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Abstract Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a severe disease, with systemic involvement and complex diagnosis and treatment. Since the current guidelines were published by the AHA/ASA, Neurocritical Care Society and the European Stroke Organization in 2012-2013,there has been an evolution in the comprehension of SAH-associated brain injury and its multiple underlying mechanisms. As a result, several clinical and translational trials were developed or are underway. Objective: The aim of this article is to review some updates in the diagnosis and treatment of neurological complications of SAH. Methods: A review of PubMed (May, 2010 to February, 2022) was performed. Data was summarized. Results: Content of five meta-analyses, nine review articles and 23 new clinical trials, including pilots, were summarized. Conclusions:Advances in the comprehension of pathophysiology and improvements in critical care have been reflected in the reduction of mortality in SAH. However, despite the number of publications, the only treatments shown to be effective in adequate, well-controlled clinical trials are nimodipine and repair of the ruptured aneurysm. Thus, doubts about the optimal management of SAH still persist.
Resumo Antecedentes: Hemorragia subaracnóide aneurismática (HSAa) é uma doença grave, com envolvimento sistêmico, complexo diagnóstico e tratamento. Desde a publicação dos atuaisprotocolos de conduta pela AHA/ASA, NeurocriticalCare Society e EuropeanStrokeOrganization de 2012-2013, houve evolução na compreensão da lesão cerebral associada à HSA e seus múltiplos mecanismos subjacentes. Como resultado, muitos trabalhos clínicos e translacionais foram desenvolvidos ou estão em andamento. Objetivos: O objetivo deste artigo é revisar algumas das atualizações no diagnóstico e tratamento de complicações neurológicas de HSA. Métodos: Revisão de Pubmed (Maio de 201o a Fevereiro de 2022) foi realizada. Dados foram sintetizados. Resultados: O conteúdo de 5 metanálises, 9 artigos de revisão e 23 novos estudos clínicos, incluindo pilotos, foram sumarizados. Conclusões: Avanços na compreensão da fisiopatologia e melhorias no cuidado crítico têm se refletido na redução da mortalidade em HSA. Entretanto, apesar do volume de publicações, os únicos tratamentos que se mostraram efetivos com testes clínicos bem controlados são o uso de nimodipino e o tratamento dos aneurisma rotos. Assim, dúvidas acerca do manejo ideal em HSA ainda persistem.
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We report the diagnosis and treatment of a case of reversible cerebral vasoconstriction syndrome characterized by postpartum thunderclap headache. The patient experienced a thunderclap headache on the second day after delivery, which gradually worsened. On postpartum day 4, she presented with sudden convulsion and hypertension on admission on May 19, 2020, and was initially diagnosed with postpartum eclampsia. We confirmed the diagnosis of reversible cerebral vasoconstriction syndrome based on the results of cranial magnetic resonance angiography (MRA) and other examinations and the consultation with neurologists. After antihypertensive and spasmolytic treatment, the patient's blood pressure returned to normal, and she was discharged on postpartum day 8. Reexamination with cranial MRA at 50 + days after delivery indicated that the cerebral vasospasm was relieved. No severe headaches or convulsions were observed during follow-up till June 2021.
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Objective:To evaluate the efficacy and safety of fasudil on vasospasm caused by subarachnoid hemorrhage in elderly patients.Methods:A total of 100 elderly patients with subarachnoid hemorrhage admitted to our hospital from January 2015 to May 2018 were enrolled as research objects.They were randomly divided into the Fasudil group(n=50, receiving the Rho kinase inhibitor Fasudil therapy)and the Nimodipine group(n=50, receiving Nimodipine therapy). The cerebral vasospasm and cerebral infarction lesions, the ability of daily life, clinical prognostic score, the incidence of symptomatic cerebral vasospasm and adverse reactions during treatment were evaluated and compared between the two groups.Results:After treatment, the incidences of cerebral vasospasm and cerebral infarction in Fasudil group were 2.04%(1/49)and 6.12%(3/49), respectively, which were lower than those in the Nimodipine group[12.50%(6/48)and 20.83%(10/48), respectively]( χ2=6.134 and 6.794, P=0.047 and 0.033). The scores of daily living ability was better in the Fasudil group than in the Nimodipine group(16.09±1.06 vs.22.91±1.66, t=7.721, P=0.026). The incidence of adverse reactions was lower in the Fasudil group than in the Nimodipine group(4.08% or 2/49 vs.16.7% or 8/48, χ2=6.362, P=0.040). There was no statistically significant difference in the proportion of patients with good prognosis between Fasudil group and Nimodipine group. Conclusions:Rho kinase inhibitor Fasudil can effectively prevent and improve cerebral vasospasm caused by subarachnoid hemorrhage, which is beneficial for improving the clinical prognosis and quality of life of the elderly patients with subarachnoid hemorrhage.
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RESUMO Objetivo: Revisar sistematicamente a evidência atual da eficácia de milrinona no tratamento do vasoespasmo cerebral após hemorragia subaracnóidea. Métodos: Triaram-se as bases de dados Pubmed®, Cochrane e Embase quanto a artigos publicados entre abril de 2001 e fevereiro de 2019. Dois revisores independentes realizaram uma triagem metodológica da qualidade e a extração dos dados dos estudos. Resultados: Encontraram-se 22 estudos considerados relevantes, sendo que apenas um deles era um ensaio randomizado controlado. Os estudos demonstraram acentuada heterogeneidade e debilidade de seus critérios metodológicos. A maioria dos pacientes apresentava vasoespasmo moderado a grave. O principal método para diagnóstico do vasoespasmo foi a angiografia. Em três estudos, realizou-se administração de milrinona por via intra-arterial; em nove estudos, a administração foi endovenosa, e, em seis estudos, utilizaram-se ambas as vias de administração. A via intratecal foi utilizada em dois estudos, em um estudo, a administração foi realizada via cisterna e, em um estudo, a via de administração foi a endovascular. Os efeitos colaterais de milrinona foram descritos em seis estudos. Vinte e um estudos indicaram a resolução do vasoespasmo. Conclusão: A evidência atual indica que o uso de milrinona teve um papel no tratamento do vasoespasmo após hemorragia subaracnóidea aneurismática. Contudo, só foi realizado um ensaio randomizado controlado, com baixo nível de qualidade. Nossos achados indicam a necessidade de futuros estudos randomizados controlados com desfechos centrados no paciente, com o fim de proporcionar recomendações definitivas.
ABSTRACT Objective: To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage. Methods: The Pubmed®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies. Results: Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm. Conclusion: The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.
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Humans , Subarachnoid Hemorrhage/complications , Subarachnoid Hemorrhage/drug therapy , Vasospasm, Intracranial/etiology , Vasospasm, Intracranial/drug therapy , Vasodilator Agents/adverse effects , Infusions, Intravenous , Randomized Controlled Trials as Topic , Milrinone/therapeutic useABSTRACT
Resumen El vasoespasmo cerebral es una complicación severa de la hemorragia subaracnoidea. La monitorización y la detección del vasoespasmo por mé- todos no invasivos, así como la terapia endovascular, han revolucionado la atención médica tradicional. Se presenta el caso de un paciente masculino de 45 años con aneurisma roto de la arteria comunicante anterior, quien desarrolló vasoespasmo severo refractario desde el octavo día de hemorragia subaracnoidea. El vasoespasmo fue detectado oportunamente con técnicas no invasivas y tratado en cinco ocasiones mediante terapia endovascular, logrando mejoría inmediata de los síntomas y sin secuelas neurológicas. Este reporte contribuye a demostrar el beneficio de la terapia endovascular múltiple para el manejo del vasoespasmo cerebral refractario, en combinación con la utilización de técnicas no invasivas para la monitorización y detección oportuna del vasoespasmo. Adicionalmente, se revisan las recomendaciones actuales de medicina basada en la evidencia sobre el uso del Doppler transcraneal para la detección del vasoespasmo cerebral.
Abstract Cerebral vasospasm is a severe complication of subarachnoid hemorrhage. Monitoring and detection of vasospasm by non-invasive methods as well as the endovascular therapy have revolutionized healthcare. A 45-years-old male patient presented with a ruptured aneurysm in the anterior communicating artery and developed severe refractory vasospasm since the eighth day of aneurysm rupture. Vasospasm was timely detected with non-invasive techniques and successfully endovascular therapy was provided five times with neurological and radiological recovery each time and no neurological sequelae. This report contributes to current practice as it demonstrates the benefit of repeated endovascular therapy for refractory cerebral vasospasm, especially when clinical and non-invasive monitoring shows persistence of this complication. Furthermore, we review the current evidence-based medicine recommendations about Transcranial Doppler Ultrasonography that support the monitoring and detection of cerebral vasospasm.
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Objective@#To evaluate the effect of prophylactic nimodipine in vasospasm prevention and outcome improvement in children with subarachnoid hemorrhage (SAH).@*Methods@#A prospective, randomized controlled clinical trial which enrolled children with SAH who were admitted to pediatric intensive care unit (PICU) of Beijing Children′s Hospital from January 2015 to October 2018 was conducted. A total of 43 patients were randomly divided into nimodipine group (24 patients) and control group (19 patients) according to random number table. Transcranial Doppler (TCD) was used to dynamically monitor blood flow velocity and spectrum monography of bilateral middle cerebral artery (MCA) for vasospasm evaluation. Pediatric cerebral performance category (PCPC) scale was used to evaluate patients′ brain function on 28th day after discharge. Data were analyzed by t test, Mann-Whitney U test, χ2 test.@*Results@#Except heart rate ((157±26) vs. (137±34) beats/min, t=2.079, P=0.045), no significant differences existed between the two groups in basic demographic characteristics, primary diseases, and clinical manifestations (all P>0.05). The peak velocities of bilateral MCA on the 5th day after admission were significantly lower in nimodipine group (left MCA (136±34) vs. (158±23) cm/s, t=-2.890, P=0.006; right MCA (129±34) vs. (176±27) cm/s, t=-3.717, P=0.001). Likewise, a lower peak velocity of left MCA was observed on the 7th day after admission in nimodipine group ((127±45) vs. (152±13) cm/s, t=-2.903, P=0.007), but no significant difference existed in that of right MCA ((131±48) vs. (150±22) cm/s, t=-1.760, P=0.090). Eleven patients suffered from vasospasm, 25% (6/24) in nimodipine group and 26% (5/19) in control group (χ2=0.010, P=1.000), within whom 8 patients had complete remission after continuing nimodipine treatment, one died in hospital and the other two′s vasospasm still existed at the time of discharge. No significant differences were found between the two groups in mean length of hospitalization, proportion of mechanical ventilation, Glasgow coma scale at discharge, survival rate at discharge or survival rate on 28th day after discharge (all P>0.05). However, nimodipine group had a higher proportion of favorable PCPC brain function (92% (22/24) vs. 63% (12/19), χ2=5.208, P=0.030). No side effects such as hypotension, rash or injection site erythema were observed.@*Conclusion@#Prophylactic nimodipine cannot reduce vasospasm incidence in children with SAH but may improve short-term brain function, without any significant safety issues.
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Objective@#To investigate the effect of nimodipine combined with cerebrospinal fluid replacement on hemoglobin concentration, Toll-like receptor 4 (TLR4) expression level and cerebral vasospasm (CVS) in patients with CVS after aneurysmal subarachnoid hemorrhage (aSAH).@*Methods@#One hundred and twenty patients with CVS after aSAH admitted to the Department of Neurosurgery, the Sixth Medical Center of PLA General Hospital from May 2013 to May 2015 were selected. They were randomly divided into control group and observation group (n=60 in each group). The control group received conventional treatment and nimodipine infusion after embolization of the aneurysms, and the observation group underwent cerebrospinal fluid replacement by lumbar puncture on this basis. The clinical efficacy, Glasgow Coma Scale (GCS) scores, hemoglobin concentration and TLR4 expression levels before and after treatment, and adverse reactions were compared between the two groups.@*Results@#One month after treatment, the improvement rate of vasospasm in the observation group was significantly higher than that in the control group (86.7% vs. 60.0%; χ2=9.590, P=0.002). Three months after the treatment, the good rate of clinical outcome (the modified Rankin Scale score 0-2) was significantly higher than that of the control group (88.3% vs. 58.3%; χ2 =13.807, P<0.001). Before treatment, there were no significant differences in hemoglobin concentration and TLR4 expression levels between the two groups; after treatment, the hemoglobin concentration and TLR4 expression levels of both groups were significantly reduced (P<0.05). Compared with the control group, the hemoglobin concentration (119.9±19.8 g/L vs. 137.6±17.8 g/L; t=3.270, P=0.001) and TLR4 expression level (2.5±1.2 vs. 4.5±1.5; t=8.060, P<0.001) in the observation group decreased more significantly. Multivariate logistic regression analysis showed that hypertension (odds ratio [OR] 5.19, 95% confidence interval [CI] 2.31-6.71), hyperlipidemia (OR 2.70, 95% CI 1.93-4.86), previous history of stroke or transient ischemic attack (OR 6.29, 95% CI 3.23-7.32), smoking (OR 4.80, 95% CI 2.18-6.19), and the TLR4 expression level before treatment (OR 3.28, 95% CI 2.87-6.93) were independently correlated with the lack of improvement in CVS, and cerebrospinal fluid replacement was independently correlated with CVS improvement (OR 0.40, 95% CI 0.14-0.89). There was no significant difference in the incidence of adverse reactions such as blood pressure drop, obstructive hydrocephalus and gastrointestinal hemorrhage between the observation group and the control group, but the incidence of delayed CVS (13.3% vs. 36.7%; χ2=7.510, P=0.006) and secondary cerebral infarction (8.3% vs. 31.7%; χ2=8.800, P=0.003) in the observation group were significantly lower than those of the observation group.@*Conclusion@#Nimodipine infusion combined with cerebrospinal fluid replacement by lumbar puncture affected the hemoglobin concentration and TLR4 expression levels, improved the CVS improvement rate, and significantly improved the clinical outcome in patients with CVS after aSAH.
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Objective To investigate the effect of nimodipine combined with cerebrospinal fluid replacement on hemoglobin concentration,Toll-like receptor 4 (TLR4) expression level and cerebral vasospasm (CVS) in patients with CVS after aneurysmal subarachnoid hemorrhage (aSAH).Methods One hundred and twenty patients with CVS after aSAH admitted to the Department of Neurosurgery,the Sixth Medical Center of PLA General Hospital from May 2013 to May 2015 were selected.They were randomly divided into control group and observation group (n =60 in each group).The control group received conventional treatment and nimodipine infusion after embolization of the aneurysms,and the observation group underwent cerebrospinal fluid replacement by lumbar puncture on this basis.The clinical efficacy,Glasgow Coma Scale (GCS) scores,hemoglobin concentration and TLR4 expression levels before and after treatment,and adverse reactions were compared between the two groups.Results One month after treatment,the improvement rate of vasospasm in the observation group was significantly higher than that in the control group (86.7％ vs.60.0％;x2 =9.590,P =0.002).Three months after the treatment,the good rate of clirnical outcome (the modified Rankin Scale score 0-2) was significantly higher than that of the control group (88.3％ vs.58.3％;x2 =13.807,P＜0.001).Before treatment,there were no significant differences in hemoglobin concentration and TLR4 expression levels between the two groups;after treatment,the hemoglobin concentration and TLR4 expression levels of both groups were significantly reduced (P ＜0.05).Compared with the control group,the hemoglobin concentration (119.9 ± 19.8 g/L vs.137.6 ± 17.8 g/L;t =3.270,P =0.001) and TLR4 expression level (2.5 ± 1.2 vs.4.5 ± 1.5;t =8.060,P ＜0.001) in the observation group decreased more significantly.Multivariate logistic regression analysis showed that hypertension (odds ratio [OR] 5.19,95％ confidence interval [CI] 2.31-6.71),hyperlipidemia (OR 2.70,95％ CI 1.93-4.86),previous history of stroke or transient ischemic attack (OR 6.29,95％ CI 3.23-7.32),smoking (OR 4.80,95％ CI 2.18-6.19),and the TLR4 expression level before treatment (OR 3.28,95％ CI 2.87-6.93) were independently correlated with the lack of improvement in CVS,and cerebrospinal fluid replacement was independently correlated with CVS improvement (OR 0.40,95％ CI 0.14-0.89).There was no significant difference in the incidence of adverse reactions such as blood pressure drop,obstructive hydrocephalus and gastrointestinal hemorrhage betw een the observation group and the control group,but the incidence of delayed CVS (13.3％ vs.36.7％;x2 =7.510,P =0.006) and secondary cerebral infarction (8.3％ vs.31.7％;x2 =8.800,P =0.003) in the observation group were significantly lower than those of the observation group.Conclusion Nimodipine infusion combined with cerebrospinal fluid replacement by lumbar puncture affected the hemoglobin concentration and TLR4 expression levels,improved the CVS improvement rate,and significantly improved the clinical outcome in patients with CVS after aSAH.
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Aneurysmal subarachnoid hemorrhage (aSAH) has high disability and mortality.Cerebral vasospasm is the main cause of ischemic neurological deficit and even cerebral infarction after aSAH.At present,there are many studies on molecular signaling pathways of cerebral vasospasm.This article reviews the signaling pathways of cerebral vasospasm after aSAH.
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Objective To investigate the effect of Rhodiola on levels of inflammatory mediators and vascular endothelial function in rats with cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH).Methods Forty adult male SD rats were randomly divided into the sham operation group, model group, low-dose Rhodiola group, and high-dose Rhodiola group, with 10 rats in each group.Except for the sham operation group, rat models of CVS after SAH were established by cisterna magna twice method.1-5 d after modeling, the model group were treated with intraperitoneal injection of normal saline.The low-dose and high-dose Rhodiola groups were injected with 5mg/kg and 10mg/kg of Rhodiola respectively.5 days later, docking was performed and blood was collected to determine the levels of serum endothelin-1 (ET-1), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and cyclic guanosine monophosphate (cGMP).Then the rats were killed, and HE staining was performed to measure the diameter of basilar artery.The expression levels of basilar artery interleukin-6 (IL-6) mRNA, interleukin-1 β (IL-1 β) mRNA, vascular endothelial growth factor (VEGF) mRNA, endothelial nitric oxide synthase (eNOS), and inducible nitric oxide synthase (iNOS) were determined by real-time fluorescence quantitative polymerase chain reaction (RT-q-PCR).Results (1) The diameters of basilar arteries showed model group ＜ low-dose and high-dose groups ＜ the sham operation group (P ＜ 0.05).(2) The levels of ET-1, IL-6, TNF-α, IL-6 mR-NA, IL-1β mRNA and iNOS mRNA showed model group ＞ low-dose and high-dose Rhodiola groups ＞ the sham operation group while levels of cGMP, VEGF mRNA and eNOS mRNA showed model group ＜ low dose and high-dose Rhodiola groups ＜ the sham operation group (P ＜ 0.05).Conclusions Rhodiola can reduce the expressions of inflammatory reactions, improve the vascular endothelial function, and promote the expressions of vascular endothelial growth factor in rats with CVS after SAH.
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Objective To investigate the corrections of critical closing pressure (CrCP) with cerebral vasospasm (CVS),delayed cerebral ischemia (DCI) and outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH).Methods Patients with aSAH were retrospectively enrolled.CrCP was calculated on the basis of recorded arterial pressure and blood flow velocities at the proximal middle cerebral artery detected by transcranial Doppler.Univariate analysis and multivariable logistic regression analysis were used to identify the factors influencing CVS,DCI and poor outcome (Glasgow Outcome Scale scores 1-3).The correlations between CrCP and CVS,DCI and poor outcome was analyzed.Results A total of 104 patients with aSAH were included in the study,including 56 (53.8％) with CVS,and 36 (34.6％) with DCI.100 patients were included in the analysis of the outcome,including 47 cases of poor outcome.There were significant differences in CrCP values before and after CVS (40.2 ± 11.5 mmHg vs 33.8 ± 10.4 mmHg,1 mmHg =0.133 kPa;t =3.089,P=0.001).Multivariable logistic regression analysis showed that CrCP is the independent risk factor of CVS (odds ratio [OR] 1.149,95％ confidence interval[CI] 1.112-1.352;P =0.019),DCI (OR 13.413,95％ CI 3.458-51.710;P =0.005) and poor outcome (OR 1.832,95％ CI 1.088-3.357;P =0.042) in patients with aSAH.Conclusion Increased CrCP was independently associated with CVS,DCI,and poor outcome in patients with aSAH.
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Objective To investigate the occurrence status quo and related factors of cerebral vasospasm after cerebral ruptured aneurysms embolization.Methods Sixty-six patients withruptured cerebral aneurysms undergoing embolization treatment were selected as the research subjects,and conducted routine aneurysm embolization treatment.The cerebral vasospasm occurrence rate during hospitalization period was statistically calculated,and the related factors of cerebral vasospasm after cerebral aneurysm rupture embolization were analyzed.Results The cerebral vasospasm occurrence rate was 22.73 ％.Age,body mass index (BMI),hypertension rate,smoking history,aneurysms number,Fisher grade,Hunt-Hess grade,operation timing and Glasgow coma index (GCS) had statistically significant difference between the patients with and without cerebral vasospasm (P＜0.05).The related factors of cerebral vasospasm after embolization of ruptured aneurysms were age,hypertension,smoking history,number of aneurysms,Fisher grade,Hunt-Hess grade,operation timing and GCS index.Conclusion The cerebral vasospasm rate after embolization of ruptured aneurysms is high,and related to age,hypertension,smoking history,number of aneurysms,Fisher grade,Hunt-Hess grade,operation timing and GCS index.
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Objective :To explore therapeutic effect of subhypothermia combined cisternal nimodipine perfusion (CNP) on cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH).Methods :A total of 92 patients with CVS after SAH treated in our hospital from Feb 2014 to May 2016 were selected .The patients were randomly and e-qually divided into subhypothermia group (received subhypothermia treatment ) and combined treatment group (re-ceived subhypothermia treatment combined CNP) ,both groups were treated for 3 d .Therapeutic effect ,Glasgow coma scale (GCS) score ,middle cerebral artery (MCA) mean blood flow velocity ,serum levels of tumor necrosis factor (TNF)-α ,high sensitive C reactive protein (hsCRP) and interleukin (IL)-6 before and after treatment , and incidence rate of adverse events were compared between two groups .Results : Compared with before treat-ment ,after treatment ,there was significant rise in GCS score ,and significant reductions in MCA mean blood flow velocity ,serum levels of TNF-α ,hsCRP and IL-6 in two groups , P＝ 0.001 all ;compared with subhypothermia group after treatment ,there was significant rise in GCS score [ (10.26 ± 2.14) scores vs .(12.35 ± 2.56) scores] , and significant reductions in MCA mean blood flow velocity [(97.48 ± 18.20) cm/s vs.(89.74 ± 18.40) cm/s] ,se-rum levels of TNF-α [(0.56 ± 0.17) ng/ml vs.(0.34 ± 0.11) ng/ml] ,hsCRP [(186.75 ± 15.19) ng/L vs.(173.24 ± 15.23) ng/L] and IL-6 [ (10.41 ± 2.06) ng/L vs .(8.51 ± 2.13) ng/L] in combined treatment group ,P＜0.05 or ＜0. 01. Total effective rate of combined treatment group was significantly higher than that of subhypothermia group (91.30% vs.71.74%) , P＝0.016 ;and incidence rate of adverse events was significantly lower than that of subhypothermia group (6.52% vs.21.74%) ,P＝0.032 .Conclusion :Subhypothermia treatment combined cisternal nimodipine perfusion can effectively reduce MCA blood flow velocity ,relieve inflammation and improve therapeutic effect with less adverse events ,which is worth extending .
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Objeetive To investigate the effects of nimodipine combined with edaravone on cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH).Methods The consecutive patients with aSAH who underwent microsurgical clipping were included retrospectively.All patients received intravenous prophylaxis with nimodipine,and some patients also used edaravone (30 mg,twice a day for 2 weeks).They were divided into either a CVS group or a non-CVS group according to the findings of transcranial Doppler.They were also divided into a DCI group and a non-DCI group according to the findings of CT reexamination and clinical examination.The demographics,baseline clinical data,Glasgow Coma Scale (GCS) score,Fisher grade,Humt-Hess grade,and aneurysm location of all patients were collected.The multivariate logistics regression analysis was used to identify the independent risk factors for CVS and DCI.Results A total of 220 patients with aSAH were enrolled in the study,132 (60.0％) had CVS and 106 (48.2％) had DCI.One hundred twenty-three patients (55.9％)were treated with nimodipine + edaravone,97 were treated with nimodipine alone,none of them died.The incidences of CVS (51.2％ vs.71.1％;x2 =8.962,P =0.003) and DCI (35.0％ vs.65.0％;x2 =19.535,P ＜0.001) in patients receiving nimodipine + edaravone therapy were significantly lower than those receiving nimodipine alone.The proportions of hypertension,hyperlipidemia,diabetes,smoking,high Fisher grade in the CVS group were significantly higher than those in the non-CVS group (all P ＜0.05),while the proportion of patients receiving nimodipine + edaravone therapy (47.7％ vs.68.2％;g2 =8.962,P =0.003) and the GCS score (11.2 ±3.1 vs.13.4 ±2.6;t =5.492,P＜0.001) were significantly lower than those in the non-CVS group.Multivariate logistic regression analysis showed that low GCS score (odds ratio [OR] 6.57,95％ confidence interval [CI] 1.04-12.96;P=0.001),high Fisher grade (OR 5.39,95％ CI 4.09-20.15;P =0.004),hyperlipidemia (OR 4.39,95％ CI 2.97-34.15;P =0.004),hypertension (OR 3.24,95％ CI 1.06-13.47;P=0.016) were the independent risk factors for CVS,while received nimodipine + edaravone was the independent protective factor for CVS (OR 0.39,95％ CI0.13-0.91;P =0.039).The proportions of patients with hypertension,hyperlipidemia,diabetes,smoking,and high Fisher grade in the DCI group were significantly higher than those in the non-DCI group (all P ＜0.05),while the proportion of patients received nimodipine + edaravone (40.6％ vs.70.2％;x2 =19.535,P ＜ 0.001) and the GCS score (10.2 ± 2.4 vs.13.8 ± 2.6;t =10.648,P ＜ 0.001) were significantly lower.Multivariate logistic regression analysis showed that low GCS score (OR 8.92,95％ CI 2.48-26.94;P =0.001),high Fisher grade (OR 7.49,95％ CI 1.96-20.47;P =0.001) were the independent risk factors for DCI,while.received nimodipine +edaravone was an independent protective factor for DCI (OR 0.27,95％ CI 0.08-0.97;P =0.020).Conclusions Compared with nimodipine alone,nimodipine combined with edaravone can significantly reduce the incidences of CVS and DCI.The GCS score,high Fisher grade,and hypertension are the independent risk factors for CVS and DCI in patients with aSAH,and nimodipine combined with edaravone is the independent protective factor for CVS and DCI.
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Objective To evaluate the efficacy of continuous stellate ganglion block (SGB) for prevention of cerebral vasospasm (CVS) following interventional treatment of intracranial aneurysms.Methods Forty patients of both sexes with ruptured intracranial aneurysm,aged 20-60 yr,of American Society of Anesthesiologists physical status Ⅱ or Ⅲ,with Hunt-Hess grade Ⅰ-Ⅲ,scheduled for elective interventional treatment of intracranial aneurysms,were divided into 2 groups (n =20 each) using a random number table:control group (C group) and continuous SGB group (SGB group).After induction of anesthesia,patients received ipsilateral continuous SGB with 0.25％ ropivacaine 6-8 ml followed by continuous infusion of 0.2％ ropivacaine 2 ml/h for 3 days in group SGB.Transcranial Doppler ultrasound was used to measure the blood flow in bilateral middle cerebral arteries and internal carotid arteries within 3 days after operation,and the development of CVS was assessed.Before operation and at 2 and 6 h and 1 and 3 days after operation,blood samples were collected from the internal jugular vein for determination of plasma melatonin (MT) and endothelin-1 (ET-1) concentrations by enzyme-linked immunosorbent assay.Results Compared with group C,the incidence of CVS (5％) was significantly decreased,and the plasma ET-1 concentration was decreased at 2 and 6 h and 1 and 3 days after operation (P ＜ 0.05),and no significant change was found in plasma MT concentrations at each time point in group SGB (P＞0.05).Conclusion Continuous SGB can effectively prevent the development of CVS following interventional treatment of intracranial aneurysms,and the mechanism may be related to inhibited release of ET-1 from vascular endothelial cells,but not related to MT.
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Objetivo: El propósito de este estudio es describir las características clínicas, epidemiológicas e imaginológicas de 5 pacientes con diagnóstico de síndrome de vasoconstricción reversible. Métodos: Se hizo una evaluación retrospectiva de las historias clínicas de cinco pacientes con clínica e imágenes compatibles con síndrome de vasoconstricción cerebral reversible en un hospital de alta complejidad de la ciudad de Medellín. Resultados: Los cinco casos correspondían a mujeres con una edad promedio de 50 años. En un caso se identificó como posible agente causal el consumo de bebidas energizantes con alto contenido de taurina. Todos los pacientes se presentaron con hemorragia subaracnoidea en la convexidad y evolucionaron de forma favorable. Conclusión: El síndrome de vasoconstricción cerebral reversible debe ser uno de los diagnósticos diferenciales etiológicos de hemorragia subaracnoidea de la convexidad; se presenta predominantemente en mujeres entre la cuarta y sexta década de la vida y usualmente tiene un curso benigno.
Objective: The purpose of this study is to describe the clinical, epidemiological and imaging characteristics of 5 patients with a diagnosis of reversible vasoconstriction syndrome. Methods: A retrospective evaluation of the clinical records of 5 patients with clinical and imaging diagnosis of reversible cerebral vasoconstriction syndrome was carried out in a high complexity hospital in the city of Medellín. Results: The five cases were women with an average age of 50 years. In one case, the consumption of energy drinks with a high taurine content was identified as a possible causative agent. All cases presented with brain convexity subarachnoid haemorrhage. The clinical outcome was favorable. Conclusion: The reversible cerebral vasoconstriction syndrome should be included in the differential diagnosis of convexity subarachnoid haemorrhage. It occurs predominantly in women between the fourth and sixth decade of life and usually has a benign course.
Subject(s)
Humans , Vasospasm, Intracranial , Subarachnoid Hemorrhage , VasoconstrictionABSTRACT
Objetivos: Establecer la asociación de vasoespasmo cerebral detectado por Doppler transcraneal y la condición clínica, de acuerdo con la escala de la Federación Mundial de Sociedades de Neurocirugía, y con otros factores de riesgo en pacientes con hemorragia subaracnoidea espontánea. Materiales y métodos: Estudio observacional retrospectivo de casos y controles, con 141 pacientes diagnosticados con hemorragia subaracnoidea espontánea a quienes se les realizó Doppler transcraneal de seguimiento entre el 8 de marzo de 2011 y el 15 de marzo de 2015. Del total de pacientes se escogieron 47 con vasoespasmo detectado por Doppler transcraneal y 2 controles, sin vasoespasmo, por cada caso (94 pacientes). En las historias clínicas y las imágenes de los pacientes se estableció la asociación entre la detección de vasoespasmo por Doppler transcraneal con la condición clínica neurológica en el momento del examen, y otros factores de riesgo. Para el análisis de las variables cualitativas se utilizaron frecuencias absolutas y relativas. Para variables cuantitativas se utilizó la prueba de Shapiro Wilk. Los datos con distribución normal se presentan con medias y desviaciones estándar y aquellos sin distribución normal con medianas y rangos intercuartiles. Se evaluó la homogeneidad entre los dos grupos a través de la prueba de Chi cuadrado y el test de homogeneidad de varianzas (Levene) de acuerdo con el tipo de variable. Se consideró estadísticamente significativa una p ≤ 0,05. Resultados: El análisis bivariado no demostró resultados estadísticamente significativos en la relación entre la condición clínica neurológica y el vasoespasmo, pero sí encontró que pacientes menores de 50 años de edad presentaron más vasoespasmo (OR de 3,55 [95 % IC; 1,52-7,39]), y p: 0,003 que los de mayor edad. Conclusiones: Los pacientes menores de 50 años de edad tienen más riesgo de desarrollar vasoespasmo y no existe asociación entre la condición clínica y los resultados del Doppler transcraneal.
Objectives: Establish the association between cerebral vasospasm, detected by transcranial doppler, with the clinical condition according to the scale of the World Federation of Neurosurgical Societies (WFNS) and other risk factors in patients with spontaneous subarachnoid hemorrhage. Materials and methods: This is an observational retrospective case-control study, including 141 patients with a diagnosis of spontaneous subarachnoid hemorrhage who underwent transcranial doppler monitoring in the radiology department of the University Hospital San Vicente Foundation (HUSVF) from 8 March 2011 to 15 March 2015. Of the total number of patients with subarachnoid hemorrhage, 47 cases with vasospasm, detected by transcranial Doppler, and two controls without vasospasm (94 patients) were consecutively chosen. Subsequently, we review the medical records and images stored in the hospital´s radiology department and established the association between vasospasm detection by trasncranial Doppler with clinical neurological status at the time of the study and other risk factors. For the analysis of the qualitative variables, absolute and relative frequencies were used. Quantitative variables were tested for normal distribution with a Shapiro Wilk test. Data with normal distribution were presented with means and standard deviations and those without normal distribution with medians and interquartile ranges. Homogeneity between the two groups were evaluated by Chi-square test and test for homogeneity of variances, Levene's test, according to the type of variable (qualitative and quantitative respectively). Results were considered statistically significant if p ≤ 0.05. Results: Data from 141 patients (47 cases and 94 controls) were analyzed. The bivariate analysis didn´t show statistically significant results in the relationship between vasospasm and clinical neurological condition but found that patients younger than 50 years had more vasospasm. In the adjusted model for patients with this age, the OR was 3.55 (95 % CI, 1.52-7.39) and p: 0.003 when compared with older patients. Conclusions: This study found that patients under 50 have a higher risk of developing vasospasm compared with older patients and that there is no association between clinical condition and the results of transcranial Doppler.
Subject(s)
Humans , Vasospasm, Intracranial , Subarachnoid Hemorrhage , Ultrasonography, Doppler, TranscranialABSTRACT
RESUMO Objetivo: Comparar a evolução clínica da hemorragia subaracnóidea perimesencefálica com a da hemorragia subaracnóidea não perimesencefálica. Métodos: Estudo retrospectivo, que incluiu pacientes portadores de hemorragia subaracnóidea sem causa conhecida em um hospital terciário localizado na região norte de Portugal. Os dados epidemiológicos, clínicos e de imagem foram analisados estatisticamente, levando em conta a divisão dos pacientes em duas categorias: hemorragia subaracnóidea perimesencefálica e hemorragia subaracnóidea não perimesencefálica. Resultados: Cumpriram os critérios de inclusão 62 pacientes, 46,8% deles com hemorragia subaracnóidea perimesencefálica e 53,2% com hemorragia subaracnóidea não perimesencefálica. As caraterísticas demográficas, assim como os antecedentes clínicos, foram similares entre os grupos. As complicações foram observadas mais comumente no grupo com hemorragia subaracnóidea não perimesencefálica, sendo que 84,8% desses pacientes tiveram, no mínimo, uma complicação, comparados a 48,3% dos pacientes com hemorragia subaracnóidea perimesencefálica. Vasoespasmo, infecções e hidrocefalia foram as complicações mais comuns - todas observadas mais frequentemente nos pacientes com hemorragia subaracnóidea não perimesencefálica. Dois pacientes vieram a falecer, ambos com hemorragia subaracnóidea não perimesencefálica. A mediana do tempo de permanência no hospital foi maior nos pacientes com hemorragia subaracnóidea não perimesencefálica (21 dias, em comparação aos 14 dias observados nos pacientes com hemorragia subaracnóidea perimesencefálica). Não se observaram recidivas de sangramento durante o acompanhamento (tempo médio de 15 ± 10,3 meses). Conclusão: As hemorragias subaracnóideas perimesencefálica e não perimesencefálica tiveram formas diferentes de evolução clínica, principalmente no que se referiu à taxa de complicações e ao tempo mediano de permanência no hospital. Assim, a abordagem dessas duas formas de hemorragia subaracnóidea deve ser distinta, tanto em busca de melhorar o tratamento dos pacientes quanto para obter um melhor aproveitamento dos recursos de saúde.
ABSTRACT Objective: To compare the clinical evolution of perimesencephalic subarachnoid hemorrhage and non-perimesencephalic subarachnoid hemorrhage. Methods: The study was conducted retrospectively in a tertiary hospital center in the north region of Portugal. Included patients had no identifiable cause for subarachnoid hemorrhage. Several epidemiologic, clinical and imaging aspects were statistically analyzed, taking into account the differences in perimesencephalic subarachnoid hemorrhage and non-perimesencephalic subarachnoid hemorrhage. Results: Sixty-two patients met the inclusion criteria (46.8% - perimesencephalic subarachnoid hemorrhage; 53.2% - non-perimesencephalic subarachnoid hemorrhage). Demographic and clinical background characteristics were similar in both groups. Complications were more frequent in patients with non-perimesencephalic subarachnoid hemorrhage - 84.8% of the patients had at least one complication versus 48.3% in perimesencephalic subarachnoid hemorrhage. Vasospasm, infection and hydrocephaly were the most common complications (each was detected more frequently in the non-perimesencephalic subarachnoid hemorrhage group than in perimesencephalic subarachnoid hemorrhage group). Two patients died, both had a non-perimesencephalic subarachnoid hemorrhage. The median inpatient time was longer in the non-perimesencephalic subarachnoid hemorrhage group (21 versus 14 days). No incidents of rebleeding were reported during the follow-up period (mean time of 15 ± 10.3 months). Conclusion: Perimesencephalic subarachnoid hemorrhage and non-perimesencephalic subarachnoid hemorrhage are two different entities that have different clinical outcomes, namely in terms of complication rate and median inpatient time. The management of these patients should respect this difference to improve treatment and optimize health care resources.
Subject(s)
Humans , Male , Female , Adult , Aged , Subarachnoid Hemorrhage/physiopathology , Vasospasm, Intracranial/etiology , Hydrocephalus/etiology , Infections/etiology , Portugal , Subarachnoid Hemorrhage/complications , Time Factors , Retrospective Studies , Follow-Up Studies , Vasospasm, Intracranial/epidemiology , Tertiary Care Centers , Hydrocephalus/epidemiology , Infections/epidemiology , Length of Stay , Middle AgedABSTRACT
Objective To observe the effect of electroacupuncture in preventing delayed cerebral vasospasm (DCVS).Method Sixteen healthy Japanese big ear rabbits were randomized into a treatment group and a control group, 8 in each group. The treatment group was developed into models by intramuscular anesthesia on the 6th day after 5 days’ 20-min daily intervention of transcutaneous acupoint electrical stimulation during a specific time period; the control group was developed into models by the same way on the 6th day but without electrical stimulation. The diameter of basilar artery was measured by using CTA prior to the electrical stimulation and after modeling in both groups, the plasma levels of ET-1, CGRP, and IL-6 were detected, and behavioral changes 1 d, 3 d, and 5 d after modeling were observed.Result After modeling, there was a significant difference in comparing the basilar artery diameter between the two groups (P<0.05). The plasma levels of ET-1, CGRP, and IL-6 in the treatment group were significantly different from that in the control group (P<0.05). In the treatment group, the neural function scores 3 d and 5 d after modeling were markedly different from that 1 d after modeling (P<0.05). There were significant differences in comparing the neural function scores 3 d and 5 d after modeling between the two groups (P<0.05).Conclusion Pre-intervention with electroacupuncture prevents and improves DCVS possibly via modulating the levels of ET-1, CGRP, and IL-6, and subsequently involving in anti-inflammation, immune inhibition, and vasodilation.
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Subarachnoid hemorrhage (SAH) is a common cerebrovascular disease,its disability and mortality rates are higher.It has been confkmed that early brain injury (EBI) and cerebral vasospasm (CVS) are the major pathophysiological mechanisms of causing neurological dysfunction and death after SAH.There are a variety of factors of causing CVS and EBI,including nitric oxide,endothelin,oxyhemoglobin,and proinflarnmatory cytokines.A large number of animal experiments and clinical research have confrmed that statins have neuroprotective effects.This article reviews the neuroprotective effects and its mechanisms of statins in SAH