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Dinh DD, Wan H, Lidington D, Bolz SS. Female mice display sex-specific differences in cerebrovascular function and subarachnoid haemorrhage-induced injury. EBioMedicine 2024; 102:105058. [PMID: 38490104 PMCID: PMC10955634 DOI: 10.1016/j.ebiom.2024.105058] [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: 03/22/2023] [Revised: 02/06/2024] [Accepted: 02/29/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND In male mice, a circadian rhythm in myogenic reactivity influences the extent of brain injury following subarachnoid haemorrhage (SAH). We hypothesized that female mice have a different cerebrovascular phenotype and consequently, a distinct SAH-induced injury phenotype. METHODS SAH was modelled by pre-chiasmatic blood injection. Olfactory cerebral resistance arteries were functionally assessed by pressure myography; these functional assessments were related to brain histology and neurobehavioral assessments. Cystic fibrosis transmembrane conductance regulator (CFTR) expression was assessed by PCR and Western blot. We compared non-ovariectomized and ovariectomized mice. FINDINGS Cerebrovascular myogenic reactivity is not rhythmic in females and no diurnal differences in SAH-induced injury are observed; ovariectomy does not unmask a rhythmic phenotype for any endpoint. CFTR expression is rhythmic, with similar expression levels compared to male mice. CFTR inhibition studies, however, indicate that CFTR activity is lower in female arteries. Pharmacologically increasing CFTR expression in vivo (3 mg/kg lumacaftor for 2 days) reduces myogenic tone at Zeitgeber time 11, but not Zeitgeber time 23. Myogenic tone is not markedly augmented following SAH in female mice and lumacaftor loses its ability to reduce myogenic tone; nevertheless, lumacaftor confers at least some injury benefit in females with SAH. INTERPRETATION Female mice possess a distinct cerebrovascular phenotype compared to males, putatively due to functional differences in CFTR regulation. This sex difference eliminates the CFTR-dependent cerebrovascular effects of SAH and may alter the therapeutic efficacy of lumacaftor compared to males. FUNDING Brain Aneurysm Foundation, Heart and Stroke Foundation and Ted Rogers Centre for Heart Research.
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Affiliation(s)
- Danny D Dinh
- Department of Physiology, University of Toronto, Toronto, Canada; Toronto Centre for Microvascular Medicine at The Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, Canada; Toronto Centre for Microvascular Medicine at The Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, Canada
| | - Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, Canada; Toronto Centre for Microvascular Medicine at The Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, Canada; Toronto Centre for Microvascular Medicine at The Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, Canada; Heart & Stroke / Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, Canada.
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Athiraman U, Norris AJ, Jayaraman K, Lele AV, Kentner R, Singh PM, Higo OM, Zipfel GJ, Dhar R. Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2023; 12:5488. [PMID: 37685555 PMCID: PMC10488211 DOI: 10.3390/jcm12175488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Cerebral autoregulation impairment is a critical aspect of subarachnoid hemorrhage (SAH)-induced secondary brain injury and is also shown to be an independent predictor of delayed cerebral ischemia (DCI) and poor neurologic outcomes. Interestingly, intraoperative hemodynamic and ventilatory parameters were shown to influence patient outcomes after SAH. The aim of the current study was to evaluate the association of intraoperative hypotension and hypocapnia with the occurrence of angiographic vasospasm, DCI, and neurologic outcomes at discharge. Intraoperative data were collected for 390 patients with aneurysmal SAH who underwent general anesthesia for aneurysm clipping or coiling between January 2010 and May 2018. We measured the mean intraoperative blood pressure and end-tidal carbon dioxide (ETCO2), as well as the area under the curve (AUC) for the burden of hypotension: SBP below 100 or MBP below 65 and hypocapnia (ETCO2 < 30), during the intraoperative period. The outcome measures were angiographic vasospasm, DCI, and the neurologic outcomes at discharge as measured by the modified Rankin scale score (an mRS of 0-2 is a good outcome, and 3-6 is a poor outcome). Univariate and logistic regression analyses were performed to evaluate whether blood pressure (BP) and ETCO2 variables were independently associated with outcome measures. Out of 390 patients, 132 (34%) developed moderate-to-severe vasospasm, 114 (29%) developed DCI, and 46% (169) had good neurologic outcomes at discharge. None of the measured intraoperative BP and ETCO2 variables were associated with angiographic vasospasm, DCI, or poor neurologic outcomes. Our study did not identify an independent association between the degree of intraoperative hypotension or hypocapnia in relation to angiographic vasospasm, DCI, or the neurologic outcomes at discharge in SAH patients.
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Affiliation(s)
| | - Aaron J. Norris
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Keshav Jayaraman
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Abhijit V. Lele
- Department of Anesthesiology, University of Washington, Seattle, WA 98122, USA
| | - Rainer Kentner
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | | | - Omokhaye M. Higo
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Gregory J. Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO 63110, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO 63110, USA
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Kataria K, Panda NB, Luthra A, Mahajan S, Bhagat H, Chauhan R, Soni S, Jangra K, Kaloria N, Paul S, Bloria S, Gupta S, Chhabra R. Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study. Surg Neurol Int 2023; 14:290. [PMID: 37680917 PMCID: PMC10481860 DOI: 10.25259/sni_25_2023] [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: 01/08/2023] [Accepted: 07/11/2023] [Indexed: 09/09/2023] Open
Abstract
Background Cerebral autoregulation (CA) is crucial for the maintenance of cerebral homeostasis. It can be assessed by measuring transient hyperemic response ratio (THRR) using transcranial Doppler (TCD). We aimed at assessing the incidence of impaired CA (ICA) and its correlation with the neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods One hundred consecutive patients with aSAH scheduled for aneurysmal clipping were enrolled in this prospective and observational study. Preoperative and consecutive 5-day postoperative THRR measurements were taken. Primary objective of the study was to detect the incidence of ICA and its correlation with vasospasm (VS) postclipping, and neurological outcome at discharge and 1, 3, and 12 months was secondary objectives. Results ICA (THRR < 1.09) was observed in 69 patients preoperatively, 74 patients on the 1st and 2nd postoperative day, 76 patients on 3rd postoperative day, and 78 patients on 4th and 5th postoperative day. Significant VS was seen in 13.4% and 61.5% of patients with intact THRR and deranged THRR, respectively (P < 0.000). Out of 78 patients who had ICA, 42 patients (53.8%) at discharge, 60 patients (76.9%) at 1 month, 54 patients (69.2%) at 3 month, and 55 patients (70.5%) at 12 months had unfavorable neurological outcome significantly more than those with preserved CA. Conclusion Incidence of ICA assessed in aSAH patients varies from 69% to 78% in the perioperative period. The deranged CA was associated with significantly poor neurological outcome. Therefore, CA assessment using TCD-based THRR provides a simple, noninvasive bedside approach for predicting neurological outcome in aSAH.
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Affiliation(s)
- Ketan Kataria
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai, India
| | - Nidhi Bidyut Panda
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalvi Mahajan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Soni
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kaloria
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shamik Paul
- Department of Anaesthesiology and Critical Care, Armed Forces Medical College (AFMC), Pune, India
| | - Summit Bloria
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shailesh Gupta
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Liu M, Jayaraman K, Mehla J, Diwan D, Nelson JW, Hussein AE, Vellimana AK, Abu-Amer Y, Zipfel GJ, Athiraman U. Isoflurane Conditioning Provides Protection against Subarachnoid Hemorrhage Induced Delayed Cerebral Ischemia through NF-kB Inhibition. Biomedicines 2023; 11:biomedicines11041163. [PMID: 37189781 DOI: 10.3390/biomedicines11041163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Delayed cerebral ischemia (DCI) is the largest treatable cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Nuclear Factor Kappa-light-chain-enhancer of Activated B cells (NF-kB), a transcription factor known to function as a pivotal mediator of inflammation, is upregulated in SAH and is pathologically associated with vasospasm. We previously showed that a brief exposure to isoflurane, an inhalational anesthetic, provided multifaceted protection against DCI after SAH. The aim of our current study is to investigate the role of NF-kB in isoflurane-conditioning-induced neurovascular protection against SAH-induced DCI. Twelve-week-old wild type male mice (C57BL/6) were divided into five groups: sham, SAH, SAH + Pyrrolidine dithiocarbamate (PDTC, a selective NF-kB inhibitor), SAH + isoflurane conditioning, and SAH + PDTC with isoflurane conditioning. Experimental SAH was performed via endovascular perforation. Anesthetic conditioning was performed with isoflurane 2% for 1 h, 1 h after SAH. Three doses of PDTC (100 mg/kg) were injected intraperitoneally. NF-kB and microglial activation and the cellular source of NF-kB after SAH were assessed by immunofluorescence staining. Vasospasm, microvessel thrombosis, and neuroscore were assessed. NF-kB was activated after SAH; it was attenuated by isoflurane conditioning. Microglia was activated and found to be a major source of NF-kB expression after SAH. Isoflurane conditioning attenuated microglial activation and NF-kB expression in microglia after SAH. Isoflurane conditioning and PDTC individually attenuated large artery vasospasm and microvessel thrombosis, leading to improved neurological deficits after SAH. The addition of isoflurane to the PDTC group did not provide any additional DCI protection. These data indicate isoflurane-conditioning-induced DCI protection after SAH is mediated, at least in part, via downregulating the NF-kB pathway.
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Affiliation(s)
- Meizi Liu
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Keshav Jayaraman
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Jogender Mehla
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Deepti Diwan
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - James W Nelson
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Ahmed E Hussein
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Ananth K Vellimana
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Yousef Abu-Amer
- Department of Orthopedic Surgery and Cell Biology & Physiology, Shriners Hospital for Children, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gregory J Zipfel
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology, Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO 63110, USA
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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Role of SIRT1 in Isoflurane Conditioning-Induced Neurovascular Protection against Delayed Cerebral Ischemia Secondary to Subarachnoid Hemorrhage. Int J Mol Sci 2021; 22:ijms22084291. [PMID: 33924243 PMCID: PMC8074752 DOI: 10.3390/ijms22084291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 12/19/2022] Open
Abstract
We recently reported that isoflurane conditioning provided multifaceted protection against subarachnoid hemorrhage (SAH)-induced delayed cerebral ischemia (DCI), and this protection was through the upregulation of endothelial nitric oxide synthase (eNOS). SIRT1, an NAD-dependent deacetylase, was shown to be one of the critical regulators of eNOS. The aim of our current study is to examine the role of SIRT1 in isoflurane conditioning-induced neurovascular protection against SAH-induced DCI. Mice were divided into four groups: sham, SAH, or SAH with isoflurane conditioning (with and without EX-527). Experimental SAH via endovascular perforation was performed. Anesthetic conditioning was performed with isoflurane 2% for 1 h, 1 h after SAH. EX-527, a selective SIRT1 inhibitor, 10 mg/kg was injected intraperitoneally immediately after SAH in the EX-527 group. SIRT1 mRNA expression and activity levels were measured. Vasospasm, microvessel thrombosis, and neurological outcome were assessed. SIRT1 mRNA expression was downregulated, and no difference in SIRT1 activity was noted after isoflurane exposure. Isoflurane conditioning with and without EX-527 attenuated vasospasm, microvessel thrombosis and improved neurological outcomes. Our data validate our previous findings that isoflurane conditioning provides strong protection against both the macro and micro vascular deficits induced by SAH, but this protection is likely not mediated through the SIRT1 pathway.
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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Reiff T, Barthel O, Schönenberger S, Mundiyanapurath S. High-normal P aCO 2 values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study. BMC Neurol 2020; 20:31. [PMID: 31959120 PMCID: PMC6972024 DOI: 10.1186/s12883-020-1603-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/06/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND While both hypercapnia and hypocapnia are harmful in patients with subarachnoid hemorrhage (SAH), it is unknown whether high-normal PaCO2 values are better than low-normal values. We hypothesized that high-normal PaCO2 values have more detrimental than beneficial effects on outcome. METHODS Consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation treated in a tertiary care university hospital were retrospectively analyzed regarding the influence of PaCO2 on favorable outcome, defined as modified Rankin scale score < 3 at discharge. Primary endpoint was the difference in the proportion of PaCO2 values above 40 mmHg in relation to all measured PaCO2 values between patients with favorable and unfavorable outcome. RESULTS 150 patients were included. Median age was 57 years (p25:50, p75:64), median Hunt-Hess score was 4 (p25:3, p75:5). PaCO2 values were mainly within normal range (median 39.0, p25:37.5, p75:41.4). Patients with favorable outcome had a lower proportion of high-normal PaCO2 values above 40 mmHg compared to patients with unfavorable outcome (0.21 (p25:0.13, p75:0.50) vs. 0.4 (p25:0.29, p75:0.59)) resulting in a lower chance for favorable outcome (OR 0.04, 95% CI 0.00-0.55, p = 0.017). In multivariable analysis adjusted for Hunt-Hess score, pneumonia and length of stay, elevated PaCO2 remained an independent predictor of outcome (OR 0.05, 95% CI 0.00-0.81, p = 0.035). CONCLUSIONS A higher proportion of PaCO2 values above 40 mmHg was an independent predictor of outcome in patients with aSAH in our study. The results need to be confirmed in a prospective trial.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Oliver Barthel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Sibu Mundiyanapurath
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany.
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Impaired cerebrovascular reactivity may predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurol Sci 2019; 407:116539. [DOI: 10.1016/j.jns.2019.116539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/16/2019] [Accepted: 10/15/2019] [Indexed: 02/03/2023]
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Time Course of Cerebrovascular Reactivity in Patients Treated for Unruptured Intracranial Aneurysms: A One-Year Transcranial Doppler and Acetazolamide Follow-Up Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6489276. [PMID: 29854773 PMCID: PMC5944219 DOI: 10.1155/2018/6489276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/04/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022]
Abstract
Background Cerebrovascular reactivity (CVR) is often impaired in the early phase after aneurysmal subarachnoid hemorrhage. There is, however, little knowledge about the time course of CVR in patients treated for unruptured intracranial aneurysms (UIA). Methods CVR, assessed by transcranial Doppler and acetazolamide test, was examined within the first postoperative week after treatment for UIA and reexamined one year later. Results Of 37 patients initially assessed, 34 were reexamined after one year. Bilaterally, baseline and acetazolamide-induced blood flow velocities were higher in the postoperative week compared with one year later (p < 0.001). CVR on the ipsilateral side of treatment was lower in the initial examination compared with follow-up (58.9% versus 66.1%, p = 0.04). There was no difference in CVR over time on the contralateral side (63.4% versus 65.0%, p = 0.65). When mean values of right and left sides were considered there was no difference in CVR between exams. Larger aneurysm size was associated with increased change in CVR (p = 0.04), and treatment with clipping was associated with 13.8%-point increased change in CVR compared with coiling (p = 0.03). Conclusion Patients with UIA may have a temporary reduction in CVR on the ipsilateral side after aneurysm treatment. The change in CVR appears more pronounced for larger-sized aneurysms and in patients treated with clipping. We recommend that ipsilateral and contralateral CVR should be assessed separately, as mean values can conceal side-differences.
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Westermaier T, Stetter C, Kunze E, Willner N, Holzmeier J, Weiland J, Koehler S, Lotz C, Kilgenstein C, Ernestus RI, Roewer N, Muellenbach RM. Controlled Hypercapnia Enhances Cerebral Blood Flow and Brain Tissue Oxygenation After Aneurysmal Subarachnoid Hemorrhage: Results of a Phase 1 Study. Neurocrit Care 2017; 25:205-14. [PMID: 26886010 DOI: 10.1007/s12028-016-0246-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study investigated if cerebral blood flow (CBF) regulation by changes of the arterial partial pressure of carbon dioxide (PaCO2) can be used therapeutically to increase CBF and improve neurological outcome after subarachnoid hemorrhage (SAH). METHODS In 12 mechanically ventilated poor-grade SAH-patients, a daily trial intervention was performed between day 4 and 14. During this intervention, PaCO2 was decreased to 30 mmHg and then gradually increased to 40, 50, and 60 mmHg in 15-min intervals by modifications of the respiratory minute volume. CBF and brain tissue oxygen saturation (StiO2) were the primary and secondary endpoints. Intracranial pressure was controlled by an external ventricular drainage. RESULTS CBF reproducibly decreased during hyperventilation and increased to a maximum of 141 ± 53 % of baseline during hypercapnia (PaCO2 60 mmHg) on all days between day 4 and 14 after SAH. Similarly, StiO2 increased during hypercapnia. CBF remained elevated within the first hour after resetting ventilation to baseline parameters and no rebound effect was observed within this time-span. PaCO2-reactivities of CBF and StiO2 were highest between 30 and 50 mmHg and slightly decreased at higher levels. CONCLUSION CBF and StiO2 reproducibly increased by controlled hypercapnia of up to 60 mmHg even during the period of the maximum expected vasospasm. The absence of a rebound effect within the first hour after hypercapnia indicates that an improvement of the protocol is possible. The intervention may yield a therapeutic potential to prevent ischemic deficits after aneurysmal SAH.
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Affiliation(s)
- Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Nadine Willner
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Judith Holzmeier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Stefan Koehler
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Christopher Lotz
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
| | - Christian Kilgenstein
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Norbert Roewer
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
| | - Ralf Michael Muellenbach
- Department of Anesthesia and Critical Care, University Hospital Wuerzburg, 97080, Würzburg, Germany
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Ghani AA, Nayan SAM, Kandasamy R, Ghani ARI, Rosman AK. Assessment of Pre- and Post-Operative Cerebral Perfusion in Anterior Circulation Intracranial Aneurysm Clipping Patients at Hospital Sungai Buloh Using CT Perfusion Scan and Correlations to Fisher, Navarro and WFNS Scores. Malays J Med Sci 2017; 24:47-58. [PMID: 28461780 DOI: 10.21315/mjms2017.24.1.6] [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: 08/28/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Intracranial aneurysms may rupture and are typically associated with high morbidity and mortality, commonly due to vasospasm after rupture. Once the aneurysm ruptures, the patient's cerebral blood flow may be disturbed during the acute phase, affecting cerebral circulation and thus cerebral perfusion prior to the onset of vasospasm. Fisher and Navarro scores are used to predict vasospasm, while World Federation of Neurosurgical Societies (WFNS) scores are used to predict patient outcomes. Several score modifications are available to obtain higher sensitivity and specificity for the prediction of vasospasm development, but these scores are still unsuccessful. Alternatively, cerebral CT perfusion scan (CTP) is a non-invasive method for measuring cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) in regions of interests (ROI) to obtain the cerebral perfusion status as well as detecting vasospasm. METHODS A total of 30 patients' data with clipped anterior circulation intracranial aneurysms admitted to the hospital between 1 January 2013 and 30 June 2014, were collected from the hospital's electronic database. The data collected included patients' admissions demographic profiles, Fisher, Navarro and WFNS scores; and their immediate pre- and post-operative CTP parameters. RESULTS This study found a significant increase in post-operative MTT (pre- and post-operative MTT) were 9.75 (SD = 1.31) and 10.44 (SD = 1.56) respectively, (P < 0.001)) as well as a significant reduction in post-operative CBF (pre- and post-operative mean CBF were 195.29 (SD = 24.92) and 179.49 (SD = 31.17) respectively (P < 0.001)). There were no significant differences in CBV. There were no significant correlations between the pre- and post-operative CTP parameters and Fisher, Navarro or WFNS scores. CONCLUSION Despite the interest in using Fisher, Navarro and WFNS scores to predict vasospasm and patient outcomes for ruptured intracranial aneurysms, this study found no significant correlations between these scores in either pre- or post-operative CTP parameters. These results explain the disagreement in the field regarding the multiple proposed grading systems for vasospasm prediction. CTP measures more than just anatomical structures; therefore, it is more sensitive towards minor changes in cerebral perfusion that would not be detected by WFNS, Fisher or Navarro scores.
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Affiliation(s)
- Ailani Ab Ghani
- Department of Neurosurgery, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia.,Center for Neuroscience Services and Research, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Neurosciences, Hospital Universiti Sains Malaysia, Jalan Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Neurosciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Saiful Azli Mat Nayan
- Department of Neurosurgery, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
| | - Regunath Kandasamy
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Jalan Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Abdul Rahman Izani Ghani
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Jalan Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Azmin Kass Rosman
- Department of Neurosurgery, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
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Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Using Cerebral Blood Flow Velocities and Cerebral Autoregulation Assessment. Neurocrit Care 2016; 23:253-8. [PMID: 25716738 DOI: 10.1007/s12028-015-0125-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The risk of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with large cerebral artery vasospasm, but vasospasm is not a strong predictor for DCI. Assessment of cerebral autoregulation with transcranial Doppler (TCD) may improve the prediction of DCI. The aim of this prospective study was to assess the value of TCD-derived variables to be used alone or in combination for prediction of DCI. METHODS We included consecutive patients with low-grade aneurysmal SAH within 4 days of aneurysm rupture. Cerebral autoregulation was evaluated using the moving correlation coefficient Mx calculated from spontaneous fluctuations of cerebral blood flow velocities and arterial blood pressure. Transcranial color-coded sonography was performed to assess large artery vasospasm. RESULTS Thirty patients (19 women and 11 men; mean age ± SD 44.7 ± 12.1 years) were included. Twenty (66.7%) patients had vasospasm. DCI occurred in six (20%) patients after a median delay of 10 days (range 8-13 days). Cerebral autoregulation was impaired at baseline and at day 7 and then returned to normal at day 14. Neither cerebral autoregulation impairment nor large artery vasospasm alone was associated with DCI. In contrast, the combination of large artery vasospasm with worsening impairment of cerebral autoregulation from baseline to day 7 was significantly correlated to subsequent DCI (p = 0.007). CONCLUSIONS Early deterioration of cerebral autoregulation was strongly predictive of DCI in patients with large artery vasospasm after low-grade SAH. Our results suggest that consideration to both cerebral blood flow velocities and cerebral autoregulation may improve the prediction of DCI.
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Cerebrovascular reactivity after treatment of unruptured intracranial aneurysms — A transcranial Doppler sonography and acetazolamide study. J Neurol Sci 2016; 363:97-103. [DOI: 10.1016/j.jns.2015.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 11/19/2022]
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Suzuki K, Ueno E, Kasuya H. Origin of Sylvian Hematoma in Patients with Subarachnoid Hemorrhage: Findings of Extravasation on Multiphase Contrast-Enhanced Computed Tomography. World Neurosurg 2014; 82:e747-51. [DOI: 10.1016/j.wneu.2013.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 02/02/2013] [Indexed: 10/27/2022]
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16
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Fan F, Geurts AM, Pabbidi MR, Smith SV, Harder DR, Jacob H, Roman RJ. Zinc-finger nuclease knockout of dual-specificity protein phosphatase-5 enhances the myogenic response and autoregulation of cerebral blood flow in FHH.1BN rats. PLoS One 2014; 9:e112878. [PMID: 25397684 PMCID: PMC4232417 DOI: 10.1371/journal.pone.0112878] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 10/18/2014] [Indexed: 12/11/2022] Open
Abstract
We recently reported that the myogenic responses of the renal afferent arteriole (Af-Art) and middle cerebral artery (MCA) and autoregulation of renal and cerebral blood flow (RBF and CBF) were impaired in Fawn Hooded hypertensive (FHH) rats and were restored in a FHH.1BN congenic strain in which a small segment of chromosome 1 from the Brown Norway (BN) containing 15 genes including dual-specificity protein phosphatase-5 (Dusp5) were transferred into the FHH genetic background. We identified 4 single nucleotide polymorphisms in the Dusp5 gene in FHH as compared with BN rats, two of which altered CpG sites and another that caused a G155R mutation. To determine whether Dusp5 contributes to the impaired myogenic response in FHH rats, we created a Dusp5 knockout (KO) rat in the FHH.1BN genetic background using a zinc-finger nuclease that introduced an 11 bp frame-shift deletion and a premature stop codon at AA121. The expression of Dusp5 was decreased and the levels of its substrates, phosphorylated ERK1/2 (p-ERK1/2), were enhanced in the KO rats. The diameter of the MCA decreased to a greater extent in Dusp5 KO rats than in FHH.1BN and FHH rats when the perfusion pressure was increased from 40 to 140 mmHg. CBF increased markedly in FHH rats when MAP was increased from 100 to 160 mmHg, and CBF was better autoregulated in the Dusp5 KO and FHH.1BN rats. The expression of Dusp5 was higher at the mRNA level but not at the protein level and the levels of p-ERK1/2 and p-PKC were lower in cerebral microvessels and brain tissue isolated from FHH than in FHH.1BN rats. These results indicate that Dusp5 modulates myogenic reactivity in the cerebral circulation and support the view that a mutation in Dusp5 may enhance Dusp5 activity and contribute to the impaired myogenic response in FHH rats.
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Affiliation(s)
- Fan Fan
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Aron M. Geurts
- Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Mallikarjuna R. Pabbidi
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Stanley V. Smith
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - David R. Harder
- Department of Physiology and Cardiovascular Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Howard Jacob
- Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Richard J. Roman
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- * E-mail:
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Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract 2014; 2014:595837. [PMID: 24723946 PMCID: PMC3958760 DOI: 10.1155/2014/595837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/26/2014] [Indexed: 01/08/2023] Open
Abstract
Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.
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da Costa L, Fierstra J, Fisher JA, Mikulis DJ, Han JS, Tymianski M. BOLD MRI and early impairment of cerebrovascular reserve after aneurysmal subarachnoid hemorrhage. J Magn Reson Imaging 2013; 40:972-9. [PMID: 24243534 DOI: 10.1002/jmri.24474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 09/09/2013] [Indexed: 11/06/2022] Open
Abstract
Currently no biological or radiological marker is available to identify patients at risk of delayed ischemic deficit (DIND) after aneurysmal subarachnoid hemorrhage (aSAH). We hypothesized whether MR-based quantitative assessment of cerebrovascular reserve (CVR) would detect early radiological markers of vasospasm and DIND. This manuscript describes our initial experience with this population. Five patients with aSAH underwent blood-oxygen level dependent-MRI (BOLD-MRI) with CO2 challenge for assessment of whole brain CVR. Patients were examined as soon as possible after aneurysm treatment. We obtained good quality anatomical and functional images without complications. Initial anatomical cerebrovascular imaging showed no vasospasm in all patients. Two patients had abnormal CVR-MRI tests and both developed DIND. Of the 3 others with normal CVR-MRI, one developed posterior circulation DIND. One patient with a normal CVR-MRI developed angiographic vasospasm but no DIND. Changes in CVR maps as early as 36 h after hemorrhage had good spatial correlation with delayed ischemia during short-term follow-up. Our series shows that MRI with CO2 challenge is feasible in this difficult population. Further developments might allow BOLD-MRI with CO2 challenge to identify patients at risk and provide anatomical correlation with future DIND, opening a new venue for prophylactic treatments. Further study is warranted in a larger patient cohort.
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Affiliation(s)
- Leodante da Costa
- Division of Neurosurgery, Sunnybrook Hospital, University of Toronto, Ontario, Canada; Department of Medical Imaging, Toronto Western Hospital and University Health Network, University of Toronto, Ontario, Canada
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Diringer MN. Controversy: does prevention of vasospasm in subarachnoid hemorrhage improve clinical outcome? Stroke 2013; 44:S29-30. [PMID: 23709720 DOI: 10.1161/strokeaha.111.000008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Michael N Diringer
- Department of Neurology, Washington University, 660 S Euclid Ave, St Louis, MO 63110, USA.
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Jarus-Dziedzic K, Głowacki M, Warzecha A, Jurkiewicz J, Czernicki Z, Fersten E. Cerebrovascular reactivity evaluated by transcranial doppler sonography in patients after aneurysmal subarachnoid haemorrhage treated with microsurgical clipping or endovascular coiling technique. Neurol Res 2013; 33:18-23. [DOI: 10.1179/016164110x12700393823534] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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21
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Starke RM, Dumont AS. Improvements in imaging in subarachnoid hemorrhage and identification of active bleeding. World Neurosurg 2013; 82:e685-7. [PMID: 23523675 DOI: 10.1016/j.wneu.2013.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 03/12/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Robert M Starke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA; Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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23
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Peebles KC, Ball OG, MacRae BA, Horsman HM, Tzeng YC. Sympathetic regulation of the human cerebrovascular response to carbon dioxide. J Appl Physiol (1985) 2012; 113:700-6. [DOI: 10.1152/japplphysiol.00614.2012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although the cerebrovasculature is known to be exquisitely sensitive to CO2, there is no consensus on whether the sympathetic nervous system plays a role in regulating cerebrovascular responses to changes in arterial CO2. To address this question, we investigated human cerebrovascular CO2 reactivity in healthy participants randomly assigned to the α1-adrenoreceptor blockade group (9 participants; oral prazosin, 0.05 mg/kg) or the placebo control (9 participants) group. We recorded mean arterial blood pressure (MAP), heart rate (HR), mean middle cerebral artery flow velocity (MCAV mean), and partial pressure of end-tidal CO2 (PetCO2) during 5% CO2 inhalation and voluntary hyperventilation. CO2 reactivity was quantified as the slope of the linear relationship between breath-to-breath PetCO2 and the average MCAvmean within successive breathes after accounting for MAP as a covariate. Prazosin did not alter resting HR, PetCO2, MAP, or MCAV mean. The reduction in hypocapnic CO2 reactivity following prazosin (−0.48 ± 0.093 cm·s−1·mmHg−1) was greater compared with placebo (−0.19 ± 0.087 cm·s−1·mmHg−1; P < 0.05 for interaction). In contrast, the change in hypercapnic CO2 reactivity following prazosin (−0.23 cm·s−1·mmHg−1) was similar to placebo (−0.31 cm·s−1·mmHg−1; P = 0.50 for interaction). These data indicate that the sympathetic nervous system contributes to CO2 reactivity via α1-adrenoreceptors; blocking this pathway with prazosin reduces CO2 reactivity to hypocapnia but not hypercapnia.
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Affiliation(s)
- K. C. Peebles
- Cardiovascular Systems Laboratory, Department of Surgery and Anaesthesia, University of Otago, Wellington South, New Zealand
| | - O. G. Ball
- Cardiovascular Systems Laboratory, Department of Surgery and Anaesthesia, University of Otago, Wellington South, New Zealand
| | - B. A. MacRae
- Cardiovascular Systems Laboratory, Department of Surgery and Anaesthesia, University of Otago, Wellington South, New Zealand
| | - H. M. Horsman
- Cardiovascular Systems Laboratory, Department of Surgery and Anaesthesia, University of Otago, Wellington South, New Zealand
| | - Y. C. Tzeng
- Cardiovascular Systems Laboratory, Department of Surgery and Anaesthesia, University of Otago, Wellington South, New Zealand
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Mahaney KB, Todd MM, Bayman EO, Torner JC. Acute postoperative neurological deterioration associated with surgery for ruptured intracranial aneurysm: incidence, predictors, and outcomes. J Neurosurg 2012; 116:1267-1278. [PMID: 22404668 DOI: 10.3171/2012.1.jns111277] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Subarachnoid hemorrhage (SAH) results in significant morbidity and mortality, even among patients who reach medical attention in good neurological condition. Many patients have neurological decline in the perioperative period, which contributes to long-term outcomes. The focus of this study is to characterize the incidence of, characteristics predictive of, and outcomes associated with acute postoperative neurological deterioration in patients undergoing surgery for ruptured intracranial aneurysm. METHODS The Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) was a multicenter randomized clinical trial that enrolled 1001 patients and assesssed the efficacy of hypothermia as neuroprotection during surgery to secure a ruptured intracranial aneurysm. All patients had a radiographically confirmed SAH, were classified as World Federation of Neurosurgical Societies (WFNS) Grade I-III immediately prior to surgery, and underwent surgery to secure the ruptured aneurysm within 14 days of SAH. Neurological assessment with the National Institutes of Health Stroke Scale (NIHSS) was performed preoperatively, at 24 and 72 hours postoperatively, and at time of discharge. The primary outcome variable was a dichotomized scoring based on an IHAST version of the Glasgow Outcome Scale (GOS) in which a score of 1 represents a good outcome and a score > 1 a poor outcome, as assessed at 90-days' follow-up. Data from IHAST were analyzed for occurrence of a postoperative neurological deterioration. Preoperative and intraoperative variables were assessed for associations with occurrence of postoperative neurological deterioration. Differences in baseline, intraoperative, and postoperative variables and in outcomes between patients with and without postoperative neurological deterioration were compared with Fisher exact tests. The Wilcoxon rank-sum test was used to compare variables reported as means. Multiple logistic regression was used to adjust for covariates associated with occurrence of postoperative deficit. RESULTS Acute postoperative neurological deterioration was observed in 42.6% of the patients. New focal motor deficit accounted for 65% of postoperative neurological deterioration, while 60% was accounted for using the NIHSS total score change and 51% by Glasgow Coma Scale score change. Factors significantly associated with occurrence of postoperative neurological deterioration included: age, Fisher grade on admission, occurrence of a procedure prior to aneurysm surgery (ventriculostomy), timing of surgery, systolic blood pressure during surgery, ST segment depression during surgery, history of abnormality in cardiac valve function, use of intentional hypotension during surgery, duration of anterior cerebral artery occlusion, intraoperative blood loss, and difficulty of aneurysm exposure. Of the 426 patients with postoperative neurological deterioration at 24 hours after surgery, only 46.2% had a good outcome (GOS score of 1) at 3 months, while 77.7% of those without postoperative neurological deterioration at 24 hours had a good outcome (p < 0.05). CONCLUSIONS Neurological injury incurred perioperatively or in the acute postoperative period accounts for a large percentage of poor outcomes in patients with good admission WFNS grades undergoing surgery for aneurysmal SAH. Avoiding surgical factors associated with postoperative neurological deterioration and directing investigative efforts at developing improved neuroprotection for use in aneurysm surgery may significantly improve long-term neurological outcomes in patients with SAH.
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Affiliation(s)
- Kelly B Mahaney
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA.
| | - Michael M Todd
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA
| | - Emine O Bayman
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA
- Department of Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA
| | - James C Torner
- Department of Epidemiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA
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Jaeger M, Soehle M, Schuhmann MU, Meixensberger J. Clinical significance of impaired cerebrovascular autoregulation after severe aneurysmal subarachnoid hemorrhage. Stroke 2012; 43:2097-101. [PMID: 22618384 DOI: 10.1161/strokeaha.112.659888] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the relationship between cerebrovascular autoregulation and outcome after aneurysmal subarachnoid hemorrhage. METHODS In a prospective observational study, 80 patients after severe subarachnoid hemorrhage were continuously monitored for cerebral perfusion pressure and partial pressure of brain tissue oxygen for an average of 7.9 days (range, 1.9-14.9 days). Autoregulation was assessed using the index of brain tissue oxygen pressure reactivity (ORx), a moving correlation coefficient between cerebral perfusion pressure and partial pressure of brain tissue oxygen. High ORx indicates impaired autoregulation; low ORx signifies intact autoregulation. Outcome was determined at 6 months and dichotomized into favorable (Glasgow Outcome Scale 4-5) and unfavorable outcome (Glasgow Outcome Scale 1-3). RESULTS Twenty-four patients had a favorable and 56 an unfavorable outcome. In a univariate analysis, there were significant differences in autoregulation (ORx 0.19±0.10 versus 0.37±0.11, P<0.001, for favorable versus unfavorable outcome, respectively), age (44.1±11.0 years versus 54.2±12.1 years, P=0.001), occurrence of delayed cerebral infarction (8% versus 46%, P<0.001), use of coiling (25% versus 54%, P=0.02), partial pressure of brain tissue oxygen (24.9±6.6 mm Hg versus 21.8±6.3 mm Hg, P=0.048), and Fisher grade (P=0.03). In a multivariate analysis, ORx (P<0.001) and age (P=0.003) retained an independent predictive value for outcome. ORx correlated with Glasgow Outcome Scale (r=-0.70, P<0.001). CONCLUSIONS The status of cerebrovascular autoregulation might be an important pathophysiological factor in the disease process after subarachnoid hemorrhage, because impaired autoregulation was independently associated with an unfavorable outcome.
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Affiliation(s)
- Matthias Jaeger
- Department of Neurosurgery, University of Leipzig, Leipzig, Germany.
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Mahaney KB, Todd MM, Torner JC. Variation of patient characteristics, management, and outcome with timing of surgery for aneurysmal subarachnoid hemorrhage. J Neurosurg 2011; 114:1045-1053. [PMID: 21250801 DOI: 10.3171/2010.11.jns10795] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The past 30 years have seen a shift in the timing of surgery for aneurysmal subarachnoid hemorrhage (SAH). Earlier practices of delayed surgery that were intended to avoid less favorable surgical conditions have been replaced by a trend toward early surgery to minimize the risks associated with rebleeding and vasospasm. Yet, a consensus as to the optimal timing of surgery has not been reached. The authors hypothesized that earlier surgery, performed using contemporary neurosurgical and neuroanesthesia techniques, would be associated with better outcomes when using contemporary management practices, and sought to define the optimal time interval between SAH and surgery. METHODS Data collected as part of the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) were analyzed to investigate the relationship between timing of surgery and outcome at 3 months post-SAH. The IHAST enrolled 1001 patients in 30 neurosurgical centers between February 2000 and April 2003. All patients had a radiographically confirmed SAH, were World Federation of Neurosurgical Societies Grades I-III at the time of surgery, and underwent surgical clipping of the presumed culprit aneurysm within 14 days of the date of hemorrhage. Patients were seen at 90-day follow-up visits. The primary outcome variable was a Glasgow Outcome Scale score of 1 (good outcome). Intergroup differences in baseline, intraoperative, and postoperative variables were compared using the Fisher exact tests. Variables reported as means were compared with ANOVA. Multiple logistic regression was used for multivariate analysis, adjusting for covariates. A p value of less than 0.05 was considered to be significant. RESULTS Patients who underwent surgery on Days 1 or 2 (early) or Days 7-14 (late) (Day 0 = date of SAH) fared better than patients who underwent surgery on Days 3-6 (intermediate). Specifically, the worst outcomes were observed in patients who underwent surgery on Days 3 and 4. Patients who had hydrocephalus or Fisher Grade 3 or 4 on admission head CT scans had better outcomes with early surgery than with intermediate or late surgery. CONCLUSIONS Early surgery, in good-grade patients within 48 hours of SAH, is associated with better outcomes than surgery performed in the 3- to 6-day posthemorrhage interval. Surgical treatment for aneurysmal SAH may be more hazardous during the 3- to 6-day interval, but this should be weighed against the risk of rebleeding.
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Affiliation(s)
- Kelly B Mahaney
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA.
| | - Michael M Todd
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA
| | - James C Torner
- Department of Epidemiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52245, USA
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Carbon dioxide influence on nitric oxide production in endothelial cells and astrocytes: cellular mechanisms. Brain Res 2011; 1386:50-7. [PMID: 21362408 DOI: 10.1016/j.brainres.2011.02.066] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 01/19/2011] [Accepted: 02/21/2011] [Indexed: 11/21/2022]
Abstract
Cerebral vessels may regulate cerebral blood flow by responding to changes in carbon dioxide (CO(2)) through nitric oxide (NO) production. To better determine the role of NO production by human adult cerebral microvascular endothelial cells and human fetal astrocytes under different CO(2) conditions, we studied endothelial cell and astrocyte production of NO under hypo-, normo- and hypercapnic conditions. Human cerebral endothelial cell and fetal astrocyte cultures were exposed to hypocapnic (pCO(2) 21.7±6.7mmHg), normocapnic (pCO(2) 40.1±0.9mmHg) and hypercapnic (pCO(2) 56.3±8.7mmHg) conditions. NO production was recorded continuously over 24hours with stable pH. N-nitro-l-arginine [NLA; a nitric oxide synthase (NOS) inhibitor] and l-arginine (substrate for NO production via NOS) were used to further define the role of NOS in chemoregulation. NO levels in endothelial cells increased during hypercapnia by 36% in 8hours and remained 25% above baseline. NO increase in astrocytes was 30% after 1hour but returned to baseline at 8hours. NLA blocked NO increase in endothelial cells under hypercapnia. During hypocapnia, NO levels in the endothelial cells decreased by 30% at 8hours but were unchanged in astrocytes. l-arginine prevented NO decrease in endothelial cells under hypocapnia. NO changes in the endothelial cells correlated with changes in pCO(2) (R=0.99) and were independent of pH. This study suggests that cerebral endothelial cells and astrocytes release NO under normocapnic conditions and NO production is increased during hypercapnia and decreased during hypocapnia independent of pH. Further, this demonstrates that endothelial cells may play a pivotal role in chemoregulation by modulating NOS activity.
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Lanterna LA, Lunghi A, Martchenko S, Gritti P, Bonaldi G, Biroli F. Cerebral watershed hypoperfusion in subarachnoid hemorrhage: computed tomography perfusion analysis. J Neurosurg 2010; 114:961-8. [PMID: 20849218 DOI: 10.3171/2010.8.jns091766] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT A better understanding of the pathophysiology of vasospasm-induced delayed cerebral ischemia and earlier detection of hypoperfusion before ischemic injury are needed to guide therapy in subarachnoid hemorrhage (SAH). The cerebrovascular physiology of the major arterial territories differs from that of the watershed zones (WZs) in a way that would suggest a differential topographic sensitivity of the brain to vasospasm. The primary end point of the study was to investigate the vasospasm-induced hypoperfusion in relation to cerebrovascular topography and timing from the onset of SAH. METHODS Forty-one patients were prospectively enrolled and scheduled for perfusion-weighted (PW) CT at 3 time points (≤ 3 days, Days 4-8, and Days 9-15 after SAH). Perfusion-weighted CT maps were visually assessed for side-to-side perfusion asymmetry. The PW CT topographic pattern was categorized into absence of asymmetry, WZ, and vascular territory hypoperfusion. Perfusion-weighted CT revision was performed by investigators blinded to clinical information. The null hypothesis for the primary end point was that there would be no difference in hypoperfusion space-time distribution among the different vascular territories. Multivariate logistic regression and Cox proportional hazards modeling were used for statistical analysis. RESULTS Delayed cerebral ischemia occurred in 26 patients and its predicting variables were increasing age (p = 0.045), Fisher grade (p = 0.007), and hypoperfusion on the PW CT performed within the 1st 72 hours after SAH (p = 0.004). The timing of the PW CT with respect to the day of SAH affected the topographic pattern of hypoperfusion: watershed-zone hypoperfusion was more common within the first 3 days after SAH (p = 0.018), while the proportion of territorial hypoperfusion increased subsequently. Among the different covariates, a young age was independently associated with a higher risk of developing hypoperfusion in the WZs (p = 0.02). CONCLUSIONS This study suggests the existence of a cerebral topographic heterogeneity to the hemodynamic effects of SAH and differential pathogenetic mechanisms of hypoperfusion according to timing, age, and brain topography. Hypoperfusion in the WZs may be an early precursor to more profound ischemic events. The PW CT detection of such brain-sensitive zones could offer a warning signal of the early hemodynamic effects of SAH and cerebral vasospasm.
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Affiliation(s)
- Luigi Andrea Lanterna
- Department of Neuroscience and Surgery of Nervous System, Ospedali Riuniti, Bergamo, Italy.
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Cerebral Autoregulation and CO2 Reactivity Before and After Elective Supratentorial Tumor Resection. J Neurosurg Anesthesiol 2010; 22:132-7. [DOI: 10.1097/ana.0b013e3181c9fbf1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW The aim of this article is to summarize recent concepts regarding the intensive care management of patients with subarachnoid haemorrhage, emphasizing the detection and treatment of cerebral vasospasm and the management of systemic complications. RECENT FINDINGS Aneurysmal subarachnoid haemorrhage is a potentially devastating disease that requires complex treatment strategies and extended monitoring. The prognosis of subarachnoid haemorrhage depends on the severity of the initial bleed, the success of the procedure to secure the aneurysm and the occurrence and severity of sequelae, including cerebral vasospasm. Patients with subarachnoid haemorrhage benefit from multidisciplinary neurointensive care where management is targeted at securing the ruptured aneurysm, optimizing cardiovascular variables, detecting and treating cerebral vasospasm and managing systemic complications. SUMMARY The complex treatment strategies applied after subarachnoid haemorrhage call for interdisciplinary collaboration between neurosurgeons, neuroradiologists, neurointensivists and specialist nurses. Specialized neuromonitoring and neuroimaging techniques must also be available. The neurointensive care unit serves as the focal point for these combined efforts.
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Affiliation(s)
- Martin Smith
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London, UK.
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Diringer MN, Axelrod Y. Hemodynamic manipulation in the neuro-intensive care unit: cerebral perfusion pressure therapy in head injury and hemodynamic augmentation for cerebral vasospasm. Curr Opin Crit Care 2007; 13:156-62. [PMID: 17327736 DOI: 10.1097/mcc.0b013e32807f2aa5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The intent of this manuscript is to summarize the pathophysiologic basis for hemodynamic manipulation in subarachnoid hemorrhage and traumatic brain injury, highlight the most recent literature and present expert opinion on indications and use. RECENT FINDINGS Hemodynamic augmentation with vasopressors and inotropes along with hypervolemia are the mainstay of treatment of vasospasm due to subarachnoid hemorrhage. Considerable variation continues to exist regarding fluid management and the use of vasopressors and inotropes. Blood pressure augmentation, volume expansion and cardiac contractility enhancement improve cerebral blood flow in ischemic areas, ameliorate vasospasm and improve clinical condition. In patients suffering from severe traumatic brain injury, while every attempt is made to control intracranial hypertension, cerebral perfusion-directed therapy with fluids and vasopressors is also used to keep cerebral perfusion pressure above 60-70 mmHg. Yet, recent observations suggest that posttraumatic mitochondrial dysfunction has been proposed as an alternative explanation for lower cerebral blood flow after acute trauma. SUMMARY Hemodynamic manipulation is routinely used in the management of patients with acute vasospasm following subarachnoid hemorrhage and severe head injury. The rationale is to improve blood flow to the injured brain and prevent secondary ischemia.
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Affiliation(s)
- Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Barnes-Jewish Hospital, Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Mocco J, Prickett CS, Komotar RJ, Connolly ES, Mayer SA. Potential mechanisms and clinical significance of global cerebral edema following aneurysmal subarachnoid hemorrhage. Neurosurg Focus 2007; 22:E7. [PMID: 17613238 DOI: 10.3171/foc.2007.22.5.8] [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: 11/06/2022]
Abstract
✓In an attempt to elucidate the pathophysiology and clinical significance of global cerebral edema (GCE) following aneurysmal subarachnoid hemorrhage (SAH), the authors explored potential mechanisms and reviewed findings associated with this phenomenon. Admission computed tomography (CT) scans show GCE in up to 20% of patients experiencing aneurysmal SAH. This edema is likely to have been initiated by transient global ischemia, as indicated by an association between ictal loss of consciousness and the development of edema. A further cascade of events, including a rise in intracranial pressure and compromise of the blood–brain barrier, are also likely contributors. Clinically, GCE on CT after aneurysmal SAH is predictive of a poor outcome. Further investigation is needed to gain a full understanding of edema development following SAH, with the hope that the knowledge can be used to influence treatment positively and improve outcome.
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Affiliation(s)
- J Mocco
- Department of Neurosurgery, Columbia University, New York, New York 10032, USA.
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Abstract
Raised intracranial pressure (ICP) and low cerebral blood flow (CBF) are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these parameters. This overview summarizes the technical aspects of ICP and CBF monitoring, and their role in the clinical management of brain-injured patients. Furthermore, some applications of these methods in current research are highlighted. ICP is typically measured using probes that are inserted into one of the lateral ventricles or the brain parenchyma. Therapeutic measures used to control ICP have relevant side-effects and continuous monitoring is essential to guide such therapies. ICP is also required to calculate cerebral perfusion pressure which is one of the most important therapeutic targets in brain-injured patients. Several bedside CBF monitoring devices are available. However, most do not measure CBF but rather a parameter that is thought to be proportional to CBF. Frequently used methods include transcranial Doppler which measures blood flow velocity and may be helpful for the diagnosis and monitoring of cerebral vasospasm after subarachnoid haemorrhage or jugular bulb oximetry which gives information on adequacy of CBF in relation to the metabolic demand of the brain. However, there is no clear evidence that incorporating data from CBF monitors into our management strategies improves outcome in brain-injured patients.
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Affiliation(s)
- L A Steiner
- Surgical Intensive Care Unit, Department of Anaesthesia, University Hospital Basel, CH-4031 Basel, Switzerland.
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Blissitt PA, Mitchell PH, Newell DW, Woods SL, Belza B. Cerebrovascular Dynamics With Head-of-Bed Elevation in Patients With Mild or Moderate Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Am J Crit Care 2006. [DOI: 10.4037/ajcc2006.15.2.206] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background In patients with aneurysmal subarachnoid hemorrhage, elevation of the head of the bed during vasospasm has been limited in an attempt to minimize vasospasm or its sequelae or both. Consequently, some patients have remained on bed rest for weeks.
• Objectives To determine how elevations of the head of the bed of 20° and 45° affect cerebrovascular dynamics in adult patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage and to describe the response of mild or moderate vasospasm to head-of-bed elevations of 20° and 45° with respect to variables such as grade of subarachnoid hemorrhage and degree of vasospasm.
• Methods A within-patient repeated-measures design was used. The head of the bed was positioned in the sequence of 0°-20°-45°-0° in 20 patients with mild or moderate vasospasm between days 3 and 14 after aneurysmal subarachnoid hemorrhage. Continuous transcranial Doppler recordings were obtained for 2 to 5 minutes after allowing approximately 2 minutes for stabilization in each position.
• ResultsNo patterns or trends indicated that having the head of the bed elevated increases vasospasm. As a group, there were no significant differences within patients at the different positions of the head of the bed. Utilizing repeated-measures analysis of variance, P values ranged from .34 to .97, well beyond .05. No neurological deterioration occurred.
• Conclusions In general, elevation of the head of the bed did not cause harmful changes in cerebral blood flow related to vasospasm.
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Affiliation(s)
- Patricia A. Blissitt
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - Pamela H. Mitchell
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - David W. Newell
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - Susan L. Woods
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
| | - Basia Belza
- The Neuroscience Intensive Care Unit, Duke University Medical Center, Durham, NC (pab), Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash (phm, slw, bb), and Seattle Neuroscience Institute at Swedish Medical Center, Seattle, Wash (dwn)
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Abstract
This review examines the available data on the use of osmotic agents in patients with head injury and ischemic stroke, summarizes the physiological effects of osmotic agents, and presents the leading hypotheses regarding the mechanism by which they reduce ICP. Finally, it addresses the validity of the following commonly held beliefs: mannitol accumulates in injured brain; mannitol shrinks only normal brain and can increase midline shift; osmolality can be used to monitor mannitol administration; mannitol should be not be administered if osmolality is >320 mOsm; and hypertonic saline is equally effective as mannitol.
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Affiliation(s)
- Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit and Stroke Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Beydon L, Audibert G, Berré J, Boulard G, Gabrillargues J, Bruder N, Hans P, Puybasset L, Ravussin P, de Kersaint-Gilly A, Ter Minassian A, Dufour H, Lejeune JP, Proust F, Bonafé A. [Pain management in severe subarachnoid haemorrhage]. ACTA ACUST UNITED AC 2005; 24:782-6. [PMID: 15922538 DOI: 10.1016/j.annfar.2005.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- L Beydon
- Département d'anesthésie-réanimation chirurgicale, CHU, 4, rue Larrey, 49933 Angers cedex 01, France.
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Smith MJ, Le Roux PD, Elliott JP, Winn HR. Blood transfusion and increased risk for vasospasm and poor outcome after subarachnoid hemorrhage. J Neurosurg 2004; 101:1-7. [PMID: 15255244 DOI: 10.3171/jns.2004.101.1.0001] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Object. Nitric oxide (NO) metabolism may influence vasospasm after subarachnoid hemorrhage (SAH). It has been demonstrated in recent studies that erythrocytes carry NO for release in vessels, whereas transfused erythrocytes may lack stored NO. Several converging lines of evidence also indicate that blood transfusion may exacerbate poor outcomes in some critically ill patients. In this study the authors hypothesized that patients with SAH who received red blood cell (RBC) transfusions were at greater risk for vasospasm and poor outcome.
Methods. The authors retrospectively reviewed a prospective observational database, including hospital records, computerized tomography (CT) scans, and pre- and postoperative four-vessel angiograms, in which the management methods used in 441 patients undergoing surgery for ruptured cerebral aneurysms were described. Two hundred seventy patients (61.2%) received an RBC transfusion during their hospital stay. After adjustment for Hunt and Hess grade, SAH grade on CT scans, delay between rupture and surgery, smoking status, and intraoperative aneurysm rupture, a worse outcome was more likely in patients who received intraoperative blood (odds ratio [OR] 2.44, confidence interval [CI] 1.32–4.52; 120 patients). Intraoperative RBC transfusion did not influence subsequent angiographically confirmed vasospasm (OR 0.92, CI 0.6–1.4). Worse outcome was observed in patients who received blood postoperatively (OR 1.81, CI 1.21–2.7), but not after adjustments were made for confounding variables (OR 1.48, CI 0.83–2.63). Angiographic vasospasm was observed in 217 patients and, after adjusting for confounding variables, was more frequent among patients who received postoperative RBC transfusion (OR 1.68, CI 1.02–2.75). Among patients in whom angiographically confirmed vasospasm developed there was a tendency to have received more blood than in those with no vasospasm; however, a clear dose-dependent response was not observed.
Conclusions. Development of angiographically confirmed vasospasm after SAH is associated with postoperative RBC transfusion and worse outcome is associated with intraoperative RBC transfusion. Before blood is transfused, patients with SAH should be carefully assessed to determine if they are symptomatic because of anemia.
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Affiliation(s)
- Michelle J Smith
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19107, USA
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Iuliano BA, Pluta RM, Jung C, Oldfield EH. Endothelial dysfunction in a primate model of cerebral vasospasm. J Neurosurg 2004; 100:287-94. [PMID: 15086237 DOI: 10.3171/jns.2004.100.2.0287] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECT Although abnormalities in the control of endothelial vasomotility have been reported in both experimental and clinical studies, the mechanism of the endothelial dysfunction that occurs following subarachnoid hemorrhage (SAH) remains unclear. Because of the absence of previous in vivo studies of endothelial function in cerebral vessels in response to SAH or cerebral vasospasm, the authors investigated endothelium-dependent responses in an established primate model of vasospasm after SAH. Endothelial function was assessed by examining vascular responses to intracarotid injections of various drugs known to act via the endothelium. Drugs that have a rapid total body clearance were selected so that their pharmacological effects would be limited to the cerebral circulation after an intracarotid infusion. METHODS Seventeen adult male cynomolgus monkeys were used. Cerebrovascular endothelium-dependent responses were examined in control animals and in animals with SAH 7, 14, and 21 days after placement of a subarachnoid clot around the right middle cerebral artery. Cortical cerebral blood flow (CBF) and cerebrovascular resistance (CVR) were recorded continuously during 5-minute intracarotid infusions of 5% dextrose vehicle, acetylcholine, histamine, bradykinin, or Calcimycin. In control animals the intracarotid infusion of acetylcholine produced a significant (7.8 +/- 9.5%) increase in CBF and a 9.3 +/- 8.7% reduction in CVR in comparison with a control infusion of dextrose vehicle. The responses to acetylcholine disappeared in animals 7 days post-SAH, specifically in the subset of animals in which arteriography confirmed the presence of vasospasm. Infusion of Calcimycin produced no significant changes in CBF or CVR in control animals, but resulted in a significant reduction in CBF and increase in CVR in animals 7 days after SAH and in animals with vasospasm. An infusion of histamine or bradykinin had no significant effect on CBF or CVR. CONCLUSIONS An intracarotid infusion of acetylcholine, but not one of histamine, bradykinin, or Calcimycin, produced a measurable physiological response in the normal primate cerebrovasculature. Cerebral vasospasm that occurred after SAH produced a pathophysiological effect similar to the endothelial denudation shown in the in vitro experiments of Furchgott and Zawadzki, in which acetylcholine constricted the vessels via activation of receptors on smooth-muscle cells. Changes in vascular responses to acetylcholine and Calcimycin in animals with vasospasm, compared with control animals, provide evidence that endothelial dysfunction plays a key role in the development and/or sustenance of vasospasm after SAH.
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Affiliation(s)
- Brian A Iuliano
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA
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Soehle M, Czosnyka M, Pickard JD, Kirkpatrick PJ. Continuous assessment of cerebral autoregulation in subarachnoid hemorrhage. Anesth Analg 2004; 98:1133-1139. [PMID: 15041613 DOI: 10.1213/01.ane.0000111101.41190.99] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Cerebral vasospasm remains a leading cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Cerebral ischemia may ensue when autoregulation fails to compensate for spasm. We examined how autoregulation is affected by vasospasm by using transcranial Doppler. The moving correlation coefficient between slow changes of arterial blood pressure and mean or systolic flow velocity (FV), termed "Mx" and "Sx," respectively, was used to characterize cerebral autoregulation. Vasospasm was declared when the mean FV increased to more than 120 cm/s and the Lindegaard ratio was more than 3. This occurred in 15 of 32 SAH patients. On the basis of the bilateral transcranial Doppler recordings of the middle cerebral artery in vasospastic patients, Mx and Sx were calculated for baseline and vasospasm. Mx increased during vasospasm (0.46 +/- 0.32; mean +/- SD) and was significantly higher (P = 0.021) than at baseline (0.21 +/- 0.24). Sx was also increased (0.22 +/- 0.26 vs 0.05 +/- 0.21 at baseline; P = 0.03). Mx correlated with mean FV (r = 0.577; P = 0.025) and the Lindegaard ratio (r = 0.672; P < 0.006). Mx (P = 0.006) and Sx (P = 0.044) were higher on the vasospastic side (Mx, 0.44 +/- 0.27; Sx, 0.24 +/- 0.23) when compared with the contralateral side (Mx, 0.34 +/- 0.29; Sx, 0.16 +/- 0.25). The increased Mx and Sx during cerebral vasospasm demonstrate impaired cerebral autoregulation. Mx and Sx provide additional information on changes in autoregulation in SAH patients. IMPLICATIONS The moving correlation coefficients between slow changes of arterial blood pressure and mean or systolic flow velocity, termed "Mx" and "Sx," respectively, characterize cerebral autoregulation but have not been applied to subarachnoid hemorrhage. A study in 15 patients revealed that Mx and Sx were significantly increased, indicating impaired autoregulation during vasospasm as compared with baseline, as well as on the side of vasospasm in comparison with the contralateral side.
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Affiliation(s)
- Martin Soehle
- *Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany; and †Academic Neurosurgery Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Vates GE, Zabramski JM, Spetzler RF, Lawton MT. Intracranial Aneurysms. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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Sherman RW, Bowie RA, Henfrey MME, Mahajan RP, Bogod D. Cerebral haemodynamics in pregnancy and pre-eclampsia as assessed by transcranial Doppler ultrasonography. Br J Anaesth 2002. [DOI: 10.1093/bja/89.5.687] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Steinmeier R, Bauhuf C, Hübner U, Hofmann RP, Fahlbusch R. Continuous cerebral autoregulation monitoring by cross-correlation analysis: evaluation in healthy volunteers. Crit Care Med 2002; 30:1969-75. [PMID: 12352028 DOI: 10.1097/00003246-200209000-00004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In a former study, we applied cross-correlation (CC) analysis to recordings of arterial blood pressure (BP), intracranial pressure (ICP), and intracranial blood flow velocity (FV). A lack of significant time delay and a positive correlation coefficient of slow oscillations between these parameters was interpreted as indicative of impaired cerebral autoregulation, whereas a significant time delay and a negative correlation was regarded as preserved autoregulation. To test this hypothesis, cross-correlation was applied on recordings of BP and FV (CC [BP --> FV]) in healthy volunteers with a presumably preserved cerebral autoregulation. DESIGN Study of a diagnostic test. SUBJECTS A total of 17 healthy volunteers. MEASUREMENTS AND MAIN RESULTS BP was recorded by using a tonometric device, and bilateral FV in the middle cerebral arteries (MCA) was measured by transcranial Doppler sonography. Signals were sampled at a resting horizontal position for 29 mins. Cluster analysis showed a mean +/- sd time delay for CC [BP --> FV(MCA right)] of 6.45 +/- 2.1 secs, and for CC [BP --> FV(MCA left) ] of 6.09 +/- 1.8 secs. The mean correlation coefficient was -.33 +/-.17 for the left and -.36 +/-.09 for the right side. In about 30%, differing results with a correlation coefficient between -.2 and.2 and a time delay near zero were found. Cross-correlation between left and right FV showed a mean time delay of 0.09 +/- 0.18 secs, with a mean correlation coefficient of.82 +/-.16. CONCLUSION Spontaneous slow oscillations of BP and FV were detected, and cross-correlation analysis showed a negative correlation and a positive time delay in about 70% of the examinations. These findings corroborate the hypothesis that CC [BP --> FV] might be able to assess the status of cerebral autoregulation continuously. The observed time delay between BP and FV oscillations is in good agreement with former studies on the dynamic properties of cerebral autoregulation.
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Affiliation(s)
- Ralf Steinmeier
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany.
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Laidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg 2002; 97:250-8; discussion 247-9. [PMID: 12186450 DOI: 10.3171/jns.2002.97.2.0250] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study was undertaken to determine the outcomes in an unselected group of patients treated with semiurgent surgical clipping of aneurysms following subarachnoid hemorrhage (SAH). METHODS A clinical management outcome audit was conducted to determine outcomes in a group of 391 consecutive patients who were treated with a consistent policy of ultra-early surgery (all patients treated within 24 hours after SAH and 85% of them within 12 hours). All neurological grades were included, with 45% of patients having poor grades (World Federation of Neurosurgical Societies [WFNS] Grades IV and V). Patients were not selected on the basis of age; their ages ranged between 15 and 93 years and 19% were older than 70 years. The series included aneurysms located in both anterior and posterior circulations. Eighty-eight percent of all patients underwent surgery and only 2.5% of the series were selectively withdrawn (by family request) from the prescribed surgical treatment. In patients with good grades (WFNS Grades I-III) the 3-month postoperative outcomes were independence (good outcome) in 84% of cases, dependence (poor outcome) in 8% of cases, and death in 9%. In patients with poor grades the outcomes were independence in 40% of cases, dependence in 15% of cases, and death in 45%. There was a 12% rate of rebleeding with all cases of rebleeding occurring within the first 12 hours after SAH; however, outcomes of independence were achieved in 46% of cases in which rebleeding occurred (43% mortality rate). Rebleeding was more common in patients with poor grades (20% experienced rebleeding, whereas only 5% of patients with good grades experienced rebleeding). CONCLUSIONS The major risk of rebleeding after SAH is present within the first 6 to 12 hours. This risk of ultra-early rebleeding is highest for patients with poor grades. Securing ruptured aneurysms by surgery or coil placement on an emergency basis for all patients with SAH has a strong rational argument.
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Affiliation(s)
- John D Laidlaw
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria, Australia.
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Vavilala MS, Lee LA, Lam AM. Cerebral blood flow and vascular physiology. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2002; 20:247-64, v. [PMID: 12165993 DOI: 10.1016/s0889-8537(01)00012-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The cerebral circulation is tightly regulated to meet the brain's metabolic demands. Although the mechanism is not fully understood, the major physiologic influences on cerebral blood flow have been well documented. In this chapter the basic vascular anatomy, and physiologic control of the cerebral circulation are reviewed. Clinical implications are emphasized.
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Affiliation(s)
- Monica S Vavilala
- Department of Anesthesiology, Harborview Medical Center, Box 359724, 325 Ninth Avenue, Seattle, WA 98104, USA
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Suarez JI, Qureshi AI, Yahia AB, Parekh PD, Tamargo RJ, Williams MA, Ulatowski JA, Hanley DF, Razumovsky AY. Symptomatic vasospasm diagnosis after subarachnoid hemorrhage: evaluation of transcranial Doppler ultrasound and cerebral angiography as related to compromised vascular distribution. Crit Care Med 2002; 30:1348-55. [PMID: 12072693 DOI: 10.1097/00003246-200206000-00035] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the reliability of transcranial Doppler ultrasound in detecting symptomatic vasospasm in patients after aneurysmal subarachnoid hemorrhage and monitoring response after hypertensive and endovascular treatments. DESIGN Retrospective chart review. SETTING Neurosciences critical care unit in a tertiary-care university hospital. PATIENTS All patients admitted to a neurosciences critical care unit with the diagnosis of subarachnoid hemorrhage between January 1990 and June 1997. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS We reviewed transcranial Doppler ultrasound data of 199 patients; 55 had symptomatic vasospasm. Clinical symptoms and corresponding vascular distributions were identified, as was angiographic vasospasm (n = 35). The sensitivity and specificity of transcranial Doppler ultrasound for anterior circulation vessels were calculated by using a mean cerebral blood flow velocity criterion of >120 cm/sec. Clinical diagnosis of symptomatic vasospasm was used as the standard to determine sensitivity and specificity of transcranial Doppler ultrasound and cerebral angiography. The sensitivity of transcranial Doppler ultrasound for anterior circulation in patients with symptomatic vasospasm was 73% with a specificity of 80%. The sensitivity of cerebral angiography was 80%. For individual vessels, the sensitivity and specificity of transcranial Doppler ultrasound were middle cerebral artery, 64% and 78%; anterior cerebral artery, 45% and 84%; and internal carotid artery, 80% and 77%, respectively. The mean times for symptomatic and transcranial Doppler ultrasound signs of vasospasm presentation were 6.4 +/- 2 and 6.1 +/- 3 days, respectively. In patients without symptomatic vasospasm, the mean time for mean cerebral blood flow velocities >120 cm/sec was 7.0 +/- 3 days (p <.05). Symptomatic vasospasm also was associated with thickness of clot on head computed tomography scan and rapidly increasing mean cerebral blood flow velocities. Transcranial Doppler ultrasound signs of vasospasm improved after endovascular treatment in 30 patients. CONCLUSIONS The reliability of transcranial Doppler ultrasound was better at detecting high mean cerebral blood flow velocities in patients with symptomatic vasospasm related to middle cerebral and internal carotid artery distributions than for anterior cerebral artery distribution. Transcranial Doppler ultrasound was as sensitive as cerebral angiography at detecting symptomatic vasospasm. High mean cerebral blood flow velocities can be apparent before the presence of symptomatic vasospasm. Daily transcranial Doppler ultrasound monitoring could provide early identification of patients with aneurysmal subarachnoid hemorrhage who are at high risk for symptomatic vasospasm and may be helpful at following success of endovascular treatment.
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Affiliation(s)
- Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Claassen J, Carhuapoma JR, Kreiter KT, Du EY, Connolly ES, Mayer SA. Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome. Stroke 2002; 33:1225-32. [PMID: 11988595 DOI: 10.1161/01.str.0000015624.29071.1f] [Citation(s) in RCA: 391] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral edema visualized by CT is often seen after subarachnoid hemorrhage (SAH). Inflammatory or circulatory mechanisms have been postulated to explain this radiographic observation after SAH. We sought to determine the frequency, causes, and impact on outcome of early and delayed global cerebral edema after SAH. METHODS We evaluated the presence of global edema on admission and follow-up CT scans in 374 SAH patients admitted within 5 days of onset to our Neurological Intensive Care Unit between July 1996 and February 2001. Using multivariate analysis, we identified predictors of global cerebral edema and evaluated the impact of global edema on outcome 3 months after onset with the modified Rankin Scale. RESULTS Global edema was present on admission CT scans in 8% (n=29) and developed secondarily in 12% (n=44) of the patients. Global edema on admission was predicted by loss of consciousness at ictus and increasing Hunt-Hess grade. Delayed global edema was predicted by aneurysm size >10 mm, loss of consciousness at ictus, use of vasopressors, and increased SAH sum scores. Thirty-seven percent (n=137) of the patients were dead or severely disabled (modified Rankin Scale 4 to 6) at 3 months. Death or severe disability was predicted by any global edema, aneurysm size >10 mm, loss of consciousness at ictus, increased National Institutes of Health Stroke Scale scores, and older age. CONCLUSIONS Global edema is an independent risk factor for mortality and poor outcome after SAH. Loss of consciousness, which may reflect ictal cerebral circulatory arrest, is a risk factor for admission global edema, and vasopressor-induced hypertension is associated with the development of delayed global edema. Critical care management strategies that minimize edema formation after SAH may improve outcome.
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Affiliation(s)
- Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Schaller C, Nakase H, Kotani A, Nishioka T, Meyer B, Sakaki T. Impairment of autoregulation following cortical venous occlusion in the rat. Neurol Res 2002; 24:210-4. [PMID: 11877906 DOI: 10.1179/016164102101199620] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Recent experiments showed an upward shift of the lower limit of autoregulation (AR) following photochemical occlusion of cortical veins in the rat. The goal of the present study was to prove the hypothesis that occlusion of cortical veins will be associated with impairment of the upper limit of autoregulation as well. In n = 28 Wistar rats unilateral frontoparietal cranial windows were drilled for transdural assessment of regional cerebral blood flow (rCBF) by laser Doppler scanning. The animals were allotted to two groups: (1) Group A (n = 5), control group for determination of the upper limit of autoregulation with stepwise induced arterial hypertension by intravenous administration of the alpha adrenergic drug methoxamine under continuous monitoring of mean arterial blood pressure (MABP); (2) Group B (n = 23), in which two cortical veins were photochemically occluded with rose bengal dye and fiberoptic illumination upon baseline CBF measurement. This was followed by repeated rCBF measurements under AR testing. Loss of AR in control Group A with passive increase of rCBF occurred at MABP of 147.5 +/- 2.9 mmHg. In Group B venous occlusion was followed by an initial phase of reduced rCBF, and then by pressure passive increases, thereby indicating loss of AR. Statistically significant changes of rCBF when compared to baseline MABP occurred at MABPbaseline + 10% (112.7 +/- 6.6 mmHg). We conclude that AR is impaired upon cortical venous occlusion with the propensity for hyperperfusion injury at a lower level of MABP when compared with a control group. In the context with earlier findings this may lead to narrowing of the corridor for MABP management following intra-operative occlusion of large cortical veins.
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Affiliation(s)
- Carlo Schaller
- Department of Neurosurgery, University of Bonn, Germany.
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Lam JM, Smielewski P, Czosnyka M, Pickard JD, Kirkpatrick PJ. Predicting delayed ischemic deficits after aneurysmal subarachnoid hemorrhage using a transient hyperemic response test of cerebral autoregulation. Neurosurgery 2000; 47:819-25; discussions 825-6. [PMID: 11014420 DOI: 10.1097/00006123-200010000-00004] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To assess whether the development of delayed ischemic deficits (DIDs) after aneurysmal subarachnoid hemorrhage can be predicted using transcranial Doppler ultrasonography and the transient hyperemic response test (THRT). METHODS An increase in the middle cerebral artery peak flow velocity (FV) of more than 9% of baseline values after 5 to 9 seconds of carotid artery compression was defined as a normal THRT result, indicating good autoregulatory reserve. The transcranial Doppler criteria for vasospasm were a FV of more than 120 cm/s and a Lindegaard ratio of more than 3. Twenty patients with no immediate postoperative neurological deficits were studied. The FVs at all of the major cerebral arteries were measured daily after surgery, and the THRT results were assessed bilaterally. RESULTS Five of six patients with abnormal THRT results in the first examination after surgery (primary THRT impairment) developed DIDs; none of the remaining patients developed DIDs (Fisher exact test, P = 0.0004). All five patients with DIDs initially exhibited low FVs but all subsequently developed increases in FVs to values of more than 150 cm/s and four exhibited FVs of more than 200 cm/s. The time of onset of DIDs corresponded to the time of onset of moderate vasospasm (FV > 150 cm/s). None of the patients with initially normal THRT results developed DIDs, although four patients did exhibit late (secondary) THRT impairment, which was associated with FVs of more than 120 cm/s. CONCLUSION When the effects of primarily impaired (after surgery) autoregulation are magnified by vasospasm, the risk of DIDs seems to be very high. Vasospasm alone does not seem to cause DIDs. The development of DIDs could therefore be predicted using the THRT for patients after aneurysm clipping.
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Affiliation(s)
- J M Lam
- Wolfson Brain Imaging Centre, and Academic Neurosurgical Unit, Addenbrooke's Hospital, Cambridge, England
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Oláh L, Valikovics A, Bereczki D, Fülesdi B, Munkácsy C, Csiba L. Gender-related differences in acetazolamide-induced cerebral vasodilatory response: a transcranial Doppler study. J Neuroimaging 2000; 10:151-6. [PMID: 10918741 DOI: 10.1111/jon2000103151] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Cerebrovascular reactivity, cerebrovascular reserve capacity, and velocity acceleration can be easily and reliably assessed by measuring acetazolamide-induced changes using transcranial Doppler. The authors' aim was to determine whether there are gender-related differences in these parameters. Fifty-six healthy subjects (27 males, 29 females) were examined using transcranial Doppler. Velocities in the middle cerebral artery on both sides were recorded before and at 5, 10, 15, and 20 minutes after intravenous administration of 1 g acetazolamide. The baseline mean flow velocity in the middle cerebral artery was significantly higher in women than in men (p < 0.02). After acetazolamide administration, significantly higher cerebrovascular reactivity, cerebrovascular reserve capacity, and velocity acceleration were observed in females than in males (p < 0.001 in all cases). Subgroup analysis showed that women before menopause responded with higher cerebrovascular reserve capacity and velocity acceleration than age-matched men (p < 0.01 and p < 0.001, respectively), but no significant difference was found between females after menopause and men of similar age.
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Affiliation(s)
- L Oláh
- Department of Neurology, University Medical School of Debrecen, Hungary
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Chang HS, Hongo K, Nakagawa H. Adverse effects of limited hypotensive anesthesia on the outcome of patients with subarachnoid hemorrhage. J Neurosurg 2000; 92:971-5. [PMID: 10839257 DOI: 10.3171/jns.2000.92.6.0971] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study was aimed at clarifying the effect of intraoperative hypotensive anesthesia on the outcome of early surgery in patients with subarachnoid hemorrhage (SAH) caused by saccular cerebral aneurysms. Other factors were also screened for possible effects on the outcome. METHODS Hospital charts in 84 consecutive patients with SAH who underwent aneurysm clipping by Day 4 were examined. Possible factors affecting the outcome were analyzed using multiple logistic regression with the dichotomous Glasgow Outcome Scale score as the outcome variable. The relationship between the intraoperative hypotension and the occurrence and severity of vasospasm was studied using both single- and multivariate analyses. CONCLUSIONS Intraoperative hypotension had a significantly adverse effect on the outcome of SAH. Hypotension was also related to more frequent and severe manifestations of vasospasm. A long-lasting effect of brain retraction is possibly the cause of this phenomenon. The data contained in this study preclude the use of intraoperative hypotension even in a limited form.
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Affiliation(s)
- H S Chang
- Department of Neurological Surgery, Aichi Medical University, Japan.
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