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Welling LC, Rabelo NN, de Sena Barbosa MG, Cherain LGG, Figueiredo EG. A promising therapeutic approach for cerebral vasospasm in patients with subarachnoid hemorrhage. Clin Neurol Neurosurg 2024; 244:108417. [PMID: 38996801 DOI: 10.1016/j.clineuro.2024.108417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 06/14/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Leonardo C Welling
- Department of Neurosurgery, State University of Ponta Grossa, PR, Brazil.
| | - Nicollas Nunes Rabelo
- Division of Neurosurgery, School of Medicine - University of São Paulo (FMUSP), Hospital das Clínicas / FMUSP, São Paulo, SP, Brazil; Department of Neurosurgery, Atenas University Medical School, Passos, MG, Brazil.
| | | | | | - Eberval Gadelha Figueiredo
- Division of Neurosurgery, School of Medicine - University of São Paulo (FMUSP), Hospital das Clínicas / FMUSP, São Paulo, SP, Brazil.
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2
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Welling LC, Rabelo NN, de Sena Barbosa MG, Messias BR, Pinto CG, Figueiredo EG. Stellate ganglion block: what else is necessary to include in the treatment of subarachnoid hemorrhage patients? Chin Neurosurg J 2024; 10:21. [PMID: 39085877 PMCID: PMC11292912 DOI: 10.1186/s41016-024-00374-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/26/2024] [Indexed: 08/02/2024] Open
Abstract
Cerebral vasospasm is determined as a temporary narrowing of cerebral arteries a few days after an aneurysmal subarachnoid hemorrhage. The onset of this vascular event usually evolves with new neurological deficits or progression of ischemic areas. The success of interventions to treat or revert this condition is not satisfying. In addition to cerebral vasospasm, early brain injury plays an important role as a contributor to subarachnoid hemorrhage's mortality. In this sense, stellate ganglion block appears as an alternative to reduce sympathetic system's activation, one of the main pathophysiological mechanisms involved in brain injury. Over the past few years, there is growing evidence that stellate ganglion block can contribute to decline patient morbidity from subarachnoid hemorrhage. Is it time to include this procedure as a standard treatment after aneurysm rupture?
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Affiliation(s)
- Leonardo C Welling
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Nicollas Nunes Rabelo
- Division of Neurosurgery, School of Medicine, University of São Paulo (FMUSP)/Hospital das Clínicas, Dr. Enéas de Carvalho Aguiar Street, 255, São Paulo, SP, 05403-010, Brazil.
- Department of Neurosurgery, Atenas Medical School, Passos, MG, Brazil.
| | | | | | | | - Eberval Gadelha Figueiredo
- Division of Neurosurgery, School of Medicine, University of São Paulo (FMUSP)/Hospital das Clínicas, Dr. Enéas de Carvalho Aguiar Street, 255, São Paulo, SP, 05403-010, Brazil
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3
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Shamshad A, Persad-Paisley EM, Wendell LC, Thompson BB, Reznik ME, Furie KL, Mahta A. Association of asymptomatic cerebral vasospasm with outcomes in survivors of aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106821. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 11/21/2022] Open
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4
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Khan MM, Shaikh N, Yousaf Z, Sultan H, Sadek G, Khan A, Kamran S, Ahmed AZ, Albanna W, Belkhair S, Ayyad A. Risk Factors for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Tertiary Care Center Experience. Asian J Neurosurg 2022; 17:242-247. [PMID: 36120624 PMCID: PMC9473800 DOI: 10.1055/s-0042-1750838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives
Cerebral vasospasm in subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. There is a lack of consensus on the risk factors leading to cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this retrospective study, our objective was to determine the association of risk factors for cerebral vasospasm aSAH.
Methods
A total of 259 charts of aSAH patients consecutively admitted to the surgical intensive care unit of Hamad General Hospital from January 2007 to December 2016 were reviewed and included. The patient's demographic data, including comorbidities like hypertension (HTN), was recorded. Variables of interest included measurements of the neurological deficit on admission, the severity of SAH, treatment modality, and the initial computerized tomography scan of the head for intraventricular hemorrhage, intracerebral hemorrhage, or hydrocephalus. Multivariate analysis and multiple logistic regression analyzed the relationship to identify the association of independent variables.
Results
Out of the 259 patients, 34% (
n
= 87) suffered from cerebral vasospasm. The severity of SAH was associated with the development of cerebral vasospasm (
p
< 0.05). The presence of HTN and neurological deficits on admission were associated with an increased risk of cerebral vasospasm (
p
< 0.05,
p
< 0.01, respectively). Hydrocephalus requiring treatment using external ventricular drains decreased the risk of cerebral vasospasm (
p
< 0.05). Intraventricular and intracerebral hemorrhage were not associated with cerebral vasospasm (
p
= 0.25,
p
= 0.16). The endovascular treatment of cerebral aneurysms was associated with an increased risk of cerebral vasospasm (
p
< 0.05).
Conclusion
Cerebral vasospasm is common among patients admitted with aSAH. It is significantly associated with the history of HTN, the neurological deficit on admission that corelates more strongly to the motor deficit on admission, the severity of hemorrhage (modified Fischer score), and endovascular treatment. External ventricular drainage was associated with a decrease in cerebral vasospasm. The present study's findings shed light on cerebral vasospasm's risk factors in the country and the region.
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Affiliation(s)
| | - Nissar Shaikh
- Surgical Intensive Care Unit, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Hussain Sultan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - George Sadek
- Weill Cornell Medicine, Education City, Al Luqta St, Ar-Rayyan, Qatar
| | - Adnan Khan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- Weill Cornell Medicine, Education City, Al Luqta St, Ar-Rayyan, Qatar
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Ayman Z. Ahmed
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Sirajeddin Belkhair
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ali Ayyad
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
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5
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Kanjilal S, Mehrotra A, Singh V, Dikshit P, Prasad SN, Kumar Verma P, Das KK, Bhaisora K, Kumar Jaiswal A, Behari S, Kumar R. Non-aneurysmal subarachnoid hemorrhage: Is the deep venous system the hidden culprit? Acta Neurochir (Wien) 2022; 164:1827-1835. [PMID: 35524811 DOI: 10.1007/s00701-022-05222-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/15/2022] [Indexed: 11/01/2022]
Abstract
AIM The exact cause of bleeding in non-aneurysmal sub-arachnoid hemorrhage (SAH) is yet to be established. The present study intends to evaluate the morphological variants of deep cerebral venous drainage, especially basal veins of Rosenthal (BVR), and to correlate if such a venous anomaly is associated with increased incidence of non-aneurysmal SAH. METHODS A prospective analysis of all the patients of age more than 12 years with spontaneous non-aneurysmal SAH and undergone 4-vessel DSA for the diagnosis of the source of bleeding was included in the study (n = 59). The anatomy of the basal venous distribution was evaluated and was divided into 3 different types, namely normal (Type A), normal variant (Type B), and primitive (Type C), based on DSA findings. The follow-up of these cases was noted. The three groups were compared with one another. RESULTS The median age of presentation was 51 years with slight male predominance (52%). Primitive venous drainage was associated with a poorer grade at presentation (p = 0.002), more severe bleed (p = 0.001), vasospasm (p = 0.045), and a poorer outcome at 6 months (p = 0.019). Hydrocephalous and vasospasm were seen in patients with primitive venous drainage. On multivariate regression analysis for poorer outcome, it was observed that a worse grade at presentation, extensive bleed, primitive venous drainage are independent predictors of an adverse outcome. CONCLUSION The presence of primitive venous drainage has a linear relationship with the development of non-aneurysmal SAH with multi-cisternal hemorrhage, worse grade at presentation, and unfavorable outcome.
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6
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Fung C, Heiland DH, Reitmeir R, Niesen WD, Raabe A, Eyding J, Schnell O, Rölz R, Z Graggen WJ, Beck J. Ultrasound Perfusion Imaging for the Detection of Cerebral Hypoperfusion After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:149-159. [PMID: 35211837 PMCID: PMC9283360 DOI: 10.1007/s12028-022-01460-z] [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: 09/17/2021] [Accepted: 01/27/2022] [Indexed: 11/24/2022]
Abstract
Background Delayed cerebral ischemia increases mortality and morbidity after aneurysmal subarachnoid hemorrhage (aSAH). Various techniques are applied to detect cerebral vasospasm and hypoperfusion. Contrast-enhanced ultrasound perfusion imaging (UPI) is able to detect cerebral hypoperfusion in acute ischemic stroke. This prospective study aimed to evaluate the use of UPI to enable detection of cerebral hypoperfusion after aSAH. Methods We prospectively enrolled patients with aSAH and performed UPI examinations every second day after aneurysm closure. Perfusion of the basal ganglia was outlined to normalize the perfusion records of the anterior and posterior middle cerebral artery territory. We applied various models to characterize longitudinal perfusion alterations in patients with delayed ischemic neurologic deficit (DIND) across the cohort and predict DIND by using a multilayer classification model. Results Between August 2013 and December 2015, we included 30 patients into this prospective study. The left–right difference of time to peak (TTP) values showed a significant increase at day 10–12. Patients with DIND demonstrated a significant, 4.86 times increase of the left–right TTP ratio compared with a mean fold change in patients without DIND of 0.9 times (p = 0.032). Conclusions UPI is feasible to enable detection of cerebral tissue hypoperfusion after aSAH, and the left–right difference of TTP values is the most indicative result of this finding.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany. .,Medical Faculty, University of Freiburg, Freiburg, Germany.
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Raluca Reitmeir
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Wolf-Dirk Niesen
- Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jens Eyding
- Department of Neurology, Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke, Herdecke, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Roland Rölz
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Werner J Z Graggen
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.,Medical Faculty, University of Freiburg, Freiburg, Germany
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Lee D, Lee J, Kim KH, Kim JH, Lee J. Diffuse Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage in a 15-Year-Old Girl: A Case Report. FRONTIERS IN RADIOLOGY 2022; 1:774739. [PMID: 37492181 PMCID: PMC10365113 DOI: 10.3389/fradi.2021.774739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/20/2021] [Indexed: 07/27/2023]
Abstract
Diffuse cerebral vasospasm after subarachnoid hemorrhage (SAH) is a complication resulting in an ischemic condition presenting with altered mentality and followed by motor or speech impairment. It is uncommon in pediatric population and requires differential diagnosis from Moyamoya disease, which is relatively common in Korea. We report a case of a 15-year-old girl who was presented with a seizure and subsequent headache, poor oral intake, and altered mentality, who was finally diagnosed with sporadic vasospasm followed by multiple aneurysm ruptures. The patient had recurrent seizures and persistent headache at the time of transfer. On the second day after transfer, she showed focal motor weakness and dysarthria, and her symptoms gradually progressed, showing paraplegia and aphasia on the third hospitalization day. Brain magnetic resonance imaging and magnetic resonance angiography demonstrated diffuse narrowing cerebral vasospasm of bilateral middle cerebral arteries, anterior cerebral arteries, and distal internal carotid arteries and three unruptured aneurysms. The patient was treated with intravenous hydration and nimodipine to expand the narrowed vessels. After confirming that the vessels were enlarged, we successfully executed the endovascular coil embolization. Her neurological deficits were improved through medical, interventional, and rehabilitation treatments and fully restored 11 months after discharge.
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Affiliation(s)
- Dajeong Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jiwon Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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8
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Croci DM, Sivanrupan S, Wanderer S, Agnoletto GJ, Chiappini A, Grüter BE, Andereggen L, Mariani L, Taussky P, Marbacher S. Preclinical and clinical role of interleukin-6 in the development of delayed cerebral vasospasm and neuronal cell death after subarachnoid hemorrhage: towards a potential target therapy? Neurosurg Rev 2021; 45:395-403. [PMID: 34448990 PMCID: PMC8391870 DOI: 10.1007/s10143-021-01628-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 12/28/2022]
Abstract
Delayed cerebral vasospasm (DCVS), early brain injury (EBI), and delayed cerebral ischemia (DCI) are devastating complications after aneurysmal subarachnoid hemorrhage (SAH). Interleukin (IL)-6 seems to be an important interleukin in the inflammatory response after SAH, and many studies describe a strong correlation between IL-6 and worse outcome. The aim of this study was to systematically review preclinical and clinical studies that evaluated systemic and cerebral IL-6 levels after SAH and their relation to DCVS, neuronal cell death, and DCI. We conducted two systematic literature searches using PubMed to identify preclinical and clinical studies evaluating the role of IL-6 after SAH. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 61 and 30 preclinical and clinical articles, respectively, were included in the systematic reviews. Of the preclinical studies in which IL-6 was measured in cerebrospinal fluid (CSF), parenchyma, and systemically, 100%, 94.4%, and 81.3%, respectively, showed increased expression of IL-6 after SAH. Preclinical results were mirrored by clinical findings in which elevated levels of IL-6 in CSF and plasma were found after SAH, correlating with DCVS, DCI, and worse outcome. Only two preclinical studies analyzed the direct inhibition of IL-6, which resulted in reduced DCVS and neuronal cell death. IL-6 is a marker of intracranial inflammation and plays a role in the pathophysiology of DCVS and DCI after SAH in preclinical animal models and clinical studies. Its inhibition might have therapeutic potential to improve the outcome of SAH patients.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA. .,Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland. .,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland.
| | - Sivani Sivanrupan
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Stefan Wanderer
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Guilherme J Agnoletto
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Alessio Chiappini
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Basil E Grüter
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Lukas Andereggen
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Serge Marbacher
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
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9
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Ehlert A, Starekova J, Manthei G, Ehlert-Gamm A, Flack J, Gessert M, Gerss J, Hesselmann V. Nitric Oxide-Based Treatment of Poor-Grade Patients After Severe Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 32:742-754. [PMID: 31418143 PMCID: PMC7272492 DOI: 10.1007/s12028-019-00809-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Patients with aneurysmal subarachnoid hemorrhage (aSAH) require close treatment in neuro intensive care units (NICUs). The treatments available to counteract secondary deterioration and delayed ischemic events remain restricted; moreover, available neuro-monitoring of comatose patients is undependable. In comatose patients, clinical signs are hidden, and timing interventions to prevent the evolution of a perfusion disorder in response to fixed ischemic brain damage remain a challenge for NICU teams. Consequently, comatose patients often suffer secondary brain infarctions. The outcomes for long-term intubated patients w/wo pupil dilatation are the worst, with only 10% surviving. We previously added two nitroxide (NO) donors to the standard treatment: continuous intravenous administration of Molsidomine in patients with mild-to-moderate aSAH and, if required as a supplement, intraventricular boluses of sodium nitroprusside (SNP) in high-risk patients to overcome the so-called NO-sink effect, which leads to vasospasm and perfusion disorders. NO boluses were guided by clinical status and promptly reversed recurrent episodes of delayed ischemic neurological deficit. In this study, we tried to translate this concept, the initiation of intraventricular NO application on top of continuous Molsidomine infusion, from awake to comatose patients who lack neurological–clinical monitoring but are primarily monitored using frequently applied transcranial Doppler (TCD). Methods In this observational, retrospective, nonrandomized feasibility study, 18 consecutive aSAH comatose/intubated patients (Hunt and Hess IV/V with/without pupil dilatation) whose poor clinical status precluded clinical monitoring received standard neuro-intensive care, frequent TCD monitoring, continuous intravenous Molsidomine plus intraventricular SNP boluses after TCD-confirmed macrospasm during the daytime and on a fixed nighttime schedule. Results Very likely associated with the application of SNP, which is a matter of further investigation, vasospasm-related TCD findings promptly and reliably reversed or substantially weakened (p < 0.0001) afterward. Delayed cerebral ischemia (DCI) occurred only during loose, low-dose or interrupted treatment (17% vs. an estimated 65% with secondary infarctions) in 17 responders. However, despite their worse initial condition, 29.4% of the responders survived (expected 10%) and four achieved Glasgow Outcome Scale Extended (GOSE) 8–6, modified Rankin Scale (mRS) 0–1 or National Institutes of Health Stroke Scale (NIHSS) 0–2. Conclusions Even in comatose/intubated patients, TCD-guided dual-compartment administration of NO donors probably could reverse macrospasm and seems to be feasible. The number of DCI was much lower than expected in this specific subgroup, indicating that this treatment possibly provides a positive impact on outcomes. A randomized trial should verify or falsify our results.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany.
| | - Jitka Starekova
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Gerd Manthei
- Department of Neurosurgery, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | | | - Joachim Flack
- Doctor's Office, Breitenfelderstr. 7, 20251, Hamburg, Germany
| | - Marie Gessert
- Department of Neurology, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University Hospital Münster, Schmeddingstr. 56, 48149, Münster, Germany
| | - Volker Hesselmann
- Department of Neuroradiology, Asklepios Hospital Nord, Tangstedter Landstr. 400, 22417, Hamburg, Germany
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10
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Catapano JS, Srinivasan VM, Rumalla K, Labib MA, Nguyen CL, Cole TS, Baranoski JF, Rutledge C, Rahmani R, Lawton MT, Ducruet AF, Albuquerque FC. Length of hospital stay in aneurysmal subarachnoid hemorrhage patients without vasospasm on angiography: potential for a fast-track discharge cohort. J Neurointerv Surg 2021; 14:376-379. [PMID: 34078646 DOI: 10.1136/neurintsurg-2021-017424] [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] [Received: 02/11/2021] [Accepted: 05/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with aneurysmal subarachnoid hemorrhage (aSAH) frequently suffer from vasospasm. We analyzed the association between absence of early angiographic vasospasm and early discharge. METHODS All aSAH patients treated from August 1, 2007, to July 31, 2019, at a single tertiary center were reviewed. Patients undergoing diagnostic digital subtraction angiography (DSA) on post-aSAH days 5 to 7 were analyzed; cohorts with and without angiographic vasospasm (angiographic reports by attending neurovascular surgeons) were compared. Primary outcome was hospital length of stay; secondary outcomes were intensive care unit length of stay, 30 day return to the emergency department (ED), and poor neurologic outcome, defined as a modified Rankin Scale (mRS) score >2. RESULTS A total of 298 patients underwent DSA on post-aSAH day 5, 6, or 7. Most patients (n=188, 63%) had angiographic vasospasm; 110 patients (37%) did not. Patients without vasospasm had a significantly lower mean length of hospital stay than vasospasm patients (18.0±7.1 days vs 22.4±8.6 days; p<0.001). The two cohorts did not differ significantly in the proportion of patients with mRS scores >2 at last follow-up or those returning to the ED before 30 days. After adjustment for Hunt and Hess scores, Fisher grade, admission Glasgow Coma Scale score, and age, logistic regression analysis showed that the absence of vasospasm on post-aSAH days 5-7 predicted discharge on or before hospital day 14 (OR 3.4, 95% CI 1.8 to 6.4, p<0.001). CONCLUSION Lack of angiographic vasospasm 5 to 7 days after aSAH is associated with shorter hospitalization, with no increase in 30 day ED visits or poor neurologic outcome.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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11
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Intravenous milrinone for treatment of delayed cerebral ischaemia following subarachnoid haemorrhage: a pooled systematic review. Neurosurg Rev 2021; 44:3107-3124. [PMID: 33682040 DOI: 10.1007/s10143-021-01509-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
Small trials have demonstrated promising results utilising intravenous milrinone for the treatment of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Here we summarise and contextualise the literature and discuss the future directions of intravenous milrinone for DCI. A systematic, pooled analysis of literature was performed in accordance with the PRISMA statement. Methodological rigour was analysed using the MINORS criteria. Extracted data included patient population; treatment protocol; and clinical, radiological, and functional outcome. The primary outcome was clinical resolution of DCI. Eight hundred eighteen patients from 10 single-centre, observational studies were identified. Half (n = 5) of the studies were prospective and all were at high risk of bias. Mean age was 52 years, and females (69%) outnumbered males. There was a similar proportion of low-grade (WFNS 1-2) (49.7%) and high-grade (WFNS 3-5) (50.3%) SAH. Intravenous milrinone was administered to 523/818 (63.9%) participants. Clinical resolution of DCI was achieved in 375/424 (88%), with similar rates demonstrated with intravenous (291/330, 88%) and combined intra-arterial-intravenous (84/94, 89%) therapy. Angiographic response was seen in 165/234 (71%) receiving intravenous milrinone. Hypotension (70/303, 23%) and hypokalaemia (31/287, 11%) were common drug effects. Four cases (0.5%) of drug intolerance occurred. Good functional outcome was achieved in 271/364 (74%) patients. Cerebral infarction attributable to DCI occurred in 47/250 (19%), with lower rates in asymptomatic spasm. Intravenous milrinone is a safe and feasible therapy for DCI. A signal for efficacy is demonstrated in small, low-quality trials. Future research should endeavour to establish the optimal protocol and dose, prior to a phase-3 study.
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Seo Y, Lee HG, Jin C, Yang SB, Cho SY, Park SU, Jung WS, Moon SK, Park JM, Ko CN, Cho KH, Kwon S. Herbal medicines for the prevention and treatment of cerebral vasospasm after subarachnoid hemorrhage: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23388. [PMID: 33327263 PMCID: PMC7738086 DOI: 10.1097/md.0000000000023388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Despite the rapid advances in medical technology, including endovascular interventions and medications, cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) is still one of the major threats to the lives of patients with SAH. In East Asian countries, various types of herbal medicines have been used to treat cerebrovascular diseases, including SAH. In this review, we aim to evaluate the efficacy and safety of herbal medicines for the prevention and treatment of CVS after SAH. METHODS AND ANALYSIS Seven databases will be searched for relevant studies from inception to the present date "June 2020". Only randomized controlled trials (RCTs) that assess the effect and safety of herbal medicines for the prevention and treatment of CVS after SAH will be included. The methodological quality will be evaluated using the Cochrane risk of bias assessment tool. After selecting the appropriate studies, a meta-analysis of the RCTs will be performed. RESULTS This study will provide a high-quality synthesis of current evidence of herbal medicines for CVS after SAH. CONCLUSION Our systematic review will provide evidence to judge whether herbal medicines are effective interventions for patients with CVS after SAH. ETHICS AND DISSEMINATION Ethical approval is not required, as this study is based on a review of published research. This review will be published in a peer-reviewed journal and disseminated electronically and in print. TRIAL REGISTRATION NUMBER Research registry reviewregistry923.
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Affiliation(s)
- Yuna Seo
- Department of Korean Medicine Cardiology and Neurology, Graduate School, Kyung Hee University, Seoul
| | - Han-Gyul Lee
- Department of Korean Medicine Cardiology and Neurology, Graduate School, Kyung Hee University, Seoul
| | - Chul Jin
- Department of Korean Medicine Cardiology and Neurology, Graduate School, Kyung Hee University, Seoul
| | - Seung-bo Yang
- Department of Korean Internal Medicine, College of Korean Medicine, Gachon University, Gyeonggi-do
| | - Seung-Yeon Cho
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Seong-Uk Park
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Woo-Sang Jung
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Kwan Moon
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Jung-Mi Park
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Chang-Nam Ko
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ki-Ho Cho
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Seungwon Kwon
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
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Afat S, Brockmann C, Nikoubashman O, Müller M, Thierfelder KM, Brockmann MA, Nikolaou K, Wiesmann M, Kim JH, Othman AE. Diagnostic Accuracy of Simulated Low-Dose Perfusion CT to Detect Cerebral Perfusion Impairment after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Analysis. Radiology 2018; 287:643-650. [PMID: 29309735 DOI: 10.1148/radiol.2017162707] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose To evaluate diagnostic accuracy of low-dose volume perfusion (VP) computed tomography (CT) compared with original VP CT regarding the detection of cerebral perfusion impairment after aneurysmal subarachnoid hemorrhage. Materials and Methods In this retrospective study, 85 patients (mean age, 59.6 years; 62 women) with aneurysmal subarachnoid hemorrhage and who were suspected of having cerebral vasospasm at unenhanced CT and VP CT (tube voltage, 80 kVp; tube current-time product, 180 mAs) were included, 37 of whom underwent digital subtraction angiography (DSA) within 6 hours. Low-dose VP CT data sets at tube current-time product of 72 mAs were retrospectively generated by validated realistic simulation. Perfusion maps were generated from both data sets and reviewed by two neuroradiologists for overall image quality, diagnostic confidence and presence and/or severity of perfusion impairment indicating vasospasm. An interventional neuroradiologist evaluated 16 vascular segments at DSA. Diagnostic accuracy of low-dose VP CT was calculated with original VP CT as reference standard. Agreement between findings of both data sets was assessed by using weighted Cohen κ and findings were correlated with DSA by using Spearman correlation. After quantitative volumetric analysis, lesion volumes were compared on both VP CT data sets. Results Low-dose VP CT yielded good ratings of image quality and diagnostic confidence and classified all patients correctly with high diagnostic accuracy (sensitivity, 99.0%; specificity, 99.5%) without significant differences regarding presence and/or severity of perfusion impairment between original and low-dose data sets (Z = -0.447; P = .655). Findings of both data sets correlated significantly with DSA (original, r = 0.671; low dose, r = 0.667). Lesion volume was comparable for both data sets (relative difference, 5.9% ± 5.1 [range, 0.2%-25.0%; median, 4.0%]) with strong correlation (r = 0.955). Conclusion The results suggest that radiation dose reduction to 40% of original dose levels (tube current-time product, 72 mAs) may be performed in VP CT imaging of patients with aneurysmal subarachnoid hemorrhage without compromising the diagnostic accuracy regarding detection of cerebral perfusion impairment indicating vasospasm. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Saif Afat
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Carolin Brockmann
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Omid Nikoubashman
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Marguerite Müller
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Kolja M Thierfelder
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Marc A Brockmann
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Konstantin Nikolaou
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Martin Wiesmann
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Jong Hyo Kim
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
| | - Ahmed E Othman
- From the Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany (S.A., O.N., M.M., M.W., A.E.O.); Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.A., K.N., A.E.O.); Department of Neuroradiology, University Hospital Mainz, Mainz, Germany (M.A.B., C.B.); Institute for Clinical Radiology, Ludwig-Maximilian-University Hospital Munich, Munich, Germany (K.M.T.); Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, South Korea (J.H.K.); Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea (J.H.K.); and Center for Medical-IT Convergence Technology Research, Advanced Institute of Convergence Technology, Suwon, South Korea (J.H.K.)
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Baicalin Attenuates Subarachnoid Hemorrhagic Brain Injury by Modulating Blood-Brain Barrier Disruption, Inflammation, and Oxidative Damage in Mice. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:1401790. [PMID: 28912935 PMCID: PMC5587966 DOI: 10.1155/2017/1401790] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 06/23/2017] [Accepted: 07/03/2017] [Indexed: 12/11/2022]
Abstract
In subarachnoid hemorrhagic brain injury, the early crucial events are edema formation due to inflammatory responses and blood-brain barrier disruption. Baicalin, a flavone glycoside, has antineuroinflammatory and antioxidant properties. We examined the effect of baicalin in subarachnoid hemorrhagic brain injury. Subarachnoid hemorrhage was induced through filament perforation and either baicalin or vehicle was administered 30 min prior to surgery. Brain tissues were collected 24 hours after surgery after evaluation of neurological scores. Brain tissues were processed for water content, real-time PCR, and immunoblot analyses. Baicalin improved neurological score and brain water content. Decreased levels of tight junction proteins (occludin, claudin-5, ZO-1, and collagen IV) required for blood-brain barrier function were restored to normal level by baicalin. Real-time PCR data demonstrated that baicalin attenuated increased proinflammatory cytokine (IL-1β, IL-6, and CXCL-3) production in subarachnoid hemorrhage mice. In addition to that, baicalin attenuated microglial cell secretion of IL-1β and IL-6 induced by lipopolysaccharide (100 ng/ml) dose dependently. Finally, baicalin attenuated induction of NOS-2 and NOX-2 in SAH mice at the mRNA and protein level. Thus, we demonstrated that baicalin inhibited microglial cell activation and reduced inflammation, oxidative damage, and brain edema.
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Ning B, Guo G, Liu H, Ning L, Sun BL, Li Z, Wang S, Lv ZW, Fan CD. MSK1 downregulation is associated with neuronal and astrocytic apoptosis following subarachnoid hemorrhage in rats. Oncol Lett 2017; 14:2940-2946. [PMID: 28927047 PMCID: PMC5588107 DOI: 10.3892/ol.2017.6496] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 04/28/2017] [Indexed: 11/06/2022] Open
Abstract
MSK (mitogen- and stress-activated protein kinase) proteins are a family of mitogen-activated protein kinases. MSKs represent a novel type of pro-survival genes, potentially enhancing the phosphorylation of Bcl2-associated agonist of cell death. However, MSK's function and expression are poorly understood in the central nervous system. In the present study, a subarachnoid hemorrhage (SAH) model was established in SD rats and the expression of MSK1 in the brain subsequent to experimental SAH was investigated. In response to SAH, MSK1 mRNA and protein levels gradually declined, reaching the lowest point at 3 days, and increased thereafter. The expression of active caspase-3 was negatively correlated with MSK1 level. Colocalization and correlating changes in expression of MSK1 and active caspase-3 at neurons and astrocytes indicated that MSK1 downregulation may contribute to SAH-induced apoptosis, validating that MSK1 may be involved in the pathophysiology of the brain cortex subsequent to SAH.
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Affiliation(s)
- Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, Guangdong 510220, P.R. China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Geng Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China.,Department of Neurosurgery, The First Hospital, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Hong Liu
- Department of Scientific Research, Taian Central Hospital, Taian, Shandong 271000, P.R. China
| | - Lei Ning
- Department of Medical Records, Affiliated Hospital of Taishan Medical University, Taian, Shandong 271000, P.R. China
| | - Bao-Liang Sun
- Key Lab of Cerebral Microcirculation in Universities of Shandong, Taishan Medical University, Taian, Shandong 271000, P.R. China
| | - Zhen Li
- Department of Neurosurgery, Taian Central Hospital, Taian, Shandong 271000, P.R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Zheng-Wen Lv
- Department of Neurosurgery, Taian Central Hospital, Taian, Shandong 271000, P.R. China
| | - Cun-Dong Fan
- Key Lab of Cerebral Microcirculation in Universities of Shandong, Taishan Medical University, Taian, Shandong 271000, P.R. China
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Othman AE, Afat S, Nikoubashman O, Müller M, Schubert GA, Bier G, Brockmann MA, Wiesmann M, Brockmann C. Volume perfusion CT imaging of cerebral vasospasm: diagnostic performance of different perfusion maps. Neuroradiology 2016; 58:787-92. [PMID: 27194077 DOI: 10.1007/s00234-016-1695-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In this study, we aimed to evaluate the diagnostic performance of different volume perfusion CT (VPCT) maps regarding the detection of cerebral vasospasm compared to angiographic findings. METHODS Forty-one datasets of 26 patients (57.5 ± 10.8 years, 18 F) with subarachnoid hemorrhage and suspected cerebral vasospasm, who underwent VPCT and angiography within 6 h, were included. Two neuroradiologists independently evaluated the presence and severity of vasospasm on perfusion maps on a 3-point Likert scale (0-no vasospasm, 1-vasospasm affecting <50 %, 2-vasospasm affecting >50 % of vascular territory). A third neuroradiologist independently assessed angiography for the presence and severity of vasospasm on a 3-point Likert scale (0-no vasospasm, 1-vasospasm affecting < 50 %, 2-vasospasm affecting > 50 % of vessel diameter). Perfusion maps of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time to drain (TTD) were evaluated regarding diagnostic accuracy for cerebral vasospasm with angiography as reference standard. Correlation analysis of vasospasm severity on perfusion maps and angiographic images was performed. Furthermore, inter-reader agreement was assessed regarding findings on perfusion maps. RESULTS Diagnostic accuracy for TTD and MTT was significantly higher than for all other perfusion maps (TTD, AUC = 0.832; MTT, AUC = 0.791; p < 0.001). TTD revealed higher sensitivity than MTT (p = 0.007). The severity of vasospasm on TTD maps showed significantly higher correlation levels with angiography than all other perfusion maps (p ≤ 0.048). Inter-reader agreement was (almost) perfect for all perfusion maps (kappa ≥ 0.927). CONCLUSION The results of this study indicate that TTD maps have the highest sensitivity for the detection of cerebral vasospasm and highest correlation with angiography regarding the severity of vasospasm.
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Affiliation(s)
- Ahmed E Othman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany. .,Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, 72076, Tübingen, Germany.
| | - Saif Afat
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Marguerite Müller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | | | - Georg Bier
- Department for Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany
| | - Marc A Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany.,Department of Neuroradiology, University Hospital Mainz, Mainz, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Carolin Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
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Ehlert A, Manthei G, Hesselmann V, Mathias K, Bein B, Pluta R. A Case of Hyperacute Onset of Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Refractory Vasospasm Treated with Intravenous and Intraventricular Nitric Oxide: A Mini Review. World Neurosurg 2016; 91:673.e11-8. [PMID: 27109628 DOI: 10.1016/j.wneu.2016.04.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/13/2016] [Accepted: 04/14/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND A case of hyperacute vasospasm, indicating a poor prognosis after aneurysmal subarachnoid hemorrhage (SAH), is reported, and a review is presented of the literature addressing use of nitric oxide (NO) donors in cases of refractory vasospasm and recurrent delayed cortical ischemias (DCI). CASE DESCRIPTION A 65-year-old woman was admitted within 1 hour after aneurysmal SAH (Hunt and Hess grade III, Fisher modified by Frontera grade IV). A hyperacute vasospasm had been confirmed arteriographically, the right middle cerebral artery (MCA) aneurysm was immediately coiled and a standard antivasospastic therapy was started. Within 48 hours, the patient developed cerebral vasospasm with DCI. Because the standard therapy failed to control clinical symptoms and to address severe vasospasm, an individualized rescue treatment with NO donors was initiated. A continuous intravenous molsidomine infusion was started and clinical stabilization was achieved for a week (Hunt and Hess grade I; World Federation of Neurological Surgeons grade I; Glasgow Coma Scale score, 15) after which vasospasm and DCI recurred. During a subsequent DCI, we escalated NO donor therapy by adding intraventricular boluses of sodium nitroprusside (SNP). Over the course of the following 22 days, 7 transient DCIs (Glasgow Coma Scale score, 8) were treated with boluses of SNP during continued molsidomine therapy and each time vasospasm and DCI were completely reversed. Despite initial poor prognosis, the clinical outcome was excellent; at 3, 6, and 12 months follow-up the patient's modified National Institutes of Health-Stroke Scale and modified Rankin Scale scores were 0, with no cognitive deficits. CONCLUSIONS The review of the literature suggested that combined intravenous molsidomine with intraventricular SNP treatment reversed refractory, recurrent vasospasm and DCIs probably by addressing the hemoglobin NO sink effect, NO depletion, and decreased NO availability after aneurysmal SAH.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Klinik St. Georg, Hamburg, Germany.
| | - Gerd Manthei
- Department of Neurosurgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Volker Hesselmann
- Department of Neuroradiology, Asklepios Clinic North, Hamburg, Germany
| | - Klaus Mathias
- Department of Neuroradiology, Asklepios Clinic, St. Georg, Hamburg, Germany
| | - Berthold Bein
- Department of Anesthesiology, Asklepios Clinic, St. Georg, Hamburg, Germany
| | - Ryszard Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, Maryland, USA
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Tang H, Zhao D, Chen S, Fang M, Wang F, Cui Y, Tang N, Chen Q. Expression of Sphingosine-1-phosphate (S1P) on the cerebral vasospasm after subarachnoid hemorrhage in rabbits. Acta Cir Bras 2016; 30:654-9. [PMID: 26560422 DOI: 10.1590/s0102-865020150100000001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/17/2015] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To demonstrate the relationship between of sphingosine-1-phosphate (S1P) expression and subarachnoid hemorrhage (SAH). METHODS The basilar arteries from a "double-hemorrhage" rabbit model of SAH were used to investigate the relation between S1P expression and SAH. Various symptoms, including blood clots, basilar artery cross-sectional area, and S1P phosphatase expression were measured at day 3, 5, 7, 9. RESULTS The expression of S1P was enhanced in the cerebral vasospasm after subarachnoid hemorrhage in the rabbits. And S1P expression was consistent with the basilar artery cross-sectional area changes at day 3, 5, 7, 9. CONCLUSION Sphingosine-1-phosphate expression in the cerebral arterial may be a new indicator in the development of cerebral vasospasm after subarachnoid hemorrhage and provide a new therapeutic method for SAH.
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Affiliation(s)
- Hua Tang
- Department of Neurosurgery, Wuhan University, Hubei Province, P.R.C, China
| | - Donggang Zhao
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
| | - Shaojun Chen
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
| | - Ming Fang
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
| | - Feifan Wang
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
| | - Ying Cui
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
| | - Na Tang
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital, Three Gorges University, Hubei Province, P.R.C., China
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Ehlert A, Schmidt C, Wölfer J, Manthei G, Jacobs AH, Brüning R, Heindel W, Ringelstein EB, Stummer W, Pluta RM, Hesselmann V. Molsidomine for the prevention of vasospasm-related delayed ischemic neurological deficits and delayed brain infarction and the improvement of clinical outcome after subarachnoid hemorrhage: a single-center clinical observational study. J Neurosurg 2015; 124:51-8. [PMID: 26162034 DOI: 10.3171/2014.12.jns13846] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Delayed ischemic neurological deficits (DINDs) and cerebral vasospasm (CVS) are responsible fora poor outcome in patients with aneurysmal subarachnoid hemorrhage (SAH), most likely because of a decreased availability of nitric oxide (NO) in the cerebral microcirculation. In this study, the authors examined the effects of treatment with the NO donor molsidomine with regard to decreasing the incidence of spasm-related delayed brain infarctions and improving clinical outcome in patients with SAH. METHODS Seventy-four patients with spontaneous aneurysmal SAH were included in this post hoc analysis. Twenty-nine patients with SAH and proven CVS received molsidomine in addition to oral or intravenous nimodipine. Control groups consisted of 25 SAH patients with proven vasospasm and 20 SAH patients without. These patients received nimodipine therapy alone. Cranial computed tomography (CCT) before and after treatment was analyzed for CVS-related infarcts. A modified National Institutes of Health Stroke Scale (mNIHSS) and the modified Rankin Scale (mRS) were used to assess outcomes at a 3-month clinical follow-up. RESULTS Four of the 29 (13.8%) patients receiving molsidomine plus nimodipine and 22 of the 45 (48%) patients receiving nimodipine therapy alone developed vasospasm-associated brain infarcts (p < 0.01). Follow-up revealed a median mNIHSS score of 3.0 and a median mRS score of 2.5 in the molsidomine group compared with scores of 11.5 and 5.0, respectively, in the nimodipine group with CVS (p < 0.001). One patient in the molsidomine treatment group died, and 12 patients in the standard care group died (p < 0.01). CONCLUSIONS In this post hoc analysis, patients with CVS who were treated with intravenous molsidomine had a significant improvement in clinical outcome and less cerebral infarction. Molsidomine offers a promising therapeutic option in patients with severe SAH and CVS and should be assessed in a prospective study.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St. Georg, Hamburg;
| | | | | | - Gerd Manthei
- Department of Neurosurgery, Asklepios Hospital St. Georg, Hamburg;
| | | | - Roland Brüning
- Department of Radiology, Asklepios Hospital Barmbek, Hamburg
| | | | | | | | - Ryszard M Pluta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Volker Hesselmann
- Radiology, and.,Asklepios Hospital Hamburg North, Hamburg, Germany; and
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Caspers J, Rubbert C, Turowski B, Martens D, Reichelt DC, May R, Aissa J, Hänggi D, Etminan N, Mathys C. Timing of Mean Transit Time Maximization is Associated with Neurological Outcome After Subarachnoid Hemorrhage. Clin Neuroradiol 2015; 27:15-22. [PMID: 25939528 DOI: 10.1007/s00062-015-0399-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/15/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Computed tomography perfusion (CTP) has gained significant relevance for the radiological screening of patients at risk of developing delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Particularly, the impact of MTTPEAK, i.e., the maximal mean transit time value in a series of CTP measurements, for the prediction of long-term outcome has recently been demonstrated by our group. Complementing this recent work, the present study investigated how the timing of MTTPEAK affected the long-term outcome after aneurysmal subarachnoid hemorrhage. METHODS CTP examinations from 103 patients with clinical deterioration attributed to DCI after aSAH were retrospectively analyzed for time interval between SAH ictus and onset of MTTPEAK in association with modified Rankin Scale (mRS) 23.1 months after SAH. RESULTS Patients with unfavorable outcome (mRS > = 2) suffered significant earlier MTTPEAK onsets than patients with favorable outcome (mRS = 0 and 1). MTTPEAK within the first week was associated with significantly higher mRS scores compared to later MTTPEAK. Timing of MTTPEAK together with the value of MTTPEAK and initial World Federation of Neurosurgical Societies (WFNS) grade was a significant predictor for an unfavorable outcome (mRS > = 2). CONCLUSIONS The current findings suggest a presumably higher vulnerability of the brain to early microcirculatory impairments after aSAH and highlight that timing of MTT elevations could be considered for the identification of patients at increased risk for poor neurological outcome due to DCI.
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Affiliation(s)
- J Caspers
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, 52425, Jülich, Germany
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany.
| | - B Turowski
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Martens
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D C Reichelt
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - R May
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - J Aissa
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - N Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - C Mathys
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
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Dhar R, Diringer MN. Relationship between angiographic vasospasm, cerebral blood flow, and cerebral infarction after subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:161-5. [PMID: 25366617 DOI: 10.1007/978-3-319-04981-6_27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Delayed cerebral ischemia (DCI) and cerebral infarction are major contributors to poor functional recovery after subarachnoid hemorrhage (SAH). Cerebral vasospasm, the narrowing of proximal intracranial arteries after SAH, has long been assumed to be the primary cause of DCI, and has therefore been the primary therapeutic target in attempts to diminish disability after SAH. However, emerging evidence has questioned the strength and causality of the relationship between vasospasm and DCI. To address this fundamental question, we performed two parallel studies assessing the relationship between the presence of vasospasm in a vascular territory and both regional reductions in cerebral blood flow (CBF) and development of cerebral infarction.In a cohort of SAH patients at high-risk for DCI, we identified regions of hypoperfusion using positron emission tomography (PET) and compared their distribution with territories exhibiting vasospasm on concurrent angiography. We found that regional hypoperfusion was common in the absence of proximal vasospasm and that some patients without any significant vasospasm still could have hypoperfused brain regions. Similarly, our parallel study demonstrated that both patients and brain territories without vasospasm could develop delayed cerebral infarction, and that such vasospasm-independent infarcts account for more than a quarter of the infarct burden from DCI. These findings suggest that other processes, perhaps at a microvascular level, contribute at least part of the burden of DCI and future interventions should also address these other pathophysiologic processes.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology (Neurocritical Care Section), Washington University in St. Louis School of Medicine, 8111, 660S Euclid Avenue, St. Louis, MO, 63110, USA,
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Hu N, Wu Y, Chen BZ, Han JF, Zhou MT. Protective effect of stellate ganglion block on delayed cerebral vasospasm in an experimental rat model of subarachnoid hemorrhage. Brain Res 2014; 1585:63-71. [DOI: 10.1016/j.brainres.2014.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/27/2014] [Accepted: 08/07/2014] [Indexed: 11/26/2022]
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To look beyond vasospasm in aneurysmal subarachnoid haemorrhage. BIOMED RESEARCH INTERNATIONAL 2014; 2014:628597. [PMID: 24967389 PMCID: PMC4055362 DOI: 10.1155/2014/628597] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 05/07/2014] [Indexed: 12/26/2022]
Abstract
Delayed cerebral vasospasm has classically been considered the most important and treatable cause of mortality and morbidity in patients with aneurysmal subarachnoid hemorrhage (aSAH). Secondary ischemia (or delayed ischemic neurological deficit, DIND) has been shown to be the leading determinant of poor clinical outcome in patients with aSAH surviving the early phase and cerebral vasospasm has been attributed to being primarily responsible. Recently, various clinical trials aimed at treating vasospasm have produced disappointing results. DIND seems to have a multifactorial etiology and vasospasm may simply represent one contributing factor and not the major determinant. Increasing evidence shows that a series of early secondary cerebral insults may occur following aneurysm rupture (the so-called early brain injury). This further aggravates the initial insult and actually determines the functional outcome. A better understanding of these mechanisms and their prevention in the very early phase is needed to improve the prognosis. The aim of this review is to summarize the existing literature on this topic and so to illustrate how the presence of cerebral vasospasm may not necessarily be a prerequisite for DIND development. The various factors determining DIND that worsen functional outcome and prognosis are then discussed.
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Chen S, Feng H, Sherchan P, Klebe D, Zhao G, Sun X, Zhang J, Tang J, Zhang JH. Controversies and evolving new mechanisms in subarachnoid hemorrhage. Prog Neurobiol 2014; 115:64-91. [PMID: 24076160 PMCID: PMC3961493 DOI: 10.1016/j.pneurobio.2013.09.002] [Citation(s) in RCA: 270] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 09/07/2013] [Accepted: 09/12/2013] [Indexed: 12/13/2022]
Abstract
Despite decades of study, subarachnoid hemorrhage (SAH) continues to be a serious and significant health problem in the United States and worldwide. The mechanisms contributing to brain injury after SAH remain unclear. Traditionally, most in vivo research has heavily emphasized the basic mechanisms of SAH over the pathophysiological or morphological changes of delayed cerebral vasospasm after SAH. Unfortunately, the results of clinical trials based on this premise have mostly been disappointing, implicating some other pathophysiological factors, independent of vasospasm, as contributors to poor clinical outcomes. Delayed cerebral vasospasm is no longer the only culprit. In this review, we summarize recent data from both experimental and clinical studies of SAH and discuss the vast array of physiological dysfunctions following SAH that ultimately lead to cell death. Based on the progress in neurobiological understanding of SAH, the terms "early brain injury" and "delayed brain injury" are used according to the temporal progression of SAH-induced brain injury. Additionally, a new concept of the vasculo-neuronal-glia triad model for SAH study is highlighted and presents the challenges and opportunities of this model for future SAH applications.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Department of Physiology & Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Prativa Sherchan
- Department of Physiology & Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Damon Klebe
- Department of Physiology & Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shanxi, China
| | - Xiaochuan Sun
- Department of Neurosurgery, First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jiping Tang
- Department of Physiology & Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology & Pharmacology, Loma Linda University, Loma Linda, CA, USA; Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA.
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Izzy S, Muehlschlegel S. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage and traumatic brain injury. Curr Treat Options Neurol 2013; 16:278. [PMID: 24347030 DOI: 10.1007/s11940-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OPINION STATEMENT Cerebral vasospasm (cVSP) consists of the vasoconstriction of large and small intracranial vessels which can lead to cerebral hypoperfusion, and in extreme cases, delayed ischemic deficits with stroke. While most commonly observed after aneurysmal subarachnoid hemorrhage (aSAH), cVSP can also occur after traumatic brain injury (TBI) as we have described in detail in this review. For the past decades, the research attention has focused on cVSP because of its association with delayed cerebral ischemia, which is the largest contributor of morbidity and mortality after aSAH. New discoveries in the cVSP pathophysiology involving multifactorial complex cascades and pathways pose new targets for therapeutic interventions in the prevention and treatment of cVSP. The goal of this review is to demonstrate the commonalities and differences in epidemiology and pathophysiology of both aSAH and TBI-associated cVSP, and highlight the more recently discovered pathways of cVSP. Finally, the latest cVSP surveillance methods and treatment options are illustrated.
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Affiliation(s)
- Saef Izzy
- Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
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26
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Güresir E, Vasiliadis N, Konczalla J, Raab P, Hattingen E, Seifert V, Vatter H. Erythropoietin prevents delayed hemodynamic dysfunction after subarachnoid hemorrhage in a randomized controlled experimental setting. J Neurol Sci 2013; 332:128-35. [DOI: 10.1016/j.jns.2013.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 06/30/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
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Latorre JGS, Lodi Y, El-Zammar Z, Devasenapathy A. Is asymptomatic vasospasm associated with poor outcome in subarachnoid hemorrhage? Neurohospitalist 2013; 1:165-71. [PMID: 23983851 DOI: 10.1177/1941875211413134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Vasospasm occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH), but only half becomes symptomatic. It is unclear whether asymptomatic vasospasm (AV) detected by noninvasive testing affects outcome. Prophylactic hemodilutional, hypertensive, and hypervolemic (HHH) therapy is widely used but the benefit remains unproven. We aim to determine whether AV increases the risk of poor outcome and whether HHH is safe. METHODS A total of 175 consecutive patients with aSAH without clinical vasospasm were included. Patients with sonographic (transcranial doppler) or radiologic (computed tomography [CT] Angiography) vasospasm were assigned to AV group, while those without were assigned to no vasospasm (NV) group. Logistic regression was used to determine the association between AV and HHH on poor outcome, defined as modified Rankin scale (mRS) >3 at discharge or 3 to 6 months' follow-up. RESULTS In all, 106 patients had NV and 25 received HHH. A total of 69 patients had AV and 54 received HHH. Asymptomatic vasospasm compared to NV was not associated with poor outcome (odds ratio [OR] 2.6, 95% confidence interval [CI]: 0.75-8.9; P = .1). Hemodilutional, hypertensive, and hypervolemic use in patients with AV did not improve the outcome (OR 0.16, 95%CI: 0.009-2.84; P = .2). In patients with NV, HHH use showed trend toward poor outcome after multivariable adjustment (OR 12.6, 95%CI: 1.08-146.5 P = .04). CONCLUSION Asymptomatic vasospasm does not appear to be associated with poor outcome in aSAH. Hemodilutional, hypertensive, and hypervolemic therapy in AV was not associated with improved outcome and may be harmful to patients who do not have vasospasm. Further research is needed to validate this finding.
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Hong Y, Guo S, Chen S, Sun C, Zhang J, Sun X. Beneficial effect of hydrogen-rich saline on cerebral vasospasm after experimental subarachnoid hemorrhage in rats. J Neurosci Res 2012; 90:1670-80. [PMID: 22589232 DOI: 10.1002/jnr.22739] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 06/02/2011] [Accepted: 06/16/2011] [Indexed: 01/10/2023]
Abstract
Cerebral vasospasm (CV) remains a common and devastating complication in patients with subarachnoid hemorrhage (SAH). Despite its clinical significance and extensive research, the underlying pathogenesis and therapeutic perspectives of CV remain incompletely understood. Recently, it has been suggested that molecular hydrogen (H(2)) can selectively reduce levels of hydroxyl radicals (·OH) and ameliorate oxidative and inflammatory injuries to organs in many models. However, whether H(2) can ameliorate CV after SAH is still unknown. This study was designed to evaluate the efficacy of H(2) in preventing SAH-induced CV. Experimental SAH was induced in Sprague-Dawley rats using cisterna magna blood injection. Hydrogen-rich saline (HS) was injected intraperitoneally (5 ml/kg) immediately and at 24 hr after injury. All rats were sacrificed 48 hr after the neurological examination scores had been recorded following SAH. Levels of oxidative stress and inflammation were evaluated. Basilar artery vasospasm was assessed by histological examination using light and transmission electron microscopy. HS treatment significantly improved neurological outcomes and attenuated morphological vasospasm of the basilar artery after SAH. In addition, we found that the beneficial effects of HS treatment on SAH-induced CV were associated with decreased levels of lipid peroxidation, increased activity of antioxidant enzymes, and reduced levels of proinflammatory cytokines in the basilar artery. These results indicate that H(2) has the potential to be a novel therapeutic strategy for the treatment of CV after SAH, and its neuroprotective effect might be partially mediated via limitation of vascular inflammation and oxidative stress.
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Affiliation(s)
- Yuan Hong
- Department of Neurosurgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
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Pisapia JM, Xu X, Kelly J, Yeung J, Carrion G, Tong H, Meghan S, El-Falaky OM, Grady MS, Smith DH, Zaitsev S, Muzykantov VR, Stiefel MF, Stein SC. Microthrombosis after experimental subarachnoid hemorrhage: time course and effect of red blood cell-bound thrombin-activated pro-urokinase and clazosentan. Exp Neurol 2011; 233:357-63. [PMID: 22079156 DOI: 10.1016/j.expneurol.2011.10.029] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/24/2011] [Accepted: 10/28/2011] [Indexed: 10/15/2022]
Abstract
Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality for patients surviving the rupture of an intracranial aneurysm. Despite an association between vasospasm and DCI, thrombosis and thromboembolism may also contribute to DCI. In this study we investigate the time course of intravascular microclot formation after experimental subarachnoid hemorrhage (SAH) and assess the effects of the following two drugs on microclot burden: mutant thrombin-activated urokinase-type plasminogen activator (scFv/uPA-T), which is bound to red blood cells for use as a thromboprophylactic agent, and clazosentan, an endothelin antagonist. In the first study, adult male C57BL/6 mice were sacrificed at 24 (n=5), 48 (n=6), 72 (n=8), and 96 (n=3) hours after SAH induced by filament perforation of the anterior cerebral artery. Sham animals (n=5) underwent filament insertion without puncture. In the second study, animals received scFv/uPA-T (n=5) 3 hours after hemorrhage, clazosentan (n=5) by bolus and subcutaneous pump after SAH just prior to skin closure, or a combination of scFv/uPA-T and clazosentan (n=4). Control (n=6) and sham (n=5) animals received saline alone. All animals were sacrificed at 48 hours and underwent intra-cardiac perfusion with 4% paraformaldehyde. The brains were then extracted and sliced coronally on a cryostat and processed for immunohistochemistry. An antibody recognizing thrombin-anti-thrombin complexes was used to detect microclots on coronal slices. Microclot burden was calculated for each animal and compared among groups. Following SAH, positive anti-thrombin staining was detected bilaterally in the following brain regions, in order of decreasing frequency: cortex; hippocampus; hypothalamus; basal ganglia. Few microclots were found in the shams. Microclot burden peaked at 48 hours and then decreased gradually. Animals receiving scFv/uPA-T and scFv/uPA-T+clazosentan had a lower microclot burden than controls, whereas animals receiving clazosentan alone had a higher microclot burden (p<0.005). The overall mortality rate in the time course study was 40%; mortality was highest among control animals in the second study. Intravascular microclots form in a delayed fashion after experimental SAH. Microclots may be safely reduced using a novel form of thromboprophylaxis provided by RBC-targeted scFv/uPA-T and represent a potential target for therapeutic intervention in the treatment of DCI.
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Affiliation(s)
- Jared M Pisapia
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Killeen RP, Mushlin AI, Johnson CE, Comunale JP, Tsiouris AJ, Delaney H, Dunning A, Sanelli PC. Comparison of CT perfusion and digital subtraction angiography in the evaluation of delayed cerebral ischemia. Acad Radiol 2011; 18:1094-100. [PMID: 21652232 DOI: 10.1016/j.acra.2011.04.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 04/14/2011] [Accepted: 04/20/2011] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES Delayed cerebral ischemia (DCI) is a devastating condition that occurs secondary to aneurysmal subarachnoid hemorrhage (A-SAH). The purpose is to compare computed tomography perfusion (CTP) and digital subtraction angiography (DSA) for determining DCI in A-SAH. MATERIALS AND METHODS A retrospective study of A-SAH patients admitted at our institution between December 2004 and December 2008 was performed. CTP and DSA were obtained at days 6-8 after aneurysm rupture. Both qualitative and quantitative analyses of CT perfusion deficits were performed. DSA was categorized as presence or absence of vasospasm. The reference standard for determining DCI was based on clinical deterioration or infarction on CT or MRI. The test characteristics of CTP and DSA were calculated and their graphs of conditional probabilities were constructed using Bayesian analysis. RESULTS Fifty-seven patients were included; 79% (45/57) had DCI. Seventy percent (40/57) had CTP perfusion deficits; 80% (36/45) of the DCI and 33% (4/12) of no DCI patients. Sixty-three percent (36/57) had DSA demonstrating vasospasm; 73% (33/45) of the DCI and 25% (3/12) of no DCI patients. Quantitative analysis of the CTP data revealed a significant difference in cerebral blood flow values for the DCI (29.4 mL/100 g/minute) and no DCI groups (40.5 mL/100 g/minute, P = .0213). The sensitivity, specificity, and positive and negative predictive values for CTP were 0.80 (95% CI 0.68-0.92), 0.67 (95% CI 0.40-0.93), 0.90 (95% CI 0.82-0.96), 0.47 (95% CI 0.27-0.62), and for DSA were 0.73 (95% CI 0.60-0.86), 0.75 (95% CI 0.50-0.99), 0.92 (95% CI 0.82-0.98), and 0.43 (95% CI 0.26-0.53), respectively. CONCLUSION CTP and DSA have similar test characteristics and Bayesian analysis for determining DCI in A-SAH patients.
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Affiliation(s)
- Ronan P Killeen
- Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medical College, NY 10065, USA.
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Tomycz L, Shekhawat N, Forbes J, Ghiassi M, Ghiassi M, Lockney D, Velez D, Mericle R. The spectrum of management practices in nontraumatic subarachnoid hemorrhage: A survey of high-volume centers in the United States. Surg Neurol Int 2011; 2:90. [PMID: 21748042 PMCID: PMC3130463 DOI: 10.4103/2152-7806.82372] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 05/17/2011] [Indexed: 01/23/2023] Open
Abstract
Background: There is a considerable variety of management practices for nontraumatic subarachnoid hemorrhage (ntSAH) across high-volume centers in the United States. We sought to design a survey which would highlight areas of controversy in the modern management of ntSAH and identify specific areas of interest fo further study. Methods: A questionnaire on management practices in ntSAH was formulated using a popular web-based survey tool (SurveyMonkey™, Palo Alto, CA) and sent to endovascular neurointerventionists and cerebrovascular surgeons who manage a high volume of these patients annually. Two-hundred questionnaires were delivered electronically, and after a period of 2 months, the questionnaire was resent to nonresponders. Results: Seventy-three physicians responded, representing a cross-section of academic and other high-volume centers of excellence from around the country. On average, the responding interventionists in this survey each manage approximately 100 patients with ntSAH annually. Over 57% reported using steroids to treat this patient population. Approximately 18% of the respondents use intrathecal thrombolytics in ntSAH. Over 90% of responding physicians administer nimodipine to all patients with ntSAH. Over 40% selectively administer antiepileptic drugs to patients with ntSAH. Several additional questions were posed regarding the methods of detecting and treating vasospasm, as well as the indications for CSF diversion in patients with ntSAH further demonstrating the great diversity in management. Conclusion: This survey illustrates the astonishing variety of treatment practices for patients with ntSAH and underscores the need for further study.
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Affiliation(s)
- Luke Tomycz
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Verger Bennasar AM, Romero Kräuchi O. [Protective measures against cerebral ischemia following subarachnoid hemorrhage: Part 2]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:236-242. [PMID: 21608280 DOI: 10.1016/s0034-9356(11)70046-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- A M Verger Bennasar
- Unidad de Reanimación, Servicio de Anestesiologfa y Reanimación, Hospital Universitario Son Dureta, Palma de Mallorca.
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Scherle-Matamoros C, Pérez-Nellar J, Fernández-Cue L. Vasoespasmo sintomático. Caracterización clínica. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70008-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Al-Tamimi YZ, Orsi NM, Quinn AC, Homer-Vanniasinkam S, Ross SA. A review of delayed ischemic neurologic deficit following aneurysmal subarachnoid hemorrhage: historical overview, current treatment, and pathophysiology. World Neurosurg 2010; 73:654-67. [PMID: 20934153 DOI: 10.1016/j.wneu.2010.02.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 01/30/2010] [Indexed: 01/10/2023]
Abstract
Delayed ischemic neurologic deficit (DIND) is a serious and poorly understood complication of aneurysmal subarachnoid hemorrhage. Although advances in treatment have improved prognosis for these patients, long-term clinical outcomes remain disappointing. Historically, angiographic vasospasm was thought to result in a DIND, although an increasing body of evidence suggests that this is an oversimplification, because interventions that have effectively targeted angiographic vasospasm have not improved outcome. Consequently, the relationship between angiographic vasospasm and neurologic outcome may be associative rather than causative. Although our understanding of the underlying molecular processes and pathophysiology is improving, responsible mediators or pathways have yet to be identified. The aim of this review is to summarize the key historical events that have helped shape our understanding of the pathophysiology of this phenomenon (microcirculation, autoregulation, microthrombosis, inflammation, apoptosis, spreading depolarization, oxidative stress) and to present the evidence underlying current treatment strategies (hemodynamic therapy, oral nimodipine, endovascular therapy, statins, cerebrospinal fluid drainage, thrombolysis, magnesium) and the translational and clinical research investigating DIND.
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Affiliation(s)
- Yahia Z Al-Tamimi
- Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom.
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Abstract
Despite advances in aneurysm ablation and the initial management of patients presenting with aneurysmal subarachnoid hemorrhage, delayed cerebral ischemia remains a significant source of morbidity. Traditionally, delayed cerebral ischemia was thought to be a result of vasospasm of the proximal intracranial vessels, and clinical trials have relied largely on radiographic evidence of vasospasm as a surrogate for functional outcome. However, a number of trials have demonstrated a dissociation between angiographic vasospasm and outcome, and more recent data suggest that other mechanisms of injury, such as microvascular dysfunction and complex neuronal-glial interactions, may influence the development of delayed ischemic deficit after aneurysmal subarachnoid hemorrhage. Our evolving understanding of the pathophysiology of delayed cerebral ischemia may offer the opportunity to test new therapeutic strategies in this area and improve clinical trial design.
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Affiliation(s)
- Daniel T Laskowitz
- Departments of Medicine Neurology, Duke University, Durham NC 27710, USA.
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Lanterna LA, Lunghi A, Martchenko S, Gritti P, Bonaldi G, Biroli F. Cerebral watershed hypoperfusion in subarachnoid hemorrhage: computed tomography perfusion analysis. J Neurosurg 2010; 114:961-8. [PMID: 20849218 DOI: 10.3171/2010.8.jns091766] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT A better understanding of the pathophysiology of vasospasm-induced delayed cerebral ischemia and earlier detection of hypoperfusion before ischemic injury are needed to guide therapy in subarachnoid hemorrhage (SAH). The cerebrovascular physiology of the major arterial territories differs from that of the watershed zones (WZs) in a way that would suggest a differential topographic sensitivity of the brain to vasospasm. The primary end point of the study was to investigate the vasospasm-induced hypoperfusion in relation to cerebrovascular topography and timing from the onset of SAH. METHODS Forty-one patients were prospectively enrolled and scheduled for perfusion-weighted (PW) CT at 3 time points (≤ 3 days, Days 4-8, and Days 9-15 after SAH). Perfusion-weighted CT maps were visually assessed for side-to-side perfusion asymmetry. The PW CT topographic pattern was categorized into absence of asymmetry, WZ, and vascular territory hypoperfusion. Perfusion-weighted CT revision was performed by investigators blinded to clinical information. The null hypothesis for the primary end point was that there would be no difference in hypoperfusion space-time distribution among the different vascular territories. Multivariate logistic regression and Cox proportional hazards modeling were used for statistical analysis. RESULTS Delayed cerebral ischemia occurred in 26 patients and its predicting variables were increasing age (p = 0.045), Fisher grade (p = 0.007), and hypoperfusion on the PW CT performed within the 1st 72 hours after SAH (p = 0.004). The timing of the PW CT with respect to the day of SAH affected the topographic pattern of hypoperfusion: watershed-zone hypoperfusion was more common within the first 3 days after SAH (p = 0.018), while the proportion of territorial hypoperfusion increased subsequently. Among the different covariates, a young age was independently associated with a higher risk of developing hypoperfusion in the WZs (p = 0.02). CONCLUSIONS This study suggests the existence of a cerebral topographic heterogeneity to the hemodynamic effects of SAH and differential pathogenetic mechanisms of hypoperfusion according to timing, age, and brain topography. Hypoperfusion in the WZs may be an early precursor to more profound ischemic events. The PW CT detection of such brain-sensitive zones could offer a warning signal of the early hemodynamic effects of SAH and cerebral vasospasm.
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Affiliation(s)
- Luigi Andrea Lanterna
- Department of Neuroscience and Surgery of Nervous System, Ospedali Riuniti, Bergamo, Italy.
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Kramer AH, Fletcher JJ. Statins in the management of patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurocrit Care 2010; 12:285-96. [PMID: 19921470 DOI: 10.1007/s12028-009-9306-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed ischemic neurological deficits (DINDs) contribute to morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Based on promising preliminary reports, some clinicians routinely administer statins to prevent DINDs. METHODS Without language restriction, we searched MEDLINE, EMBASE, the Cochrane Central Register, references of review articles, proceedings of the International Stroke Conference, and gray literature sources. Studies were selected if they compared outcomes between statin-treated and untreated patients during the 2 weeks following SAH. Data were extracted and appraised independently and in duplicate, using standardized forms. Fixed or random effects models, as appropriate based on the degree of study heterogeneity, were applied to calculate summary measures. RESULTS Four RCTs, two "pseudo" RCTs, five cohort studies, and one case-control study met eligibility criteria. In the RCTs, which enrolled a total of 309 patients, statins were found to significantly reduce the occurrence of DINDs [OR 0.38 (0.23-0.65); P < 0.001], but not mortality [OR 0.51 (0.25-1.02); P = 0.06] or poor neurological recovery [OR 0.81 (0.49-1.32); P = 0.39]. Observational studies assessed 1,542 patients, of whom 385 received statins. Statin-use was not associated with any reduction in DINDs [OR 0.96 (0.71-1.31); P = 0.80], mortality [OR 1.16 (0.78-1.73); P = 0.47] or poor neurological recovery [OR 1.20 (0.84-1.72); P = 0.31]. When the results of all studies were combined, statins had no statistically significant effect. CONCLUSIONS Existing RCTs suggest that statins reduce DINDs, with a possible trend toward lower mortality. These findings are not supported by observational research. Although not assessed in all studies, current data do not indicate that statins improve neurological outcomes.
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Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Foothills Medical Center, Calgary, AB T2N 2T9, Canada.
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Hattingen E, Blasel S, Dumesnil R, Vatter H, Zanella FE, Weidauer S. MR angiography in patients with subarachnoid hemorrhage: adequate to evaluate vasospasm-induced vascular narrowing? Neurosurg Rev 2010; 33:431-9. [PMID: 20532584 DOI: 10.1007/s10143-010-0267-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 03/16/2010] [Accepted: 04/25/2010] [Indexed: 10/19/2022]
Abstract
The diagnosis of cerebral vasospasm (CVS) following subarachnoid hemorrhage (SAH) is still challenging. We evaluate the accuracy of time of flight MR angiography (TOF-MRA) to assess the arterial diameters of the circle of Willis in SAH patients with suspected CVS. MR examinations (1.5 Tesla) including 3D TOF-MRA with maximum intensity projections (MIP) and digital subtraction angiography (DSA) were performed within 24 h in 21 patients with acute aneurysmal SAH and suspicion of CVS. Arterial diameters of the circle of Willis including the distal internal carotid artery (ICA) were measured as ratios to the extradural ICA in standard projections. The diagnosis of CVS was established by comparing the luminal size of baseline and follow-up DSA. The correlation between the arterial ratios measured on MIP angiograms and on follow-up DSA was assessed with Pearson's linear regression analysis. Arterial ratios on MIP angiograms were categorized as correct, overestimated, and underestimated compared to the ratios on follow-up DSA. Pearson's correlation coefficient between the ratios of MIP angiograms and DSA was r = 0.5799 and the regression coefficient was b = 0.4775. Highest correlation was found for the category of severe CVS (r = 0.8201). Of all MIP angiograms, 34.9% showed consistent results compared to the DSA, while 44.2% of MIP images overestimated the vascular narrowing. Standard MIP angiograms from TOF-MRA are not accurate to assess vascular narrowing in patients with suspected CVS after aneurysmal SAH. The multifocal arterial stenoses in CVS may induce severe changes in blood flow dynamics, which compromise the diagnostic accuracy of the TOF-MRA.
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Affiliation(s)
- Elke Hattingen
- Institute of Neuroradiology, Goethe University Frankfurt, Frankfurt/M, Germany.
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Bosche B, Graf R, Ernestus RI, Dohmen C, Reithmeier T, Brinker G, Strong AJ, Dreier JP, Woitzik J. Recurrent spreading depolarizations after subarachnoid hemorrhage decreases oxygen availability in human cerebral cortex. Ann Neurol 2010; 67:607-17. [PMID: 20437558 PMCID: PMC2883076 DOI: 10.1002/ana.21943] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 11/25/2009] [Accepted: 11/30/2009] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Delayed ischemic neurological deficit (DIND) contributes to poor outcome in subarachnoid hemorrhage (SAH) patients. Because there is continuing uncertainty as to whether proximal cerebral artery vasospasm is the only cause of DIND, other processes should be considered. A potential candidate is cortical spreading depolarization (CSD)-induced hypoxia. We hypothesized that recurrent CSDs influence cortical oxygen availability. METHODS Centers in the Cooperative Study of Brain Injury Depolarizations (COSBID) recruited 9 patients with severe SAH, who underwent open neurosurgery. We used simultaneous, colocalized recordings of electrocorticography and tissue oxygen pressure (p(ti)O(2)) in human cerebral cortex. We screened for delayed cortical infarcts by using sequential brain imaging and investigated cerebral vasospasm by angiography or time-of-flight magnetic resonance imaging. RESULTS In a total recording time of 850 hours, 120 CSDs were found in 8 of 9 patients. Fifty-five CSDs ( approximately 46%) were found in only 2 of 9 patients, who later developed DIND. Eighty-nine ( approximately 75%) of all CSDs occurred between the 5th and 7th day after SAH, and 96 (80%) arose within temporal clusters of recurrent CSD. Clusters of CSD occurred simultaneously, with mainly biphasic CSD-associated p(ti)O(2) responses comprising a primary hypoxic and a secondary hyperoxic phase. The frequency of CSD correlated positively with the duration of the hypoxic phase and negatively with that of the hyperoxic phase. Hypoxic phases significantly increased stepwise within CSD clusters; particularly in DIND patients, biphasic p(ti)O(2) responses changed to monophasic p(ti)O(2) decreases within these clusters. Monophasic hypoxic p(ti)O(2) responses to CSD were found predominantly in DIND patients. INTERPRETATION We attribute these clinical p(ti)O(2) findings mainly to changes in local blood flow in the cortical microcirculation but also to augmented metabolism. Besides classical contributors like proximal cerebral vasospasm, CSD clusters may reduce O(2) supply and increase O(2) consumption, and thereby promote DIND.
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Affiliation(s)
- Bert Bosche
- Department of Neurosurgery, University of Cologne, Cologne, Germany.
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The prognostic value of NSE and S100B from serum and cerebrospinal fluid in patients with spontaneous subarachnoid hemorrhage. J Neurosurg Anesthesiol 2010; 22:21-31. [PMID: 20027011 DOI: 10.1097/ana.0b013e3181bdf50d] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neuron-specific enolase (NSE) and S100B protein have been shown to be increased in cerebrospinal fluid (CSF) and serum of patients suffering from subarachnoid hemorrhage. This study was designed to evaluate the accuracy of NSE and S100B from CSF and serum for the prognosis of outcome and the detection of cerebral infarction, vasospasm and intracranial hypertension. In 55 patients with spontaneous subarachnoid hemorrhage and requiring external ventricular drainage the concentrations of NSE and S100B were determined daily from the serum and the CSF from admission until day 8. At ICU discharge patients' outcome was assessed by the Glasgow outcome scale and occurrence of cerebral infarction, vasospasm and intracranial hypertension were registered. Mean and peak values of each parameter for each patient were calculated. For accuracy assessment receiver operating characteristics were used. Bad outcome (Glasgow outcome scale 1 to 3) was found in 33 patients. Cerebral infarction, vasospasm, and intracranial hypertension were found in 31 (56%), 34 (62%), and 36 (65%) patients. Mean and peak values of NSE CSF (P<0.001), S100B CSF (P<0.001), and S100B serum (P<0.001) but not of NSE serum provided the ability to distinguish between patients with good and bad outcome. The accuracy of NSE CSF and S100B CSF did not differ significantly from that of S100B serum. NSE CSF (P<0.001), S100B CSF (P<0.001), and S100B serum (P<0.001) allowed the detection of cerebral infarction and intracranial hypertension. Cerebral vasospasm was detected by none of the parameters. In conclusion, NSE CSF, S100B CSF, and S100B serum provide similar prognostic values for outcome, intracranial hypertension and cerebral infarction. Significantly lower accuracy was found for NSE serum.
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Role of gap junctions in early brain injury following subarachnoid hemorrhage. Brain Res 2009; 1315:150-8. [PMID: 20018179 DOI: 10.1016/j.brainres.2009.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 11/30/2009] [Accepted: 12/04/2009] [Indexed: 11/21/2022]
Abstract
Gap junction inhibition has been demonstrated to reverse the vascular contraction that follows experimental subarachnoid hemorrhage. This study hypothesizes that the use of established gap junction inhibitors: octonal and carbenoxolone, to interrupt cell to cell communication will provide neuroprotection against early brain injury after SAH. The filament perforation model of SAH was performed in male Sprague-Dawley rats weighing between 300 and 380 g. Octanol (260.46 mg or 781.38 mg/kg), carbenoxolone (100 mg/kg), or vehicles were given via intraperitoneal injection 1 h after SAH. Neurologic deficits and cerebral apoptosis were assessed 24 and 72 h after SAH. In addition, Western blot analysis was performed to confirm the in vivo inhibition of CNS gap junctions. The administration of octanol and carbenoxolone both failed to attenuate the neurological deficits induced by SAH, and they did not reduce neuronal apoptosis. Additionally, carbenoloxone increased post SAH mortality and exacerbated SAH-induced apoptosis. Despite previous studies that show gap junction inhibitors reverse vasospasm following experimental SAH, they failed to improve clinical outcomes or provide neuroprotection in this study.
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Simvastatin Treatment Duration and Cognitive Preservation in Experimental Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2009; 21:326-33. [DOI: 10.1097/ana.0b013e3181acfde7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jeon H, Ai J, Sabri M, Tariq A, Shang X, Chen G, Macdonald RL. Neurological and neurobehavioral assessment of experimental subarachnoid hemorrhage. BMC Neurosci 2009; 10:103. [PMID: 19706182 PMCID: PMC2749856 DOI: 10.1186/1471-2202-10-103] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 08/25/2009] [Indexed: 01/14/2023] Open
Abstract
About 50% of humans with aneurysmal subarachnoid hemorrhage (SAH) die and many survivors have neurological and neurobehavioral dysfunction. Animal studies usually focused on cerebral vasospasm and sometimes neuronal injury. The difference in endpoints may contribute to lack of translation of treatments effective in animals to humans. We reviewed prior animal studies of SAH to determine what neurological and neurobehavioral endpoints had been used, whether they differentiated between appropriate controls and animals with SAH, whether treatment effects were reported and whether they correlated with vasospasm. Only a few studies in rats examined learning and memory. It is concluded that more studies are needed to fully characterize neurobehavioral performance in animals with SAH and assess effects of treatment.
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Affiliation(s)
- Hyojin Jeon
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Kang DH, Park J, Lee SH, Park SH, Kim YS, Hamm IS. Does non-perimesencephalic type non-aneurysmal subarachnoid hemorrhage have a benign prognosis? J Clin Neurosci 2009; 16:904-8. [PMID: 19362482 DOI: 10.1016/j.jocn.2008.10.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Accepted: 10/05/2008] [Indexed: 10/20/2022]
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Abstract
OBJECTIVE Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many patients with SAH are seriously ill and require a prolonged intensive care unit stay. Cardiopulmonary complications are common. The management of patients with SAH focuses on the anticipation, prevention, and management of these secondary complications. DATA SOURCES Source data were obtained from a PubMed search of the medical literature. DATA SYNTHESIS AND CONCLUSION The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means. During the first 1-2 weeks after hemorrhage, patients are at risk of delayed ischemic deficits due to vasospasm, autoregulatory failure, and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty, and intra-arterial vasodilators. SAH is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
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Vasospasm after aneurysmal subarachnoid hemorrhage: need for further study. CEREBRAL HEMORRHAGE 2009; 105:207-10. [DOI: 10.1007/978-3-211-09469-3_39] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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Macdonald RL. Clazosentan: an endothelin receptor antagonist for treatment of vasospasm after subarachnoid hemorrhage. Expert Opin Investig Drugs 2009; 17:1761-7. [PMID: 18922111 DOI: 10.1517/13543784.17.11.1761] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Clazosentan (Ro 61-1790, VML-588 or AXV-034) is under study in clinical trials for the treatment of patients with aneurysmal subarachnoid hemorrhage (SAH) by Actelion Pharmaceuticals. It is a synthetic endothelin (ET) A receptor antagonist that decreases and reverses cerebral vasospasm after experimental SAH. Remarkable dose-dependent effects were observed on angiographic vasospasm in the CONSCIOUS-1 human clinical trial, supporting proceeding with a Phase III clinical trial. This study (CONSCIOUS-2) will enroll approximately 765 patients randomized 2:1 to clazosentan 5 mg/h intravenously or placebo. All patients will undergo neurosurgical aneurysm clipping and outcome will be assessed primarily based on mortality and vasospasm-related morbidity.
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Affiliation(s)
- R Loch Macdonald
- University of Toronto, St Michael Hospital, Division of Neurosurgery, Keenan Research Centre, Toronto, Ontario, Canada.
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Macdonald RL. Clazosentan: a review of subarachnoid hemorrhage data. FUTURE NEUROLOGY 2009. [DOI: 10.2217/14796708.4.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Clazosentan (Ro 61–1790, VML-588 or AXV-034) is a synthetic endothelin (ET)-receptor antagonist that was derived from one of the first nonselective synthetic ET-receptor antagonists, bosentan. The structural modifications were designed to increase selectivity for the ETA receptor and optimize aqueous solubility, both of which were fulfilled. Selectivity is approximately 1000-fold greater for the ETA receptor with a pA2 in the nanomolar range. The half-life in humans is less than 2 h and the main side effects are headache, nausea and vomiting in clinically important doses, although they are not reported to be a problem in target disease populations. Clazosentan reverses established vasospasm in dogs with subarachnoid hemorrhage (SAH) and in preliminary studies in humans. It also prevents vasospasm in the double hemorrhage model of vasospasm in dogs and significantly decreases angiographic vasospasm after aneurysmal SAH in humans. The doses required are in the range of 5 to 15 mg/h in humans and correspond to effective doses in animal studies. These doses are also associated with relevant plasma and cerebrospinal fluid concentrations of the drug. A dose-finding study of clazosentan for prevention of vasospasm after SAH in humans showed a significant dose-dependent decrease in vasospasm and was favorable enough to lead to a Phase III trial.
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
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Sabri M, Kawashima A, Ai J, Macdonald RL. Neuronal and astrocytic apoptosis after subarachnoid hemorrhage: a possible cause for poor prognosis. Brain Res 2008; 1238:163-71. [PMID: 18786513 DOI: 10.1016/j.brainres.2008.08.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 08/07/2008] [Accepted: 08/08/2008] [Indexed: 01/05/2023]
Abstract
Clinical evidence suggests that factors other than cerebral vasospasm, such as delayed neuronal and astrocytic cell death, may play a role in the poor prognosis of patients with subarachnoid hemorrhage (SAH). Here we examined this using immunohistochemistry and confocal microscopy in 3 different brain areas in a dog model of SAH. Using antibodies against neuronal marker neuronal nuclear protein (NeuN) and astrocyte marker glial fibrillary acidic protein (GFAP) in conjunction with apoptosis marker (cleaved caspase-3), we quantified neurons and astrocytes to monitor the degree of apoptosis in both groups. Experimental SAH group showed 44 +/- 1% caspase-3 positive neurons in comparison to the 2.0 +/- 0.1% in the control group (P < 0.001, 6 animals each group). For astrocytes, a total 25 +/- 1% were caspase-3 positive in day 7 SAH group, as compared to 0.40 +/- 0.01% for controls (P < 0.001). Regional analysis revealed that neuronal caspase-3 immunoreactivity in all 3 regions were significantly higher (P < 0.001) in SAH animals than that in the control animals. However, the analysis of total area, size and signal co-localization of GFAP with caspase-3 indicated that astrocytic reactivity and proliferation are seen primarily in the hippocampal area, with the least changes detectable in the brainstem. We conclude that in the dog model, there was a significant increase of neuronal and astrocytic cleaved caspase-3, possibly reflecting apoptosis, following SAH induction. These changes coupled with neurological deterioration seen in patients may present a possible reason for the poor outcome in SAH patients.
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Affiliation(s)
- Mohammed Sabri
- Division of Neurosurgery, St Michael's Hospital, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's, Toronto, Ontario, Canada
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The use of S100B as a biomarker in subarachnoid hemorrhage: Clarity in its promise and limits*. Crit Care Med 2008; 36:2452-3. [DOI: 10.1097/ccm.0b013e3181810457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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