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Vandenbulcke A, Messerer M, Garvayo Navarro M, Peters DR, Starnoni D, Giammattei L, Ben-Hamouda N, Puccinelli F, Saliou G, Cossu G, Daniel RT. Cisternal nicardipine for prevention of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a comparative retrospective cohort study. Acta Neurochir (Wien) 2024; 166:133. [PMID: 38472426 DOI: 10.1007/s00701-024-06023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile. METHODS We performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group). RESULTS Seventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group. CONCLUSION Administration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Marta Garvayo Navarro
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - David R Peters
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Lorenzo Giammattei
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland.
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Vandenbulcke A, Messerer M, Daniel RT, Cossu G. The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review. Brain Sci 2023; 13:1580. [PMID: 38002540 PMCID: PMC10670052 DOI: 10.3390/brainsci13111580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, 1015 Lausanne, Switzerland
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Sathialingam E, Cowdrick KR, Liew AY, Fang Z, Lee SY, McCracken CE, Akbik F, Samuels OB, Kandiah P, Sadan O, Buckley EM. Microvascular cerebral blood flow response to intrathecal nicardipine is associated with delayed cerebral ischemia. Front Neurol 2023; 14:1052232. [PMID: 37006474 PMCID: PMC10064128 DOI: 10.3389/fneur.2023.1052232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 03/19/2023] Open
Abstract
One of the common complications of non-traumatic subarachnoid hemorrhage (SAH) is delayed cerebral ischemia (DCI). Intrathecal (IT) administration of nicardipine, a calcium channel blocker (CCB), upon detection of large-artery cerebral vasospasm holds promise as a treatment that reduces the incidence of DCI. In this observational study, we prospectively employed a non-invasive optical modality called diffuse correlation spectroscopy (DCS) to quantify the acute microvascular cerebral blood flow (CBF) response to IT nicardipine (up to 90 min) in 20 patients with medium-high grade non-traumatic SAH. On average, CBF increased significantly with time post-administration. However, the CBF response was heterogeneous across subjects. A latent class mixture model was able to classify 19 out of 20 patients into two distinct classes of CBF response: patients in Class 1 (n = 6) showed no significant change in CBF, while patients in Class 2 (n = 13) showed a pronounced increase in CBF in response to nicardipine. The incidence of DCI was 5 out of 6 in Class 1 and 1 out of 13 in Class 2 (p < 0.001). These results suggest that the acute (<90 min) DCS-measured CBF response to IT nicardipine is associated with intermediate-term (up to 3 weeks) development of DCI.
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Affiliation(s)
- Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Kyle R. Cowdrick
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Amanda Y. Liew
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Zhou Fang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Seung Yup Lee
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Electrical and Computer Engineering, Kennesaw State University, Marietta, GA, United States
| | - Courtney E. McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States
| | - Feras Akbik
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Owen B. Samuels
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Prem Kandiah
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Erin M. Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, United States
- Children's Research Scholar, Children's Healthcare of Atlanta, Atlanta, GA, United States
- *Correspondence: Erin M. Buckley
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Dodson V, Majmundar N, El-ghanem M, Amuluru K, Gupta G, Nuoman R, Wainwright J, Kaur G, Cole C, Santarelli J, Chandy D, Bowers C, Gandhi C, Al-mufti F. Intracranial Administration of Nicardipine After Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature. World Neurosurg 2019; 125:511-518.e1. [DOI: 10.1016/j.wneu.2019.01.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 01/08/2023]
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Satoh S, Yamamoto Y, Toshima Y, Ikegaki I, Asano T, Suzuki Y, Shibuya M. Fasudil, a protein kinase inhibitor, prevents the development of endothelial injury and neutrophil infiltration in a two-haemorrhage canine subarachnoid model. J Clin Neurosci 1999; 6:394-9. [DOI: 10.1016/s0967-5868(99)90034-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Shibuya M, Suzuki Y, Enomoto H, Okada T, Ogura K, Sugita K. Effects of prophylactic intrathecal administrations of nicardipine on vasospasm in patients with severe aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 1994; 131:19-25. [PMID: 7709781 DOI: 10.1007/bf01401450] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Calcium antagonists are currently most widely used for chronic cerebral vasospasm after aneurysmal subarachnoid haemorrhage (SAH). However, the vasodilatory effects of systemically administered calcium antagonists can be limited secondary to hypotension. We previously compared intrathecal and intravenous routes of administration of nicardipine. Intrathecal administration of nicardipine significantly dilated spastic basilar arteries on day 7 in a two-haemorrhage canine model of vasospasm. In the present communication, the effects of prophylactic, serial administration of intrathecal nicardipine on vasospasm was examined in 50 patients. Patients were classified as Fisher SAH group 3 and all had their aneurysms clipped within 3 days of SAH. Following placement of a cisternal drain, 2 mg of nicardipine was injected, three times each day for an average of 10 days. The control group consisted of 91 similar patients with cisternal drainage not treated with nicardipine. Intrathecal administration of nicardipine decreased the incidence of symptomatic vasospasm by 26%, angiographic vasospasm by 20% and increased good clinical outcome at one month after the haemorrhage by 15%. Postoperative angiograms revealed that patients in the nicardipine group showed less vasospasm of major cerebral arteries, near the tip of a drain in the basal cistern, but vasospasm in the A2 and M2 segments was not decreased. Radio-isotope cisternography suggested that nicardipine might not reach the subarachnoid space around A2 and M2 segments. Nine patients complained of headache probably secondary to nicardipine induced vasodilation. Two patients suffered from meningitis, both were successfully treated. Intrathecal administration nicardipine appears to be effective in the treatment of vasospasm, but side effects were significant.
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Affiliation(s)
- M Shibuya
- Department of Neurosurgery, Nagoya University, Japan
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