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Muraoka S, Asai T, Fukui T, Ota S, Shimato S, Koketsu N, Nishizawa T, Araki Y, Saito R. Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study. Neurosurg Rev 2023; 46:195. [PMID: 37555872 DOI: 10.1007/s10143-023-02104-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/10/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.
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Affiliation(s)
- Shinsuke Muraoka
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan.
| | - Takumi Asai
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takahiko Fukui
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shinji Ota
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Shinji Shimato
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Naoki Koketsu
- Department of Neurosurgery, Tosei General Hospital, Seto, Aichi, Japan
| | - Toshihisa Nishizawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Gempeler A, Gaviria L, Ortiz A, Jaramillo N, Beltrán L, Escobar S, Rondón M, Rosselli D, Martinez-Buitrago JE, Mejía-Mantilla JH. Effect of an Albumin Infusion Treatment Protocol on Delayed Cerebral Ischemia and Relevant Outcomes in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:180-190. [PMID: 37231237 DOI: 10.1007/s12028-023-01731-3] [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: 06/30/2022] [Accepted: 04/06/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND An institutional management protocol for patients with subarachnoid hemorrhage (SAH) based on initial cardiac assessment, permissiveness of negative fluid balances, and use of a continuous albumin infusion as the main fluid therapy for the first 5 days of the intensive care unit (ICU) stay was implemented at our hospital in 2014. It aimed at achieving and maintaining euvolemia and hemodynamic stability to prevent ischemic events and complications in the ICU by reducing periods of hypovolemia or hemodynamic instability. This study aimed at assessing the effect of the implemented management protocol on the incidence of delayed cerebral ischemia (DCI), mortality, and other relevant outcomes in patients with SAH during ICU stay. METHODS We conducted a quasi-experimental study with historical controls based on electronic medical records of adults with SAH admitted to the ICU at a tertiary care university hospital in Cali, Colombia. The patients treated between 2011 and 2014 were the control group, and those treated between 2014 and 2018 were the intervention group. We collected baseline clinical characteristics, cointerventions, occurrence of DCI, vital status after 6 months, neurological status after 6 months, hydroelectrolytic imbalances, and other SAH complication. Multivariable and sensitivity analyses that controlled for confounding and considered the presence of competing risks were used to adequately estimate the effects of the management protocol. The study was approved by our institutional ethics review board before study start. RESULTS One hundred eighty-nine patients were included for analysis. The management protocol was associated with a reduced incidence of DCI (hazard ratio 0.52 [95% confidence interval 0.33-0.83] from multivariable subdistribution hazards model) and hyponatremia (relative risk 0.55 [95% confidence interval 0.37-0.80]). The management protocol was not associated with higher hospital or long-term mortality, nor with a higher occurrence of other unfavorable outcomes (pulmonary edema, rebleeding, hydrocephalus, hypernatremia, pneumonia). The intervention group also had lower daily and cumulative administered fluids compared with historic controls (p < 0.0001). CONCLUSIONS A management protocol based on hemodynamically oriented fluid therapy in combination with a continuous albumin infusion as the main fluid during the first 5 days of the ICU stay appears beneficial for patients with SAH because it was associated with reduced incidence of DCI and hyponatremia. Proposed mechanisms include improved hemodynamic stability that allows euvolemia and reduces the risk of ischemia, among others.
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Affiliation(s)
- Andrés Gempeler
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia.
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Cali, Colombia.
| | - Leidy Gaviria
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Alejandra Ortiz
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia
| | | | | | | | - Martín Rondón
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Cali, Colombia
| | - Diego Rosselli
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Cali, Colombia
| | | | - Jorge H Mejía-Mantilla
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia
- Department of Intensive Care Medicine, Fundación Valle del Lili, Cali, Colombia
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Maslonka MA, Sheehan KN, Datar SV, Vachharajani V, Namen A. Pathophysiology and Management of Neurogenic Pulmonary Edema in Patients with Acute Severe Brain Injury. South Med J 2022; 115:784-789. [DOI: 10.14423/smj.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Monov D, Lilyanov N, Bogovsky S, Sirakova K, Nikolakov D. Cerebral vasospasm after subarachnoid hemorrhage from intracranial aneurysm rupture in SARS-CoV-2 positive patients. A retrospective review from two Bulgarian hospitals. BIOTECHNOL BIOTEC EQ 2022. [DOI: 10.1080/13102818.2022.2092421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Dimitar Monov
- Department of Anesthesiology and Intensive Care, St. Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Nikolay Lilyanov
- Department of Anesthesiology and Intensive Care, St. Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Stefan Bogovsky
- Radiology Department, St. Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Kristina Sirakova
- Radiology Department, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Dimitar Nikolakov
- Department of Anesthesiology and Intensive Care, St. Anna University Hospital, Sofia, Bulgaria
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Hemodynamic Monitoring in Patients With Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. J Neurosurg Anesthesiol 2021; 33:285-292. [PMID: 32011413 DOI: 10.1097/ana.0000000000000679] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/29/2019] [Indexed: 11/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) often causes cardiopulmonary dysfunction. Therapeutic strategies can be guided by standard (invasive arterial/central venous pressure measurements, fluid balance assessment), and/or advanced (pulse index continuous cardiac output, pulse dye densitometry, pulmonary artery catheterization) hemodynamic monitoring. We conducted a systematic review and meta-analysis of the literature to determine whether standard compared with advanced hemodynamic monitoring can improve patient management and clinical outcomes after aSAH. A literature search was performed for articles published between January 1, 2000 and January 1, 2019. Studies involving aSAH patients admitted to the intensive care unit and subjected to any type of hemodynamic monitoring were included. A total of 14 studies were selected for the qualitative synthesis and 3 randomized controlled trials, comparing standard versus advanced hemodynamic monitoring, for meta-analysis. The incidence of delayed cerebral ischemia was lower in the advanced compared with standard hemodynamic monitoring group (relative risk [RR]=0.71, 95% confidence interval [CI]=0.52-0.99; P=0.044), but there were no differences in neurological outcome (RR=0.83, 95% CI=0.64-1.06; P=0.14), pulmonary edema onset (RR=0.44, 95% CI=0.05-3.92; P=0.46), or fluid intake (mean difference=-169 mL; 95% CI=-1463 to 1126 mL; P=0.8) between the 2 groups. In summary, this systematic review and meta-analysis found only low-quality evidence to support the use of advanced hemodynamic monitoring in selected aSAH patients. Because of the small number and low quality of studies available for inclusion in the review, further studies are required to investigate the impact of standard and advanced hemodynamic monitoring-guided management on aSAH outcomes.
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Hasegawa Y, Uchikawa H, Kajiwara S, Morioka M. Central sympathetic nerve activation in subarachnoid hemorrhage. J Neurochem 2021; 160:34-50. [PMID: 34525222 DOI: 10.1111/jnc.15511] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 12/12/2022]
Abstract
Subarachnoid hemorrhage (SAH) is a life-threatening condition, and although its two main complications-cerebral vasospasm (CVS)/delayed cerebral ischemia (DCI) and early brain injury (EBI)-have been widely studied, prognosis has not improved over time. The sympathetic nerve (SN) system is important for the regulation of cardiovascular function and is closely associated with cerebral vessels and the regulation of cerebral blood flow and cerebrovascular function; thus, excessive SN activation leads to a rapid breakdown of homeostasis in the brain. In the hyperacute phase, patients with SAH can experience possibly lethal conditions that are thought to be associated with SN activation (catecholamine surge)-related arrhythmia, neurogenic pulmonary edema, and irreversible injury to the hypothalamus and brainstem. Although the role of the SN system in SAH has long been investigated and considerable evidence has been collected, the exact pathophysiology remains undetermined, mainly because the relationships between the SN system and SAH are complicated, and many SN-modulating factors are involved. Thus, research concerning these relationships needs to explore novel findings that correlate with the relevant concepts based on past reliable evidence. Here, we explore the role of the central SN (CSN) system in SAH pathophysiology and provide a comprehensive review of the functional CSN network; brain injury in hyperacute phase involving the CSN system; pathophysiological overlap between the CSN system and the two major SAH complications, CVS/DCI and EBI; CSN-modulating factors; and SAH-related extracerebral organ injury. Further studies are warranted to determine the specific roles of the CSN system in the brain injuries associated with SAH.
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Affiliation(s)
- Yu Hasegawa
- Department of Pharmaceutical Science, School of Pharmacy at Fukuoka, International University of Health and Welfare, Okawa, Fukuoka, Japan.,Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Hiroki Uchikawa
- Department of Neurosurgery, Kumamoto University School of Medicine, Kumamoto, Kumamoto, Japan
| | - Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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Li X, Tuerxun T, Xie Z, Ma L, Wang Y, Liu B, Yu X. Extravascular Lung Water and Intrathoracic Blood Volume Index Are Associated With Liver Function in Brain Dead Donors for Organ Transplant. EXP CLIN TRANSPLANT 2021; 19:450-456. [PMID: 33736588 DOI: 10.6002/ect.2020.0492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Hemodynamic measurements during organ transplant procedures are essential. MATERIALS AND METHODS In this observational study, we measured clinical and hemodynamic parameters in 11 patients with advanced pulse indicator continuous cardiac output monitoring. Normally distributed clinical data were calculated as means ± standard deviation; hemodynamic, metabolic, and respiratory parameters related to liver and renal function were compared by linear regression analysis using Pearson correlation. RESULTS Compared with the normal range, systemic vascular resistance was high (2278.02 ± 719.6 dyne·s/cm²/m²) and intrathoracic blood volume was low (787.37 ± 224.01 mL/m²) in our patient group. C-reactive protein and interleukin 6 levels were 96.26 ± 68.10 mg/mL and 246.24 ± 355.74 mmol/L, respectively. Liver and renal function parameters were in normal ranges. Extravascular lung water was correlated with total, conjugated, and unconjugated bilirubin and albumin (r = 0.342/P = .005; r = 0.338/ P = .005; r = 0.394/P = .001, and r = 0.358/P = .003) but not with aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and serum creatinine. Intrathoracic blood volume index was correlated with total bilirubin, unconjugated bilirubin, and albumin (r = 0.324/P = .007; r = 0.394/P = .001, and r = 0.296/P = .015) but not with conjugated bilirubin, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and serum creatinine. Lactate was not correlated with total bilirubin, unconjugated bilirubin, albumin, and serum creatinine, but base excess was correlated with total bilirubin, unconjugated bilirubin, alanine aminotransferase, and albumin. PO₂ and Pco₂ were not correlated with liver function, although PO₂ was correlated with albumin. CONCLUSIONS No correlations were shown between intrathoracic blood volume index, extravascular lung water, and liver function, but metabolic parameters, including base excess and lactate, were correlated with liver function. Pulse indicator continuous cardiac output monitoring may be a useful method to assess organ function and tissue perfusion in organ transplant.
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Affiliation(s)
- Xiaopeng Li
- From the Department of Neurointensive Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Beijing
| | - Tuerhong Tuerxun
- From the Department of Neurointensive Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Beijing
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9
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Kutty RK, Sivanandapanicker JL, Sreemathyamma SB, Prabhakar RB, Peethambaran A, Libu GK. The Outcome of Aneurysm Clipping in Septuagenarians - A Retrospective Analysis in a Basic Neurovascular Unit. Neurol India 2020; 68:101-107. [PMID: 32129256 DOI: 10.4103/0028-3886.279659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit. Materials and Methods A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3. Results There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes. Conclusion A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Rajmohan B Prabhakar
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Gnanaseelan K Libu
- Department of Community Medicine and Government Medical College, Thiruvananthapuram, Kerala, India
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Zeng M, Li S, Li M, Yan X, Li R, Dong J, Zhang Y, Miao Z, Wang S, Peng Y, Han R. The Perioperative Management of Subarachnoid Hemorrhage During the Coronavirus Disease 2019 Pandemic in China. World Neurosurg 2020; 143:502-506.e1. [PMID: 32777392 PMCID: PMC7413212 DOI: 10.1016/j.wneu.2020.08.007] [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] [Received: 06/22/2020] [Revised: 07/29/2020] [Accepted: 08/01/2020] [Indexed: 01/08/2023]
Abstract
Background For most of the international community outside the epicenter, coronavirus disease 2019 (COVID-19) containment is normalizing, and daily medical practice runs parallel to preventing and treating COVID-19. This experience of simultaneously conducting emergent surgery and infection control for COVID-19 disease is useful outside the epicenter during the pandemic. Case Description In this single-center retrospective observational study, we enrolled patients with subarachnoid hemorrhage (SAH) who were emergently admitted from January 23 to April 8, 2020. Based on the COVID-19 triage, patients with SAH were divided into 3 categories: positive, negative, and under investigation. During 77 days, 90 patients with SAH were admitted at the center. The median age was 55 years (range, 18–80 years) and 40 patients (44.4%) were male. None was positive, 42 patients were negative, and 48 patients were under investigation for COVID-19 before surgery. During the same period, 9 patients were diagnosed with COVID-19 without nosocomial infection. Conclusions Rescuing patients with SAH and containment of COVID-19 benefit from joint prevention and control, a centralized system of equipment distribution and personnel assignment, and quick workflow establishment.
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Affiliation(s)
- Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruowen Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuewei Zhang
- Department of Infection Prevention and Control, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Neuro-intervention, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Bender M, Stein M, Uhl E, Reinges MHT. Serum Cortisol as an Early Biomarker of Cardiopulmonary Parameters Within the First 24 Hours After Aneurysmal Subarachnoid Hemorrhage in Intensive Care Unit Patients. J Intensive Care Med 2019; 35:1173-1179. [PMID: 30913956 DOI: 10.1177/0885066619837910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cardiopulmonary complications/stress are well-known phenomena in patients after aneurysmal subarachnoid hemorrhage (aSAH) and might be associated with an elevated serum troponin I (TNI) level. Since the glucocorticoid hormone cortisol is released during stress situations, the present study was conducted to investigate the influence of serum cortisol (SC) on cardiac and pulmonary parameters in patients after aSAH within the first 24 hours of intensive care unit (ICU) treatment. PATIENTS AND METHODS We retrospectively analyzed a cohort of 104 patients with aSAH admitted to our emergency department between January 2008 and April 2017. Blood samples were taken to determine SC and TNI. Demographics, initial Glasgow Coma Scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) score, and Fisher grade were evaluated retrospectively. Mean norepinephrine application rate (NAR) in µg/kg/min and mean inspiratory oxygen fraction (OF) within the first 24 hours were defined as cardiopulmonary parameters. RESULTS An elevated SC value was found in 44 (42%) patients, and 27 (26%) patients showed an increased TNI value. In patients with initially increased SC value, a significant higher NAR (P = .04) was needed. Furthermore, patients with initially elevated TNI value had a lower GCS score (P = .0013) and a higher WFNS score (P = .003) on admission and required a higher NAR (P = .02) as well as OF (P = .0008) within the first 24 hours of ICU treatment. CONCLUSIONS In the current study, initially elevated SC values were associated with a higher need of NAR within the first 24 hours of ICU treatment after aSAH. Moreover, patients with initially elevated TNI values required an increased NAR and a higher OF so that these biomarkers could be useful to improve ICU treatment.
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Affiliation(s)
- Michael Bender
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - M Stein
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - E Uhl
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - M H T Reinges
- Department of Neurosurgery, Bremen-Mitte Hospital, Bremen, Germany
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Abstract
PURPOSE OF REVIEW The acute care of a patient with severe neurological injury is organized around one relatively straightforward goal: avoid brain ischemia. A coherent strategy for fluid management in these patients has been particularly elusive, and a well considered fluid management strategy is essential for patients with critical neurological illness. RECENT FINDINGS In this review, several gaps in our collective knowledge are summarized, including a rigorous definition of volume status that can be practically measured; an understanding of how electrolyte derangements interact with therapy; a measurable endpoint against which we can titrate our patients' fluid balance; and agreement on the composition of fluid we should give in various clinical contexts. SUMMARY As the possibility grows closer that we can monitor the physiological parameters with direct relevance for neurological outcomes and the various complications associated with neurocritical illness, we may finally move away from static therapy recommendations, and toward individualized, precise therapy. Although we believe therapy should ultimately be individualized rather than standardized, it is clear that the monitoring tools and analytical methods used ought to be standardized to facilitate appropriately powered, prospective clinical outcome trials.
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Bender M, Stein M, Uhl E, Reinges MHT. Troponin I as an Early Biomarker of Cardiopulmonary Parameters Within the First 24 Hours After Nontraumatic Subarachnoid Hemorrhage in Intensive Care Unit Patients. J Intensive Care Med 2019; 35:1368-1373. [PMID: 30621496 DOI: 10.1177/0885066618824568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The elevation of serum cardiac troponin I (TNI) in patients with nontraumatic subarachnoid hemorrhage (ntSAH) is a well-known phenomenon. However, the relation between elevated TNI and different cardiopulmonary parameters (CPs) within the first 24 hours after ntSAH is unknown. The present study was conducted to investigate the association between TNI and different CP in patients with ntSAH within the first 24 hours of intensive care unit (ICU) treatment. PATIENTS AND METHODS We retrospectively analyzed a consecutive group of 117 patients with ntSAH admitted to our emergency department between January 2008 and February 2017. Blood samples were taken to determine TNI values on admission. Demographic data, baseline Glasgow Coma Scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) score, baseline Fisher grade (FG), norepinephrine application rate (NAR) in µg/kg/min, and inspiratory oxygen fraction (OF) were recorded within the first 24 hours. RESULTS An increased TNI value was found in 32 (27.4%) of 117 patients. There was a significant correlation between initial elevated TNI and a low WFNS score (P = .007), a low GCS score (P = .003) as well as a high OF (P = <.001). The FG (P = .27) and NAR (P = .08) within the first 24 hours of ICU treatment did not show any significant correlation. CONCLUSIONS In the present study, an increased TNI value was significantly associated with a low WFNS score and GCS score on admission. The TNI was a predictor of the need for a higher OF within the first 24 hours after ntSAH so that TNI could be an informative biomarker to improve ICU therapy.
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Affiliation(s)
- Michael Bender
- Department of Neurosurgery, 236221Justus-Liebig-University Gießen, Gießen, Germany
| | - Marco Stein
- Department of Neurosurgery, 236221Justus-Liebig-University Gießen, Gießen, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, 236221Justus-Liebig-University Gießen, Gießen, Germany
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Barrow JW, Turan N, Wangmo P, Roy AK, Pradilla G. The role of inflammation and potential use of sex steroids in intracranial aneurysms and subarachnoid hemorrhage. Surg Neurol Int 2018; 9:150. [PMID: 30105144 PMCID: PMC6080146 DOI: 10.4103/sni.sni_88_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/15/2018] [Indexed: 12/11/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) continues to be a devastating neurological condition with a high risk of associated morbidity and mortality. Inflammation has been shown to increase the risk of complications associated with aSAH such as vasospasm and brain injury in animal models and humans. The goal of this review is to discuss the inflammatory mechanisms of aneurysm formation, rupture and vasospasm and explore the role of sex hormones in the inflammatory response to aSAH. Methods A literature review was performed using PubMed using the following search terms: "intracranial aneurysm," "cerebral aneurysm," "dihydroepiandrosterone sulfate" "estrogen," "hormone replacement therapy," "inflammation," "oral contraceptive," "progesterone," "sex steroids," "sex hormones" "subarachnoid hemorrhage," "testosterone." Only studies published in English language were included in the review. Results Studies have shown that administration of sex hormones such as progesterone and estrogen at early stages in the inflammatory cascade can lower the risk and magnitude of subsequent complications. The exact mechanism by which these hormones act on the brain, as well as their role in the inflammatory cascade is not fully understood. Moreover, conflicting results have been published on the effect of hormone replacement therapy in humans. This review will scrutinize the variations in these studies to provide a more detailed understanding of sex hormones as potential therapeutic agents for intracranial aneurysms and aSAH. Conclusion Inflammation may play a role in the pathogenesis of intracranial aneurysm formation and subarachnoid hemorrhage, and administration of sex hormones as anti-inflammatory agents has been associated with improved functional outcome in experimental models. Further studies are needed to determine the therapeutic role of these hormones in the intracranial aneurysms and aSAH.
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Affiliation(s)
- Jack W Barrow
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Mercer University School of Medicine, Savannah, Georgia, USA
| | - Nefize Turan
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pasang Wangmo
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anil K Roy
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Chen F, Lu J, Chen F, Lin Z, Lin Y, Yu L, Su X, Yao P, Cai B, Kang D. Recombinant neuroglobin ameliorates early brain injury after subarachnoid hemorrhage via inhibiting the activation of mitochondria apoptotic pathway. Neurochem Int 2018; 112:219-226. [DOI: 10.1016/j.neuint.2017.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/17/2017] [Accepted: 07/29/2017] [Indexed: 01/17/2023]
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Hall A, O'Kane R. The Extracranial Consequences of Subarachnoid Hemorrhage. World Neurosurg 2017; 109:381-392. [PMID: 29051110 DOI: 10.1016/j.wneu.2017.10.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is managed across the full spectrum of healthcare, from clinical diagnosis to management of the hemorrhage and associated complications. Knowledge of the pathogenesis and pathophysiology of SAH is widely known; however, a full understanding of the underlying molecular, cellular, and circulatory dynamics has still to be achieved. Intracranial complications including delayed ischemic neurologic deficit (vasospasm), rebleed, and hydrocephalus form the targets for initial management. However, the extracranial consequences including hypertension, hyponatremia, and cardiopulmonary abnormalities can frequently arise during the management phase and have shown to directly affect clinical outcome. This review will provide an update on the pathophysiology of SAH, including the intra- and extracranial consequences, with a particular focus on the extracranial consequences of SAH. METHODS We review the literature and provide a comprehensive update on the extracranial consequences of SAH that we hope will help the management of these cohort of patients. RESULTS In addition to the pathophysiology of SAH, the following complications were examined and discussed: vasospasm, seizures, rebleed, hydrocephalus, fever, anemia, hypertension, hypotension, hyperglycemia, hyponatremia, hypernatremia, cardiac abnormalities, pulmonary edema, venous thromboembolism, gastric ulceration, nosocomial infection, bloodstream infection/sepsis, and iatrogenic complications. CONCLUSIONS Although the intracranial complications of SAH can take priority in the initial management, the extracranial complications should be monitored for and recognized as early as possible because these complications can develop at varying times throughout the course of the condition. Therefore, a variety of investigations, as described by this article, should be undertaken on admission to maximize early recognition of any of the extracranial consequences. Furthermore, because the extracranial complications have a direct effect on clinical outcome and can lead to and exacerbate the intracranial complications, monitoring, recognizing, and managing these complications in parallel with the intracranial complications is important and would allow optimization of the patient's management and thus help improve their overall outcome.
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Affiliation(s)
- Allan Hall
- Department of Neurosurgery, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom.
| | - Roddy O'Kane
- Department of Neurosurgery, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Post R, Coert BA, Verbaan D, Vandertop WP. Letter to the Editor: Volume management after subarachnoid hemorrhage. J Neurosurg 2017; 126:1371-1373. [PMID: 28128696 DOI: 10.3171/2016.9.jns162321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- René Post
- Academic Medical Center, Amsterdam, The Netherlands
| | - Bert A Coert
- Academic Medical Center, Amsterdam, The Netherlands
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Abstract
For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.
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Affiliation(s)
- Charles L Francoeur
- Critical Care Division, Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Québec, Canada
| | - Stephan A Mayer
- Department of Neurology (Neurocritical Care), Mount Sinai, New York, NY, USA.
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1522, New York, NY, 10029-6574, USA.
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