I2=0). Funnel plot was visually symmetric in sensitivity analysis. Despite good performance in reversing vasospasm in previous studies, endovascular therapy did not show superiority to traditional medical treatment in improving patient outcomes. Further randomized controlled studies are needed to elucidate this issue.
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Affiliation(s)
- Zhong Yao
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China.
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3
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Park ES, Kim DW, Kang SD. Endovascular Treatment of Symptomatic Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Three-year Experience. J Cerebrovasc Endovasc Neurosurg 2017; 19:155-161. [PMID: 29159148 PMCID: PMC5680078 DOI: 10.7461/jcen.2017.19.3.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/28/2017] [Accepted: 09/17/2017] [Indexed: 11/23/2022] Open
Abstract
Objective The cause of severe clinical vasospasm after aneurysmal subarachnoid hemorrhage remains unknown, despite extensive research over the past 30 years. However, the intra-arterial administration of vasodilating agents and balloon angioplasty have been successfully used in severe refractory cerebral vasospasm. Materials and Methods We retrospectively analyzed the data of 233 patients admitted to our institute with aneurysmal subarachnoid hemorrhage (SAH) over the past 3 years. Results Of these, 27 (10.6%) developed severe symptomatic vasospasm, requiring endovascular therapy. Vasospasm occurred at an average of 5.3 days after SAH. A total of 46 endovascular procedures were performed in 27 patients. Endovascular therapy was performed once in 18 (66.7%) patients, 2 times in 4 (14.8%) patients, 3 or more times in 5 (18.5%) patients. Intra-arterial vasodilating agents were used in 44 procedures (27 with nimodipine infusion, 17 with nicardipine infusion). Balloon angioplasty was performed in only 2 (7.4%) patients. The Average nimodipine infusion volume was 2.47 mg, and nicardipine was 3.78 mg. Most patients recovered after the initial emergency room visit. Two patients (7.4%) worsened, but there were no deaths. Conclusion With advances in endovascular techniques, administration of vasodilating agents and balloon angioplasty reduces the morbidity and mortality of vasospasm after aneurysmal SAH.
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Affiliation(s)
- Eun-Sung Park
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
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4
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Kimball MM, Velat GJ, Hoh BL. Critical care guidelines on the endovascular management of cerebral vasospasm. Neurocrit Care 2012; 15:336-41. [PMID: 21761272 DOI: 10.1007/s12028-011-9600-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.
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Affiliation(s)
- Matthew M Kimball
- Department of Neurosurgery, University of Florida, 1600 South West Archer Rd, P.O. Box 100265, Gainesville, FL 32610, USA
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5
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Hwang G, Jung C, Sheen SH, Kim SH, Park SQ, Oh CW, Kwon OK. Procedural predictors of delayed cerebral infarction after intra-arterial vasodilator infusion for vasospasm following aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2010; 152:1503-9; discussion 1509-10. [PMID: 20577888 DOI: 10.1007/s00701-010-0715-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 06/09/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE The goals of this study were to identify predictors of delayed cerebral infarction in aneurysmal SAH after intra-arterial (IA) vasodilator infusion and to select proper parameters for treatment success. METHODS Forty-three patients qualified for review. Cerebral infarction was determined by DWI within 1 week of angiographic vasospasm. RESULTS Infarction developed in 18 of the 43 patients (41.9%) after IA vasodilator infusion and was associated with a high degree of proximal vessel residual narrowing and angiographic cerebral circulation time (CCT) prolongation at the end of IA vasodilator infusion (p < 0.001). A high degree of proximal residual narrowing (p = 0.018; odds ratio = 1.071; 95% confidence interval [CI] 1.012-1.123) and CCT prolongation at the end of the procedure (p = 0.007; odds ratio = 2.203; 95% CI 1.254-4.232) were found to be predictors of infarction by multivariate analysis. Furthermore, receiver operating characteristic (ROC) curves showed that both variables predicted the development of infarction (proximal vessel residual narrowing, area under the ROC curve [AUC], 0.828; CCT, AUC, 0.866). When proximal vessel narrowing of >30% or a CCT of >7 s by final angiography during IA vasodilator infusion were used as a threshold, the negative predictive value for infarction was 88.9% (95% CI 65.3-98.6%), and when narrowing was >30% and CCT was >7 s, the probability of subsequent cerebral infarction was 100% (95% CI 71.7-100%). CONCLUSIONS Angiographic CCT and residual narrowing at the end of IA vasodilator infusion were found to predict the subsequent occurrence of cerebral infarction. The authors suggest that residual narrowing of 30% and a CCT of 7 s could be used as a minimum indicator of IA vasodilator infusion endpoints.
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Weant KA, Ramsey CN, Cook AM. Role of Intraarterial Therapy for Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage. Pharmacotherapy 2010; 30:405-17. [DOI: 10.1592/phco.30.4.405] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Komotar RJ, Zacharia BE, Otten ML, Mocco J, Lavine SD. CONTROVERSIES IN THE ENDOVASCULAR MANAGEMENT OF CEREBRAL VASOSPASM AFTER INTRACRANIAL ANEURYSM RUPTURE AND FUTURE DIRECTIONS FOR THERAPEUTIC APPROACHES. Neurosurgery 2008; 62:897-905; discussion 905-7. [DOI: 10.1227/01.neu.0000318175.05591.c3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
CEREBRAL VASOSPASM IS one of the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Despite maximal medical therapy, however, up to 15% of patients surviving the ictus of subarachnoid hemorrhage experience stroke or death from vasospasm. For those cases of vasospasm that are refractory to medical treatment, endovascular techniques are frequently used, including balloon angioplasty with or without intra-arterial infusion of vasodilators, combined endovascular modalities, and aortic balloon devices. In this article, we review each of these therapies and their expanding role in the management of this condition. Moving forward, rigorous prospective outcome assessments after endovascular treatment of cerebral vasospasm are necessary to clearly delineate the efficacy and indications for these techniques.
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Affiliation(s)
- Ricardo J. Komotar
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Brad E. Zacharia
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Marc L. Otten
- Department of Neurological Surgery, Columbia University, New York, New York
| | - J Mocco
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Sean D. Lavine
- Department of Neurological Surgery, Columbia University, New York, New York
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8
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Zwienenberg-Lee M, Hartman J, Rudisill N, Muizelaar JP. Endovascular Management of Cerebral Vasospasm. Neurosurgery 2006; 59:S139-47; discussion S3-13. [PMID: 17053596 DOI: 10.1227/01.neu.0000239252.07760.59] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
CEREBRAL VASOSPASM REMAINS a leading cause of death and disability in patients with ruptured cerebral aneurysms. The development of endovascular intervention in the past two decades has shown promising results in the treatment of vasospasm. Endovascular techniques that have been used in humans include intra-arterial infusion of vasorelaxants and direct mechanical dilation with transluminal balloon angioplasty. This article reviews the current indications and role of endovascular therapy in the management of cerebral vasospasm, its clinical significance, and potential future therapies.
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Affiliation(s)
- Marike Zwienenberg-Lee
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA 95817, USA.
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9
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Terry A, Zipfel G, Milner E, Cross DT, Moran CJ, Diringer MN, Dacey RG, Derdeyn CP. Safety and technical efficacy of over-the-wire balloons for the treatment of subarachnoid hemorrhage–induced cerebral vasospasm. Neurosurg Focus 2006; 21:E14. [PMID: 17029338 DOI: 10.3171/foc.2006.21.3.14] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Over the past decade, low-pressure, flow-directed balloons have been replaced by over-the-wire balloons in the treatment of vasospasm induced by subarachnoid hemorrhage (SAH). The authors assess the procedural safety and technical efficacy of these newer devices.
Methods
Seventy-five patients who underwent 85 balloon angioplasty procedures for the treatment of SAH-induced vasospasm were identified from a prospective quality-assurance database. Medical records and angiographic reports were reviewed for evidence of procedural complications and technical efficacy.
No vessel rupture or perforation occurred, but thromboembolic complications were noted in four (4.7%) of the 85 procedures. Balloon angioplasty was frequently attempted and successfully accomplished in the distal internal carotid (100%), proximal middle cerebral (94%), vertebral (73%), and basilar (88%) arteries. Severe narrowing was present in 89 proximal anterior cerebral arteries. Angioplasty was attempted in 41 of these vessels and was successful in only 14 (34%). In 19 of the 27 unsuccessful attempts, the balloon could not be advanced over the wire due to severe vasospasm or unfavorable vessel angle. Follow-up angiography in a subset of patients demonstrated that severe recurrent vasospasm occurred in 15 (13%) of 116 vessels studied after angioplasty.
Conclusions
Over-the-wire balloons involve a low risk for vessel rupture. The anterior cerebral artery remains difficult to access and successfully treat with current devices. Further improvements in balloon design, such as smaller inflated diameters and better tracking, are necessary. Finally, thromboembolic complications remain an important concern, and severe vasospasm may recur after balloon angioplasty.
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Affiliation(s)
- Anna Terry
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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10
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Stiefel MF, Spiotta AM, Udoetuk JD, Maloney-Wilensky E, Weigele JB, Hurst RW, LeRoux PD. Intra-arterial papaverine used to treat cerebral vasospasm reduces brain oxygen. Neurocrit Care 2006; 4:113-8. [PMID: 16627898 DOI: 10.1385/ncc:4:2:113] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Intra-arterial papaverine (IAP) is used to treat symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). IAP, however, can increase intracranial pressure (ICP). In this study we examined whether IAP alters brain oxygen (BtO2). METHODS Poor clinical grade (Hunt & Hess IV or V) SAH patients who underwent continuous ICP and BtO2 monitoring during IAP infusion for symptomatic cerebral vasospasm were evaluated as part of a prospective observational study. RESULTS Data are available for five patients (median age 58) who received IAP for cerebral vasospasm 4 to 7 days after SAH. In each patient, angiographic vasospasm was improved on postinfusion angiogram. Mean ICP before IAP was 23.04 +/- 1.18 mmHg; it increased immediately after IAP infusion and remained elevated (29.89 +/- 1.18 mmHg; p < 0.05) during IAP and for approximately 10 minutes after IAP ended. Baseline mean arterial pressure (MAP) was 110.55 +/- 1.36 mmHg. During IAP treatment MAP remained stable (110.90 +/- 2.00 mmHg; p = 0.31). Mean BtO2 before IAP was 32.99 +/- 1.45 mmHg. There was a significant BtO2 decrease in all patients during IAP to a mean of 22.96 +/- 2.9 mmHg (p < 0.05). BtO2 returned to baseline within 10 minutes after IAP ended. There was a modest relationship between the ICP increase and BtO2 decrease (R2 = 0.526). CONCLUSION IAP infusion to treat cerebral vasospasm following SAH can increase ICP and reduce BtO2. The IAP-induced reduction in BtO2 may help explain why IAP, although it reverses arterial narrowing, does not improve patient outcome.
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Affiliation(s)
- Michael F Stiefel
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19107, USA
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Abstract
The elusive nature of events that sustain cerebral vasospasm after subarachnoid hemorrhage resulting from a ruptured aneurysm presents major challenges in designing effective therapies for this frequently devastating condition. Protracted cerebral artery constriction entails several dynamic components in intracellular signaling events initiated by endothelial factors, products of hemolysate, and numerous kinases, as well as increased intracellular Ca(2+). The rationale for potential treatment modalities and their efficacy are discussed in this brief review.
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Affiliation(s)
- Shigeru Nishizawa
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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12
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Abstract
The treatment of vasospasm after subarachnoid hemorrhage remains a formidable challenge. The prompt recognition of this complication is essential to prevent ischemic damage. Initial orders should include adequate fluid and sodium supplementation to avoid volume depletion. Prophylactic hypervolemia is not effective in reducing the incidence of vasospasm and may be deleterious. Oral nimodipine (60 mg every 4 hours for 21 days) should be started on admission because it protects against delayed ischemic damage. Increasing blood flow velocities on serial transcranial Doppler studies are reliable indicators of early development of vasospasm. When symptomatic vasospasm occurs, hemodynamic augmentation therapy should be instituted. Crystalloids and colloids may be used to promote hypervolemia. Colloids may provide additional benefit by producing hemodilution. However, the rheological benefits of hemodilution may be offset by reduced oxygen carrying capacity when hematocrit drops below 28%. Hypertension may be induced by administering inotropic drugs and, in certain cases, cardiac output optimization using dobutamine also is necessary. When aggressive medical therapy fails to reverse ischemic deficits, prompt endovascular intervention is indicated. Focal vasospasm of larger vessels may be effectively treated with angioplasty and the benefits of this procedure are durable. Diffuse vasospasm involving smaller arterial branches may be treated with intra-arterial infusion of vasodilators, such as papaverine, verapamil, or nicardipine. Unfortunately, these dilatory effects tend to be short-lasting. In refractory cases, hypothermia may be considered, although value of this strategy remains largely unexplored.
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Smith WS, Dowd CF, Johnston SC, Ko NU, DeArmond SJ, Dillon WP, Setty D, Lawton MT, Young WL, Higashida RT, Halbach VV. Neurotoxicity of Intra-arterial Papaverine Preserved with Chlorobutanol Used for the Treatment of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Stroke 2004; 35:2518-22. [PMID: 15472097 DOI: 10.1161/01.str.0000144682.00822.83] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Papaverine is used to vasodilate cerebral arteries undergoing vasospasm from subarachnoid hemorrhage. However, papaverine inhibits cellular respiration in vitro and could cause neurotoxicity in humans. METHODS We studied 5 consecutive patients with cerebral vasospasm who were treated with intra-arterial papaverine preserved with chlorobutanol and imaged with MRI fluid-attenuated inversion recovery and diffusion-weighted imaging after treatment. One patient had histological analysis of the brain at autopsy. RESULTS All 5 patients exhibited marked neurological decline immediately after treatment, and this was sustained through hospital discharge. In all cases, MRI images showed selective gray matter-only signal changes within the vascular territory treated with papaverine. Histological analysis of 1 case brought to autopsy showed selective injury to islands of neurons with relative sparing of white matter. CONCLUSIONS Intra-arterial delivery of papaverine preserved with chlorobutanol into vasospastic anterior cerebral arteries may result in marked neurological deterioration with selective gray matter changes on MRI imaging. This effect is consistent with a permanent toxic effect to human brain. It is unclear whether this toxicity is caused by papaverine or chlorobutanol, and its use in the treatment of cerebral vasospasm should be reserved for cases without alternatives.
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Affiliation(s)
- Wade S Smith
- Department of Neurology, University of California, San Francisco, Calif 94134-0114, USA.
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Georgiadis D, Schwab S, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50060-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Hoelper BM, Hofmann E, Sporleder R, Soldner F, Behr R. Transluminal balloon angioplasty improves brain tissue oxygenation and metabolism in severe vasospasm after aneurysmal subarachnoid hemorrhage: case report. Neurosurgery 2003; 52:970-4; discussion 974-6. [PMID: 12657196 DOI: 10.1227/01.neu.0000053033.98317.a3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2002] [Accepted: 11/08/2002] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE The effect of transluminal balloon angioplasty on cerebral biochemical monitoring during treatment of severe cerebral vasospasm after subarachnoid hemorrhage (SAH) was investigated. CLINICAL PRESENTATION In a 36-year-old man, an anterior communicating artery aneurysm caused an SAH (Hunt and Hess Grade IV, Fisher Grade III). After clipping, intraparenchymal monitoring (intracranial pressure, brain tissue oxygen tension [P(ti)O(2)], and microdialysis sampling of extracellular glucose, lactate, pyruvate, and glutamate) was initiated. Flow velocities obtained by transcranial Doppler sonography increased in the internal carotid artery (ICA)/middle cerebral artery bilaterally. INTERVENTION After a decrease of P(ti)O(2) to less than 2 mm Hg and an increase of the lactate-to-pyruvate ratio to 44 in the territorial region of the left ICA, angiography demonstrated a 70 to 80% stenosis of the left ICA, which was dilated by a temporary occlusion balloon. This maneuver normalized the ICA diameter, P(ti)O(2) increased immediately from 1.5 to 40 mm Hg, the lactate-to-pyruvate ratio decreased from 44 to 30, and extracellular glucose increased from 0.4 to 0.9 mmol/L. No major changes in glutamate or intracranial pressure were seen. In the clinical follow-up, the patient showed a good recovery 6 months after SAH. CONCLUSION Transluminal balloon angioplasty led to a continuous and effective resolution of cerebral vasospasm observed by sustained, improved cerebral biochemical parameters. Both P(ti)O(2) and lactate-to-pyruvate ratio might provide an early diagnosis of severe cerebral vasospasm after SAH and continuous surveillance of threatened tissue regions after transluminal balloon angioplasty.
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Affiliation(s)
- Bernd Manfred Hoelper
- Department of Neurosurgery, Klinikum Fulda, Academic Hospital of Philips University Marburg, Fulda, Germany.
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16
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Oskouian RJ, Martin NA, Lee JH, Glenn TC, Guthrie D, Gonzalez NR, Afari A, Viñuela F. Multimodal quantitation of the effects of endovascular therapy for vasospasm on cerebral blood flow, transcranial doppler ultrasonographic velocities, and cerebral artery diameters. Neurosurgery 2002; 51:30-41; discussion 41-3. [PMID: 12182433 DOI: 10.1097/00006123-200207000-00005] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The goal of this study was to quantify the effects of endovascular therapy on vasospastic cerebral vessels. METHODS We reviewed the medical records for 387 patients with ruptured intracranial aneurysms who were treated at a single institution (University of California, Los Angeles) between May 1, 1993, and March 31, 2001. Patients who developed cerebral vasospasm and underwent cerebral arteriographic, transcranial Doppler ultrasonographic, and cerebral blood flow (CBF) studies before and after endovascular therapy for cerebral arterial spasm (vasospasm) were included in this study. RESULTS Forty-five patients fulfilled the aforementioned criteria and were treated with either papaverine infusion, papaverine infusion with angioplasty, or angioplasty alone. After balloon angioplasty (12 patients), CBF increased from 27.8 +/- 2.8 ml/100 g/min to 28.4 +/- 3.0 ml/100 g/min (P = 0.87); the middle cerebral artery blood flow velocity was 1 57.6 +/- 9.4 cm/s and decreased to 76.3 +/- 9.3 cm/s (P < 0.05), with a mean increase in cerebral artery diameters of 24.4%. Papaverine infusion (20 patients) transiently increased the CBF from 27.5 +/- 2.1 ml/100 g/min to 38.7 +/- 2.8 ml/100 g/min (P < 0.05) and decreased the middle cerebral artery blood flow velocity from 109.9 +/- 9.1 cm/s to 82.8 +/- 8.6 cm/s (P < 0.05). There was a mean increase in vessel diameters of 30.1% after papaverine infusion. Combined treatment (13 patients) significantly increased the CBF from 33.3 +/- 3.2 ml/100 g/min to 41.7 +/- 2.8 ml/100 g/min (P< 0.05) and decreased the transcranial Doppler velocities from 148.9 +/- 12.7 cm/s to 111.4 +/- 10.6 cm/s (P < 0.05), with a mean increase in vessel diameters of 42.2%. CONCLUSION Balloon angioplasty increased proximal vessel diameters, whereas papaverine treatment effectively dilated distal cerebral vessels. In our small series, we observed no correlation between early clinical improvement or clinical outcomes and any of our quantitative or physiological data (CBF, transcranial Doppler velocities, or vessel diameters).
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MESH Headings
- Adult
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/epidemiology
- Aneurysm, Ruptured/therapy
- Angioplasty, Balloon/statistics & numerical data
- Blood Flow Velocity/physiology
- Brain/blood supply
- Cerebral Angiography
- Combined Modality Therapy/statistics & numerical data
- Data Interpretation, Statistical
- Female
- Humans
- Intracranial Aneurysm/diagnostic imaging
- Intracranial Aneurysm/epidemiology
- Intracranial Aneurysm/therapy
- Male
- Middle Aged
- Outcome and Process Assessment, Health Care/statistics & numerical data
- Papaverine/administration & dosage
- Papaverine/adverse effects
- Regional Blood Flow/drug effects
- Regional Blood Flow/physiology
- Retrospective Studies
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/physiopathology
- Subarachnoid Hemorrhage/therapy
- Ultrasonography, Doppler, Transcranial/statistics & numerical data
- Vasodilation/drug effects
- Vasodilation/physiology
- Vasodilator Agents/administration & dosage
- Vasodilator Agents/adverse effects
- Vasospasm, Intracranial/diagnostic imaging
- Vasospasm, Intracranial/epidemiology
- Vasospasm, Intracranial/therapy
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Affiliation(s)
- Rod J Oskouian
- Division of Neurosurgery and Cerebral Blood Flow Laboratory, University of California, Los Angeles, School of Medicine, USA.
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17
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Barreau X, Pastore M, Piotin M, Spelle C, Moret J. Endovascular treatment of cerebral vasospasm following S.A.H. ACTA NEUROCHIRURGICA. SUPPLEMENT 2002; 77:177-80. [PMID: 11563281 DOI: 10.1007/978-3-7091-6232-3_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- X Barreau
- Interventional Neuroradiology Service, Rothschild Foundation, 25-29 Rue Manin, 75940 Paris, France
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18
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Katoh H, Shima K, Tsuzuki N, Ishihara S, Nawashiro H, Miyazawa T, Ohnuki A, Suzuki T, Fukui S, Nomura N. Cisternal MHPG level inversely correlates with Glasgow coma scale after aneurysmal subarachnoid hemorrhage. Neurol Res 2001; 23:795-800. [PMID: 11760868 DOI: 10.1179/016164101101199360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We measured the concentrations of monoamines and amino acids in the cisternal cerebrospinal fluid obtained from 15 patients after aneurysmal subarachnoid hemorrhage. Based on the Glasgow Coma Scale (GCS), the patients were divided into two conscious (GCS always 14 or better from the third post-operative day to Day 12; n = 8) and unconscious groups (n = 7). We examined the concentrations of monoamines and amino acids between the two groups and evaluated the correlation between the concentrations and the GCS at CSF sampling. The concentration of MHPG was significantly higher in the unconscious than in the conscious group from Days 4 to 12. A significant inverse correlation was observed between the MHPG concentration and the GCS (r = approximately 0.635, p < 0.0001). Measuring the cisternal MHPG concentration may be useful for estimating convalescence after subarachnoid hemorrhage.
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Affiliation(s)
- H Katoh
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan.
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19
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Abstract
A high percentage of the population has aneurysms of the cerebral vessels, which are detected only by chance or after spontaneous rupture. Subarachnoid haemorrhage is still a problem because of high morbidity and mortality. Many patients do not fully recover neurologically and suffer from physical and psychosocial symptoms. The aims of treatment are to prevent the patient from rebleeding and to prevent secondary neurological damage. Whereas in former times, clipping of the aneurysm was often delayed for days or weeks, early operative intervention is the rule today, if the patient is not moribund and if there is no significant cerebral oedema. The anaesthetist can support the neurosurgeon with a spectrum of different methods of anaesthesia and monitoring, individually tailored to the needs of the patient. Most important, however, is a stable haemodynamic status, stable and normal intracranial pressure and a sufficient cerebral perfusion pressure. Vasospasm is still the main problem, as is early rebleeding. To treat this, nimodipine is the drug of choice combined with volume therapy, a slightly elevated cardiac output and a modestly elevated blood pressure.
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Affiliation(s)
- J F Zander
- Department of Anaesthesia, Städtische Kliniken Dortmund, Dortmund, Germany.
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