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Takenaka T, Nakamura H, Yamada S, Kidani T, Tateishi A, Toyota S, Fujinaka T, Taki T, Wakayama A, Kishima H. A novel predictor of ischemic complications in the treatment of ruptured middle cerebral artery aneurysms: Neck-branching angle. World Neurosurg X 2024; 23:100370. [PMID: 38584877 PMCID: PMC10998237 DOI: 10.1016/j.wnsx.2024.100370] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
Objective The risk factors of procedural cerebral ischemia (CI) in ruptured middle cerebral artery (MCA) aneurysms are unclear. This study proposed the neck-branching angle (NBA), a simple quantitative indicator of the aneurysm neck and branch vessels, and analyzed its usefulness as a predictor of procedural CI in ruptured MCA aneurysms. Methods We retrospectively analyzed 128 patients with ruptured saccular MCA aneurysms who underwent surgical or endovascular treatment between January 2014 and June 2021. We defined the NBA as the angle formed by the MCA aneurysm neck and M2 superior or inferior branch vessel line. The superior and inferior NBA were measured on admission via three-dimensional computed tomography angiography on admission. We divided the patients into clipping (106 patients) and coiling (22 patients) groups according to the treatment. Risk factors associated with procedural CI were analyzed in each group. Results Both groups showed that an enlarged superior NBA was a significant risk factor for procedural CI (clipping, P < 0.0005; coiling group, P = 0.007). The receiver operating characteristic curve showed the closed thresholds of the superior NBA with procedural CI in both groups (clipping group, 128.5°, sensitivity and specificity of 0.667 and 0.848, respectively; coiling group, 130.9°, sensitivity and specificity of 1 and 0.889, respectively). Conclusion The NBA can estimate the procedural risk of ruptured MCA aneurysms. In addition, an enlarged superior NBA is a risk factor for procedural CI in both clipping and coiling techniques.
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Affiliation(s)
- Tomofumi Takenaka
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shuhei Yamada
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Osaka, Osaka, Japan
| | - Akihiro Tateishi
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Shingo Toyota
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Osaka, Osaka, Japan
| | - Takuyu Taki
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Akatsuki Wakayama
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Yokota M, Okada T, Asaeda M, Iida T, Tanada S, Tuji S, Nigami T. Effect of Intrathecal Urokinase Infusion on Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2024; 181:e678-e684. [PMID: 37898263 DOI: 10.1016/j.wneu.2023.10.113] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/22/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) causes serious neurological complications, despite surgical clipping of the aneurysm. Intrathecal urokinase (UK) infusion has been shown to effectively prevent symptomatic vasospasm in patients who have undergone endovascular obliteration of the ruptured aneurysms. OBJECTIVE To investigate whether intrathecal UK infusion can prevent symptomatic vasospasm in patients undergoing surgical or endovascular treatment. METHODS A total of 90 patients with severe aneurysmal SAH were enrolled and assigned to a surgical neck clipping (n = 56) or an endovascular coil embolization (n = 34) groups. After treatment, UK infusion from the lumbar drain was repeated in 32 patients in the surgical neck clipping group (group B) and all in the endovascular coil embolization group (group C) until complete resolution of the SAH was observed on computed tomography. The remaining 24 of the surgical neck clipping group, without UK infusion, were assigned to group A. RESULTS Symptomatic vasospasm occurred in 7 (29.2%) patients in group A, 2 (6.3%) in group B, and none in group C (group A vs. group B [P = 0.02]; group B vs. group C [P = 0.14]). Excellent clinical outcomes (modified Rankin score, 0 or 1) were observed in 37.5%, 59.4%, and 76.5% of patients in group A, B, and C, respectively (group A vs. group B [P = 0.11]). CONCLUSION Clearance of SAH via intrathecal UK infusion significantly reduced symptomatic vasospasm in patients in both UK groups, resulting in better clinical outcomes.
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Affiliation(s)
- Masayuki Yokota
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan.
| | - Takuya Okada
- Department of Anesthesiology, School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Masahiro Asaeda
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Tomoko Iida
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Shuichi Tanada
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Shoichiro Tuji
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Taishi Nigami
- Department of Neurosurgery, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
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Zeineddine HA, Divito A, McBride DW, Pandit P, Capone S, Dawes BH, Chen CJ, Grotta JC, Blackburn SL. Subarachnoid Blood Clearance and Aneurysmal Subarachnoid Hemorrhage Outcomes: A Retrospective Review. Neurocrit Care 2023; 39:172-179. [PMID: 37100974 DOI: 10.1007/s12028-023-01729-x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/03/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) continues to be a significant contributor to morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Subarachnoid blood and its degradation products have been implicated in DCI, and faster blood clearance has been hypothesized to confer better outcomes. This study evaluates the relationship between blood volume and its clearance on DCI (primary outcome) and location at 30 days (secondary outcome) after aSAH. METHODS This is a retrospective review of adult patients presenting with aSAH. Hijdra sum scores (HSS) were assessed independently for each computed tomography (CT) scan of patients with available scans on post-bleed days 0-1 and 2-10. This cohort was used to evaluate the course of subarachnoid blood clearance (group 1). A subset of patients in the first cohort with available CT scans on both post-bleed days 0-1 and post-bleed days 3-4 composed the second cohort (group 2). This group was used to evaluate the association between initial subarachnoid blood (measured via HSS post-bleed days 0-1) and its clearance (measured via percentage reduction [HSS %Reduction] and absolute reduction [HSS-Abs-Reduction] in HSS between days 0-1 and 3-4) on outcomes. Univariable and multivariable logistic regression models were used to identify outcome predictors. RESULTS One hundred fifty-six patients were in group 1, and 72 patients were in group 2. In this cohort, HSS %Reduction was associated with decreased risk of DCI in univariate (odds ratio [OR] = 0.700 [0.527-0.923], p = 0.011) and multivariable (OR = 0.700 [0.527-0.923], p = 0.012) analyses. Higher HSS %Reduction was significantly more likely to have better outcomes at 30 days in the multivariable analysis (OR = 0.703 [0.507-0.980], p = 0.036). Initial subarachnoid blood volume was associated with outcome location at 30 days (OR = 1.331 [1.040-1.701], p = 0.023) but not DCI (OR = 0.945 [0.780-1.145], p = 0.567). CONCLUSIONS Early blood clearance after aSAH was associated with DCI (univariable and multivariable analyses) and outcome location at 30 days (multivariable analysis). Methods facilitating subarachnoid blood clearance warrant further investigation.
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Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Anthony Divito
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Devin W McBride
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Peeyush Pandit
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Stephen Capone
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Bryden H Dawes
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, University of Texas Health Science Center at Houston, University of Texas McGovern Medical School, Houston, TX, USA.
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NAGAI A, SUZUKI Y, ISHIDA T, SATO Y, INOUE T, TOMINAGA T. Marked Reduction of Cerebral Vasospasm with Intrathecal Urokinase Infusion Therapy after Endovascular Coil Embolization of the Aneurysmal Subarachnoid Hemorrhage: A Case Series. Neurol Med Chir (Tokyo) 2022; 62:566-574. [PMID: 36223948 PMCID: PMC9831621 DOI: 10.2176/jns-nmc.2022-0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Delayed cerebral vasospasms after subarachnoid hemorrhage (SAH) are a risk factor for poor prognosis after successful treatment of ruptured intracranial aneurysms. Different strategies to remove clots from the subarachnoid space and prevent vasospasms have different outcomes. Intrathecal urokinase infusion therapy combined with endovascular treatment (EVT) can reduce the incidence of symptomatic vasospasms. To analyze the relationship between symptomatic vasospasms and residual SAHs after urokinase infusion therapy, we retrospectively reviewed the records of 348 consecutive patients managed with EVT and intrathecal urokinase infusion therapy for aneurysmal SAH at our institution between 2010 and 2021. Among them, 163 patients met the study criteria and were classified into two groups according to the presence of residual SAH in the cisterns, Sylvian fissures, and frontal interhemispheric fissure. The incidence of symptomatic vasospasms and the clinical outcomes were assessed. In total, eight (5.0%) patients developed symptomatic vasospasms. Patients with symptomatic vasospasms had a significantly higher incidence of residual SAH in the Sylvian or frontal interhemispheric fissures than those without (P <.0001). No patient with SAHs resolved by urokinase infusion therapy developed symptomatic vasospasms. However, the two groups did not differ significantly in terms of modified Rankin scale scores at discharge. Treatment with intrathecal urokinase infusion after EVT for aneurysmal SAH can substantially reduce the risk of clinically evident vasospasms.
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Affiliation(s)
- Arata NAGAI
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Yasuhiro SUZUKI
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Tomohisa ISHIDA
- Department of Neurosurgery, Iwaki City Medical Center, Iwaki, Fukushima, Japan
| | - Yoshimichi SATO
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tomoo INOUE
- Department of Neurosurgery, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Sugiyama H, Tsutsumi S, Ishii H. Oculomotor nerve palsy presumably caused by cisternal drain during microsurgical clipping. Surg Neurol Int 2022; 13:398. [PMID: 36128102 PMCID: PMC9479575 DOI: 10.25259/sni_364_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/18/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Oculomotor nerve palsy can be caused by diverse etiologies, but no report has yet documented its association with a cisternal drain. Case Description: A 35-year-old woman presented with severe headache. The patient did not exhibit oculomotor nerve palsy at presentation. Cranial computed tomography (CT) revealed diffuse subarachnoid hemorrhage. The patient underwent open microsurgical clipping of a ruptured middle cerebral artery aneurysm. During surgery, a cisternal drain was placed in the basal cistern at the medial aspect of the clinoidal portion of the internal carotid artery. The patient presented with the left oculomotor nerve palsy immediately after surgery. CT revealed displacement of the cisternal drain to the lateral aspect of the anterior clinoid process. The patient’s mydriasis and sluggish light reaction recovered after 7 days, while extraocular movements persisted for 50 days. The constructive interference steady-state sequence detected the left oculomotor nerve coursing adjacent to the clinoidal internal carotid artery. Conclusion: Oculomotor nerve palsy can be caused by collision with a thin silastic tube placed during surgery for aneurysmal subarachnoid hemorrhage. Withdrawal of the drain as early as possible is recommended when drain-associated oculomotor nerve palsy is suspected.
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Florez-perdomo W, García-ballestas E, Lozada-martínez ID, Quiñones-ossa GA, Joaquim A, Agrawal A, Janjua T, Rahman S, Suarez-causado A, Moscote-salazar LR. Cisternal irrigation and clot removal to prevent vasospasm and poor outcome in aneurysmal subarachnoid hemorrhage: Systematic review and meta-analysis. International Journal of Surgery Open 2022. [DOI: 10.1016/j.ijso.2022.100459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Fang Y, Wang X, Lu J, Shi H, Huang L, Shao A, Zhang A, Liu Y, Ren R, Lenahan C, Tang J, Zhang J, Zhang JH, Chen S. Inhibition of caspase-1-mediated inflammasome activation reduced blood coagulation in cerebrospinal fluid after subarachnoid haemorrhage. EBioMedicine 2022; 76:103843. [PMID: 35101655 PMCID: PMC8822177 DOI: 10.1016/j.ebiom.2022.103843] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background Neuroinflammation and blood coagulation responses in cerebrospinal fluid (CSF) contribute to the poor outcome associated with subarachnoid haemorrhage (SAH). We explored the role of caspase-1-mediated inflammasome activation on extrinsic blood coagulation in CSF after SAH. Methods Post-SAH proteomic changes and correlation between caspase-1 with extrinsic coagulation factors in human CSF after SAH were analysed. Time course and cell localisation of brain inflammasome and extrinsic coagulation proteins after SAH were explored in a rat SAH model. Pharmacological inhibition of caspase-1 via VX-765 was used to explore the role of caspase-1 in blood clearance and CSF circulation after SAH in rats. Primary astrocytes were used to evaluate the role of caspase-1 in haemoglobin-induced pyroptosis and tissue factor (TF) production/release. Findings Neuroinflammation and blood coagulation activated after SAH in human CSF. The caspase-1 levels significantly correlated with the extrinsic coagulation factors. The activated caspase-1 and extrinsic coagulation initiator TF was increased on astrocytes after SAH in rats. VX-765 attenuated neurological deficits by accelerating CSF circulation and blood clearance through inhibiting pyroptotic neuroinflammation and TF-induced fibrin deposition in the short-term, and improved learning and memory capacity by preventing hippocampal neuronal loss and hydrocephalus in the long-term after SAH in rats. VX-765 reduced haemoglobin-induced pyroptosis and TF production/release in primary astrocytes. Interpretation Inhibition of caspase-1 by VX-765 appears to be a potential treatment against neuroinflammation and blood coagulation in CSF after SAH. Funding This study was supported by National Institutes of Health of United States of America, and National Natural Science Foundation of China.
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Affiliation(s)
- Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Jianan Lu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Hui Shi
- Department of Neurosurgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Lei Huang
- Department of Neurosurgery, Loma Linda University, 11041 Campus St, Risley Hall, Room 219, Loma Linda, CA 92354, United States; Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Reng Ren
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China
| | - Cameron Lenahan
- Department of Neurosurgery, Loma Linda University, 11041 Campus St, Risley Hall, Room 219, Loma Linda, CA 92354, United States; Burrell College of Osteopathic Medicine, Las Cruces, NM, United States
| | - Jiping Tang
- Department of Neurosurgery, Loma Linda University, 11041 Campus St, Risley Hall, Room 219, Loma Linda, CA 92354, United States; Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States; Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - John H Zhang
- Department of Neurosurgery, Loma Linda University, 11041 Campus St, Risley Hall, Room 219, Loma Linda, CA 92354, United States; Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States; Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States.
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
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Balança B, Bouchier B, Ritzenthaler T. The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Rev Neurol (Paris) 2021; 178:64-73. [PMID: 34961603 DOI: 10.1016/j.neurol.2021.11.006] [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: 05/02/2021] [Revised: 10/20/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a rare event affecting relatively young patients therefore leading to a high social impact. The management of SAH follows a biphasic course with early brain injuries in the first 72 hours followed by a phase at risk of secondary deterioration due to delayed cerebral ischemia (DCI) in 20 to 30% patients. Cerebral infarction from DCI is the most preventable cause of mortality and morbidity after SAH. DCI prevention, early detection and treatment is therefore advocated. Formerly limited to the occurrence of vasospasm, DCI is now associated with multiple pathophysiological processes involving for instance the macrocirculation, the microcirculation, neurovascular units, and inflammation. Therefore, the therapeutic targets and management strategies are also evolving and are not only focused on proximal vasospasm. In this review, we describe the current knowledge of DCI pathophysiology. We then discuss the diagnosis strategies that may guide physicians at the bedside with a multimodal approach in the unconscious patient. We will present the prevention strategies that have proven efficient as well as future targets and present the therapeutic approach that is currently being developed when a DCI occurs.
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Affiliation(s)
- B Balança
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France; Équipe TIGER, U1028, UMR5292, centre de recherche en neurosciences de Lyon, université de Lyon, 69500 Bron, France.
| | - B Bouchier
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France
| | - T Ritzenthaler
- Service d'anesthésie réanimation, hospices civils de Lyon, hôpital neurologique, 59, boulevard Pinel, 69500 Bron, France; InserMU1044, INSA-Lyon, CNRS UMR5220, Université Lyon 1, hospices civils de Lyon, université de Lyon CREATIS, Bron cedex, France
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Hvas CL, Hvas AM. Hemostasis and Fibrinolysis following Aneurysmal Subarachnoid Hemorrhage: A Systematic Review on Additional Knowledge from Dynamic Assays and Potential Treatment Targets. Semin Thromb Hemost 2021; 48:356-381. [PMID: 34261149 DOI: 10.1055/s-0041-1730346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mortality after aneurysmal subarachnoid hemorrhage (aSAH) is augmented by rebleeding and delayed cerebral ischemia (DCI). A range of assays evaluating the dynamic process of blood coagulation, from activation of clotting factors to fibrinolysis, has emerged and a comprehensive review of hemostasis and fibrinolysis following aSAH may reveal targets of treatment. We conducted a systematic review of existing literature assessing coagulation and fibrinolysis following aSAH, but prior to treatment. PubMed, Embase, and Web of Science were searched on November 18, 2020, without time boundaries. In total, 45 original studies were eventually incorporated into this systematic review, divided into studies presenting data only from conventional or quantitative assays (n = 22) and studies employing dynamic assays (n = 23). Data from conventional or quantitative assays indicated increased platelet activation, whereas dynamic assays detected platelet dysfunction possibly related to an increased risk of rebleeding. Secondary hemostasis was activated in conventional, quantitative, and dynamic assays and this was related to poor neurological outcome and mortality. Studies systematically investigating fibrinolysis were sparse. Measurements from conventional or quantitative assays, as well as dynamic fibrinolysis assays, revealed conflicting results with normal or increased lysis and changes were not associated with outcome. In conclusion, dynamic assays were able to detect reduced platelet function, not revealed by conventional or quantitative assays. Activation of secondary hemostasis was found in both dynamic and nondynamic assays, while changes in fibrinolysis were not convincingly demonstrable in either dynamic or conventional or quantitative assays. Hence, from a mechanistic point of view, desmopressin to prevent rebleeding and heparin to prevent DCI may hold potential as therapeutic options. As changes in fibrinolysis were not convincingly demonstrated and not related to outcome, the use of tranexamic acid prior to aneurysm closure is not supported by this review.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Motoyama Y, Kogeichi Y, Matsuoka R, Takamura Y, Takeshima Y, Matsuda R, Tamura K, Nishimura F, Yamada S, Nakagawa I, Saito K, Park YS, Sugie K, Fukushima H, Nakase H. External Brain Tamponade Paradoxically Induced by Cerebrospinal Fluid Hypovolemia After Decompressive Craniectomy: A Retrospective Cohort Study. Neurosurg open 2021. [DOI: 10.1093/neuopn/okaa023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chan AY, Choi EH, Yuki I, Suzuki S, Golshani K, Chen JW, Hsu FP. Cerebral vasospasm after subarachnoid hemorrhage: Developing treatments. Brain Hemorrhages 2021. [DOI: 10.1016/j.hest.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Tsunoda S, Inoue T, Ono H, Naemura K, Akabane A. Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports. Surg Neurol Int 2020; 11:164. [PMID: 32637217 PMCID: PMC7332699 DOI: 10.25259/sni_47_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/10/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Some complications associated with cisternal drainage have been reported; however, there are few reports on direct vascular injury caused by cisternal drain. We experienced two rare cases of thalamic infarction caused by cisternal drain placement during open clipping for a ruptured anterior communicating artery (AcomA) aneurysm through an anterior interhemispheric approach. Case Description: Two cases of ruptured AcomA aneurysm were treated by surgical clipping through an anterior interhemispheric approach, and then a cisternal drain was inserted from opticocarotid space toward prepontine cistern. Postoperatively, the magnetic resonance imaging showed unilateral anterior-medial thalamic infarction in both two cases. By reviewing the postoperative computed tomography and digital subtraction angiography, it was suspected that the cisternal drain, which was inserted slightly deep, obstructed the P1 perforator because of an anatomical variation involving a lowered basilar bifurcation and caused postoperative unilateral paramedian thalamic infarction. Conclusion: To avoid these complications, neurosurgeons should consider the potential for P1 perforator injury related to cisternal drain placement.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa, Tokyo
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa, Tokyo
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Sugita, Fujinomiya, Shizuoka, Japan
| | - Kazuaki Naemura
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa, Tokyo
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa, Tokyo
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Shimohata N, Echigo R, Karatsu K, Uchikawa S, Suzuki S, Chung UI, Sasaki N, Mochizuki M. Trehalose decreases blood clotting in the cerebral space after experimental subarachnoid hemorrhage. J Vet Med Sci 2020; 82:566-570. [PMID: 32173691 PMCID: PMC7273599 DOI: 10.1292/jvms.19-0201] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) frequently results in several serious complications, such as cerebral vasospasm. We previously reported the effect of trehalose on vasospasm, inflammatory
responses, and lipid peroxidation induced by blood exposure. Herein, to further elucidate the mechanism of action of trehalose, we investigated whether or not post-administration of
trehalose can directly influence blood clotting in the cistern. As a result of trehalose injection after the onset of experimental SAH, blood clotting around the basilar artery was clearly
inhibited. We also found that trehalose positively impacted coagulation and fibrinolysis parameters in rat, rabbit and human plasma in vitro. These findings suggest that
trehalose has suppressive effects on blood clotting in addition to vasospasm, inflammatory responses, and lipid peroxidation after SAH.
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Affiliation(s)
- Nobuyuki Shimohata
- Department of Biomedical Sciences, College of Life Sciences, Ritsumeikan University, 1-1-1 Nojihigashi, Kusatsu, Shiga 525-8577, Japan
| | - Ryosuke Echigo
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan.,Faculty of Veterinary Medicine, Hokkaido University, Kita 18, Nishi 9, Kita-ku, Sapporo, Hokkaido 080-0818, Japan
| | - Kensuke Karatsu
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Saori Uchikawa
- Department of Biomedical Sciences, College of Life Sciences, Ritsumeikan University, 1-1-1 Nojihigashi, Kusatsu, Shiga 525-8577, Japan
| | - Shigeki Suzuki
- NEXT21 K.K., 3-38-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Ung-Il Chung
- Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 2-11-16 Yayoi, Bunkyo-ku, Tokyo 113-8656, Japan.,Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Nobuo Sasaki
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Manabu Mochizuki
- Department of Veterinary Surgery, Graduate School of Agriculture and Life Science, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
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Khani M, Sass LR, Sharp MK, McCabe AR, Zitella Verbick LM, Lad SP, Martin BA. In vitro and numerical simulation of blood removal from cerebrospinal fluid: comparison of lumbar drain to Neurapheresis therapy. Fluids Barriers CNS 2020; 17:23. [PMID: 32178689 PMCID: PMC7077023 DOI: 10.1186/s12987-020-00185-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/06/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Blood removal from cerebrospinal fluid (CSF) in post-subarachnoid hemorrhage patients may reduce the risk of related secondary brain injury. We formulated a computational fluid dynamics (CFD) model to investigate the impact of a dual-lumen catheter-based CSF filtration system, called Neurapheresis™ therapy, on blood removal from CSF compared to lumbar drain. METHODS A subject-specific multiphase CFD model of CSF system-wide solute transport was constructed based on MRI measurements. The Neurapheresis catheter geometry was added to the model within the spinal subarachnoid space (SAS). Neurapheresis flow aspiration and return rate was 2.0 and 1.8 mL/min, versus 0.2 mL/min drainage for lumbar drain. Blood was modeled as a bulk fluid phase within CSF with a 10% initial tracer concentration and identical viscosity and density as CSF. Subject-specific oscillatory CSF flow was applied at the model inlet. The dura and spinal cord geometry were considered to be stationary. Spatial-temporal tracer concentration was quantified based on time-average steady-streaming velocities throughout the domain under Neurapheresis therapy and lumbar drain. To help verify CFD results, an optically clear in vitro CSF model was constructed with fluorescein used as a blood surrogate. Quantitative comparison of numerical and in vitro results was performed by linear regression of spatial-temporal tracer concentration over 24-h. RESULTS After 24-h, tracer concentration was reduced to 4.9% under Neurapheresis therapy compared to 6.5% under lumbar drain. Tracer clearance was most rapid between the catheter aspiration and return ports. Neurapheresis therapy was found to have a greater impact on steady-streaming compared to lumbar drain. Steady-streaming in the cranial SAS was ~ 50× smaller than in the spinal SAS for both cases. CFD results were strongly correlated with the in vitro spatial-temporal tracer concentration under Neurapheresis therapy (R2 = 0.89 with + 2.13% and - 1.93% tracer concentration confidence interval). CONCLUSION A subject-specific CFD model of CSF system-wide solute transport was used to investigate the impact of Neurapheresis therapy on tracer removal from CSF compared to lumbar drain over a 24-h period. Neurapheresis therapy was found to substantially increase tracer clearance compared to lumbar drain. The multiphase CFD results were verified by in vitro fluorescein tracer experiments.
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Affiliation(s)
- Mohammadreza Khani
- Department of Biological Engineering, The University of Idaho, 875 Perimeter Drive, MS 0904, Moscow, ID, 83844-0904, USA
| | - Lucas R Sass
- Department of Biological Engineering, The University of Idaho, 875 Perimeter Drive, MS 0904, Moscow, ID, 83844-0904, USA
| | - M Keith Sharp
- Department of Mechanical Engineering, University of Louisville, 332 Eastern Pkwy, Louisville, KY, 40292, USA
| | - Aaron R McCabe
- Minnetronix Neuro, Inc., 1635 Energy Park Dr, Saint Paul, MN, 55108, USA
| | | | - Shivanand P Lad
- Department of Neurosurgery, Duke University School of Medicine, 3100 Tower Blvd, Durham, NC, 27707, USA
| | - Bryn A Martin
- Department of Biological Engineering, The University of Idaho, 875 Perimeter Drive, MS 0904, Moscow, ID, 83844-0904, USA.
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Akkaya E, Evran Ş, Çalış F, Çevik S, Hanımoğlu H, Seyithanoğlu MH, Katar S, Karataş E, Koçyiğit A, Sağlam MY, Hatiboğlu MA, Kaynar MY. Effects of Intrathecal Verapamil on Cerebral Vasospasm in Experimental Rat Study. World Neurosurg 2019; 127:e1104-e1111. [DOI: 10.1016/j.wneu.2019.04.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 01/07/2023]
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16
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Borkar SA, Singh M, Kale SS, Suri A, Chandra PS, Kumar R, Sharma BS, Gaikwad S, Mahapatra AK. Spinal Cerebrospinal Fluid Drainage for prevention of Vasospasm in Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized controlled study. Asian J Neurosurg 2018; 13:238-246. [PMID: 29682015 PMCID: PMC5898086 DOI: 10.4103/1793-5482.228512] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of mortality and morbidity. Despite various treatment modalities, the optimal management of vasospasm remains elusive. In this regard; we undertook a prospective, randomized controlled study to evaluate the effectiveness of lumbar cerebrospinal fluid drainage (LCSFD) for prevention of cerebral vasospasm and its sequelae. Materials and Methods Patients with aneurysmal SAH who met the inclusion criteria were randomized into two groups - Group I (30 patients) underwent LCSFD whereas Group II (30 patients) did not undergo LCSFD. All patients underwent aneurysmal clipping. Both the groups received standard neurosurgical treatment except for LCSFD. The outcome was measured in terms of (1) clinically evident vasospasm; (2) vasospasm-related cerebral infarction; (3) condition of the patient at the time of discharge; and (4) Glasgow outcome score (GOS) at 1- and 3-month follow-up. Results LCSFD conferred a statistically significant benefit reducing the incidence of clinical vasospasm from 63% (in non-LCSFD group) to 30% (in LCSFD group) (P = 0.01) and incidence of vasospasm-related cerebral infarction from 53% (in non-LCSFD group) to 20% (in LCSFD group) (P = 0.007). Incidence of vasospasm was quantitatively lower in LCSFD group across all Hunt and Hess grades; however, it was statistically significant in SAH Grade III (P = 0.008). Mean duration of hospital stay was slightly lower in LCSFD group compared to non-LCSFD group; however, it did not reach statistical significance. A higher incidence of meningitis in LCSFD group was not statistically significant. A higher GOS was observed in LCSFD group at 1- and 3-month follow-up as compared to non-LCSFD group. Conclusion Drainage of CSF through a lumbar drain following aneurysmal SAH caused a statistically significant reduction in the incidence of clinical and radiological vasospasm and its sequelae. It also shortens the overall duration of hospital stay and improves the outcome as evidenced by a better GOS score at 1- and 3-month follow-up. The results of this prospective, randomized study establish the efficacy of LCSFD in prevention of vasospasm following aneurysmal SAH.
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Affiliation(s)
- Sachin Anil Borkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohanjit Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rajender Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shailesh Gaikwad
- Department of Neuroradiolgy, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok Kumar Mahapatra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Yamamoto T, Mori K, Esaki T, Nakao Y, Tokugawa J, Watanabe M. Preventive effect of continuous cisternal irrigation with magnesium sulfate solution on angiographic cerebral vasospasms associated with aneurysmal subarachnoid hemorrhages: a randomized controlled trial. J Neurosurg 2015; 124:18-26. [PMID: 26230471 DOI: 10.3171/2015.1.jns142757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECT Although cerebral vasospasm (CV) is one of the most important predictors for the outcome in patients with subarachnoid hemorrhage (SAH), no treatment has yet been established for this condition. This study investigated the efficacy of continuous direct infusion of magnesium sulfate (MgSO4) solution into the intrathecal cistern in patients with an aneurysmal SAH. METHODS An SAH caused by a ruptured aneurysm was identified on CT scans within 72 hours after SAH onset. All patients were treated by surgical clipping and randomized into 2 groups: a control group of patients undergoing a standard treatment and a magnesium (Mg) group of patients additionally undergoing continuous infusion of 5 mmol/L MgSO4 solution for 14 days. The Mg(2+) concentrations in serum and CSF were recorded daily. Neurological examinations were performed by intensive care clinicians. Delayed cerebral ischemia was monitored by CT or MRI. To assess the effect of the Mg treatment on CV, the CVs were graded on the basis of the relative degree of constriction visible on cerebral angiograms taken on Day 10 after the SAH, and transcranial Doppler ultrasonography was performed daily to measure blood flow velocity in the middle cerebral artery (MCA). Neurological outcomes and mortality rates were evaluated with the Glasgow Outcome Scale and modified Rankin Scale at 3 months after SAH onset. RESULTS Seventy-three patients admitted during the period of April 2008 to March 2013 were eligible and enrolled in this study. Three patients were excluded because of violation of protocol requirements. The 2 groups did not significantly differ in age, sex, World Federation of Neurosurgical Societies grade, or Fisher grade. In the Mg group, the Mg(2+) concentration in CSF gradually increased from Day 4 after initiation of the continuous MgSO4 intrathecal administration. No such increase was observed in the control group. No significant changes in the serum Mg(2+) levels were observed for 14 days, and no cardiovascular complications such as bradycardia or hypotension were observed in any of the patients. However, bradypnea was noted among patients in the Mg group. The Mg group had a significantly better CV grade than the control group (p < 0.05). Compared with the patients in the Mg group, those in the control group had a significantly elevated blood flow velocity in the MCA. Both groups were similar in the incidences of cerebral infarction, and the 2 groups also did not significantly differ in clinical outcomes. CONCLUSIONS Continuous cisternal irrigation with MgSO4 solution starting on Day 4 and continuing to Day 14 significantly inhibited CV in patients with aneurysmal SAH without severe cardiovascular complications. However, this improvement in CV neither reduced the incidence of delayed cerebral ischemia nor improved the functional outcomes in patients with SAH.
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Affiliation(s)
- Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama; and
| | - Takanori Esaki
- Department of Rehabilitation, Gifu Central Hospital, Gifu, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
| | - Mitsuya Watanabe
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka
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Affiliation(s)
- Susanne Boettinger
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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Saito A, Inoue M, Kon H, Imaruoka S, Basaki K, Midorikawa H, Sasaki T, Nishijima M. Effectiveness of intraarterial administration of fasudil hydrochloride for preventing symptomatic vasospasm after subarachnoid hemorrhage. Acta Neurochir Suppl 2015; 120:297-301. [PMID: 25366640 DOI: 10.1007/978-3-319-04981-6_50] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
OBJECTIVE We examined the effect of intraarterial administration of fasudil hydrochloride (IAFC), a Rho kinase inhibitor, for the prevention of symptomatic vasospasm after SAH by evaluating cerebral circulation. METHODS We evaluated IAFC cases of 57 sides of 38 patients (12 men and 26 women, average age 60.2 years old) diagnosed with aneurysmal subarachnoid hemorrhage (SAH) from February 2012 to November 2012. All cases were treated by clipping or coil embolization within 48 h after onset. Indication for IAFC was the existence of a spastic change on follow-up digital subtraction angiography (DSA) compared with that of onset. RESULTS Clipping was performed in 30 cases and coil embolization in 8 cases. IAFC was performed an average of 6.6 days after onset. Color gradient mapping demonstrated reduction of the circulation time after IAFC compared with before IAFC on 39 sides, no change on 15 sides, and extension on 3 sides. Average arterial circulation time before IAFC was 2.25 ± 0.57 s and after IAFC was 1.95 ± 0.55 s. IAFC significantly shortened average arterial circulation (P = 0.005). No case developed symptomatic vasospasm after IAFC. CONCLUSION IAFC significantly reduced the cerebral circulation time after aneurysmal SAH and might be effective for the prevention of symptomatic vasospasm.
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Affiliation(s)
- Atsushi Saito
- Departments of Neurosurgery and Radiology, Aomori Prefectural Central Hospital, 2-1-1 Higashitsukurimichi, Aomori, 0308553, Japan,
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Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. Interv Neurol 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
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Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
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Mori K, Yamamoto T, Miyazaki M, Hara Y, Koike N, Nakao Y. Potential risk of artificial cerebrospinal fluid solution without magnesium ion for cerebral irrigation and perfusion in neurosurgical practice. Neurol Med Chir (Tokyo) 2014; 53:596-600. [PMID: 24067770 PMCID: PMC4508684 DOI: 10.2176/nmc.oa2012-0295] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The effect of irrigation with artificial cerebrospinal fluid (CSF) containing various magnesium ion (Mg2+) concentrations on vasospastic arteries was investigated in the dog. Cerebral vasospasm was induced by the experimental subarachnoid hemorrhage model in 15 beagle dogs. Cisternal irrigation was performed for 1 hour via a microcatheter placed in the cisterna magna with commercially available artificial CSF (ARTCEREB®) with physiological concentration of Mg2+ (2.2 mEq/l) (ACM group, n = 5), ARTCEREB solution without Mg2+ (ACR group, n = 5), and ARTCEREB solution with higher Mg2+ concentration (5 mEq/l) (ACMM group, n = 5). CSF electrolyte concentrations and the diameters of the basilar and vertebral arteries were measured. In the ACM group, no changes were detected in either CSF Mg2+ concentration or arterial diameters. In the ACR group, the CSF Mg2+ decreased significantly to 0.8 ± 0.07 mEq/l from the baseline value of 1.4 ± 0.03 mEq/l, and both basilar and vertebral artery diameters were significantly decreased to 0.61 ± 0.18 mm and 0.57 ± 0.23 mm from their baseline values of 0.74 ± 0.22 mm and 0.68 ± 0.17 mm, respectively. In the ACMM group, the CSF Mg2+ significantly increased to 2.4 ± 0.15 mEq/l from the baseline value of 1.4 ± 0.05 mEq/l, and both basilar and vertebral artery diameters were significantly increased to 0.84 ± 0.19 mm and 0.90 ± 0.22 mm from their baseline values of 0.71 ± 0.21 mm and 0.69 ± 0.24 mm, respectively. Irrigation with artificial CSF solution without Mg2+ causes vasoconstriction of the cerebral artery. Irrigation with artificial CSF with appropriate Mg2+ concentration is essential, especially in patients with subarachnoid hemorrhage.
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Affiliation(s)
- Kentaro Mori
- Department of Neurosurgery, Juntendo University Shizuoka Hospital
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22
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Kim JH, Yi H, Ko Y, Kim Y, Kim D, Kim J. Effectiveness of papaverine cisternal irrigation for cerebral vasospasm after aneurysmal subarachnoid hemorrhage and measurement of biomarkers. Neurol Sci 2014; 35:715-22. [DOI: 10.1007/s10072-013-1589-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 11/17/2013] [Indexed: 10/26/2022]
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Zhang YP, Shields LB, Yao TL, Dashti SR, Shields CB. Intrathecal Treatment of Cerebral Vasospasm. J Stroke Cerebrovasc Dis 2013; 22:1201-11. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 04/11/2012] [Indexed: 11/24/2022] Open
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Ramakrishna R, Sekhar LN, Ramanathan D, Temkin N, Hallam D, Ghodke BV, Kim LJ. Intraventricular tissue plasminogen activator for the prevention of vasospasm and hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 2013; 67:110-7; discussion 117. [PMID: 20559098 DOI: 10.1227/01.neu.0000370920.44359.91] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The sequelae of aneurysmal subarachnoid hemorrhage (SAH) include vasospasm and hydrocephalus. OBJECTIVE To assess whether intraventricular tissue plasminogen activator (tPA) results in less vasospasm, fewer angioplasties, or fewer cerebrospinal fluid shunting procedures. METHODS 41 patients (tPA group, Hunt and Hess 3, 4, 5) from 2007 to 2008 received intraventricular tPA and lumbar drainage for a minimum of 5 days (range 5-7 days) and were compared to a matched group of 35 patients from 2006 to 2007 (Control, HH 3, 4, 5). Statistical comparison was done by t test analysis or Fisher exact tests and data are expressed as average+/-standard error of the mean. RESULTS There were no significant differences in demographic data, although the tPA group had a trend toward more surgical patients. The tPA group of patients had a significantly higher modified Fisher grade than controls (P<.001) and had a significantly better Hunt and Hess grade than controls (P<.03). The angioplasty rate was significantly lower among the tPA patients (15.0%+/-5.6) than controls (40.0%+/-8.5, P=.019). The number of days spent in severe vasospasm normalized over the 14-day monitoring period by transcranial Doppler was significantly lower in the tPA group (0.09+/-0.02) than controls (0.17+/-0.03). The shunt rate was significantly lower among tPA patients (17.5%+/-6.0) than controls (42.8%+/-8.6). There were 2 clinically silent tract hemorrhages in the tPA group (4.8%). CONCLUSION Intraventricular tPA is a safe and effective treatment for reducing both angioplasty and shunting rates in patients with SAH H&H Grades 3 to 5. A randomized trial is indicated.
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Affiliation(s)
- Rohan Ramakrishna
- Department of Neurological Surgery, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington 98104, USA
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Abstract
The removal of subarachnoid clot has been thought to be effective for prevention of cerebral vasospasm. However, it is suggested that the incidence of cerebral vasospasm is not high in the cases where ruptured cerebral aneurysms are obliterated using Guglielmi detachable coils (GDC) without clot removal. The effect of subarachnoid clot removal on the occurrence of cerebral vasospasm and the different incidence of cerebral vasospasm between clipping cases and in GDC cases are reviewed.Surgical clot removal in experimental model indicated marked preventive effect on cerebral vasospasm. However, the clinical trials of clot removal during early aneurysm surgery had failed to show satisfactory preventive effect for vasospasm, and the cumulative incidence of symptomatic vasospasm in these trials was 29%. As fibrinolytic drug, intrathecal administration of tissue plasminogen activator showed sufficient elimination of subarachnoid clot and prevention of cerebral vasospasm in the experimental studies and in the clinical case trials and nonrandomized case-control trials. However, the multi-center, randomized case-control trial showed no statistically significant effect on symptomatic cerebral vasospasm. On the other hand, the cumulative incidence of cerebral vasospasm in GDC cases was 20%. The comparative studies of the incidence of vasospasm between GDC cases and in clipping cases also showed less incidence of symptomatic vasospasm and a more favorable outcome in GDC cases. From the results of studies reviewed, the incidence of cerebral vasospasm seems less in GDC cases than in clipping cases. It should be clarified why clipping could not be dominant in the prevention of cerebral vasospasm compared to GDC.
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Affiliation(s)
- Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Japan.
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Senbokuya N, Kinouchi H, Kanemaru K, Ohashi Y, Fukamachi A, Yagi S, Shimizu T, Furuya K, Uchida M, Takeuchi N, Nakano S, Koizumi H, Kobayashi C, Fukasawa I, Takahashi T, Kuroda K, Nishiyama Y, Yoshioka H, Horikoshi T. Effects of cilostazol on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a multicenter prospective, randomized, open-label blinded end point trial. J Neurosurg 2013; 118:121-30. [DOI: 10.3171/2012.9.jns12492] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of subsequent morbidity and mortality. Cilostazol, a selective inhibitor of phosphodiesterase 3, may attenuate cerebral vasospasm because of its antiplatelet and vasodilatory effects. A multicenter prospective randomized trial was conducted to investigate the effect of cilostazol on cerebral vasospasm.
Methods
Patients admitted with SAH caused by a ruptured anterior circulation aneurysm who were in Hunt and Kosnik Grades I to IV and were treated by clipping within 72 hours of SAH onset were enrolled at 7 neurosurgical sites in Japan. These patients were assigned to one of 2 groups: the usual therapy group (control group) or the add-on 100 mg cilostazol twice daily group (cilostazol group). The group assignments were done by a computer-generated randomization sequence. The primary study end point was the onset of symptomatic vasospasm. Secondary end points were the onset of angiographic vasospasm and new cerebral infarctions related to cerebral vasospasm, clinical outcome as assessed by the modified Rankin scale, and length of hospitalization. All end points were assessed for the intention-to-treat population.
Results
Between November 2009 and December 2010, 114 patients with SAH were treated by clipping within 72 hours from the onset of SAH and were screened. Five patients were excluded because no consent was given. Thus, 109 patients were randomly assigned to the cilostazol group (n = 54) or the control group (n = 55). Symptomatic vasospasm occurred in 13% (n = 7) of the cilostazol group and in 40% (n = 22) of the control group (p = 0.0021, Fisher exact test). The incidence of angiographic vasospasm was significantly lower in the cilostazol group than in the control group (50% vs 77%; p = 0.0055, Fisher exact test). Multiple logistic analyses demonstrated that nonuse of cilostazol is an independent factor for symptomatic and angiographic vasospasm. The incidence of new cerebral infarctions was also significantly lower in the cilostazol group than in the control group (11% vs 29%; p = 0.0304, Fisher exact test). Clinical outcomes at 1, 3, and 6 months after SAH in the cilostazol group were better than those in the control group, although a significant difference was not shown. There was also no significant difference in the length of hospitalization between the groups. No severe adverse event occurred during the study period.
Conclusions
Oral administration of cilostazol is effective in preventing cerebral vasospasm with a low risk of severe adverse events. Clinical trial registration no. UMIN000004347, University Hospital Medical Information Network Clinical Trials Registry.
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Affiliation(s)
- Nobuo Senbokuya
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Hiroyuki Kinouchi
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Kazuya Kanemaru
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Yasuhiro Ohashi
- 2Department of Neurosurgery and Radiology, Nasu Neurosurgical Center, Nasushiobara, Tochigi
| | - Akira Fukamachi
- 2Department of Neurosurgery and Radiology, Nasu Neurosurgical Center, Nasushiobara, Tochigi
| | - Shinichi Yagi
- 3Department of Neurosurgery, Kanto Neurosurgical Hospital, Kumagaya, Saitama
| | - Tsuneo Shimizu
- 3Department of Neurosurgery, Kanto Neurosurgical Hospital, Kumagaya, Saitama
| | - Koro Furuya
- 4Department of Neurosurgery, Suwa Central Hospital, Chino, Nagano; and
| | - Mikito Uchida
- 4Department of Neurosurgery, Suwa Central Hospital, Chino, Nagano; and
| | - Nobuyasu Takeuchi
- 5Department of Neurosurgery, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi
| | - Shin Nakano
- 5Department of Neurosurgery, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi
| | - Hidehito Koizumi
- 5Department of Neurosurgery, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi
| | | | - Isao Fukasawa
- 6Department of Neurosurgery, Kofu Johnan Hospital, Kofu, Yamanashi
| | - Teruo Takahashi
- 7Department of Neurosurgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Katsuhiro Kuroda
- 7Department of Neurosurgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Yoshihisa Nishiyama
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Hideyuki Yoshioka
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
| | - Toru Horikoshi
- 1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi
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Sato T, Sasaki T, Sakuma J, Watanabe T, Ichikawa M, Ito E, Oda K, Matsumoto Y, Ando H, Nishijima M, Saito K. Usefulness of three-dimensional computed tomography to quantify the subarachnoid hemorrhage volume: prediction of symptomatic vasospasm. Acta Neurochir Suppl 2013; 115:63-66. [PMID: 22890646 DOI: 10.1007/978-3-7091-1192-5_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We quantified the subarachnoid hemorrhage (SAH) volume in 64 patients on three-dimensional computed tomography (3D-CT) scans and studied the correlation between the SAH volume and the occurrence of symptomatic vasospasm (SVS). We studied 64 patients with SAH onset (day 0) and on days 1, 4, 7, and 14. We compared the hematoma volume by 3D-CT with 2D-CT on day 0 and examined the correlation between the hematoma volume and the occurrence of SVS. The hematoma volume, including the volume of normal structures, was automatically calculated (V1). The volume of normal structures manifesting identical CT numbers was previously calculated in patients without intracranial lesions (V2). The total hematoma volume was defined as V1 minus mean value of V2 (= 12 ml). The mean hematoma volume by 3D-CT was 48 ± 12 ml and by 2D-CT was 31 ± 45 ml (mean ± SD, n = 64). The hematoma volume was significantly larger by 3D-CT than by 2D-CT (p < 0.05). At all time points, the hematoma volumes were significantly larger in patients with than without SVS. We developed a new method for the quantitative determination of the SAH volume by 3D-CT. This method may allow us to quantify the volume of SAH in clinical studies of cerebral vasospasm.
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Affiliation(s)
- Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan.
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Inoue M, Sasaki T, Takazawa H, Morita T, Narisawa A, Saito A, Midorikawa H, Nishijima M. Symptomatic vasospasm in elderly patients with aneurysmal subarachnoid hemorrhage: comparison with nonelderly patients. Acta Neurochir Suppl 2012; 115:281-4. [PMID: 22890682 DOI: 10.1007/978-3-7091-1192-5_50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To clarify the influence of age on the occurrence of symptomatic vasospasm (SVS), we retrospectively compared 34 elderly (over 70 years) and 71 nonelderly patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS Between 2008 and 2010, at our hospital 105 patients (Hunt and Kosnik grades I-IV) underwent aneurysm surgery within 72 h of the insult. They were divided into four groups based on their age (younger/older than 70 years) and treatment (aneurysmal clipping or coiling). In all patients, we used the same protocol, which included the delivery of intrathecal urokinase and intravenous fasudil chloride; in patients with angiographic evidence of vasospasm, we also injected fasudil chloride intra-arterially. RESULTS Among the elderly patients, 4.3% of those treated by clipping and 9.1% of those treated by coiling experienced SVS; the comparative incidence in younger patients was 6.5% and 4.0%, respectively. The differences were not statistically significant (p = 0.40). The ratio of ventriculo peritoneal (VP) shunts was higher in the elderly patients (p = 0.00007). The incidence of favorable treatment outcomes was significantly lower in elderly patients (p = 0.00004). CONCLUSION Under our treatment protocol, patient age did not affect the incidence of SVS. Our protocol may be effective for the prevention of SVS after aneurysmal SAH regardless of patient age.
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Affiliation(s)
- Mizuho Inoue
- Department of Neurosurgery, Aomori Prefectural Central Hospital, Aomori, Japan
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de Aguiar PH, Barros I, Paiva BL, Simm RF. Removal of clots in subarachnoid space could reduce the vasospasm after subarachnoid hemorrhage. Acta Neurochir Suppl 2013; 115:91-3. [PMID: 22890652 DOI: 10.1007/978-3-7091-1192-5_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND Cerebral vasospasm after subarachnoid hemorrhage (SAH) is a major cause of morbidity and mortality. We studied the effects of clot removal on multiple outcome variables following the clipping of ruptured anterior communicating aneurysms. METHODS From 2007 to 2011, 30 patients with Fisher grade III aneurysmal SAH underwent clipping of an anterior communicating artery aneurysm before SAH day 3. There were 20 women and 10 men, mean age 53.4, range 28-80 years. Seventeen underwent fenestration of lamina terminalis and cisternal removal of clots (group A), and 13 did not (Group B). We compared clinical grades, presence of hydrocephalus at admission, treatment modality, occurrence of clinical vasospasm, the need for interventional vasospasm therapy, and need for ventriculoperitoneal shunting. FINDINGS Vasospasm affected 5 of 17 (29%) in group A and 8 of 13 (61.5%) in group B (p < 0.05). Endovascular treatment for vasospasm was required in one patient in group A (5.8% of 17, 20% of 5) and in five from group B (38.4% of 13, 62.5% of 8) (p < 0.05). Mortality was observed in one case in group A (5.8% of 17, 20% of 5) and in two cases in group B (15.3% of 13, 25% of 8) and was related to vasospasm after SAH. Ventriculoperitonal shunt (VPS) was required in one case in group A (5.8%) and in five cases in group B (38.4%). CONCLUSIONS Fenestration of the lamina terminalis and removal of cisternal clots significantly decreased the incidence of post-SAH hydrocephalus and was associated with better outcomes in our series.
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Starke RM, Komotar RJ, Hwang BY, Rincon F, Kotchetkov IS, Mayer SA, Connolly ES. Role of Fever in Ventriculoperitoneal Shunt Placement After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2012; 70:1361-1368. [DOI: 10.1227/neu.0b013e318246b59d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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SATO T, SASAKI T, SAKUMA J, WATANABE T, ICHIKAWA M, ITO E, MATSUMOTO Y, ANDO H, SAITO K, KIKORI K, YUSA T, SUZUKI K, WATANABE Y, TAIRA S, SATO M. Quantification of Subarachnoid Hemorrhage by Three-Dimensional Computed Tomography: Correlation Between Hematoma Volume and Symptomatic Vasospasm. Neurol Med Chir (Tokyo) 2011; 51:187-94. [DOI: 10.2176/nmc.51.187] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Taku SATO
- Department of Neurosurgery, Fukushima Medical University
| | - Tatsuya SASAKI
- Department of Neurosurgery, Aomori Prefectural Central Hospital
| | - Jun SAKUMA
- Department of Neurosurgery, Fukushima Medical University
| | | | | | - Eiji ITO
- Department of Neurosurgery, Fukushima Medical University
| | - Yuka MATSUMOTO
- Department of Neurosurgery, Fukushima Medical University
| | - Hitoshi ANDO
- Department of Neurosurgery, Fukushima Medical University
| | - Kiyoshi SAITO
- Department of Neurosurgery, Fukushima Medical University
| | | | - Takeshi YUSA
- Department of Radiology, Fukushima Medical University
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Ionita CC, Baker J, Graffagnino C, Alexander MJ, Friedman AH, Zaidat OO. Timing of symptomatic vasospasm in aneurysmal subarachnoid hemorrhage: the effect of treatment modality and clinical implications. J Stroke Cerebrovasc Dis 2010; 19:110-5. [PMID: 20189086 DOI: 10.1016/j.jstrokecerebrovasdis.2009.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Revised: 11/07/2009] [Accepted: 11/16/2009] [Indexed: 11/22/2022] Open
Abstract
A better prediction of the time course of symptomatic vasospasm (SVSP) might have a significant impact on the management and prevention of delayed neurologic ischemic deficit (DIND). We studied the influence of the treatment for ruptured aneurysm on SVSP timing. We retrospectively analyzed data of consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) admitted in our center between 1999 and 2005, treated within 72 hours of the rupture by surgical clipping or endovascular coiling and in accordance with our neuroscience unit protocol. We analyzed the presence of SVSP and recorded the timing of occurrence after the aneurysmal repair intervention. Data on demographics, premorbid conditions, time elapsed from the subarachnoid hemorrhage onset and intervention, and clinical and radiologic characteristics at admission were collected. The first occurrence of postintervention SVSP was recorded and compared between the 2 treatment groups using a proportional hazards regression model, including significant covariates. Of the 67 patients analyzed, 21 (31%) underwent endovascular coiling and 46 (69%) underwent surgical clipping. The baseline variables were similar in the 2 groups. The median time from the procedure to clinical vasospasm was 4 days in the coiled patients and 7 days in the clipped patients. In a proportional hazards model regression analysis including age, sex, Fisher and Hunt-Hess grades, time between onset to procedure, and intervention type, only intervention type emerged as a significant predictor of time to SVSP after intervention (likelihood ratio chi2 = 16.8; P < .00). Treatment modality of ruptured intracranial aneurysm may influence the timing of SVSP occurrence.
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Yamamoto T, Esaki T, Nakao Y, Mori K. Efficacy of Low-Dose Tissue-Plasminogen Activator Intracisternal Administration for the Prevention of Cerebral Vasospasm After Subarachnoid Hemorrhage. World Neurosurg 2010; 73:675-82. [DOI: 10.1016/j.wneu.2010.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 04/05/2010] [Indexed: 11/23/2022]
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Yamada K, Yoshimura S, Enomoto Y, Yamakawa H, Iwama T. Effectiveness of combining continuous cerebrospinal drainage and intermittent intrathecal urokinase injection therapy in preventing symptomatic vasospasm following aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2009; 22:649-53. [DOI: 10.1080/02688690802256373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sasaki T, Kodama N, Matsumoto M, Suzuki K, Konno Y, Sakuma J, Endo Y, Oinuma M. Blood flow disturbance in perforating arteries attributable to aneurysm surgery. J Neurosurg 2007; 107:60-7. [PMID: 17639875 DOI: 10.3171/jns-07/07/0060] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [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: 11/06/2022]
Abstract
Object
The object of this study was to investigate patients with cerebral infarction in the area of the perforating arteries after aneurysm surgery.
Methods
The authors studied the incidence of cerebral infarction in 1043 patients using computed tomography or magnetic resonance imaging and the affected perforating arteries, clinical symptoms, prognosis, and operative maneuvers resulting in blood flow disturbance.
Results
Among 46 patients (4.4%) with infarction, the affected perforating arteries were the anterior choroidal artery (AChA) in nine patients, lenticulostriate artery (LSA) in nine patients, hypothalamic artery in two patients, posterior thalamoperforating artery in five patients, perforating artery of the vertebral artery (VA) in three patients, anterior thalamoperforating artery in nine patients, and recurrent artery of Heubner in nine patients. Sequelae persisted in 21 (45.7%) of the 46 patients; 13 (28.3%) had transient symptoms and 12 (26.1%) were asymptomatic. Sequelae developed in all patients with infarctions in perforating arteries in the area of the AChA, hypothalamic artery, or perforating artery of the VA; in four of five patients with posterior thalamoperforating artery involvement; and in two of nine with LSA involvement. The symptoms of anterior thalamoperforating artery infarction or recurrent artery of Heubner infarction were mild and/or transient. The operative maneuvers leading to blood flow disturbance in perforating arteries were aneurysmal neck clipping in 21 patients, temporary occlusion of the parent artery in nine patients, direct injury in seven patients, retraction in five patients, and trapping of the parent artery in four patients.
Conclusions
The patency of the perforating artery cannot be determined by intraoperative microscopic inspection. Intraoperative motor evoked potential monitoring contributed to the detection of blood flow disturbance in the territory of the AChA and LSA.
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Affiliation(s)
- Tatsuya Sasaki
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
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Abstract
Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.
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Affiliation(s)
- Salah G Keyrouz
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
| | - Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, South Euclid Avenue, St Louis, MO 63110, USA
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Abstract
Cerebral vasospasm is delayed narrowing of the large arteries of the circle of Willis occurring 4 to 14 days after aneurysmal subarachnoid hemorrhage (SAH). It is but one cause of delayed deterioration after SAH but, in general, is the most important potentially treatable cause of morbidity and mortality after SAH. Development of vasospasm is best predicted by the volume, location, persistence and density of subarachnoid clot early after SAH. Diagnosis is made by catheter angiography or, with less accuracy, by computed tomographic angiography, transcranial Doppler ultrasound or other methods. Treatment remains problematic because it is expensive, time-consuming, associated with substantial risk and largely ineffective. Treatment includes optimization of factors that affect cerebral blood flow and metabolism, systemic administration of nimodipine, hemodynamic therapy and pharmacologic and mechanical angioplasty.
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Affiliation(s)
- R Loch Macdonald
- Section of Neurosurgery, MC3026, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, Illinois 60637, USA.
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Abstract
BACKGROUND The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management. OBJECTIVE To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation. DATA SOURCE Search of MEDLINE and Cochrane databases and manual review of article bibliographies. DATA SYNTHESIS AND CONCLUSIONS Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.
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Affiliation(s)
- Neeraj S Naval
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Inoue T, Tsutsumi K, Iijima A, Shinozaki M, Ishida J, Yako K. Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: A case report. ACTA ACUST UNITED AC 2005; 64:450-4; discussion 454-5. [PMID: 16253699 DOI: 10.1016/j.surneu.2004.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2004] [Accepted: 12/29/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. CASE DESCRIPTION We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. CONCLUSION Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.
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Affiliation(s)
- Tomohiro Inoue
- Department of Neurosurgery, Showa General Hospital, Tokyo 187-8510, Japan
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Kinouchi H, Ogasawara K, Shimizu H, Mizoi K, Yoshimoto T. Prevention of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage by intraoperative cisternal fibrinolysis using tissue-type plasminogen activator combined with continuous cisternal drainage. Neurol Med Chir (Tokyo) 2005; 44:569-75; discussion 576-7. [PMID: 15686175 DOI: 10.2176/nmc.44.569] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [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: 11/20/2022] Open
Abstract
The efficacy of intraoperative cisternal irrigation using tissue-type plasminogen activator (tPA) combined with continuous cisternal drainage was assessed for the prevention of symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). Seventy consecutive patients underwent direct surgery for aneurysm clipping within 48 hours of SAH and had computed tomography (CT) findings classified as Fisher group III or IV with densities of more than 65 Hounsfield units (HU). Fibrinolysis of the cisternal clots was performed during surgery using 1.6 mg tPA in 55 cases or 3.2 mg tPA in 15 cases. If postoperative CT within 24 hours of surgery showed areas with density more than 65 HU, additional tPA (0.8 mg/day) was administered into the cisternal catheter until the high density areas disappeared. The cisternal drainage catheters were left in place until day 14. Additional tPA injection was necessary in four of the 55 patients receiving 1.6 mg tPA. Symptomatic vasospasm occurred in three patients (4.3%) and two patients had low density areas on CT. Permanent deficit (hemiparesis) due to cerebral vasospasm remained in only one patient. Intraoperative cisternal irrigation with tPA combined with cisternal drainage is safe and effective for the prevention of symptomatic vasospasm following SAH.
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Affiliation(s)
- Hiroyuki Kinouchi
- Department of Neurosurgery, Akita University School of Medicine, Akita, Japan.
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Hirashima Y, Kurimoto M, Hayashi N, Umemura K, Hori E, Origasa H, Endo S. Duration of Cerebrospinal Fluid Drainage in Patients With Aneurysmal Subarachnoid Hemorrhage for Prevention of Symptomatic Vasospasm and Late Hydrocephalus. Neurol Med Chir (Tokyo) 2005; 45:177-82; discussion 182-3. [PMID: 15849454 DOI: 10.2176/nmc.45.177] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [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: 11/20/2022] Open
Abstract
The optimal duration of cerebrospinal fluid (CSF) drainage after acute aneurysm surgery is unclear. The association between the occurrence of symptomatic vasospasm or late hydrocephalus and the duration of CSF drainage was investigated using multiple logistic analysis in 95 consecutive patients with aneurysmal subarachnoid hemorrhage who underwent surgery within 72 hours after onset. The duration of drainage was significantly related to the occurrence of symptomatic vasospasm and late hydrocephalus. The cut-off values of the duration of drainage for preventing symptomatic vasospasm and late hydrocephalus were 11 days (adjusted odds ratio 0.347, 95% confidence interval 0.135-0.889, p = 0.0274) and 6 days (adjusted odds ratio 4.86, 95% confidence interval 1.46-16.2, p = 0.0099), respectively. Prevention of both symptomatic vasospasm and late hydrocephalus is not possible without additional procedures such as cisternal irrigation using fibrinolytic agents.
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Affiliation(s)
- Yutaka Hirashima
- Department of Neurosurgery, Toyama Medical and Pharmaceutical University, 2630 Sugutani, Toyama 930-0194, Japan.
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Sasaki T, Sato M, Oinuma M, Sakuma J, Suzuki K, Matsumoto M, Kodama N. Management of poor-grade patients with aneurysmal subarachnoid hemorrhage in the acute stage: Importance of close monitoring for neurological grade changes. ACTA ACUST UNITED AC 2004; 62:531-5; discussion 535-7. [PMID: 15576122 DOI: 10.1016/j.surneu.2004.01.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2003] [Accepted: 01/19/2004] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal management of poor-grade patients with aneurysmal subarachnoid hemorrhage (SAH) remains controversial. We evaluated therapeutic outcomes to identify appropriate treatments for SAH patients admitted with a poor grade. METHODS We retrospectively studied 136 patients admitted within 6 hours after SAH onset with a poor Hunt & Kosnik Grade (IV and V). RESULTS Of 136 poor-grade patients, 20 with massive intracerebral or subdural hematoma underwent urgent hematoma evacuation and aneurysmal neck clipping. Seven of these achieved a favorable outcome (good recovery or moderate disability). Another 7 patients with prominent hydrocephalus or massive intraventricular hematoma underwent urgent continuous ventricular drainage. Of these, 4 manifested spontaneous grade improvement and underwent neck clipping; the other 3 died resulting from rebleeding. The remaining 109 patients whose poor grade was primarily because of SAH were observed without immediate surgery. In 43 patients of 109, the grade improved within 24 hours after hospitalization and within 38 hours in the other 4 patients. Aneurysmal neck clipping was performed in these 47 patients and a favorable outcome was achieved in 25 patients. The remaining 62 patients did not improve and the outcome was unfavorable. CONCLUSIONS Poor-grade SAH patients should be treated according to the pathogenesis underlying their poor grade. Close monitoring for a grade change over the first 24 hours after hospitalization is mandatory in patients whose poor grade is primarily because of the SAH and helps to determine the appropriateness of surgery.
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Affiliation(s)
- Tatsuya Sasaki
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
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Klimo P, Kestle JRW, MacDonald JD, Schmidt RH. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. J Neurosurg 2004; 100:215-24. [PMID: 15086227 DOI: 10.3171/jns.2004.100.2.0215] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.8] [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: 11/06/2022]
Abstract
OBJECT Cerebral vasospasm after subarachnoid hemorrhage (SAH) continues to be a major source of morbidity in patients despite significant clinical and basic science research. Efforts to prevent vasospasm by removing spasmogens from the subarachnoid space have produced mixed results. The authors hypothesize that lumbar cisternal drainage can remove blood from the basal subarachnoid spaces more effectively than an external ventricular drain (EVD). This non-randomized, controlled-cohort study was undertaken to evaluate the effectiveness of a lumbar drain in patients with SAH compared with those in whom an EVD or no form of cerebrospinal fluid (CSF) drainage was used to prevent the development of clinical vasospasm and its sequelae. METHODS The authors collected data on 266 patients with nontraumatic SAH who were admitted to the University of Utah Health Sciences Center between January 1994 and January 2003. Of these, 167 met the study entry criteria. The treatment group consisted of 81 patients in whom a lumbar drain had been placed for CSF shunting, whereas the control group was composed of 86 patients who received no form of CSF drainage or who were treated solely with an EVD. Primary outcome measures were as follows: 1) clinically evident vasospasm; 2) the need for endovascular intervention; 3) vasospasm-induced infarction; 4) disposition at time of discharge; and 5) Glasgow Outcome Scale (GOS) score at 1 to 3 months postdischarge. Secondary outcomes included length of stay and the need for CSF shunting. The presence of a lumbar drain conferred a statistically significant protective and beneficial effect across all outcome measures, reducing the incidence of clinical vasospasm from 51 to 17%, the need for angioplasty from 45 to 17%, and the occurrence of vasospastic infarction from 27 to 7% (all p < or = 0.001-0.008). Patients in the treatment group were more likely to be discharged home (54% compared with 25%, p = 0.002) and to have a GOS score of 5 at follow up (71% compared with 35%, p < 0.001). The mean number of days spent in the intensive care unit and in the hospital overall was also fewer in the treatment group. A similar degree of benefit was found in patients with different Fisher grades and regardless of whether an EVD was needed on presentation, both by subgroup analysis and multivariate logistic regression modeling. There was no statistical difference between the groups in terms of patients requiring a shunt. Complications with lumbar drains were rare and yielded no permanent sequelae. CONCLUSIONS Shunting of CSF through a lumbar drain after an SAH markedly reduces the risk of clinically evident vasospasm and its sequelae, shortens hospital stay, and improves outcome. Its beneficial effects are probably mediated through the removal of spasmogens that exist in the CSF. The results of this study warrant a randomized clinical trial, which is currently under way.
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Affiliation(s)
- Paul Klimo
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah 84132-2303, USA
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Amin-Hanjani S, Ogilvy CS, Barker FG. Does Intracisternal Thrombolysis Prevent Vasospasm after Aneurysmal Subarachnoid Hemorrhage? A Meta-analysis. Neurosurgery 2004; 54:326-34; discussion 334-5. [PMID: 14744278 DOI: 10.1227/01.neu.0000103488.94855.4f] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2003] [Accepted: 10/03/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Despite existing strategies for the treatment of vasospasm after aneurysmal subarachnoid hemorrhage, vasospasm remains a persistent contributor to death and disability. The intracisternal application of thrombolytic agents to dissolve subarachnoid clot has been advocated. The goal of this analysis was to assess the currently available evidence regarding the effectiveness of this treatment.
METHODS
We conducted a systematic review of the published literature; all controlled trials were included. The outcomes of interest were delayed ischemic neurological deficits, poor Glasgow Outcome Scale scores, and death. A formal meta-analysis was performed with a random-effects model.
RESULTS
The search revealed nine trials or trial subgroups (only one of which was randomized), with a total enrollment of 652 patients. Pooled results demonstrated beneficial effects of treatment, with absolute risk reductions of 14.4% (95% confidence interval, 6.5–22.5%; P < 0.001) for delayed ischemic neurological deficits, 9.5% (95% confidence interval, 4.2–14.8%; P < 0.01) for poor Glasgow Outcome Scale scores, and 4.5% (95% confidence interval, 1.5–7.5%; P < 0.05) for death. Regression analysis revealed that treatment effects did not significantly differ among the studies on the basis of the type of thrombolytic agent used (tissue plasminogen activator versus urokinase) or the method of administration (intraoperative versus postoperative) (P > 0.10). Studies that enrolled only patients at high risk for vasospasm seemed to demonstrate greater treatment effects.
CONCLUSION
The meta-analysis suggests a clinically relevant and statistically significant beneficial effect of intracisternal thrombolysis. However, the results of the analysis are limited by the predominance of nonrandomized studies. Further randomized, blinded, placebo-controlled trials of high-risk patients would be justified.
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Affiliation(s)
- Sepideh Amin-Hanjani
- Neurosurgical Service, Massachusetts General Hospital, Harvard Medical School, Fruit Street, Boston, MA 02114, USA
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Kasner SE. Treatment of "Other" Causes of Stroke. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Weinberger J, Frishman WH, Terashita D. Drug therapy of neurovascular disease. Cardiol Rev 2003; 11:122-46. [PMID: 12705843 DOI: 10.1097/01.crd.0000053459.09918.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recent advances in the prevention and pharmacotherapy of cerebrovascular disease have provided more favorable clinical outcomes. For the treatment of an acute ischemic stroke, the early use of thrombolytic agents can reduce the degree of brain damage while improving functional outcomes. However, trials evaluating various classes of other neuroprotective agents have not shown benefit to date. For the prevention of second stroke, the use of antiplatelet drugs, HMG-CoA reductase inhibitors, and angiotensin-converting enzyme inhibitors with a diuretic have shown benefit in reducing new events. In patients with underlying heart disease or atrial fibrillation, warfarin appears to be the drug of choice in preventing stroke. Early treatment of hemorrhagic stroke with calcium channel blockers can improve the functional outcome. Innovative therapies are now available for the treatment of migraine and vascular dementia. Primary prevention of stroke remains the optimal therapeutic strategy and includes treatment of systemic hypertension and hypercholesterolemia.
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Affiliation(s)
- Jesse Weinberger
- Department of Neurology, Mt. Sinai Medical Center, New York, New York, USA.
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Kodama N, Matsumoto M, Sasaki T, Konno Y, Sato T. Cisternal irrigation therapy with urokinase and ascorbic acid for prevention of vasospasm. Acta Neurochir Suppl 2002; 77:171-4. [PMID: 11563280 DOI: 10.1007/978-3-7091-6232-3_36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- N Kodama
- Department of Neurosurgery, Fukushima Medical School, Fukushima, Japan
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Abstract
Vasospasm can have many different causes and can occur in a variety of diseases, including infectious, autoimmune, and ophthalmic diseases, as well as in otherwise healthy subjects. We distinguish between the primary vasospastic syndrome and secondary vasospasm. The term "vasospastic syndrome" summarizes the symptoms of patients having such a diathesis as responding with spasm to stimuli like cold or emotional stress. Secondary vasospasm can occur in a number of autoimmune diseases, such as multiple sclerosis, lupus erythematosus, antiphospholipid syndrome, rheumatoid polyarthritis, giant cell arteritis, Behcet's disease, Buerger's disease and preeclampsia, and also in infectious diseases such as AIDS. Other potential causes for vasospasm are hemorrhages, homocysteinemia, head injury, acute intermittent porphyria, sickle cell disease, anorexia nervosa, Susac syndrome, mitochondriopathies, tumors, colitis ulcerosa, Crohn's disease, arteriosclerosis and drugs. Patients with primary vasospastic syndrome tend to suffer from cold hands, low blood pressure, and even migraine and silent myocardial ischemia. Valuable diagnostic tools for vasospastic diathesis are nailfold capillary microscopy and angiography, but probably the best indicator is an increased plasma level of endothelin-1. The eye is frequently involved in the vasospastic syndrome, and ocular manifestations of vasospasm include alteration of conjunctival vessels, corneal edema, retinal arterial and venous occlusions, choroidal ischemia, amaurosis fugax, AION, and glaucoma. Since the clinical impact of vascular dysregulation has only really been appreciated in the last few years, there has been little research in the according therapeutic field. The role of calcium channel blockers, magnesium, endothelin and glutamate antagonists, and gene therapy are discussed.
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Affiliation(s)
- J Flammer
- University Eye Clinic Basel, Mittlere Strasse 91, CH-4012, Basel, Switzerland.
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