-
Annals of Palliative Medicine Oct 2021Lumbar continuous drainage of fluid (LCDF) has become more widely used in the diagnosis and treatment of neurological diseases in recent years. The use of LCDF can... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Lumbar continuous drainage of fluid (LCDF) has become more widely used in the diagnosis and treatment of neurological diseases in recent years. The use of LCDF can enable a better understanding of the patient's condition and reduce the incidence of related complications. LCDF can also affect complications of perforation surgery, including mortality during hospitalization, cerebral vasospasm (CVS), bleeding, and aneurysmal subarachnoid hemorrhage (aSAH).
METHODS
Articles published from library construction to April 2021 were searched for in the English-language databases PubMed, Cochrane Library, and Embase. All randomized controlled trials (RCTs) with LCDF and hole locking surgery were meta-analyzed using the Cochrane Collaboration's RevMan 5.3 software.
RESULTS
Ten RCTs involving 1,092 patients (continuous drainage group, n=585; control group, n=507) were included in the meta-analysis. For the statistical different in incidence of perioperative cerebral infarction in the two groups, the odds ratio (OR) was 5.42 [95% confidence interval (CI): (2.71, 10.83); P<0.00001], and for the statistical difference in the incidence of cerebral hemorrhage, the OR was 4.76 [95% CI: (2.11, 10.76); P=0.0002]. Perioperative complications were fewer in the LCDF-treated drainage group than in the conventional group.
DISCUSSION
This meta-analysis of 10 RCTs confirmed that LCDF compared with other treatments is associated with a lower incidence of perioperative complications, such as cerebral hemorrhage, hydrocephalus, and cerebral infarction, as well as increased Glasgow Outcome Scale (GOS).
Topics: Cerebrospinal Fluid Leak; Drainage; Humans; Perioperative Period; Subarachnoid Hemorrhage; Treatment Outcome; Vasospasm, Intracranial
PubMed: 34763473
DOI: 10.21037/apm-21-2728 -
Critical Care (London, England) Aug 2021Acute brain injuries are associated with high mortality rates and poor long-term functional outcomes. Measurement of cerebrospinal fluid (CSF) biomarkers in patients...
BACKGROUND
Acute brain injuries are associated with high mortality rates and poor long-term functional outcomes. Measurement of cerebrospinal fluid (CSF) biomarkers in patients with acute brain injuries may help elucidate some of the pathophysiological pathways involved in the prognosis of these patients.
METHODS
We performed a systematic search and descriptive review using the MEDLINE database and the PubMed interface from inception up to June 29, 2021, to retrieve observational studies in which the relationship between CSF concentrations of protein biomarkers and neurological outcomes was reported in patients with acute brain injury [traumatic brain injury, subarachnoid hemorrhage, acute ischemic stroke, status epilepticus or post-cardiac arrest]. We classified the studies according to whether or not biomarker concentrations were associated with neurological outcomes. The methodological quality of the studies was evaluated using the Newcastle-Ottawa quality assessment scale.
RESULTS
Of the 39 studies that met our criteria, 30 reported that the biomarker concentration was associated with neurological outcome and 9 reported no association. In TBI, increased extracellular concentrations of biomarkers related to neuronal cytoskeletal disruption, apoptosis and inflammation were associated with the severity of acute brain injury, early mortality and worse long-term functional outcome. Reduced concentrations of protein biomarkers related to impaired redox function were associated with increased risk of neurological deficit. In non-traumatic acute brain injury, concentrations of CSF protein biomarkers related to dysregulated inflammation and apoptosis were associated with a greater risk of vasospasm and a larger volume of brain ischemia. There was a high risk of bias across the studies.
CONCLUSION
In patients with acute brain injury, altered CSF concentrations of protein biomarkers related to cytoskeletal damage, inflammation, apoptosis and oxidative stress may be predictive of worse neurological outcomes.
Topics: Adult; Biomarkers; Brain Injuries; Cerebrospinal Fluid; Humans; Prognosis; Proteins
PubMed: 34353354
DOI: 10.1186/s13054-021-03698-z -
The Surgeon : Journal of the Royal... Dec 2023Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality....
BACKGROUND
Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes.
METHODS
A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed.
RESULTS
Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation.
CONCLUSIONS
A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.
Topics: Adult; Humans; Subarachnoid Hemorrhage; Vasospasm, Intracranial; Brain Ischemia; Aneurysm, Ruptured
PubMed: 37451887
DOI: 10.1016/j.surge.2023.06.006 -
BMJ Open Jul 2021The use of aspirin to prevent cardiovascular disease in vasospastic angina (VSA) patients without significant stenosis has yet to be investigated. This study aimed to... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The use of aspirin to prevent cardiovascular disease in vasospastic angina (VSA) patients without significant stenosis has yet to be investigated. This study aimed to investigate the efficacy of aspirin use among VSA patients.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
PubMed, Web of Science and Cochrane Central Register of Controlled Trials were searched for relevant information prior to October 2020.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Aspirin use versus no aspirin use (placebo or no treatment) among VSA patients without significant stenosis.
DATA EXTRACTION AND SYNTHESIS
Two investigators extracted the study data. ORs and 95% CIs were calculated and graphed as forest plots. The Newcastle-Ottawa Quality Assessment Scale tool and Begg's funnel plot were used to assess risk of bias.
RESULTS
Four propensity-matched cohorts, one retrospective analysis and one prospective multicentre cohort, in total comprising 3661 patients (aspirin use group, n=1695; no aspirin use group, n=1966) were included in this meta-analysis. Aspirin use and the incidence of major cardiovascular adverse events with follow-up of 1-5 years were not significantly correlated (combined OR=0.90, 95% CI: 0.55 to 1.68, p=0.829, I=82.2%; subgroup analysis: OR=1.09, 95% CI: 0.81 to 1.47, I=0%). No significant difference was found between aspirin use and the incidence of myocardial infarction (OR=0.62, 95% CI: 0.09 to 4.36, p=0.615, I=73.8%) or cardiac death (OR=1.73, 95% CI: 0.61 to 4.94, p=0.444, I=0%) during follow-up.
CONCLUSION
Aspirin use may not reduce the risk of future cardiovascular events in VSA patients without significant stenosis.
PROSPERO REGISTRATION NUMBER
CRD42020214891.
Topics: Aspirin; Coronary Vasospasm; Humans; Myocardial Infarction; Prospective Studies; Retrospective Studies
PubMed: 34326051
DOI: 10.1136/bmjopen-2021-048719 -
Acta Neurochirurgica Oct 2019In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as "non-aneurysmal" SAH (naSAH).
METHODS
A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model.
RESULTS
Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9-6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0-2) at 3-6 months following diagnosis was 92.0% [95% CI 86.0-96.5]. Complications included re-bleeding (3.1% [95% CI 1.5-5.2]), hydrocephalus (16.0% [95% CI 11.2-21.4]), vasospasm (9.6% [95% CI 6.5-13.3]) and seizure (3.5% [95% CI 1.7-5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4-21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1-92.9]) and higher risk of complications for non-PnaSAH patients.
CONCLUSION
This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients.
Topics: Angiography, Digital Subtraction; Female; Humans; Hydrocephalus; Male; Middle Aged; Subarachnoid Hemorrhage; Tomography, X-Ray Computed
PubMed: 31410556
DOI: 10.1007/s00701-019-04025-w -
Journal of the American Heart... Mar 2024Delayed cerebral ischemia represents a significant contributor to death and disability following aneurysmal subarachnoid hemorrhage. Although preclinical models have...
BACKGROUND
Delayed cerebral ischemia represents a significant contributor to death and disability following aneurysmal subarachnoid hemorrhage. Although preclinical models have shown promising results, clinical trials have consistently failed to replicate the success of therapeutic strategies. The lack of standardized experimental setups and outcome assessments, particularly regarding secondary vasospastic/ischemic events, may be partly responsible for the translational failure. The study aims to delineate the procedural characteristics and assessment modalities of secondary vasospastic and ischemic events, serving as surrogates for clinically relevant delayed cerebral ischemia, in recent rat and murine subarachnoid hemorrhage models.
METHODS AND RESULTS
We conducted a systematic review of rat and murine in vivo subarachnoid hemorrhage studies (published: 2016-2020) using delayed cerebral ischemia/vasospasm as outcome parameters. Our analysis included 102 eligible studies. In murine studies (n=30), the endovascular perforation model was predominantly used, while rat studies primarily employed intracisternal blood injection to mimic subarachnoid hemorrhage. Particularly, the injection models exhibited considerable variation in injection volume, rate, and cerebrospinal fluid withdrawal. Peri-interventional monitoring was generally inadequately reported across all models, with body temperature and blood pressure being the most frequently documented parameters (62% and 34%, respectively). Vasospastic events were mainly assessed through microscopy of large cerebral arteries. In 90% of the rat and 86% of the murine studies, only male animals were used.
CONCLUSIONS
Our study underscores the substantial heterogeneity in procedural characteristics and outcome assessments of experimental subarachnoid hemorrhage research. To address these challenges, drafting guidelines for standardization and ensuring rigorous control of methodological and experimental quality by funders and journals are essential.
REGISTRATION
URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022337279.
Topics: Animals; Male; Mice; Rats; Blood Pressure; Brain Ischemia; Cerebral Infarction; Subarachnoid Hemorrhage; Vasospasm, Intracranial
PubMed: 38420758
DOI: 10.1161/JAHA.123.032694 -
Acute and Critical Care May 2024This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes,...
BACKGROUND
This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus.
METHODS
Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed.
RESULTS
The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups.
CONCLUSIONS
TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.
PubMed: 38863359
DOI: 10.4266/acc.2024.00612 -
Frontiers in Cardiovascular Medicine 2021Delayed cerebral ischemia (DCI) is one of the main prognosis factors for disability after aneurysmal subarachnoid hemorrhage (SAH). The lack of a consensual definition...
Delayed cerebral ischemia (DCI) is one of the main prognosis factors for disability after aneurysmal subarachnoid hemorrhage (SAH). The lack of a consensual definition for DCI had limited investigation and care in human until 2010, when a multidisciplinary research expert group proposed to define DCI as the occurrence of cerebral infarction (identified on imaging or histology) associated with clinical deterioration. We performed a systematic review to assess whether preclinical models of SAH meet this definition, focusing on the combination of noninvasive imaging and neurological deficits. To this aim, we searched in PUBMED database and included all rodent SAH models that considered cerebral ischemia and/or neurological outcome and/or vasospasm. Seventy-eight publications were included. Eight different methods were performed to induce SAH, with blood injection in the being the most widely used ( = 39, 50%). Vasospasm was the most investigated SAH-related complication ( = 52, 67%) compared to cerebral ischemia ( = 30, 38%), which was never investigated with imaging. Neurological deficits were also explored ( = 19, 24%). This systematic review shows that no preclinical SAH model meets the 2010 clinical definition of DCI, highlighting the inconsistencies between preclinical and clinical standards. In order to enhance research and favor translation to humans, pertinent SAH animal models reproducing DCI are urgently needed.
PubMed: 34869659
DOI: 10.3389/fcvm.2021.752769 -
International Journal of Molecular... Apr 2020Aneurysmal subarachnoid hemorrhage (aSAH) is a complex and potentially deadly disease. Neurosurgical clipping or endovascular coiling can successfully obliterate...
Aneurysmal subarachnoid hemorrhage (aSAH) is a complex and potentially deadly disease. Neurosurgical clipping or endovascular coiling can successfully obliterate ruptured aneurysms in almost every case. However, despite successful interventions, the clinical outcomes of aSAH patients are often poor. The reasons for poor outcomes are numerous, including cerebral vasospasm (CVS), post-hemorrhagic hydrocephalus, systemic infections and delayed cerebral ischemia. Although CVS with subsequent cerebral ischemia is one of the main contributors to brain damage after aSAH, little is known about the underlying molecular mechanisms of brain damage. This review emphasizes the importance of pharmacological interventions targeting high mobility group box 1 (HMGB1)-mediated brain damage after subarachnoid hemorrhage (SAH) and CVS. We searched Pubmed, Ovid medline and Scopus for "subarachnoid hemorrhage" in combination with "HMGB1". Based on these criteria, a total of 31 articles were retrieved. After excluding duplicates and selecting the relevant references from the retrieved articles, eight publications were selected for the review of the pharmacological interventions targeting HMGB1 in SAH. Damaged central nervous system cells release damage-associated molecular pattern molecules (DAMPs) that are important for initiating, driving and sustaining the inflammatory response following an aSAH. The discussed evidence suggested that HMGB1, an important DAMP, contributes to brain damage during early brain injury and also to the development of CVS during the late phase. Different pharmacological interventions employing natural compounds with HMGB1-antagonizing activity, antibody targeting of HMGB1 or scavenging HMGB1 by soluble receptors for advanced glycation end products (sRAGE), have been shown to dampen the inflammation mediated brain damage and protect against CVS. The experimental data suggest that HMGB1 inhibition is a promising strategy to reduce aSAH-related brain damage and CVS. Clinical studies are needed to validate these findings that may lead to the development of potential treatment options that are much needed in aSAH.
Topics: Animals; Antibodies, Monoclonal; Biomarkers; Disease Management; Disease Susceptibility; HMGB1 Protein; Humans; Molecular Targeted Therapy; Subarachnoid Hemorrhage; Vasospasm, Intracranial
PubMed: 32295146
DOI: 10.3390/ijms21082709 -
Circulation Journal : Official Journal... Oct 2019We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing...
BACKGROUND
We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database.
METHODS AND RESULTS
We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics.
CONCLUSIONS
We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.
Topics: Administrative Claims, Healthcare; Aged; Aged, 80 and over; Comprehensive Health Care; Databases, Factual; Delivery of Health Care, Integrated; Delphi Technique; Feasibility Studies; Female; Guideline Adherence; Healthcare Disparities; Humans; Japan; Male; Middle Aged; Outcome and Process Assessment, Health Care; Practice Guidelines as Topic; Practice Patterns, Physicians'; Quality Improvement; Quality Indicators, Health Care; Risk Factors; Stroke; Time Factors; Treatment Outcome
PubMed: 31554766
DOI: 10.1253/circj.CJ-19-0089