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Lee CY, Jang KM, Wui SH, Park SW. The Benefits and Feasibility of External Lumbar Cerebrospinal Fluid Drainage for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis and Trial Sequential Analysis. World Neurosurg 2022; 167:e549-e560. [PMID: 35977676 DOI: 10.1016/j.wneu.2022.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral vasospasm after aneurysmal subarachnoid hemorrhage is a main cause contributing to poor outcomes. Removal of blood from the subarachnoid may decrease development of cerebral vasospasm. The purpose of this study is to determine the effect of lumbar cerebrospinal fluid (CSF) drainage on cerebral vasospasm and related complications through meta-analysis and trial sequential analysis (TSA). METHODS A systematic search of the literature was performed. Case-control studies of the effects of external lumbar drainage in patients with subarachnoid hemorrhage were included. The association between lumbar drain and vasospasm, cerebral infarction, subsequent treatment, and mortality were evaluated. RESULTS Eleven of 122 articles were included in the meta-analysis. Lumbar CSF drainage reduces occurrence of vasospasm and related complications. In meta-analysis, the pooled odds ratio for symptomatic vasospasm, cerebral infarct, endovascular treatment for vasospasm, and mortality was 0.40 (95% confidence interval [CI], 0.31-0.51; P = 0.00001), 0.47 (95% CI, 0.35-0.62; P < 0.0001), 0.29 (95% CI, 0.18-0.46; P < 0.0001), and 0.41, (95% CI, 0.23-0.74; P = 0.003), respectively, compared with the non-lumbar drainage group. In TSA, the cumulative Z line crossed α-spending boundaries and reached the required sample size in analysis of symptomatic vasospasm and endovascular treatment for vasospasm. CONCLUSIONS Lumbar CSF drainage can decrease symptomatic vasospasm, cerebral infarction, subsequent endovascular treatment, and mortality. Through TSA, the accuracy and reliability of the effect of lumbar CSF drainage-related cerebral vasospasm and endovascular treatment are increased. Further studies of the association between lumbar drain and cerebral infarction and mortality are required to confirm the generalization of the results.
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Affiliation(s)
- Cheol Young Lee
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea.
| | - Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seong Hyun Wui
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
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NAGAI A, SUZUKI Y, ISHIDA T, SATO Y, INOUE T, TOMINAGA T. Marked Reduction of Cerebral Vasospasm with Intrathecal Urokinase Infusion Therapy after Endovascular Coil Embolization of the Aneurysmal Subarachnoid Hemorrhage: A Case Series. Neurol Med Chir (Tokyo) 2022; 62:566-574. [PMID: 36223948 PMCID: PMC9831621 DOI: 10.2176/jns-nmc.2022-0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Delayed cerebral vasospasms after subarachnoid hemorrhage (SAH) are a risk factor for poor prognosis after successful treatment of ruptured intracranial aneurysms. Different strategies to remove clots from the subarachnoid space and prevent vasospasms have different outcomes. Intrathecal urokinase infusion therapy combined with endovascular treatment (EVT) can reduce the incidence of symptomatic vasospasms. To analyze the relationship between symptomatic vasospasms and residual SAHs after urokinase infusion therapy, we retrospectively reviewed the records of 348 consecutive patients managed with EVT and intrathecal urokinase infusion therapy for aneurysmal SAH at our institution between 2010 and 2021. Among them, 163 patients met the study criteria and were classified into two groups according to the presence of residual SAH in the cisterns, Sylvian fissures, and frontal interhemispheric fissure. The incidence of symptomatic vasospasms and the clinical outcomes were assessed. In total, eight (5.0%) patients developed symptomatic vasospasms. Patients with symptomatic vasospasms had a significantly higher incidence of residual SAH in the Sylvian or frontal interhemispheric fissures than those without (P <.0001). No patient with SAHs resolved by urokinase infusion therapy developed symptomatic vasospasms. However, the two groups did not differ significantly in terms of modified Rankin scale scores at discharge. Treatment with intrathecal urokinase infusion after EVT for aneurysmal SAH can substantially reduce the risk of clinically evident vasospasms.
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Affiliation(s)
- Arata NAGAI
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Yasuhiro SUZUKI
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Tomohisa ISHIDA
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Yoshimichi SATO
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tomoo INOUE
- Department of Neurosurgery, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Safety and effectiveness of lumbar cerebrospinal fluid drainage to prevent delayed cerebral ischemia after Fisher grade 3 subarachnoid hemorrhage with minimal intraventricular hemorrhage. Neurochirurgie 2020; 66:225-231. [DOI: 10.1016/j.neuchi.2020.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/22/2020] [Accepted: 03/07/2020] [Indexed: 01/29/2023]
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Lu X, Ji C, Wu J, You W, Wang W, Wang Z, Chen G. Intrathecal Fibrinolysis for Aneurysmal Subarachnoid Hemorrhage: Evidence From Randomized Controlled Trials and Cohort Studies. Front Neurol 2019; 10:885. [PMID: 31481923 PMCID: PMC6709660 DOI: 10.3389/fneur.2019.00885] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/30/2019] [Indexed: 01/09/2023] Open
Abstract
Background: The role of intrathecal fibrinolysis for the treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH) has been widely investigated; however, the results have been contradictory. In our study, we conducted a meta-analysis to evaluate the safety and efficacy of intrathecal (intracisternal or intraventricular) fibrinolysis for aSAH. Methods: PubMed, Web of Science, Embase, Medline, and the Cochrane library databases were searched up to February 1, 2019. The outcomes analyzed were neurologic recovery, delayed ischemic neurologic deficit (DIND), mortality, and the incidence of chronic hydrocephalus and hemorrhage. Results: A total of 21 studies comprising 1,373 patients were analyzed, including nine randomized controlled trials (RCTs) and 12 non-RCTs. The results showed that intracisternal fibrinolysis significantly decreased poor neurologic outcomes (RR = 0.62, 95% CI = 0.50–0.76, P < 0.001) and reduced the incidence of DIND (RR = 0.52, 95% CI = 0.41–0.65, P <0.001), chronic hydrocephalus (RR = 0.59, 95% CI = 0.42–0.82, P = 0.002) and mortality (RR = 0.58, 95% CI = 0.37, 0.93, P = 0.02). There was no significant difference in the occurrence of hemorrhage. Moreover, the results of the Egger test and Begg's funnel plot showed no evidence of publication bias. Conclusions: Current evidence suggests that intracisternal fibrinolysis has beneficial effects on the clinical outcomes of patients with aSAH. However, further well-designed randomized trials are needed to confirm the efficacy and safety of intracisternal fibrinolysis for the treatment of aSAH.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chengyuan Ji
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiang Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wanchun You
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
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De Tommasi A, De Tommasi C, Lauta E, Luzzi S, Cimmino A, Ciappetta P. Pre-Operative Subarachnoid Haemorrhage in a Patient With Spinal Tumour. Cephalalgia 2016; 26:887-90. [PMID: 16776708 DOI: 10.1111/j.1468-2982.2006.01122.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A De Tommasi
- Chair of Neurosurgery, University of Bari, Bari, Italy.
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Qian C, Yu X, Chen J, Gu C, Wang L, Chen G, Dai Y. Effect of the drainage of cerebrospinal fluid in patients with aneurismal subarachnoid hemorrhage: A meta-analysis. Medicine (Baltimore) 2016; 95:e5140. [PMID: 27741143 PMCID: PMC5072970 DOI: 10.1097/md.0000000000005140] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vasospasm-related injury such as delayed ischemic neurological defect (DIND) or cerebral infarction is an important prognostic factor for aneurismal subarachnoid hemorrhage (SAH). Whether cerebrospinal fluid (CSF) drainage can achieve a better outcome in aneurismal SAH patients after coiling or clipping remains the subject of debate. Here, we report a meta-analysis of the related available literature to assess the effect of continuous CSF drainage on clinical outcomes in patients with aneurismal SAH. METHODS Case-control studies regarding the association between aneurismal SAH and CSF drainage were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized. RESULTS This meta-analysis included 11 studies. Continuous CSF drainage obviously improved patients' long-term outcome (odds ratio [OR] of 2.86, 95% confidence interval [CI], 1.37-5.98, P < 0.01). CSF drainage also reduced angiographic vasospasm (OR of 0.35, 95% CI, 0.23-0.51, P < 0.01), symptomatic vasospasm (OR of 0.32, 95% CI, 0.32-0.43, P < 0.01), and DIND (OR of 0.48, 95% CI, 0.25-0.91, P = 0.03), but there was no significant difference between the CSF drainage group and the no CSF drainage group on shunt-dependent hydrocephalus (SDHC) prevention (OR of 1.04, 95% CI, 0.52-2.07, P = 0.91). Further analysis on lumbar drainage (LD) and external ventricular drainage (EVD) indicated that LD had a better outcome (OR of 3.11, 95% CI, 1.18-8.23, P = 0.02), whereas no significant difference in vasospasm-related injury was detected between the groups (OR of 1.13, 95% CI, 0.54-2.37, P = 0.75). CONCLUSION Continuous CSF drainage is an effective treatment for aneurismal SAH patients; lumbar drainage showed lower complications, but more well-designed studies are required to verify and consolidate this conclusion.
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Affiliation(s)
- Cong Qian
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Xiaobo Yu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Jingyin Chen
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Chi Gu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Lin Wang
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Gao Chen
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Correspondence: Gao Chen, Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China (e-mail: ); Yuying Dai, Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China (e-mail: )
| | - Yuying Dai
- Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China
- Correspondence: Gao Chen, Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China (e-mail: ); Yuying Dai, Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China (e-mail: )
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Inoue M, Sasaki T, Takazawa H, Morita T, Narisawa A, Saito A, Midorikawa H, Nishijima M. Symptomatic vasospasm in elderly patients with aneurysmal subarachnoid hemorrhage: comparison with nonelderly patients. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012; 115:281-4. [PMID: 22890682 DOI: 10.1007/978-3-7091-1192-5_50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To clarify the influence of age on the occurrence of symptomatic vasospasm (SVS), we retrospectively compared 34 elderly (over 70 years) and 71 nonelderly patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS Between 2008 and 2010, at our hospital 105 patients (Hunt and Kosnik grades I-IV) underwent aneurysm surgery within 72 h of the insult. They were divided into four groups based on their age (younger/older than 70 years) and treatment (aneurysmal clipping or coiling). In all patients, we used the same protocol, which included the delivery of intrathecal urokinase and intravenous fasudil chloride; in patients with angiographic evidence of vasospasm, we also injected fasudil chloride intra-arterially. RESULTS Among the elderly patients, 4.3% of those treated by clipping and 9.1% of those treated by coiling experienced SVS; the comparative incidence in younger patients was 6.5% and 4.0%, respectively. The differences were not statistically significant (p = 0.40). The ratio of ventriculo peritoneal (VP) shunts was higher in the elderly patients (p = 0.00007). The incidence of favorable treatment outcomes was significantly lower in elderly patients (p = 0.00004). CONCLUSION Under our treatment protocol, patient age did not affect the incidence of SVS. Our protocol may be effective for the prevention of SVS after aneurysmal SAH regardless of patient age.
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Affiliation(s)
- Mizuho Inoue
- Department of Neurosurgery, Aomori Prefectural Central Hospital, Aomori, Japan
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8
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The influence of cisternal and ventricular lavage on cerebral vasospasm in patients suffering from subarachnoid hemorrhage: analysis of effectiveness. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011. [PMID: 21125452 DOI: 10.1007/978-3-7091-0356-2_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
OBJECTIVE within the last decades several clinical trials were performed to analyze the effectiveness of cisternal and ventricular lavage on cerebral vasospasm in patients suffering from subarachnoid hemorrhage. Aim of the present analysis was to review and summarize all documented clinical studies using cisternal or ventricular lavage to prevent vasospasm. METHODS the MEDLINE Web site ( www.pub.med.com ) was searched using the clinical query function optimized for clinical therapy. Search terms were subarachnoid hemorrhage, vasospasm, cisternal and ventricular lavage. Results were divided into cisternal and ventricular lavage therapies alone and its combination with additional treatment modalities. RESULTS so far the literature search revealed a total of nine clinical trials using cisternal or ventricular lavage alone in patients suffering from subarachnoid hemorrhage. The patients were treated using urokinase or recombinant tissue plasminogen activator. A metaanalysis, investigating a total of 652 included patients revealed a significant reduction of delayed neurological deficits, a significant increase of outcome and a significant decrease of mortality in the treatment group. Additional there was no difference of effectiveness or side effects using urokinase or recombinant tissue plasminogen activator. Hence, only one of these studies was based on a prospective, randomized study design. A combination of cisternal or ventricular lavage with some sort of kinetic treatment was documented in a total of three studies. All of them were designed prospectively. The combined application demonstrated reduced delayed neurological deficits, reduced vasospasm and better outcome in two studies for the treatment group. One study was stopped early due to unexpected complication. CONCLUSIONS In conclusion, there is strong evidence that cisternal or ventricular lavage alone and in combination with kinetic therapy lead to a reduction of cerebral vasospasm and better outcome in patients suffering from subarachnoid hemorrhage. As a consequence a prospective randomized study would be of great interest.
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Efficacy of Low-Dose Tissue-Plasminogen Activator Intracisternal Administration for the Prevention of Cerebral Vasospasm After Subarachnoid Hemorrhage. World Neurosurg 2010; 73:675-82. [DOI: 10.1016/j.wneu.2010.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 04/05/2010] [Indexed: 11/23/2022]
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Pluta RM, Butman JA, Schatlo B, Johnson DL, Oldfield EH. Subarachnoid hemorrhage and the distribution of drugs delivered into the cerebrospinal fluid. Laboratory investigation. J Neurosurg 2009; 111:1001-7, 1-4. [PMID: 19374502 DOI: 10.3171/2009.2.jns081256] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Investigators in experimental and clinical studies have used the intrathecal route to deliver drugs to prevent or treat vasospasm. However, a clot near an artery or arteries after subarachnoid hemorrhage (SAH) may hamper distribution and limit the effects of intrathecally delivered compounds. In a primate model of right middle cerebral artery (MCA) SAH, the authors examined the distribution of Isovue-M 300 and 3% Evans blue after infusion into the cisterna magna CSF. METHODS Ten cynomolgus monkeys were assigned to SAH and sham SAH surgery groups (5 in each group). Monkeys received CSF injections as long as 28 days after SAH and were killed 3 hours after the contrast/Evans blue injection. The authors assessed the distribution of contrast material on serial CT within 2 hours after contrast injection and during autopsy within 3 hours after Evans blue staining. RESULTS Computed tomography cisternographies showed no contrast in the vicinity of the right MCA (p < 0.05 compared with left); the distribution of contrast surrounding the entire right cerebral hemisphere was substantially reduced. Postmortem analysis demonstrated much less Evans blue staining of the right hemisphere surface compared with the left. Furthermore, the Evans blue dye did not penetrate into the right sylvian fissure, which occurred surrounding the left MCA. The authors observed the same pattern of changes and differences in contrast distribution between SAH and sham SAH animals and between the right and the left hemispheres on Days 1, 3, 7, 14, 21, and 28 after SAH. CONCLUSIONS Intrathecal drug distribution is substantially limited by SAH. Thus, when using intrathecal drug delivery after SAH, vasoactive drugs are unlikely to reach the arteries that are at the highest risk of delayed cerebral vasospasm.
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Affiliation(s)
- Ryszard M Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
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Yamada K, Yoshimura S, Enomoto Y, Yamakawa H, Iwama T. Effectiveness of combining continuous cerebrospinal drainage and intermittent intrathecal urokinase injection therapy in preventing symptomatic vasospasm following aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2009; 22:649-53. [DOI: 10.1080/02688690802256373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Deshaies EM, Boulos AS, Popp AJ. Peri-operative medical management of cerebral vasospasm. Neurol Res 2009; 31:644-650. [DOI: 10.1179/174313209x382340] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Alaraj A, Charbel FT, Amin-Hanjani S. Peri-operative measures for treatment and prevention of cerebral vasospasm following subarachnoid hemorrhage. Neurol Res 2009; 31:651-9. [PMID: 19133166 DOI: 10.1179/174313209x382395] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high early mortality rates. Cerebral vasospasm remains the major source of morbidity after aSAH. Angiographic evidence of vasospasm is apparent in 70% of patients, while clinical manifestation of vasospasm is present in one third of patients. Early or existing vasospasm at the time of presentation poses an additional challenge in the management of the patient, and forms the basis for this review. METHODS Treatment modalities for management of ruptured aneurysms in the setting of vasospasm, including timing of aneurysm surgery and peri-operative management, are reviewed. Intraoperative measures aimed at treatment of existing vasospasm and at the prevention of vasopasm are discussed. RESULTS Operative/endovascular means to secure the ruptured aneurysm should be performed as soon as possible to facilitate treatment of the vasospasm. Surgery performed in the presence of angiographic/symptomatic vasospasm can be associated with good outcome. Operative measures to decrease the incidence of vasospasm include clot removal, intracisternal injection of thrombolytics, fenestration of the lamina terminalis and local application of vasodilatory agents. Post-operative measures include early intra-arterial injection of vasodilators (verapamil or nicardipine), percutaneous angioplasty, triple-H therapy and CSF drainage. DISCUSSION The utilization of a multimodality approach to treat patients with aneurysmal subarachnoid hemorrhage presenting with existing vasospasm can result in good outcome.
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Affiliation(s)
- Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612-5970, USA
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Hänggi D, Liersch J, Turowski B, Yong M, Steiger HJ. The effect of lumboventricular lavage and simultaneous low-frequency head-motion therapy after severe subarachnoid hemorrhage: results of a single center prospective Phase II trial. J Neurosurg 2008; 108:1192-9. [PMID: 18518727 DOI: 10.3171/jns/2008/108/6/1192] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors of recent publications have suggested that a combination of cisternal irrigation and head-shaking therapy might reduce cerebral vasospasm after subarachnoid hemorrhage (SAH) and therefore improve outcome. The authors undertook this prospective nonrandomized Phase II study to analyze the effect of enhanced washout by lumboventricular irrigation in combination with head motion (lateral rotational therapy) on the clot clearance (CC) rate, development of cerebral vasospasm, and clinical outcome.
Methods
Forty patients with aneurysmal SAHs of World Federation of Neurosurgical Societies Grades II–V (Glasgow Coma Scale Scores 13–3) and Fisher Grade 3 or 4 were included in this study. The study and control groups each consisted of 20 patients. The protocol in the study group, after the aneurysm was secured and a ventricular drain inserted, included the insertion of 2 lumbar catheters for intrathecal irrigation with Ringer solution and intrathecal pressure monitoring. Moderate head rotation in a kinetic system was also applied and was continued for 5 days. The CC rate was monitored on daily computed tomography (CT) scans. Vasospasms were identified clinically with a focus on delayed ischemic neurological deficits (DINDs), daily transcranial Doppler (TCD) ultrasonography studies, and analysis of infarction rate on CT and cerebral angiography. The data obtained in both groups were statistically evaluated.
Results
There were no procedure-related complications. The overall CC rate did not differ significantly between the groups, but there was a trend toward accelerated resolution in the study group. During observation, a new neurological deficit developed in 1 patient (5%) in the study group and 4 patients (20%) in the control group. Ischemic areas on CT scans related to vasospasm were demonstrated in 2 patients (10%) in the study group and 6 patients (30%) in the control group. The incidence of angiographic vasospasm was approximately the same in both groups. The pooled TCD flow velocities measured over a period of 14 days showed lower mean values in the study group than in the control group (p = 0.00002). The clinical outcome in the study group as evaluated with the modified Rankin scale was better in the study group than in the control group after 3 (p = 0.008) and 6 (p = 0.005) months.
Conclusions
The present study demonstrates that a combination of lumboventricular lavage and mechanical head motion reduces vasospasm on TCD ultrasonography, the incidence of DIND, and secondary infarctions on CT and improves clinical outcome. No obvious effect could be found on the rate of angiographic vasospasm.
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Affiliation(s)
| | | | | | - Mei Yong
- 3Institute of Statistics in Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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De Tommasi A, De Tommasi C, Lauta E, Luzzi S, Cimmino A, Ciappetta P. Pre-operative subarachnoid haemorrhage in a patient with spinal tumour. Cephalalgia 2006. [DOI: 10.1111/j.1468-2982.2006.01127.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Proust F, Ter Minassian A, Hans P, Puybasset L, Berré J, Bonafé A, Dufour H, Audibert G, De Kersaint-Gilly A, Boulard G, Beydon L, Ravussin P, Lejeune JP, Gabrillargues J, Bruder N. [Treatment of intracranial hypertension in patients suffering from severe subarachnoid haemorrhage]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:729-33. [PMID: 15967626 DOI: 10.1016/j.annfar.2005.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- F Proust
- Service de neurochirurgie, CHU de Rouen, hôpital Charles-Nicolle, avenue de Germont, 76031 Rouen cedex, France.
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Hanada Y, Kudo H, Kohmura E. Chronologic changes of fasudil hydrochloride and hydroxyfasudil in cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2005; 14:47-9. [PMID: 17903999 DOI: 10.1016/j.jstrokecerebrovasdis.2004.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Revised: 09/30/2004] [Accepted: 10/04/2004] [Indexed: 10/25/2022] Open
Abstract
Fasudil hydrochloride (FH) has been developed as an antivasospasm agent. Its dynamics in cerebrospinal fluid (CSF) and the vasodilating action of hydroxyfasudil (M3) have been obscure, although FH dilates spastic ateries from the inside of the vessel wall. The present study investigated concentrations of FH and M3 in serum and CSF. Dynamic studies of FH and M3 in the CSF of 10 patients with subarachnoid hemorrhage were conducted. FH (30 mg) was injected intravenously for 30 minutes, 3 times a day. Intra-arterial injection using a microcatheter from intracranial portions of the internal carotid artery was added to 3 patients with severe vasospasm. M3 remained in the serum longer than FH. Approximately 20% of the FH and M3 was transferred to CSF and remained there for a long time. The intra-arterial injections significantly increased M3 levels in CSF. These basic data may be helpful in developing future treatments.
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Affiliation(s)
- Yusei Hanada
- Department of Neurosurgery, Rokko Island Hospital, Kobe, Japan
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Andaluz N, Zuccarello M. Fenestration of the Lamina Terminalis as a Valuable Adjunct in Aneurysm Surgery. Neurosurgery 2004; 55:1050-9. [PMID: 15509311 DOI: 10.1227/01.neu.0000140837.63105.78] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2003] [Accepted: 05/06/2004] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE:
Hydrocephalus, vasospasm, and frontobasal injury are common complications after aneurysmal subarachnoid hemorrhage (SAH) from anterior communicating artery aneurysms. Previous studies have suggested that fenestration of the lamina terminalis (FLT) during surgery may be associated with reduced rates of shunt-dependent hydrocephalus and vasospasm. We report 106 patients affected by anterior communicating artery aneurysms and Fisher Grade 3 aneurysmal SAH and the affect of FLT on shunt-dependent hydrocephalus, vasospasm, and frontobasal injury.
METHODS:
During a 3-year period, 53 patients underwent FLT and 53 did not. We prospectively evaluated admission and discharge clinical grades, hydrocephalus at admission, occurrence of clinical vasospasm, need for interventional vasospasm therapy, frontobasal hypodensity incidence, and permanent ventriculoperitoneal shunting requirement. Follow-up ranged from 3 to 35 months (mean, 17.9 mo).
RESULTS:
Shunting incidence after aneurysmal SAH with hydrocephalus was 4.25% in patients who underwent FLT and 13.9% in patients who did not (P< 0.001). Clinical cerebral vasospasm occurred in 29.6% of patients who underwent FLT and in 54.7% of patients who did not (P< 0.001). Frontobasal hypodensity was identified postoperatively in 0% of patients who underwent FLT and in 5% of patients who did not. Good outcome was reported in 69.81% of patients who underwent FLT and in 33.96% of patients who did not (P< 0.001). Poor outcome was associated with higher Hunt and Hess grades, need for ventricular drainage, elevated intracranial pressure, and multiple interventional vasospasm therapies. No complications were linked to FLT.
CONCLUSION:
FLT was associated with statistically significant decreases in shunting rates, incidence of vasospasm, and better outcomes. We recommend its routine use in patients with Fisher Grade 3 anterior communicating artery aneurysmal SAH.
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Affiliation(s)
- Norberto Andaluz
- Neuroscience Institute, Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0515, USA
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Amin-Hanjani S, Ogilvy CS, Barker FG. Does Intracisternal Thrombolysis Prevent Vasospasm after Aneurysmal Subarachnoid Hemorrhage? A Meta-analysis. Neurosurgery 2004; 54:326-34; discussion 334-5. [PMID: 14744278 DOI: 10.1227/01.neu.0000103488.94855.4f] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2003] [Accepted: 10/03/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Despite existing strategies for the treatment of vasospasm after aneurysmal subarachnoid hemorrhage, vasospasm remains a persistent contributor to death and disability. The intracisternal application of thrombolytic agents to dissolve subarachnoid clot has been advocated. The goal of this analysis was to assess the currently available evidence regarding the effectiveness of this treatment.
METHODS
We conducted a systematic review of the published literature; all controlled trials were included. The outcomes of interest were delayed ischemic neurological deficits, poor Glasgow Outcome Scale scores, and death. A formal meta-analysis was performed with a random-effects model.
RESULTS
The search revealed nine trials or trial subgroups (only one of which was randomized), with a total enrollment of 652 patients. Pooled results demonstrated beneficial effects of treatment, with absolute risk reductions of 14.4% (95% confidence interval, 6.5–22.5%; P < 0.001) for delayed ischemic neurological deficits, 9.5% (95% confidence interval, 4.2–14.8%; P < 0.01) for poor Glasgow Outcome Scale scores, and 4.5% (95% confidence interval, 1.5–7.5%; P < 0.05) for death. Regression analysis revealed that treatment effects did not significantly differ among the studies on the basis of the type of thrombolytic agent used (tissue plasminogen activator versus urokinase) or the method of administration (intraoperative versus postoperative) (P > 0.10). Studies that enrolled only patients at high risk for vasospasm seemed to demonstrate greater treatment effects.
CONCLUSION
The meta-analysis suggests a clinically relevant and statistically significant beneficial effect of intracisternal thrombolysis. However, the results of the analysis are limited by the predominance of nonrandomized studies. Further randomized, blinded, placebo-controlled trials of high-risk patients would be justified.
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Affiliation(s)
- Sepideh Amin-Hanjani
- Neurosurgical Service, Massachusetts General Hospital, Harvard Medical School, Fruit Street, Boston, MA 02114, USA
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Arginteanu MS, Byun H, King W. Treatment of a recurrent subdural hematoma using urokinase. J Neurotrauma 1999; 16:1235-9. [PMID: 10619201 DOI: 10.1089/neu.1999.16.1235] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Previous reports describe the intraventricular, subarachnoid, and intraparenchymal use of thrombolytic agents. However, the use of thrombolytic agents in the management of extraaxial hematomas has not been described. Following the evacuation of a subacute subdural hematoma, this 48-year-old woman experienced declining neurologic function due to the reaccumulation of blood in the subdural space. Urokinase was administered via a subdural drain. The patient experienced rapid clinical improvement and radiographic resolution of the recrudescent subdural hematoma. If repeat surgical evacuation of a subdural hematoma is not possible, urokinase may be instilled into the subdural space to enhance drainage of a subdural hematoma.
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Affiliation(s)
- M S Arginteanu
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York, USA.
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21
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Nagashima H, Okudera H, Kobayashi S, Ichinose Y. Ventriculocisternal drainage via endoscopic third ventriculostomy after endovascular embolization for aneurysmal subarachnoid haemorrhage. J Clin Neurosci 1999. [DOI: 10.1016/s0967-5868(99)90081-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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