1
|
Crinnion W, Bhogal P, Makalanda HLD, Wong K, Arthur A, Cognard C, Henkes H, Fiorella D, Pierot L. The Woven Endobridge as a treatment for acutely ruptured aneurysms: A review of the literature. Interv Neuroradiol 2021; 27:602-608. [PMID: 33509013 PMCID: PMC8493343 DOI: 10.1177/1591019921991397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/21/2020] [Accepted: 01/06/2021] [Indexed: 11/16/2022] Open
Abstract
The Woven Endobridge (WEB; Microvention, Aliso Viejo, California, USA) is a relatively new device which has been shown to be safe and effective for the treatment of wide necked bifurcation aneurysms in multiple prospective Good Clinical Practice studies. However, the vast majority of aneurysms included in these studies have been unruptured. The aim of this review is to summarise the current evidence available on the treatment of ruptured aneurysms with the WEB.
Collapse
Affiliation(s)
- William Crinnion
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | | | - Ken Wong
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Adam Arthur
- Department of Neurosurgery, Semmes Murphy Clinic and University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Dave Fiorella
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Laurent Pierot
- Department of diagnostic and therapeutic neuroradiology, Centre Hospitalier Universitaire de Reims, Reims, France
| |
Collapse
|
2
|
Yagi K, Tao Y, Hara K, Kanda E, Hirai S, Takai H, Kinoshita K, Mimani Y, Miyazaki Y, Oyama N, Yagita Y, Matsubara S, Uno M. Increased plasma plasmin-α2-plasmin inhibitor complex levels correlate with postoperative rebleeding after endoscopic surgery for spontaneous intracerebral hemorrhage. Acta Neurochir (Wien) 2020; 162:3129-3136. [PMID: 31781996 DOI: 10.1007/s00701-019-04154-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative rebleeding (PR) is one of the most severe complications of endoscopic surgery, often performed to remove spontaneous intracerebral hemorrhage (sICH). However, the risk factors for PR remain unclear. OBJECTIVE This study retrospectively investigated whether increased preoperative plasma plasmin-α2-plasmin inhibitor complex (PIC) levels, indicating activation of fibrinolysis, are associated with PR. METHODS A total of 101 patients underwent endoscopic surgery to evacuate sICH at our institution from January 2010 to June 2019, and 79 patients who underwent examinations of plasma PIC levels at admission with available radiographical data were included. Correlations between PR and increased plasma PIC levels were retrospectively evaluated. RESULTS PR occurred in eight patients (10.1%), and high PIC levels (≥ 4 or 6 μg/ml) were significantly associated with PR. The sensitivities employing high PIC levels of ≥ 4 μg/ml and ≥ 6 μg/ml were both 0.63, and the specificities using the same PIC levels were 0.86 and 0.92, respectively. Multivariable analyses showed that high plasma PIC levels of ≥ 4 μg/ml (odds ratio (OR), 12.77; 95% confidence interval (CI), 1.65-98.77; p = 0.02) or ≥ 6 μg/ml (OR, 18.33; 95% CI, 2.32-144.82; p = 0.006) were independent predictors of PR. CONCLUSIONS This study found that increased plasma PIC levels were associated with PR following the endoscopic evacuation of sICHs, indicating that increased plasma PIC levels could be potentially used to predict PR. Further studies are needed to establish new surgical strategies and adjuvant treatments to improve surgical outcomes in patients with sICH prone to PR.
Collapse
Affiliation(s)
- Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | - Yoshifumi Tao
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Keijirou Hara
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Satoshi Hirai
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Keita Kinoshita
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Yukari Mimani
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Yuko Miyazaki
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| |
Collapse
|
3
|
Wang J, Zuo Y, Zhuang K, Luo K, Yan X, Li J, Zhang JH, Liu F. Recombinant Human Milk Fat Globule-Epidermal Growth Factor 8 Attenuates Microthrombosis after Subarachnoid Hemorrhage in Rats. J Stroke Cerebrovasc Dis 2019; 29:104536. [PMID: 31883781 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/28/2019] [Accepted: 11/09/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Microthrombosis after subarachnoid hemorrhage has an adverse effect on prognosis. Milk fat globule-epidermal growth factor 8 promotes phagocytosis of phagocytic cells and may reduce microthrombosis. This study investigated the effects of recombinant human milk fat globule-epidermal growth factor 8 on microthrombosis and neurological function after subarachnoid hemorrhage. METHODS Rats subarachnoid hemorrhage model was induced by intravascular puncture method. Western blot was performed to measure the expression of endogenous milk fat globule-epidermal growth factor 8 after subarachnoid hemorrhage. Microthrombosis was quantified by microthrombi count using immunohistochemistry and immunofluorescence. The neuroprotective effect of recombinant human milk fat globule-epidermal growth factor 8 administration was evaluated by modified Garcia score, beam balance, Rotarod test, and Morris water maze. RESULTS Endogenous milk fat globule-epidermal growth factor 8 protein level increased after subarachnoid hemorrhage. Microthrombosis was significantly increased in subarachnoid hemorrhage rats brain, while recombinant human milk fat globule-epidermal growth factor 8 dramatically reduced microthrombosis as well as improve short- and long- term neurobehavior after subarachnoid hemorrhage. CONCLUSIONS Recombinant human milk fat globule-epidermal growth factor 8 reduces microthrombosis and improves neurological function after subarachnoid hemorrhage, which may be an effective strategy for treating subarachnoid hemorrhage.
Collapse
Affiliation(s)
- Jikai Wang
- Department of Neurosurgery, Third XiangYa Hospital, Central South University, Changsha, Hunan, China
| | - Yuchun Zuo
- Department of Neurosurgery, XiangYa Hospital, Central South University, Changsha, Hunan, China
| | - Kai Zhuang
- Department of Neurosurgery, Third XiangYa Hospital, Central South University, Changsha, Hunan, China
| | - Kui Luo
- Department of Neurosurgery, Third XiangYa Hospital, Central South University, Changsha, Hunan, China
| | - Xiaoxin Yan
- Department of Anatomy and Neurobiology, XiangYa School of Medicine, Central South University, Changsha, Hunan, China
| | - Jianming Li
- Neuroscience Research Center, Changsha Medical University, Changsha, Hunan, China
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, California.
| | - Fei Liu
- Department of Neurosurgery, Third XiangYa Hospital, Central South University, Changsha, Hunan, China.
| |
Collapse
|
4
|
Liebig T, Kabbasch C, Strasilla C, Berlis A, Weber W, Pierot L, Patankar T, Barreau X, Dervin J, Kuršumović A, Rath S, Lubicz B, Klisch J. Intrasaccular Flow Disruption in Acutely Ruptured Aneurysms: A Multicenter Retrospective Review of the Use of the WEB. AJNR Am J Neuroradiol 2015; 36:1721-7. [PMID: 26138139 DOI: 10.3174/ajnr.a4347] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 02/02/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Use of the WEB intra-aneurysmal flow-disruption device in unruptured wide-neck bifurcation aneurysms has proven safety and efficacy. However, ruptured aneurysms are underrepresented in existing studies. This retrospective multicenter study describes the use of the WEB in patients with a ruptured intracranial aneurysm. MATERIALS AND METHODS Ten centers contributed to this study. Clinical and procedural data of 47 patients with 52 aneurysms were analyzed retrospectively together with follow-up angiographies. RESULTS There were 37 anterior and 15 posterior circulation aneurysms with a neck size of ≥4 mm in 49 of 52 (94%) aneurysms; 45 (87%) aneurysms were <10 mm, and 2 were partially thrombosed. Successful placement of the WEB was possible in every case. Adjunctive devices were used in 8 of 52 (15%) aneurysms. Thromboembolic events were observed in 4 of 52 (8%) patients. Adverse events occurred in 15 patients with 16 aneurysms, 9 of which were potentially related to the WEB procedure (3 thromboembolic events, 5 protrusions, and 1 perforations; 2 perforations were caused by the wire or catheter), but none had a clinical impact. Four patients were retreated. Short-term follow-up in 25 of 39 patients revealed complete occlusion in 15 of 25 (60%), 5 of 25 (20%) with residual neck, and 5 of 25 (20%) with residual aneurysm filling. Short- to midterm imaging in 9 of 25 patients revealed complete occlusion in 5 (55.6%), residual neck in 2 (22%), and residual aneurysm filling in 2 (22%). Of 47 patients, 23 (49%) had an mRS score of 0, 1, or 2; 13 (28%) had an mRS score of 3 or 4; and none had an mRS score of 5 at discharge. CONCLUSIONS This retrospective series showed good procedural safety, feasibility, and stability of midterm occlusion in ruptured wide-neck bifurcation aneurysms.
Collapse
Affiliation(s)
- T Liebig
- From the Department of Radiology (T.L., C.K.), Universitätsklinikum Köln, Cologne, Germany
| | - C Kabbasch
- From the Department of Radiology (T.L., C.K.), Universitätsklinikum Köln, Cologne, Germany
| | - C Strasilla
- Department of Diagnostic and Interventional Radiology and Neuroradiology (C.S., J.K.), Helios General Hospital, Erfurt, Germany
| | - A Berlis
- Department of Diagnostic Imaging and Neuroradiology (A.B.), Klinikum Augsburg, Augsburg, Germany
| | - W Weber
- Department of Neuroradiology (W.W.), Knappschaftskrankenhaus, Recklinghausen, Germany Department of Neuroradiology (W.W.), Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - L Pierot
- Department of Neuroradiology (L.P.), Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - T Patankar
- Leeds General Infirmary (T.P.), Leeds, United Kingdom
| | - X Barreau
- Department of Neuroimaging (X.B.), CHU Pellegrin, Bordeaux, France
| | - J Dervin
- Southern General Hospital (J.D.), Glasgow, United Kingdom
| | - A Kuršumović
- Department of Neuroradiology (A.K., S.R.), Klinikum Deggendorf, Deggendorf, Germany
| | - S Rath
- Department of Neuroradiology (A.K., S.R.), Klinikum Deggendorf, Deggendorf, Germany
| | - B Lubicz
- Department of Neuroradiology (B.L.), Erasme University Hospital, Brussels, Belgium
| | - J Klisch
- Department of Diagnostic and Interventional Radiology and Neuroradiology (C.S., J.K.), Helios General Hospital, Erfurt, Germany
| |
Collapse
|
5
|
Boluijt J, Meijers JCM, Rinkel GJE, Vergouwen MDI. Hemostasis and fibrinolysis in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review. J Cereb Blood Flow Metab 2015; 35:724-33. [PMID: 25690473 PMCID: PMC4420861 DOI: 10.1038/jcbfm.2015.13] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/09/2015] [Accepted: 01/12/2015] [Indexed: 11/09/2022]
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with microthrombosis, which can result from activated hemostasis, inhibited fibrinolysis, or both. We systematically searched the PUBMED and EMBASE databases to identify hemostatic or fibrinolytic parameters that can be used for the prediction or diagnosis of DCI, or that inform on the pathogenesis of DCI and may serve as treatment targets. We included 24 studies that fulfilled predefined criteria and described 39 biomarkers. Only one study fulfilled predefined criteria for high quality. Since no parameter on admission was associated with DCI and in none of the included studies blood was drawn at the time of clinical deterioration, none of the studied parameters can presently be used for the prediction or diagnosis of DCI. Regarding the pathogenesis of DCI, it was shown that compared with patients without DCI those with DCI had higher levels of von Willebrand factor and platelet activating factor in plasma 5 to 9 days after aSAH, membrane tissue factor in cerebrospinal fluid 5 to 9 days after aSAH, and D-dimer in plasma 11 to 14 days after aSAH. Confirmation in high-quality studies is needed to investigate whether these parameters can serve as targets for new intervention studies.
Collapse
Affiliation(s)
- Jacoline Boluijt
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost C M Meijers
- 1] Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands [2] Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- 1] Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands [2] Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Shimamura N, Naraoka M, Matsuda N, Ohkuma H. Safety of preprocedural antiplatelet medication in coil embolization of ruptured cerebral aneurysms at the acute stage. Interv Neuroradiol 2014; 20:413-7. [PMID: 25207902 PMCID: PMC4187435 DOI: 10.15274/inr-2014-10035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/26/2014] [Indexed: 11/12/2022] Open
Abstract
Preoperative antiplatelet medication for aneurysm coil embolization during acute subarachnoid hemorrhage (SAH) is not common. However, recent advances in neurointerventional devices make antiplatelet medication necessary for SAH surgery. We tested the hypothesis that preprocedural antiplatelet therapy in the acute stage of SAH prevents complications due to ischemia or induced bleeding. We retrospectively reviewed 35 consecutive ruptured cerebral saccular aneurysms that underwent coiling at our institute. Two hundred milligrams of aspirin and 150 mg of clopidogrel were administered to the patients at least two hours before coiling. Systemic heparinization was given after sheath insertion. Procedure-related thrombus formation on digital subtraction angiography, and clinical evidence of ischemia and procedure-related stroke on CT were reviewed. The median patient age was 69 years. Five males and 30 females were included. Seventy-seven percent of patients were Hunt-Hess grades 1 to 3. Assist techniques were used in 20 cases (57%). We inserted one extracranial internal carotid artery stent, but no intracranial stent. Intraoperative thrombosis occurred in one case (2.9%), with no clinical symptoms. Postoperative cerebrospinal fluid drainage was done in three cases, but we experienced no bleeding complications. Preoperative antiplatelet therapy leads to a low rate of thromboembolic events in coiling during acute stage SAH, and this strategy had no adverse influence on bleeding complications.
Collapse
Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine; Hirosaki, Aomori-prefecture, Japan -
| | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine; Hirosaki, Aomori-prefecture, Japan
| | - Naoya Matsuda
- Department of Neurosurgery, Hirosaki University School of Medicine; Hirosaki, Aomori-prefecture, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine; Hirosaki, Aomori-prefecture, Japan
| |
Collapse
|
7
|
Ji Y, Meng QH, Wang ZG. Changes in the coagulation and fibrinolytic system of patients with subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 2013; 54:457-64. [PMID: 24305025 PMCID: PMC4533443 DOI: 10.2176/nmc.oa2013-0006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to investigate the dynamic changes in the coagulation and fibrinolytic system with subarachnoid hemorrhage. The blood coagulation enzyme-AT complex (TAT), anticoagulant enzyme (AT), tissue plasminogen activator (tPA), plasminogen activin inhibitor (PAI-1), and mean blood flow velocity were measured. The TAT level was significantly higher 6 h after subarachnoid hemorrhage (SAH), whereas AT was significantly lower. These changes were maintained at 12 h to 1 d after SAH, returned to normal at 3 d, significantly changed again at 7 d to 14 d. The tPA level gradually increased after SAH and peaked at 14 d, and then returned to normal at 21 d. The PAI-1 levels were significantly lower than those in the control group 1 d after SAH gradually increased, and returned to normal at 21 d. In the cerebral vasospasm (CVS) groups, the levels of TAT, and AT significantly changed compared to the non-CVS groups after SAH. The PAI-1 levels were higher at 7 d and 14 d, but the changes were not significant. In groups Fisher III and IV as well as Hunt III to V, the TAT, AT, tPA, and PAI-1 levels were significantly higher than those in both Fisher and Hunt I and II 6 h, 12 h, 1 d, 7 d, and 14 d after SAH. The changes in the coagulation and fibrinolytic system of patients with SAH are correlated with the progress and symptoms of SAH as well as the blood content and CVS.
Collapse
Affiliation(s)
- Yong Ji
- Department of Neurosurgery, The Second Hospital of Shandong University
| | | | | |
Collapse
|
8
|
Naranjo D, Arkuszewski M, Rudzinski W, Melhem ER, Krejza J. Brain ischemia in patients with intracranial hemorrhage: pathophysiological reasoning for aggressive diagnostic management. Neuroradiol J 2013; 26:610-28. [PMID: 24355179 PMCID: PMC4202872 DOI: 10.1177/197140091302600603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/15/2013] [Indexed: 11/15/2022] Open
Abstract
Patients with intracranial hemorrhage have to be managed aggressively to avoid or minimize secondary brain damage due to ischemia, which contributes to high morbidity and mortality. The risk of brain ischemia, however, is not the same in every patient. The risk of complications associated with an aggressive prophylactic therapy in patients with a low risk of brain ischemia can outweigh the benefits of therapy. Accurate and timely identification of patients at highest risk is a diagnostic challenge. Despite the availability of many diagnostic tools, stroke is common in this population, mostly because the pathogenesis of stroke is frequently multifactorial whereas diagnosticians tend to focus on one or two risk factors. The pathophysiological mechanisms of brain ischemia in patients with intracranial hemorrhage are not yet fully elucidated and there are several important areas of ongoing research. Therefore, this review describes physiological and pathophysiological aspects associated with the development of brain ischemia such as the mechanism of oxygen and carbon dioxide effects on the cerebrovascular system, neurovascular coupling and respiratory and cardiovascular factors influencing cerebral hemodynamics. Consequently, we review investigations of cerebral blood flow disturbances relevant to various hemodynamic states associated with high intracranial pressure, cerebral embolism, and cerebral vasospasm along with current treatment options.
Collapse
Affiliation(s)
- Daniel Naranjo
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Michal Arkuszewski
- Department of Neurology, Medical University of Silesia, Central University Hospital; Katowice, Poland
| | - Wojciech Rudzinski
- Department of Cardiology, Robert Packer Hospital; Sayre, Pennsylvania USA
| | - Elias R. Melhem
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Jaroslaw Krejza
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| |
Collapse
|
9
|
Abstract
Brain injury after subarachnoid hemorrhage (SAH) is a biphasic event with an acute ischemic insult at the time of the initial bleed and secondary events such as cerebral vasospasm 3 to 7 days later. Although much has been learned about the delayed effects of SAH, less is known about the mechanisms of acute SAH-induced injury. Distribution of blood in the subarachnoid space, elevation of intracranial pressure, reduced cerebral perfusion and cerebral blood flow (CBF) initiates the acute injury cascade. Together they lead to direct microvascular injury, plugging of vessels and release of vasoactive substances by platelet aggregates, alterations in the nitric oxide (NO)/nitric oxide synthase (NOS) pathways and lipid peroxidation. This review will summarize some of these mechanisms that contribute to acute cerebral injury after SAH.
Collapse
Affiliation(s)
- Fatima A Sehba
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
| | | |
Collapse
|
10
|
Larsen CC, Astrup J. Rebleeding After Aneurysmal Subarachnoid Hemorrhage: A Literature Review. World Neurosurg 2013; 79:307-12. [DOI: 10.1016/j.wneu.2012.06.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 04/04/2012] [Accepted: 06/14/2012] [Indexed: 12/25/2022]
|
11
|
Larsen CC, Sørensen B, Nielsen JD, Astrup J. Reduced clot-stability during the first 6 hours after aneurysmal subarachnoid haemorrhage--a prospective case-control study. Thromb Res 2012; 129:e229-32. [PMID: 22386137 DOI: 10.1016/j.thromres.2012.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 01/27/2012] [Accepted: 01/30/2012] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Early rebleeding is an important cause of death and disability following aneurysmal subarachnoid haemorrhage (SAH). Recent studies have shown that 50-90% of the rebleedings occurred within the first 6 hours after the primary bleeding. The mechanism leading to rebleeding remains to be established. In the present prospective case-control study we hypothesize that patients with SAH develop a coagulopathy characterized by reduced clot stability during the early period after the initial bleeding. METHODS Patients with aneurysmal SAH was studied with a dynamic clot lysis assay and markers of fibrinolysis and clot stabilizers in blood samples taken within and after 6 hours after onset of bleeding. Results were compared with blood samples from age and gender matched healthy controls. RESULTS 36 patients were enrolled, 26 patients had blood samples collected within 6 hours after the initial bleeding whereas 10 patients had blood samples taken later than 6 hours after the initial bleeding. Patients demonstrated significantly reduced clot stability during the first 6 hours after initial bleeding. Fibrinolytic activity was increased during the first 6 hours along with the inhibitors of fibrinolysis whereas the modulators of fibrinolysis were reduced or inactivated. CONCLUSION During the first 6 hours after SAH patients exhibit reduced clot-stability. Probably a consequence of activated fibrinolysis in combination with reduced or inactivated factor XIII and thrombin-activable fibrinolysis inhibitor.
Collapse
Affiliation(s)
- Carl C Larsen
- Department of Neurosurgery, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
| | | | | | | |
Collapse
|
12
|
Blood coagulation and fibrinolysis after experimental subarachnoid hemorrhage. Acta Neurochir (Wien) 2010; 152:1577-81; discussion 1581. [PMID: 20559667 DOI: 10.1007/s00701-010-0699-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 05/22/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Aneurysmal rebleeding poses a serious risk in patients with subarachnoid hemorrhage (SAH). Studies have shown that antifibrinolytic therapy with tranexamic acid has a dramatic effect on the rate of rebleeding. Therefore, changes in the fibrinolytic system could be hypothesized. METHODS We have used an experimental SAH rat model to demonstrate serial changes in the haemostatic system as evaluated by Thromboelastography (TEG). RESULTS In the SAH group, a shorter reaction time (R-time) and higher maximum amplitude (MA) were observed. In the saline group, only a shorter R-time was observed. CONCLUSIONS The study has shown that a hypercoagulable state is present immediately after experimental SAH is induced as determined by TEG. The reduction in R-time and rise in MA observed in the SAH group indicate that blood in the subarachnoid space is necessary to accomplish a full systemic coagulation response. This abnormality in coagulation profile seems to be a response to the acute traumatic event caused by induction of SAH.
Collapse
|
13
|
Vergouwen MDI, Vermeulen M, Coert BA, Stroes ESG, Roos YBWEM. Microthrombosis after aneurysmal subarachnoid hemorrhage: an additional explanation for delayed cerebral ischemia. J Cereb Blood Flow Metab 2008; 28:1761-70. [PMID: 18628782 DOI: 10.1038/jcbfm.2008.74] [Citation(s) in RCA: 235] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with aneurysmal subarachnoid hemorrhage (SAH) who experience delayed cerebral ischemia (DCI) have an increased risk of poor outcome. Delayed cerebral ischemia is considered to be caused by vasospasm. However, not all patients with DCI have vasospasm. Inversely, not all patients with vasospasm develop clinical symptoms and signs of DCI. In the past, treatments aiming at vasospasm were not successful in preventing ischemia. The purpose of this review is to give an overview of clinical data showing that DCI cannot always be attributed to vasospasm, and to present an in-depth analysis of clinical and autopsy studies on the role of microthrombosis in the pathogenesis of DCI. Clinical studies show that DCI is associated with an activation of the coagulation cascade within a few days after SAH, preceding the time window during which vasospasm occurs. Furthermore, impaired fibrinolytic activity, and inflammatory and endothelium-related processes, lead to the formation of microthrombi, which ultimately result in DCI. The presence of microthrombi is confirmed by autopsy studies. Insight in the pathophysiology of DCI is crucial for the development of effective therapies against this complication. Because multiple pathways are involved, future research should focus on drugs with pleiotropic effects.
Collapse
Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
14
|
Luo W, Wang Y, Reiser G. Protease-activated receptors in the brain: receptor expression, activation, and functions in neurodegeneration and neuroprotection. ACTA ACUST UNITED AC 2007; 56:331-45. [PMID: 17915333 DOI: 10.1016/j.brainresrev.2007.08.002] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 08/15/2007] [Accepted: 08/18/2007] [Indexed: 11/15/2022]
Abstract
Protease-activated receptors (PARs) are G protein-coupled receptors that regulate the cellular response to extracellular serine proteases, like thrombin, trypsin, and tryptase. The PAR family consists of four members: PAR-1, -3, and -4 as thrombin receptors and PAR-2 as the trypsin/tryptase receptor, which are abundantly expressed in the brain throughout development. Recent evidence has supported the direct involvement of PARs in brain development and function. The expression of PARs in the brain is differentially upregulated or downregulated under pathological conditions in neurodegenerative disorders, like Parkinson's disease, Alzheimer's disease, multiple sclerosis, stroke, and human immunodeficiency virus-associated dementia. Activation of PARs mediates cell death or cell survival in the brain, depending on the amplitude and the duration of agonist stimulation. Interference or potentiation of PAR activation is beneficial in animal models of neurodegenerative diseases. Therefore, PARs mediate either neurodegeneration or neuroprotection in neurodegenerative diseases and represent attractive therapeutic targets for treatment of brain injuries. Here, we review the abnormal expression of PARs in the brain under pathological conditions, the functions of PARs in neurodegenerative disorders, and the molecular mechanisms involved.
Collapse
Affiliation(s)
- Weibo Luo
- Institut für Neurobiochemie, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Leipziger Strasse 44, 39120 Magdeburg, Germany
| | | | | |
Collapse
|
15
|
Ilveskero S, Juvela S, Siironen J, Lassila R. D-dimer Predicts Outcome after Aneurysmal Subarachnoid Hemorrhage: No Effect of Thromboprophylaxis on Coagulation Activity. Neurosurgery 2005; 57:16-24; discussion 16-24. [PMID: 15987536 DOI: 10.1227/01.neu.0000163085.48999.d6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2004] [Accepted: 01/13/2005] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Approximately one-third of all patients with acute nontraumatic subarachnoid hemorrhage (SAH) experience complications owing to delayed ischemic deficit. We reported recently that enoxaparin 40 mg once daily for 10 days seems safe and demonstrates thromboprophylactic efficacy, but it failed to improve outcome in a randomized SAH trial. In the present study, we assessed hemostatic variables associated with clinical status and outcome of SAH. We also monitored the effect of enoxaparin on activation of coagulation and fibrinolysis after closure of the ruptured aneurysm. METHODS Blood samples to measure activation of coagulation and fibrinolysis were collected from 42 patients participating in the enoxaparin trial for acute aneurysmal SAH at four time points: 1) at hospital admission; 2) 12 to 24 hours after aneurysm surgery but before initiation of enoxaparin therapy; 3) 3 hours after the first dose; and 4) at the conclusion of treatment. RESULTS At admission, several variables of coagulation and fibrinolysis were elevated and correlated well with clinical status. Specifically, D-dimer levels at all four time points correlated with patients' long-term outcomes. A single dose of enoxaparin suppressed early coagulation activity, but thrombin generation was not inhibited during thromboprophylaxis. However, PAI-1 activity was suppressed. CONCLUSION D-dimer offers a useful laboratory tool for assessing early and late clinical severity of SAH. A thromboprophylactic dose of enoxaparin inhibited PAI-1 activity but failed to down-regulate coagulation activity and D-dimer. These findings are compatible with the lack of efficacy of enoxaparin in reducing ischemic deficit after SAH.
Collapse
Affiliation(s)
- Sorella Ilveskero
- Wihuri Research Institute, Department of Hematology, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | | |
Collapse
|
16
|
Nina P, Schisano G, Chiappetta F, Luisa Papa M, Maddaloni E, Brunori A, Capasso F, Corpetti MG, Demurtas F. A study of blood coagulation and fibrinolytic system in spontaneous subarachnoid hemorrhage. Correlation with hunt-hess grade and outcome. ACTA ACUST UNITED AC 2001; 55:197-203. [PMID: 11358585 DOI: 10.1016/s0090-3019(01)00402-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) has been studied from various standpoints with the purpose of discovering criteria that might be useful in predicting the prognosis. In the literature a high incidence of coagulative and fibrinolytic disorders has been reported in SAH patients. A prospective study was performed to evaluate hemostatic plasmatic parameters in SAH patients. METHODS Hemostatic plasmatic parameters were prospectively studied in 76 patients with SAH. Both the coagulative (PT, APTT, fibrinogen, thrombin/antithrombin complex: TAT, and modified antithrombin III: MAT) and fibrinolytic (D-dimer) plasmatic systems were evaluated. Von Willebrand factor was also tested. RESULTS PT, APTT, and fibrinogen were within normal limits. High TAT levels were associated with clinical outcome since 16 patients out of 27 (59%) with unfavorable outcomes displayed TAT levels >20 ngzaq/L, as compared with 10 patients out of 38 (26%) with favorable outcomes. Plasmatic D-dimer, an index of subarachnoid clot lysis, was invariably found to be elevated. Nevertheless, very high levels (>1000 mcg/mL) were found in 16 patients out of 22 (73%) with unfavorable outcomes but in only 9 patients out of 38 (26%) with favorable outcomes. Significant D-dimer elevation showed a strong association with severe delayed ischemic deficit (DID). Patients were also tested for von Willebrand factor, displaying a specific increase in all cases. CONCLUSION The study provides evidence for an early activation of the coagulation and fibrinolytic system following SAH. Increase of plasmatic TAT parallels clinical outcome. A generalized increase of D-dimer was observed as well and D-dimer levels in the high range were associated with clinical outcome and poor results with DID. Our analysis shows close statistical significance between plasma levels of TAT, D-dimer, and outcome. A similar statistical significance has been found when comparing other known prognostic factors such as clinical and cerebral computerized tomography scan (CT) grade and outcome.
Collapse
Affiliation(s)
- P Nina
- Departments of Neurosurgery and Laboratory of Haematology and Pathology, Nuovo Pellegrini Hospital, Naples, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Inaba Y, Ichikawa M, Inoue A, Itoh M, Kyogashima M, Sekiguchi Y, Nakamura S, Komiyama A, Koh C. Plasma thrombin-antithrombin III complex is associated with the severity of experimental autoimmune encephalomyelitis. J Neurol Sci 2001; 185:89-93. [PMID: 11311288 DOI: 10.1016/s0022-510x(01)00468-3] [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: 11/24/2022]
Abstract
Previous studies have shown that activation of blood coagulation and fibrin depositions around CNS vessels are observed in animals with experimental autoimmune encephalomyelitis (EAE), which provides an animal model for human autoimmune demyelinating disorders. We examined the values of peripheral blood fibrinogen, thrombin-antithrombin III complex (TAT), fibrinolytic activity, and fibrin degradation products in Lewis rats with EAE to elucidate the role of the blood coagulation-fibrinolysis system in EAE. Plasma TAT values increased immediately prior to development of symptoms, and decreased according to the improvement of symptoms. There was significant correlation between TAT values and clinical scores of EAE; other markers were not correlated with the symptoms of EAE. These results suggest that plasma TAT levels are sensitive markers of the severity of EAE, and may be useful clinical indicators for the severity of human autoimmune demyelinating disorders.
Collapse
Affiliation(s)
- Y Inaba
- Department of Pediatrics, Shinshu University School of Medicine, 3-1-1 Asahi, 390-8621, Matsumoto, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Le Roux PD, Winn HR. Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient. ACTA NEUROCHIRURGICA. SUPPLEMENT 1999; 72:7-26. [PMID: 10337410 DOI: 10.1007/978-3-7091-6377-1_2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.
Collapse
Affiliation(s)
- P D Le Roux
- Department of Neurosurgery, New York University, New York, USA
| | | |
Collapse
|
19
|
Suzuki M, Kudo A, Otawara Y, Hirashima Y, Takaku A, Ogawa A. Extrinsic pathway of blood coagulation and thrombin in the cerebrospinal fluid after subarachnoid hemorrhage. Neurosurgery 1999; 44:487-93; discussion 493-4. [PMID: 10069585 DOI: 10.1097/00006123-199903000-00029] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The involvement of thrombin in the pathophysiology of subarachnoid hemorrhage (SAH) was investigated by comparing thrombin expression and extrinsic pathway activation in the cerebrospinal fluid (CSF) and blood of patients with SAH with the neurological grades, outcome, and presence of delayed cerebral vasospasm. METHODS Blood and CSF samples were obtained from 38 patients with SAH on Days 3 through 5, 7 through 9, and 12 through 14 after the onset of SAH. CSF samples were also obtained from control patients. Thrombin-antithrombin III complex, prothrombin fragment F1 +2, tissue factor, and tissue factor pathway inhibitor were analyzed using enzyme-linked immunosorbent assay. RESULTS No markers in the blood or CSF were correlated with neurological grades and outcome. Thrombin-antithrombin III complex and prothrombin fragment F1 +2 levels were significantly higher in the CSF of patients with SAH than in the blood or the CSF of control patients and were significantly higher in patients with vasospasm than in patients without vasospasm on Days 7 through 9. Tissue factor levels were significantly higher in the CSF of patients with SAH than in the blood, but the levels were close to those in the CSF of control patients. Tissue factor pathway inhibitor levels in the CSF of patients with SAH and control patients were under the detection limit. CONCLUSION Thrombin in the blood may not reflect the pathophysiology of SAH. Imbalance between tissue factor and tissue factor pathway inhibitor in the CSF may tend to thrombin generation under normal physiological conditions and also after SAH. Thrombin in the CSF may be involved in the pathophysiology of vasospasm.
Collapse
Affiliation(s)
- M Suzuki
- Department of Neurosurgery, Iwate Medical University, School of Medicine, Morioka, Japan
| | | | | | | | | | | |
Collapse
|
20
|
|
21
|
McKhann GM, Le Roux PD. Perioperative and Intensive Care Unit Care of Patients with Aneurysmal Subarachnoid Hemorrhage. Neurosurg Clin N Am 1998. [DOI: 10.1016/s1042-3680(18)30255-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
22
|
Hirashima Y, Nakamura S, Suzuki M, Kurimoto M, Endo S, Ogawa A, Takaku A. Cerebrospinal fluid tissue factor and thrombin-antithrombin III complex as indicators of tissue injury after subarachnoid hemorrhage. Stroke 1997; 28:1666-70. [PMID: 9303007 DOI: 10.1161/01.str.28.9.1666] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE No marker that reflects and predicts brain injury due to subarachnoid hemorrhage (SAH) and cerebral vasospasm has been reported. We hypothesized that membrane-bound tissue factor (mTF) and thrombin-antithrombin III complex (TAT) in the cerebrospinal fluid (CSF) of patients with SAH become markers indicating brain injury. To evaluate the hypothesis, we correlated levels of mTF and TAT in the CSF of patients with SAH with clinical severity, the degree of SAH, and outcome. METHODS We assayed CSF mTF, TAT and myelin basic protein (MBP) in patients with SAH at intervals that included days 0 to 4 and days 5 to 9 after ictus. Classification of clinical severity of disease on admission was based on Hunt and Hess grade, degree of SAH on CT on Fisher's grading, and outcome 3 months after SAH on the Glasgow Outcome Scale. RESULTS In the interval from days 0 to 4, mTF and TAT correlated with Hunt and Hess and Fisher grades, and occurrence of cerebral infarction due to vasospasm. Only mTF correlated significantly in this period with outcome. TAT, mTF, and MBP all correlated significantly with each other. From days 5 to 9, only mTF correlated with cerebral infarction, infarction volume, MBP levels, and outcome. CONCLUSIONS Both mTF and TAT reflected brain injury from SAH and predicted vasospasm, though mTF was more sensitive and a better predictor of outcome. Unlike mTF, TAT did not correlate with vasospasm during the interval when it most commonly occurs, which raised doubt about thrombin activation as a cause.
Collapse
Affiliation(s)
- Y Hirashima
- Department of Neurosurgery, Toyama Medical and Pharmaceutical University, Japan.
| | | | | | | | | | | | | |
Collapse
|
23
|
Peltonen S, Juvela S, Kaste M, Lassila R. Hemostasis and fibrinolysis activation after subarachnoid hemorrhage. J Neurosurg 1997; 87:207-14. [PMID: 9254083 DOI: 10.3171/jns.1997.87.2.0207] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The authors assessed hemostasis and fibrinolysis serially: on admission and on the 1st and 7th days after surgery for subarachnoid hemorrhage (SAH), examining the complications of aneurysm rupture and its surgical repair. Of 32 patients, 25 with SAH were compared with seven control patients who underwent surgery for an unruptured intracranial aneurysm. On admission, patients with SAH had higher thrombin-antithrombin III complex (TAT) levels (13.3 +/- 3.8 vs. 3.8 +/- 0.6 ng/ml, p = 0.01), fibrin degradation product, D-dimer levels (1310 +/- 220 vs. 556 +/- 89 ng/ml, p = 0.0001), and leukocyte counts (14.6 +/- 0.7 vs. 10.6 +/- 1.8 x 10(9) cells/L, p < 0.05) than did control patients. Postoperative D-dimer values (p = 0.007) remained higher in the SAH group. Furthermore, admission D-dimer levels were higher in the patients in poor clinical condition than in those in good condition (2017 +/- 377 vs. 934 +/- 208 ng/ml, p = 0.007), and D-dimer levels were associated with the outcome at 3 months after admission. Additionally, thrombin generation and fibrinolytic markers measured on admission were related to clinical grade, amount of subarachnoid blood seen on computerized tomography (CT) scanning, and patient fatality. Patients with hypodense lesions verified on follow-up CT scanning or with persistent neurological deficits at 3 months had higher prothrombin fragments 1 and 2, TAT, D-dimer, and plasminogen activator inhibitor-1 values on the 1st day postoperatively than did patients without such lesions. In short, in patients with SAH, activation of coagulation and fibrinolysis was strongly associated with clinical state, patient fatality, and outcome at 3 months, and postoperatively this activation correlated with the development of brain infarction.
Collapse
Affiliation(s)
- S Peltonen
- Wihuri Research Institute and Department of Neurosurgery, Helsinki University Central Hospital, Finland
| | | | | | | |
Collapse
|