Symptomatic Cerebral Vasospasm after Spontaneous Subarachnoid Hemorrhage: Comparison of Single and Multiple Intra-arterial Treatment with Respect to the Functional Outcome

2019 ◽  
Vol 81 (03) ◽  
pp. 220-226 ◽  
Author(s):  
Alexander Neumann ◽  
Claudia Ditz ◽  
Hannes Schacht ◽  
Linda Aulmann ◽  
Volker Martin Tronnier ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Functional Outcome ◽  
Cerebral Vasospasm ◽  
Statistical Significance ◽  
Demographic Data ◽  
Categorical Variables ◽  
World Federation ◽  
Fisher Exact Test ◽  
Patient Groups ◽  
Spontaneous Subarachnoid Hemorrhage

Abstract Objective In cases of spontaneous subarachnoid hemorrhage (sSAH) and symptomatic cerebral vasospasm (sCVS), multiple intra-arterial treatments (IATs) can be potentially useful for the functional outcome, even if the prognosis is initially poor. But the actual influence of the number of IATs has yet to be clarified. We wanted to assess if there are differences in the functional outcome between patients with a singular IAT and multiple IATs for sCVS after sSAH. Methods In a single-center study, 405 consecutive patients with nontraumatic SAH were analyzed retrospectively. A total of 126 developed sCVS, and 86 received IAT (32 singular and 54 multiple, i.e., more than one) with nimodipine with or without percutaneous transluminal angioplasty (PTA). Both groups were compared for demographic data, initial treatment (clipping or endovascular), and initial grading (World Federation of Neurosurgical Societies/Fisher classification, intraventricular hemorrhage, and intracerebral hemorrhage). The modified Rankin Scale (mRS) was used to assess functional outcome at the time of discharge and after 3 and 6 months. The development of CVS-associated infarction was assessed by computed tomography (CT). Categorical variables of the patient groups were analyzed in contingency tables using the Fisher exact test, chi-square test, and the Mann-Whitney U test. Statistical significance was accepted at p < 0.05. Results Patient groups with singular and multiple IATs were comparable concerning demographic data and initial grading. At the end of follow-up after 6 months, both groups showed comparable functional outcomes. A favorable outcome (mRS: 0–3) was observed in 14 of 26 patients (53.9%) with a single IAT and for 29 of 49 patients (59.2%) with multiple IATs. An unfavorable outcome (mRS: 4–6) occurred in 12 of 26 patients (46.1%) with a single IAT and for 20 of 49 patients (40.8%) with multiple IATs (p = 0.420). In the group with a single IAT, 22 of 32 patients (68.8%) developed CVS-associated infarction; 32 of 54 patients (59.3%) showed brain infarcts after multiple IATs (p = 0.259). Conclusion For patients with sCVS after sSAH, multiple IATs (nimodipine with or without additional PTA) can be applied safely because no significant differences in functional outcome were observed compared with a singular IAT. We conclude that patients should be treated repeatedly if vasospasm reoccurs.

scholarly journals Does intrathecal nicardipine for cerebral vasospasm following subarachnoid hemorrhage correlate with reduced delayed cerebral ischemia? A retrospective propensity score–based analysis

2021 ◽  
pp. 1-10
Author(s):  
Ofer Sadan ◽  
Hannah Waddel ◽  
Reneé Moore ◽  
Chen Feng ◽  
Yajun Mei ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Propensity Score ◽  
Functional Outcome ◽  
Cerebral Vasospasm ◽  
Delayed Cerebral Ischemia ◽  
University Hospital ◽  
World Federation ◽  
Ventriculoperitoneal Shunting ◽  
Fisher Grade

OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication. METHODS Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. RESULTS The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44–0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61–2.91). CONCLUSIONS IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.

scholarly journals Intrathecal Nicardipine for Cerebral Vasospasm Post Subarachnoid Hemorrhage–a Retrospective Propensity-Based Analysis

2020 ◽  
Author(s):  
Ofer Sadan ◽  
Hannah Waddel ◽  
Reneé Moore ◽  
Chen Feng ◽  
Yajun Mei ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Propensity Score ◽  
Functional Outcome ◽  
Cerebral Vasospasm ◽  
Delayed Cerebral Ischemia ◽  
University Hospital ◽  
Controlled Clinical Trial ◽  
World Federation ◽  
Ventriculoperitoneal Shunting ◽  
Fisher Grade

AbstractObjectivesCerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, we describe our experience with intrathecal (IT) nicardipine for this indication.MethodsPatients admitted to Emory University Hospital Neuroscience ICU between 2012-2017 with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. This patient cohort was compared using a propensity-score model to patients in the SAH international trialist (SAHIT) repository who did not receive intrathecal nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events.ResultsThe analysis included 1,351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n=859) the treated group was younger (51.1±12.4 vs. 56.7±14.1, p<0.01), had a higher World Federation of Neurological Surgeons score (WFNS), modified Fisher grade, and more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs. 11.3%, p<0.01). Treatment with IT nicardipine decreased daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increase rate of bacterial ventriculitis (3.1% compared with 2.7%, p>0.1) yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs. 8.8%, p<0.01). In a propensity score comparison to the SAHIT database, the odds ratio to develop DCI with IT nicardipine treatment was 0.61 with 95% CI[0.44-0.84], and to have a favorable functional outcome (mRS≤2) was 2.17[1.61-2.91].ConclusionsIT nicardipine was associated with improved outcome and reduced DCI compared with propensity matched controls. There was an increased need for permanent CSF diversion but no other safety issues. This data should be considered when selecting medications and treatments to study in future randomized controlled clinical trial for SAH.

The effect of mask use on maternal oxygen saturation in term pregnancies during the COVID-19 process

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Erzat Toprak ◽  
Ayça Nazlı Bulut
Keyword(s):  
Oxygen Saturation ◽  
Pregnant Women ◽  
Stress Test ◽  
Statistical Significance ◽  
Categorical Variables ◽  
Fisher Exact Test ◽  
Coin Toss ◽  
Arterial Blood ◽  
Surgical Masks ◽  
Before And After

AbstractObjectivesOur aim was to evaluate the effect of standard surgical and N-95 respiratory mask use on maternal oxygen saturation, vital signs and result on non-stress tests in term pregnancies.MethodsIt is a prospective observational study. The study included healthy, not in labor, singleton pregnant women of 370/7–410/7 weeks who were applied to our hospital for routine obstetric control examination between March 1, 2020, and August 31, 2020. Patients were randomised by coin toss method. Oxygen saturation, systolic, and diastolic arterial blood pressure, pulse, respiratory rate, and temperature of pregnant women using surgical masks and respiratory masks were measured before and after the non-stress test. The tolerance of the masks was also evaluated. Student’s t-test was used for variables showing parametric distribution and the Mann Whitney U-test was used for non-parametric tests. The categorical variables between the groups was analyzed by using the Chi square test or Fisher Exact test. The statistical significance level was taken as p<0.05 in all tests.ResultsA total of 297 pregnant women using masks were included in the study. The effect of mask type on oxygen saturation before and after the non-stress test was found to be significant (97.1±1.8 corresponds to 95.3±2.6 for the surgical mask, p=0.0001; 97.8±1.7 corresponds to 93.7±2.0 for the respiratory mask, p=0.0001). Mask tolerance of patients using respiratory masks was significantly higher than those using surgical masks (mean 8, 1–10, p=0.0001).ConclusionsSurgical mask and respiratory mask usage decreased significantly in oxygen saturation in term pregnancies.

Abstract 65: Intrathecal Nicardipine for Cerebral Vasospasm Post Subarachnoid Hemorrhage - A Single Center Experience

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ofer Sadan ◽  
Chen Feng ◽  
David T Pearce ◽  
Jacqueline Kraft ◽  
Cederic Pimentel ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Functional Outcome ◽  
Effective Treatment ◽  
Cerebral Vasospasm ◽  
Delayed Cerebral Ischemia ◽  
Low Grade ◽  
Single Center ◽  
Duration Of Treatment ◽  
Single Center Experience

Introduction: Cerebral vasospasm leading to delayed cerebral ischemia (DCI) is one of the most significant factors impacting functional outcome in patients diagnosed with non-traumatic subarachnoid hemorrhage (SAH). Effective treatment in this setting is lacking. We now report a single center retrospective cohort experience with intrathecal (IT) Nicardipine for this indication. Methods: All patients discharged between 2013-2017 diagnosed with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Demographics, risk factors, clinical courses, radiological DCI, and functional outcomes were analyzed. Results: 1,085 patients were admitted with aneurysmal (n=796) or idiopathic (n=289) SAH. The mean age was 54.5±14.1 and 67.7% were women. Low grade hemorrhage (WFNS 1) was found in 42.4%, medium (WFNS 2-3) in 26.9%, and high grade (WFNS 4-5) in 30.7%. Cerebral vasospasm was diagnosed in 36.6% of the patients, and 85.4% of those received IT Nicardipine (n=339). Only 8.4% of all patients required angiography to treat vasospasm. TCD data was available for 159 patients who received IT Nicardipine. Treatment reduced mean velocities in all arteries within one day by 15.4% on average (p<0.01). This reduction was sustained for the duration of treatment. Nineteen patients (1.8%) suffered from bacterial ventriculitis, and no statistically significant correlation was noted between IT treatment and infection (OR 1.06 95%CI[0.42-2.7]). The incidence of radiological DCI, identified by blinded assement of imaging, was 9.4% and clinical DCI was 5.7%. In this cohort, 65.5% had a favorable functional outcome (mRS≤2) at 90 days. Conclusions: In a retrospective analysis, off-label IT Nicardipine is a safe and potentially effective treatment for cerebral vasospasm and prevention of the subsequent cerebral ischemia. Being the largest of its kind, this cohort could serve as a baseline for future clinical trial designs assessing IT Nicardipine safety and efficacy in a prospective, controlled fashion.

Abstract T P352: Dantrolene for the Prevention and Treatment of Cerebral Vasospasm after Subarachnoid Hemorrhage - A Randomized Placebo-Controlled Trial to Assess Safety, Tolerability and Feasibility

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Susanne Muehlschlegel ◽  
Raphael Carandang ◽  
Wiley Hall ◽  
Kini Nisha ◽  
Saef Izzy ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Liver Toxicity ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Controlled Trial ◽  
Statistical Significance ◽  
Delayed Cerebral Ischemia ◽  
Double Blind ◽  
Outcome Differences ◽  
Infusion Period

Introduction: Dantrolene is neuroprotective in animal models and may attenuate cerebral vasospasm (cVSP) after aneurysmal subarachnoid hemorrhage (aSAH) in humans. We evaluated safety/tolerability and feasibility of intravenous dantrolene (IV-D) after aSAH. Methods: In this single-center, randomized, double-blind, placebo-controlled trial, 31 patients with acute aSAH were randomized to IV-D 1.25 mg IV every 6 hours x 7 days (n=16) or placebo (n=15). Primary endpoint was incidence of hyponatremia (sNa ≤ 134 mmol/L) and liver toxicity (% patients with ALT, AST and AlkPhos >5x upper limit of normal). Secondary safety endpoints included tolerability, systemic hypotension and intracranial hypertension. Efficacy was explored by clinical, transcranial Doppler (TCD) or angiographic cVSP occurrence, delayed cerebral ischemia (DCI) and 3-month modified-Rankin-Scale, Glasgow Outcome Scale and Barthel Index. Statistical analysis was performed using non-parametric tests, generalized estimating equations and mixed models. Results: Between IV-D vs. placebo, no differences were observed in the primary outcome (hyponatremia: 44% vs. 67% [p=0.29]; liver toxicity 6% vs. 0% [p=1.0]). Numerically more AEs and SAEs were seen in the IV-D group, but did not reach statistical significance (16 vs. 5 AEs, of which 5 vs. 2 were severe; RR 2.2; 95% CI 0.7-6.7; p=0.16). Three IV-D vs. two placebo patients reached stop criteria: one IV-D patient developed liver toxicity; two patients in each group developed brain edema requiring osmotherapy. No differences in angiographic, TCD, clinical cVSP, DCI, or 3-month functional outcomes were seen. Quantitative angiogram analysis revealed a trend towards increased vessel diameters in the IV-D group after the 7-day infusion-period (p=0.05). Conclusion: In this small trial, IV-Dantrolene after aSAH was feasible, tolerable and safe, but was underpowered to show efficacy or outcome differences.

Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage

Neurology ◽  
2019 ◽  
Vol 93 (5) ◽  
pp. e458-e466 ◽  
Author(s):  
Ramazan Jabbarli ◽  
Daniela Pierscianek ◽  
Roland Rölz ◽  
Marvin Darkwah Oppong ◽  
Klaus Kaier ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Functional Outcome ◽  
Cerebral Vasospasm ◽  
Delayed Cerebral Ischemia ◽  
Final Analysis ◽  
Unfavorable Outcome ◽  
Independent Effect ◽  
Preventive Strategy ◽  
Class Iii ◽  
Significant Difference

ObjectiveDelayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.MaterialsData from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.ResultsThe final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.ConclusionsA preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.Classification of evidenceThis study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.

HYPONATREMIA AND CEREBRAL VASOSPASM IN SPONTANEOUS SUBARACHNOID HEMORRHAGE

CHEST Journal ◽  
2006 ◽  
Vol 130 (4) ◽  
pp. 216S
Author(s):  
Dipak Chandy ◽  
Roger Sy ◽  
Wilbert Aronow ◽  
George Maguire ◽  
Wei-Nchih Lee
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Spontaneous Subarachnoid Hemorrhage
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