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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Vandenbulcke A, Messerer M, Garvayo Navarro M, Peters DR, Starnoni D, Giammattei L, Ben-Hamouda N, Puccinelli F, Saliou G, Cossu G, Daniel RT. Cisternal nicardipine for prevention of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a comparative retrospective cohort study. Acta Neurochir (Wien) 2024; 166:133. [PMID: 38472426 DOI: 10.1007/s00701-024-06023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile. METHODS We performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group). RESULTS Seventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group. CONCLUSION Administration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Marta Garvayo Navarro
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - David R Peters
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Lorenzo Giammattei
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland.
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Caylor MM, Macdonald RL. Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:159-169. [PMID: 37740138 DOI: 10.1007/s12028-023-01847-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/23/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries. METHODS Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan. RESULTS The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad. CONCLUSIONS We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.
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Affiliation(s)
- Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - R Loch Macdonald
- Community Neurosciences Institute, Community Health Partners, 7257 North Fresno Street, Fresno, CA, 93720, USA.
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Connor-Schuler R, Phillips S, Kuo E, Kandiah P, Sadan O. Feasibility and Reliability of Transcranial POCUS Color-Coded Duplex Sonography Performed by Physicians of Varied Ultrasound Experience in Diagnosing Vasospasm in Aneurysmal Subarachnoid Hemorrhage. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:315-322. [PMID: 37902179 DOI: 10.1002/jum.16364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023]
Abstract
PURPOSE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality, which is largely attributable to secondary complications such as vasospasm and subsequent delayed cerebral ischemia. Transcranial Doppler (TCD) is recommended for the screening of vasospasm; however, technicians are not always available. We aimed to see how feasible and reliable bedside transcranial point-of-care ultrasound (POCUS) color-coded duplex sonography was compared with formal non-imaging TCD in measuring velocities and in diagnosing vasospasm. METHODS This was a prospective observational study that took place in the neuroscience intensive care unit at a single academic medical center. Patients with aSAH who were undergoing formal TCDs were scanned on days 2-10 of their admission by physicians of ranging ultrasound experience. Absolute velocities were compared as well as the diagnosis of vasospasm via POCUS and formal TCDs. RESULTS A total of 226 bedside ultrasound exams were performed and compared with 126 formal TCD studies. Sonographic windows were obtained in 89.4% of patients. Scans took 6.6 minutes to complete on average by the advanced group versus 14.5 minutes in the beginner. Correlation ranged from .52 in the beginner group to .65 in the advanced. When good quality of images obtained at a depth of 4-5 cm were reviewed, correlation of mean velocities increased to .96. Overall sensitivity for diagnosing vasospasm was 75%, with a specificity of 99% and negative predictive value of 99%. CONCLUSION Overall, POCUS TCD cannot replace a formal study performed by expert sonographers. An abbreviated POCUS scan can be performed quickly, however, particularly with more experienced operators. POCUS TCD can also feasibly detect vasospasm, and accurate velocities can be obtained by those with all levels of ultrasound experience. Care must be taken on image interpretation that velocities are obtained at an appropriate depth to ensure appropriate insonation of the MCA as well as in optimal alignment with the vessel to obtain the most accurate velocities.
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Affiliation(s)
- Randi Connor-Schuler
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Steven Phillips
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Emory Kuo
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Prem Kandiah
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
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Umekawa M, Yoshikawa G. Impact of ventriculo-cisternal irrigation on prevention of delayed cerebral infarction in aneurysmal subarachnoid hemorrhage: a single-center retrospective study and literature review. Neurosurg Rev 2023; 47:6. [PMID: 38062206 PMCID: PMC10703947 DOI: 10.1007/s10143-023-02241-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/17/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness of ventriculo-cisternal irrigation (VCI) in preventing vasospasms and delayed cerebral infarction (DCI) by washing out subarachnoid clots earlier after aneurysm surgery. METHODS We retrospectively identified 340 subarachnoid hemorrhage (SAH) patients with ruptured intracranial aneurysms treated with postoperative VCI at our institution between December 2010 and January 2020. As VCI therapy, a ventricular drain/cisternal drain was placed during aneurysm surgery, and lactated Ringer's solution was used for irrigation until day 4 of SAH, followed by intracranial pressure control at 5-10 cmH2O until day 14. RESULTS The median age was 65 years (interquartile range 52-75), with 236 female patients (69%). The World Federation of Neurosurgical Societies grade distribution was as follows: grade I or II, 175 patients (51%); grade III or IV, 84 (25%); and grade V, 81 (24%). With VCI management in all patients, total vasospasm occurred in 162 patients (48%), although the DCI incidence was low (23 patients [6.8%]). Major drainage-related complications were observed in five patients (1.5%). Early surgery, performed on SAH day 0 or 1, was identified as a preventive factor against DCI occurrence (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.07-0.67; P = 0.008), while additional surgery (4.76, 1.62-13.98; P = 0.005) and dyslipidemia (3.27, 1.24-8.63; P = 0.017) were associated with DCI occurrence. CONCLUSION Managing vasospasms with VCI after SAH is considered a safe and effective method to prevent DCI. Early surgery after SAH may be associated with a decreased risk of DCI with VCI therapy.
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Affiliation(s)
- Motoyuki Umekawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, 187-8510, Japan.
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Gakushi Yoshikawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, 187-8510, Japan
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Vandenbulcke A, Messerer M, Daniel RT, Cossu G. The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review. Brain Sci 2023; 13:1580. [PMID: 38002540 PMCID: PMC10670052 DOI: 10.3390/brainsci13111580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, 1015 Lausanne, Switzerland
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Sadan O, Jeong YS, Cohen-Sadan S, Sathialingam E, Buckley EM, Kandiah PA, Grossberg JA, Asbury W, Jusko WJ, Samuels OB. Cerebrospinal Fluid Pharmacokinetics of Nicardipine Following Intrathecal Administration in Subarachnoid Hemorrhage Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.17.23297116. [PMID: 37905152 PMCID: PMC10614995 DOI: 10.1101/2023.10.17.23297116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are common complications following SAH and contribute significantly to the poor outcomes observed in these patients. Intrathecal (IT) nicardipine delivered via an existing external ventricular drain has been shown to be correlated with reduced DCI and improved patient outcomes. The current study aims to characterize population pharmacokinetic (popPK) properties of intermittent IT nicardipine. Following informed consent, serial cerebrospinal fluid (CSF) samples were obtained from 16 SAH patients (50.4 ± 9.3 years old; 12 females) treated with IT nicardipine every 6 hours (n=8) or every 8 hours (n=8), which were subject to high-performance liquid chromatography for measurement of its CSF concentration. Our popPK analysis showed that the CSF PK of IT nicardipine in the cohort was adequately described by a two-compartment model with a lag time, with reliable parameter estimates (relative standard error < 50%). The intracranial pressure influenced both the total clearance and the central volume. Calculated PK parameters were similar between q6h and q8h dosing regimens. Despite a small cohort of SAH patients, we successfully developed a popPK model to describe the nicardipine disposition kinetics in the CSF following IT administration. These findings may help inform future clinical trials designed to examine the optimal dosing of IT nicardipine.
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Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Yoo-Seong Jeong
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York, 14214, USA
| | - Shany Cohen-Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Prem A Kandiah
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | | | - William Asbury
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - William J Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York, 14214, USA
| | - Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
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8
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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Urner TM, Cowdrick KR, Brothers RO, Boodooram T, Zhao H, Goyal V, Sathialingam E, Quadri A, Turrentine K, Akbar MM, Triplett SE, Bai S, Buckley EM. Normative cerebral microvascular blood flow waveform morphology assessed with diffuse correlation spectroscopy. BIOMEDICAL OPTICS EXPRESS 2023; 14:3635-3653. [PMID: 37497521 PMCID: PMC10368026 DOI: 10.1364/boe.489760] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/05/2023] [Accepted: 05/20/2023] [Indexed: 07/28/2023]
Abstract
Microvascular cerebral blood flow exhibits pulsatility at the cardiac frequency that carries valuable information about cerebrovascular health. This study used diffuse correlation spectroscopy to quantify normative features of these waveforms in a cohort of thirty healthy adults. We demonstrate they are sensitive to changes in vascular tone, as indicated by pronounced morphological changes with hypercapnia. Further, we observe significant sex-based differences in waveform morphology, with females exhibiting higher flow, greater area-under-the-curve, and lower pulsatility. Finally, we quantify normative values for cerebral critical closing pressure, i.e., the minimum pressure required to maintain flow in a given vascular region.
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Affiliation(s)
- Tara M Urner
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Kyle R Cowdrick
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Rowan O Brothers
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Tisha Boodooram
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Hongting Zhao
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Vidisha Goyal
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Ayesha Quadri
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Katherine Turrentine
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Mariam M Akbar
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Sydney E Triplett
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
| | - Shasha Bai
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA 30322, USA
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA 30322, USA
- Children's Research Scholar, Children's Healthcare of Atlanta, 2015 Uppergate Dr., Atlanta, GA 30322, USA
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Petersen NH, Sheth KN, Jha RM. Precision Medicine in Neurocritical Care for Cerebrovascular Disease Cases. Stroke 2023; 54:1392-1402. [PMID: 36789774 PMCID: PMC10348371 DOI: 10.1161/strokeaha.122.036402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 12/22/2022] [Indexed: 02/16/2023]
Abstract
Scientific advances have informed many aspects of acute stroke care but have also highlighted the complexity and heterogeneity of cerebrovascular diseases. While practice guidelines are essential in supporting the clinical decision-making process, they may not capture the nuances of individual cases. Personalized stroke care in ICU has traditionally relied on integrating clinical examinations, neuroimaging studies, and physiologic monitoring to develop a treatment plan tailored to the individual patient. However, to realize the potential of precision medicine in stroke, we need advances and evidence in several critical areas, including data capture, clinical phenotyping, serum biomarker development, neuromonitoring, and physiology-based treatment targets. Mathematical tools are being developed to analyze the multitude of data and provide clinicians with real-time information and personalized treatment targets for the critical care management of patients with cerebrovascular diseases. This review summarizes research advances in these areas and outlines principles for translating precision medicine into clinical practice.
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Affiliation(s)
- Nils H Petersen
- Departments of Neurology (N.H.P., K.N.S., R.M.J.), Yale University School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Departments of Neurology (N.H.P., K.N.S., R.M.J.), Yale University School of Medicine, New Haven, CT
- Neurosurgery (K.N.S., R.M.J.), Yale University School of Medicine, New Haven, CT
- Departments of Neurology, Neurosurgery and Translational Neuroscience, Barrow Neurological Institute, Phoenix, AZ (K.N.S., R.M.J.)
| | - Ruchira M Jha
- Departments of Neurology (N.H.P., K.N.S., R.M.J.), Yale University School of Medicine, New Haven, CT
- Neurosurgery (K.N.S., R.M.J.), Yale University School of Medicine, New Haven, CT
- Departments of Neurology, Neurosurgery and Translational Neuroscience, Barrow Neurological Institute, Phoenix, AZ (K.N.S., R.M.J.)
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Sathialingam E, Cowdrick KR, Liew AY, Fang Z, Lee SY, McCracken CE, Akbik F, Samuels OB, Kandiah P, Sadan O, Buckley EM. Microvascular cerebral blood flow response to intrathecal nicardipine is associated with delayed cerebral ischemia. Front Neurol 2023; 14:1052232. [PMID: 37006474 PMCID: PMC10064128 DOI: 10.3389/fneur.2023.1052232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 03/19/2023] Open
Abstract
One of the common complications of non-traumatic subarachnoid hemorrhage (SAH) is delayed cerebral ischemia (DCI). Intrathecal (IT) administration of nicardipine, a calcium channel blocker (CCB), upon detection of large-artery cerebral vasospasm holds promise as a treatment that reduces the incidence of DCI. In this observational study, we prospectively employed a non-invasive optical modality called diffuse correlation spectroscopy (DCS) to quantify the acute microvascular cerebral blood flow (CBF) response to IT nicardipine (up to 90 min) in 20 patients with medium-high grade non-traumatic SAH. On average, CBF increased significantly with time post-administration. However, the CBF response was heterogeneous across subjects. A latent class mixture model was able to classify 19 out of 20 patients into two distinct classes of CBF response: patients in Class 1 (n = 6) showed no significant change in CBF, while patients in Class 2 (n = 13) showed a pronounced increase in CBF in response to nicardipine. The incidence of DCI was 5 out of 6 in Class 1 and 1 out of 13 in Class 2 (p < 0.001). These results suggest that the acute (<90 min) DCS-measured CBF response to IT nicardipine is associated with intermediate-term (up to 3 weeks) development of DCI.
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Affiliation(s)
- Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Kyle R. Cowdrick
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Amanda Y. Liew
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Zhou Fang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Seung Yup Lee
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Electrical and Computer Engineering, Kennesaw State University, Marietta, GA, United States
| | - Courtney E. McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States
| | - Feras Akbik
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Owen B. Samuels
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Prem Kandiah
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Erin M. Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, United States
- Children's Research Scholar, Children's Healthcare of Atlanta, Atlanta, GA, United States
- *Correspondence: Erin M. Buckley
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12
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Akbik F, Konan HD, Williams KP, Ermias LM, Shi Y, Takieddin O, Grossberg JA, Howard BM, Tong F, Cawley CM, Mei Y, Samuels OB, Sadan O. Cannabis Use Is Not Associated With Aneurysmal Subarachnoid Hemorrhage Complications or Outcomes. Stroke 2022; 53:e375-e376. [PMID: 35730458 DOI: 10.1161/strokeaha.122.038951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA. (F.A., O.T., O.S.)
| | | | | | | | - Yuyang Shi
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta (Y.S., Y.M.)
| | - Obai Takieddin
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA. (F.A., O.T., O.S.)
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Frank Tong
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Yajun Mei
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta (Y.S., Y.M.)
| | - Owen B Samuels
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA. (F.A., O.T., O.S.)
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13
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Sadan O, Akbik F. Treating Delayed Cerebral Ischemia: Should We Focus on Blood Pressure or Vasodilatation? Stroke 2022; 53:2617-2619. [DOI: 10.1161/strokeaha.122.039800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Feras Akbik
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA
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14
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Göttsche J, Piffko A, Pantel TF, Westphal M, Dührsen L, Czorlich P, Sauvigny T. Aneurysm Location Affects Clinical Course and Mortality in Patients With Subarachnoid Hemorrhage. Front Neurol 2022; 13:846066. [PMID: 35359650 PMCID: PMC8964037 DOI: 10.3389/fneur.2022.846066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The influence of preexisting factors on the clinical course of patients with subarachnoid hemorrhage (SAH), such as patient age, arterial hypertension, and aneurysm characteristics, is still a matter of debate. However, the specific impact of the exact aneurysm location has not received adequate attention. Therefore, the aim of this study was to investigate the influence of aneurysm location as a preexisting factor on the clinical course and mortality. Methods The data of consecutive patients with aneurysmal SAH who were treated from October 2010 to July 2020 were retrospectively analyzed. We distinguished four aneurysm locations: the anterior complex, internal carotid artery (ICA), middle cerebral artery (MCA), and posterior circulation. Logistic regression analysis and receiver operating characteristics were used to investigate the influence of aneurysm location on the occurrence of acute hydrocephalus, Delayed Cerebral Ischemia (DCI), neurological outcome, and in-hospital mortality. Neurological outcome was assessed 3 months after discharge using the Glasgow Outcome Scale. Results A total of 603 patients were included in this study. Patients with MCA aneurysms were 2.52 times less likely to develop acute hydrocephalus compared to patients with anterior complex aneurysms (p = 0.001). Delayed cerebral ischemia occurred most frequently in patients with an anterior complex aneurysm and least frequently in MCA aneurysms (p = 0.014). In ICA aneurysms, mortality was 2.56-fold higher than in patients with aneurysms of the anterior complex (p = 0.006). An additional ROC analysis showed a good prediction for in-hospital mortality when taking the aneurysm's location into account [AUC.855 (CI.817 −0.893)]. Conclusions The aneurysm's location proved to be a significant predictor of acute hydrocephalus, DCI, and in-hospital mortality, demonstrating the impact of this preexisting biological factor on the course of SAH.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Grossen AA, Ernst GL, Bauer AM. Update on intrathecal management of cerebral vasospasm: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E10. [PMID: 35231885 DOI: 10.3171/2021.12.focus21629] [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: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) accounts for a relatively small portion of strokes but has the potential to cause permanent neurological deficits. Vasospasm with delayed ischemic neurological deficit is thought to be responsible for much of the morbidity associated with aSAH. This has illuminated some treatment options that have the potential to target specific components of the vasospasm cascade. Intrathecal management via lumbar drain (LD) or external ventricular drain (EVD) offers unique advantages in this patient population. The aim of this review was to provide an update on intrathecal vasospasm treatments, emphasizing the need for larger-scale trials and updated protocols using data-driven evidence. METHODS A search of PubMed, Ovid MEDLINE, and Cochrane databases included the search terms (subarachnoid hemorrhage) AND (vasospasm OR delayed cerebral ischemia) AND (intrathecal OR intraventricular OR lumbar drain OR lumbar catheter) for 2010 to the present. Next, a meta-analysis was performed of select therapeutic regimens. The primary endpoints of analysis were vasospasm, delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome. RESULTS Twenty-nine studies were included in the analysis. There were 10 studies in which CSF drainage was the primary experimental group. Calcium channel antagonists were the focus of 7 studies. Fibrinolytics and other vasodilators were each examined in 6 studies. The meta-analysis included studies examining CSF drainage via LD (n = 4), tissue plasminogen activator in addition to EVD (n = 3), intraventricular nimodipine (n = 2), and cisternal magnesium (n = 2). Results showed that intraventricular nimodipine decreased vasospasm (OR 0.59, 95% CI 0.37-0.94; p = 0.03). Therapies that significantly reduced DCI were CSF drainage via LD (OR 0.47, 95% CI 0.25-0.88; p = 0.02) and cisternal magnesium (OR 0.27, 95% CI 0.07-1.02; p = 0.05). CSF drainage via LD was also found to significantly reduce the incidence of cerebral infarction (OR 0.35, 95% 0.24-0.51; p < 0.001). Lastly, functional outcome was significantly better in patients who received CSF drainage via LD (OR 2.42, 95% CI 1.39-4.21; p = 0.002). CONCLUSIONS The authors' results showed that intrathecal therapy is a safe and feasible option following aSAH. It has been shown to attenuate cerebral vasospasm, reduce the incidence of DCI, and improve clinical outcome. The authors support the use of intrathecal management in the prevention and rescue management of cerebral vasospasm. More randomized controlled trials are warranted to determine the best combination of pharmaceutical agents and administration route in order to formulate a standardized treatment approach.
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16
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Transcranial-Doppler-Measured Vasospasm Severity is Associated with Delayed Cerebral Infarction After Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:815-821. [PMID: 34751900 DOI: 10.1007/s12028-021-01382-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Angiographic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI)-related cerebral infarction (radiological DCI) and worsened neurological outcome. Transcranial Doppler (TCD) measurements of cerebral blood flow velocity are commonly used after aSAH to screen for vasospasm; however, their association with cerebral infarction is not well characterized. We sought to determine whether time-varying TCD-measured vasospasm severity is associated with cerebral infarction and investigate the performance characteristics of different time/severity cutoffs for predicting cerebral infarction. METHODS We conducted a retrospective single-center cohort study of consecutive adult patients with aSAH with at least one TCD study between 2011 and 2020. The primary outcome was radiological DCI, defined as a cerebral infarction developing at least 2 days after any surgical or endovascular intervention without an alternative cause. Cox proportional hazards models were used to examine associations between time-varying vasospasm severity and radiological DCI. Optimal TCD-based time/severity thresholds for predicting radiological DCI were then determined. RESULTS Of 262 patients with aSAH who underwent TCD studies, 27 (10%) developed radiological DCI. Patients with radiological DCI had higher modified Fisher scale scores and trended toward earlier onset of vasospasm. Adjusted for age, Hunt and Hess scores, and modified Fisher scale scores, the worst-vessel vasospasm severity was associated with radiological DCI (adjusted hazard ratio 1.7 [95% confidence interval 1.1-2.4]). Vasospasm severity within a specific vessel was associated with risk of delayed infarction in the territory supplied by that vessel. Optimal discrimination of patients with radiological DCI was achieved with thresholds of mild vasospasm on days 4-5 or moderate vasospasm on days 6-9, with negative predictive values greater than 90% and positive predictive values near 20%. CONCLUSIONS TCD-measured vasospasm severity is associated with radiological DCI after aSAH. An early, mild TCD-based vasospasm severity threshold had a high negative predictive value, supporting its role as a screening tool to identify at-risk patients.
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17
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Akbik F, Waddel H, Jaja BNR, Macdonald RL, Moore R, Samuels OB, Sadan O. Nicardipine Prolonged Release Implants for Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:106020. [PMID: 34365121 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/12/2021] [Accepted: 07/18/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES A paucity of treatments to prevent delayed cerebral ischemia (DCI) has stymied recovery after aneurysmal subarachnoid hemorrhage (aSAH). Nicardipine has long been recognized as a potent cerebrovascular vasodilator with a history off-label use to prevent vasospasm and DCI. Multiple centers have developed nicardipine prolonged release implants (NPRI) that are directly applied during clip ligation to locally deliver nicardipine throughout the vasospasm window. Here we perform a systematic review and meta-analysis to assess whether NPRI confers protection against DCI and improves functional outcomes after aSAH. MATERIALS AND METHODS A systematic search of PubMed, Ovid Embase, and Cochrane databases was performed for studies reporting the use of NPRI after aSAH published after January 1, 1980. We included all studies assessing the association of NPRI with DCI and or functional outcomes. Findings from studies with control arms were analyzed using a random effects model. A separate network meta-analysis was performed, including controlled NPRI studies, single-arm NPRI reports, and the control-arms of modern aSAH randomized clinical trials as additional comparators. RESULTS The search identified 214 unique citations. Three studies with 284 patients met criteria for the random effects model. The pooled summary odds ratio for the association of NPRI and DCI was 0.21 (95% CI 0.09-0.49, p = 0.0002) with no difference in functional outcomes (OR 1.80, 95% CI 0.63 - 5.16, p = 0.28). 10 studies of 866 patients met criteria for the network meta-analysis. The pooled summary odds ratio for the association of NPRI and DCI was 0.30 (95% CI 0.13-0.89,p = 0.017) with a trend towards improved functional outcomes (OR 1.68, 0.63 - 4.13 95% CI, p = 0.101). CONCLUSIONS In these meta-analyses, NPRI decreases the incidence of DCI with a non-significant trend towards improvement in functional outcomes. Randomized trials on the role of intrathecal calcium channel blockers are warranted to evaluate these observations in a prospective manner.
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Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
| | - Hannah Waddel
- Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, GA, USA.
| | | | - R Loch Macdonald
- Department of Neurosurgery, University of California, San Francisco, Fresno, CA, USA.
| | - Renee Moore
- Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, GA, USA.
| | - Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA
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