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BMC Neurology May 2011Angiopoietin-1 (Ang-1) and -2 (Ang-2) are keyplayers in the regulation of endothelial homeostasis and vascular proliferation. Angiopoietins may play an important role in...
BACKGROUND
Angiopoietin-1 (Ang-1) and -2 (Ang-2) are keyplayers in the regulation of endothelial homeostasis and vascular proliferation. Angiopoietins may play an important role in the pathophysiology of cerebral vasospasm (CVS). Ang-1 and Ang-2 have not been investigated in this regard so far.
METHODS
20 patients with subarachnoid hemorrhage (SAH) and 20 healthy controls (HC) were included in this prospective study. Blood samples were collected from days 1 to 7 and every other day thereafter. Ang-1 and Ang-2 were measured in serum samples using commercially available enzyme-linked immunosorbent assay. Transcranial Doppler sonography was performed to monitor the occurrence of cerebral vasospasm.
RESULTS
SAH patients showed a significant drop of Ang-1 levels on day 2 and 3 post SAH compared to baseline and HC. Patients, who developed Doppler sonographic CVS, showed significantly lower levels of Ang-1 with a sustained decrease in contrast to patients without Doppler sonographic CVS, whose Ang-1 levels recovered in the later course of the disease. In patients developing cerebral ischemia attributable to vasospasm significantly lower Ang-1 levels have already been observed on the day of admission. Differences of Ang-2 between SAH patients and HC or patients with and without Doppler sonographic CVS were not statistically significant.
CONCLUSIONS
Ang-1, but not Ang-2, is significantly altered in patients suffering from SAH and especially in those experiencing CVS and cerebral ischemia. The loss of vascular integrity, regulated by Ang-1, might be in part responsible for the development of cerebral vasospasm and subsequent cerebral ischemia.
Topics: Adult; Aged; Angiopoietin-1; Angiopoietin-2; Brain Ischemia; Female; Humans; Male; Middle Aged; Retrospective Studies; Subarachnoid Hemorrhage; Time Factors; Tomography, X-Ray Computed; Ultrasonography, Doppler, Transcranial; Vasospasm, Intracranial
PubMed: 21615958
DOI: 10.1186/1471-2377-11-59 -
AJNR. American Journal of Neuroradiology Apr 2007We investigated the association of multisection CT angiography (MSCTA) and perfusion CT (PCT) for the characterization of vasospasm secondary to aneurysmal subarachnoid... (Comparative Study)
Comparative Study
BACKGROUND AND PURPOSE
We investigated the association of multisection CT angiography (MSCTA) and perfusion CT (PCT) for the characterization of vasospasm secondary to aneurysmal subarachnoid hemorrhage.
MATERIALS AND METHODS
Among 27 patients with symptomatic cerebrovascular vasospasm investigated by digital subtraction angiography (DSA), 18 underwent both cerebral PCT and MSCTA. For the remaining 9, only PCT or MSCTA could be performed. MSCTA was compared with DSA for the detection and characterization of vasospasm on 286 intracranial arterial segments. PCT maps were visually reviewed for mean transit time, relative cerebral blood flow, and relative cerebral blood volume abnormalities and were qualitatively compared with the corresponding regional vasospasm detected by DSA.
RESULTS
Vasospasm was grouped into 2 categories: mild-moderate and severe. The depiction of vasospasm by MSCTA showed the best sensitivity, specificity, and accuracy at the level of the A2 and M2 arterial segments (100% for each), in contrast to the carotid siphon (45%, 100%, and 85% respectively). The characterization of vasospasm severity by MSCTA showed a sensitivity, specificity, and accuracy of 86.8%, 96.8%, and 95.2%, respectively, for mild-moderate vasospasm, and 76.5%, 99.5%, and 97.5%, respectively, for severe vasospasm. The PCT abnormalities were related to severe vasospasm in 9 patients and to mild-to-moderate vasospasm in 2. The sensitivity, specificity, and accuracy of PCT in detecting vasospasm were 90%, 100%, and 92.3%, respectively, for severe vasospasm, and 20%, 100%, and 38.5%, respectively, for mild-moderate vasospasm.
CONCLUSION
MSCTA/PCT can assess the location and severity of cerebrovascular vasospasm and its related perfusion abnormalities. It can identify severe vasospasm with risk of delayed ischemia and can thus guide the invasive treatment.
Topics: Adult; Aged; Aneurysm, Ruptured; Angiography, Digital Subtraction; Blood Flow Velocity; Blood Volume; Cerebral Angiography; Female; Humans; Image Processing, Computer-Assisted; Intracranial Aneurysm; Male; Middle Aged; Predictive Value of Tests; Sensitivity and Specificity; Subarachnoid Hemorrhage; Tomography, X-Ray Computed; Vasospasm, Intracranial
PubMed: 17416833
DOI: No ID Found -
Trials Nov 2022Stellate ganglion block has been reported to expand cerebral vessels and alleviate vasospasm after aneurysmal subarachnoid hemorrhage. However, the causal relationship...
INTRODUCTION
Stellate ganglion block has been reported to expand cerebral vessels and alleviate vasospasm after aneurysmal subarachnoid hemorrhage. However, the causal relationship between early stellate ganglion block and cerebral vasospasm prevention has not yet been established. The purpose of this study was to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment for cerebral vasospasm and delayed cerebral ischemia.
METHODS/DESIGN
This is a single-center, prospective, randomized, controlled, blinded endpoint assessment superiority trial. A total of 228 patients will be randomized within 48 h of aneurysmal subarachnoid hemorrhage onset in a 1:1 ratio into two groups, one group receiving an additional e-SGB and the other group receiving only a camouflaging action before anesthesia induction in the operating room. The primary outcome is the incidence of symptomatic vasospasm within 14 days after aSAH. Further safety and efficacy parameters include the incidence of radiographic vasospasm, new cerebral infarction, postoperative delirium, and complications up to 90 days after surgery; postoperative cerebral hemodynamics; Mini-Mental State Examination score; modified Rankin scale score; and all-cause mortality up to 90 days after surgery.
DISCUSSION
This is a randomized controlled trial to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment to reduce cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. If the results are positive, it may provide a new direction for the prevention and treatment of cerebral vasospasm and delayed cerebral ischemia.
TRIAL REGISTRATION
The study was registered on Clincaltrials.gov on December 13, 2020 (NCT04691271).
Topics: Humans; Vasospasm, Intracranial; Subarachnoid Hemorrhage; Prospective Studies; Stellate Ganglion; Brain Ischemia; Cerebral Infarction; Randomized Controlled Trials as Topic
PubMed: 36333751
DOI: 10.1186/s13063-022-06867-9 -
Expert Review of Cardiovascular Therapy Oct 2010Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular disorder associated with multifocal arterial constriction and dilation. RCVS is associated with... (Review)
Review
Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular disorder associated with multifocal arterial constriction and dilation. RCVS is associated with nonaneurysmal subarachnoid hemorrhage, pregnancy and exposure to certain drugs. The primary clinical manifestation is recurrent sudden-onset and severe (‘thunderclap’) headaches over 1–3 weeks, often accompanied by nausea, vomiting, photophobia, confusion and blurred vision. The primary diagnostic dilemma is distinguishing RCVS from primary CNS arteritis. Diagnosis requires demonstration of the characteristic ‘string of beads’ on cerebral angiography with resolution within 1–3 months, although many patients will initially have normal vascular imaging. Many treatments have been reported to ameliorate the headaches of RCVS, but it is unclear whether they prevent hemorrhagic or ischemic complications.
Topics: Arteritis; Cerebral Angiography; Cerebral Arterial Diseases; Diagnosis, Differential; Female; Headache Disorders, Primary; Humans; Pregnancy; Syndrome; Time Factors; Vasoconstriction; Vasospasm, Intracranial
PubMed: 20936928
DOI: 10.1586/erc.10.124 -
Neurosurgery Nov 2021Delayed cerebral vasospasm is a feared complication of aneurysmal subarachnoid hemorrhage (SAH).
BACKGROUND
Delayed cerebral vasospasm is a feared complication of aneurysmal subarachnoid hemorrhage (SAH).
OBJECTIVE
To investigate the relationship of systemic inflammation, measured using the systemic immune-inflammation (SII) index, with delayed angiographic or sonographic vasospasm. We hypothesize that early elevations in SII index serve as an independent predictor of vasospasm.
METHODS
We retrospectively reviewed the medical records of 289 SAH patients for angiographic or sonographic evidence of delayed cerebral vasospasm. SII index [(neutrophils × platelets/lymphocytes)/1000] was calculated from laboratory data at admission and dichotomized based on whether or not the patient developed vasospasm. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to determine the ability of SII index to predict the development of vasospasm.
RESULTS
A total of 246 patients were included in our study, of which 166 (67.5%) developed angiographic or sonographic evidence of cerebral vasospasm. Admission SII index was elevated for SAH in patients with vasospasm compared to those without (P < .001). In univariate logistic regression, leukocytes, neutrophils, lymphocytes, neutrophil-lymphocyte ratio (NLR), and SII index were associated with vasospasm. After adjustment for age, aneurysm location, diabetes mellitus, hyperlipidemia, and modified Fisher scale, SII index remained an independent predictor of vasospasm (odds ratio 1.386, P = .003). ROC analysis revealed that SII index accurately distinguished between patients who develop vasospasm vs those who do not (area under the curve = 0.767, P < .001).
CONCLUSION
Early elevation in SII index can independently predict the development of delayed cerebral vasospasm in aneurysmal SAH.
Topics: Humans; Inflammation; Lymphocytes; Retrospective Studies; Subarachnoid Hemorrhage; Vasospasm, Intracranial
PubMed: 34560777
DOI: 10.1093/neuros/nyab354 -
The British Journal of Radiology May 2021To evaluate the association of CT/CT angiography (CTA) findings and clinical characteristics with subsequent vasospasm in patients with aneurysmal subarachnoid... (Observational Study)
Observational Study
OBJECTIVE
To evaluate the association of CT/CT angiography (CTA) findings and clinical characteristics with subsequent vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH).
METHODS-
Consecutive presentation CTA head exams in patients with aSAH between January 2005 and June 2015 were retrospectively evaluated for intracranial arterial calcification, undulation and non-calcified stenosis. Additional variables including modified Fisher Scale (mFS), Glasgow Coma Scale (GCS) and neurological exam status were reviewed. Associations of CTA findings with the incidence of angiographic vasospasm were assessed with multivariate logistic regression models using the least absolute shrinkage and selection operator machine-learning algorithm. Model performance was summarized using c-index with bootstrap optimism-adjustment.
RESULTS
Intracranial arterial calcification, seen in 51.7% of 195 total patients, was protective against vasospasm (OR-0.6; 95% CI-0.52-0.67; = 0.009), while arterial undulation (24%) was associated with subsequent vasospasm (OR-2.6; 95% CI-1.3-5.1; = 0.007). Non-calcified intracranial arterial stenosis (5%) was associated with subsequent vasospasm, (OR-4.7; 95% CI-1.0-22.8; = 0.054). Least absolute shrinkage and selection operator selected all three CTA findings as predictors in a multivariate model for vasospasm in addition to clinical factors, which demonstrated superior predictive performance (c-index-0.74; 95% CI-0.69-0.82) compared to a model based on mFS and clinical factors only (c-index-0.66; 95% CI-0.57-0.75; = 0.010 for the difference).
CONCLUSION
Presentation CTA findings combined with clinical factors may better predict the development of vasospasm in patients with aSAH compared to current prognostic models alone.
ADVANCES IN KNOWLEDGE
The combination of initial CT/CTA and clinical findings better predict development of vasospasm after aSAH. This can lead to better markers for use in future clinical trials to develop vasospasm preventative treatments and potentially provide better targets for early aggressive treatment.
Topics: Aneurysm, Ruptured; Calcinosis; Computed Tomography Angiography; Female; Glasgow Coma Scale; Humans; Intracranial Aneurysm; Logistic Models; Machine Learning; Male; Middle Aged; Multidetector Computed Tomography; Neurologic Examination; Prognosis; Retrospective Studies; Subarachnoid Hemorrhage; Vasospasm, Intracranial
PubMed: 33661704
DOI: 10.1259/bjr.20200893 -
Neurology India 2010Cerebral vasospasm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). It usually occurs about 3-9 days after SAH. The pathogenesis involves...
Magnetic resonance imaging evaluation of subarachnoid hemorrhage in rats and the effects of intracisternal injection of papaverine and nitroglycerine in the management of cerebral vasospasm.
BACKGROUND
Cerebral vasospasm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). It usually occurs about 3-9 days after SAH. The pathogenesis involves the release of endogenous spasmogens. Though various treatment modalities are available, none are really effective.
AIMS AND OBJECTIVES
The aim of the study was to develop an effective animal model for the study of SAH and vasospasm as well as to study the efficacy of vasodilators, namely nitroglycerine and papaverine, on SAH-induced vasospasm using magnetic resonance angiography.
MATERIALS AND METHODS
Fifteen Wistar albino rats, weighing around 150-200 gm were used for the study. Five rats served as controls of SAH-induced vasospasm, while five rats each were used to study the efficacy of intracisternal injection of papaverine or nitroglycerine.
RESULTS
Rats demonstrate vasospasm in a manner similar to humans. The maximal vasospasm is seen in the basilar artery. Statistical analysis demonstrates an improvement in vasospasm after instillation of intracisternal papaverine at the end of 2 hours in basilar and left internal cerebral artery. However, nitroglycerine does not produce any significant amelioration of vasospasm. Thus, it can be deduced that the pathogenesis of the vasospasm is more due to the action of cGMPase enzyme rather than inhibition of nitric oxide (NO) synthetase by the spasmogens. The present study is the first study in the English literature to compare the effects of single bolus doses of nitroglycerine and papaverine using magnetic resonance angiography.
CONCLUSION
Rats can be used to create an effective model for SAH-induced vasospasm as the pattern resembles human SAH. Papaverine is an effective drug for ameliorating SAH-induced vasospasm. Short-acting NO donors are not as effective in ameliorating vasospasm.
Topics: Analysis of Variance; Animals; Disease Models, Animal; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Nitroglycerin; Papaverine; Radiography; Rats; Rats, Wistar; Subarachnoid Hemorrhage; Vasodilator Agents; Vasospasm, Intracranial
PubMed: 20644264
DOI: 10.4103/0028-3886.65686 -
Scientific Reports Jan 2021Although hyperglycemia is associated with worse outcomes after aneurysmal subarachnoid hemorrhage (aSAH), there is no consensus on the optimal glucose control metric,...
Although hyperglycemia is associated with worse outcomes after aneurysmal subarachnoid hemorrhage (aSAH), there is no consensus on the optimal glucose control metric, acceptable in-hospital glucose ranges, or suitable insulin regimens in this population. In this single-center retrospective cohort study of aSAH patients, admission glucose, and hospital glucose mean (MHG), minimum (MinG), maximum (MaxG), and variability were compared. Primary endpoints (mortality, complications, and vasospasm) were assessed using multivariate logistic regressions. Of the 217 patients included, complications occurred in 83 (38.2%), 124 (57.1%) had vasospasm, and 41 (18.9%) died. MHG was independently associated with (p < 0.001) mortality, MaxG (p = 0.017) with complications, and lower MinG (p = 0.015) with vasospasm. Patients with MHG ≥ 140 mg/dL had 10 × increased odds of death [odds ratio (OR) = 10.3; 95% CI 4.6-21.5; p < 0.0001] while those with MinG ≤ 90 mg/dL had nearly 2× increased odds of vasospasm (OR = 1.8; 95% CI 1.01-3.21; p = 0.0422). While inpatient insulin was associated with increased complications and provided no mortality benefit, among those with MHG ≥ 140 mg/dL insulin therapy resulted in lower mortality (OR = 0.3; 95% CI 0.1-0.9; p = 0.0358), but no increased complication risk. While elevated MHG and MaxG are highly associated with poorer outcomes after aSAH, lower MinG is associated with increased vasospasm risk. Future trials should consider initiating insulin therapy based on MHG rather than other hyperglycemia measures.
Topics: Female; Glycemic Index; Humans; Hyperglycemia; Male; Middle Aged; Odds Ratio; Retrospective Studies; Subarachnoid Hemorrhage; Treatment Outcome; Vasospasm, Intracranial
PubMed: 33420311
DOI: 10.1038/s41598-020-80513-9 -
Journal of Vascular and Interventional... Jul 2011Triple H therapy is conventionally used to treat vasospasm following sub-arachnoid hemorrhage (SAH) but can sometimes have side effects. In order to investigate...
BACKGROUND AND INTRODUCTION
Triple H therapy is conventionally used to treat vasospasm following sub-arachnoid hemorrhage (SAH) but can sometimes have side effects. In order to investigate pulmonary complications in SAH patients and relationship with age we conducted the following study.
METHODS
The charts of 121 sub-arachnoid hemorrhage patients who underwent clipping or coiling of an aneurysm were retrospectively reviewed. The diagnosis of vasospasm was documented based on Doppler and angiographic findings. All patients with vasospasm received the standard Triple H therapy (hematocrit 33-38%, central venous pressure 10-12 mmHg, systolic blood pressure 160-200 mmHg). We studied intravenous intake, artificial ventilation, hypoxemia/pulmonary edema, postoperative fever, pneumonia and death rates as outcome variables.
RESULTS
Sixty five patients developed vasospasm (15 mild, 23 moderate, 27 severe). These were significantly younger than non-vasospasm patients (51 years vs. 61 years, p=0.004). The average daily intravenous input was 1,730 cc in novasospasm patients, 2,123 cc in the mild vasospasm group, 2,399 cc in the moderate vasospasm group, and 3,040 cc in the severe vasospasm group. Younger patients with moderate to severe vasospasm received more fluids than older patients. Ten patients (8.3%) developed hypoxemia or pulmonary edema. No patient developed hypoxemia/pulmonary edema in the mild vasospasm group and the rates did not show a trend and were not statistically different (7.1%, 0.0%, 13.0%, 11.1%, p>0.05) between vasospasm and non-vasospasm groups. Likewise, postoperative fever and pneumonia rates were not different between the vasospasm and non-vasospasm groups. Using the mean age as a threshold, pulmonary-related complications including death rates tended to be higher in the older group. The rates of postoperative ventilation (30.8% vs. 57.1%, P<0.01) and hypoxemia/pulmonary edema (3.1% vs. 14.3%, P<0.05) rates were statistically higher in the older group. Patients who developed hypoxemia/pulmonary edema in the vasospasm group tended to be younger than those who developed hypoxemia/pulmonary edema in the non-vasospasm group.
CONCLUSION
Younger patients are at a higher risk of developing vasospasm than older patients possibly referable to vessel elasticity and reactive sensitivity factors. Likewise, patients who developed hypoxemia/pulmonary edema in the vasospasm group were younger than in the non-vasospasm group possibly secondary to fluid overload from triple H therapy.
PubMed: 22518269
DOI: No ID Found -
Frontiers in Neurology 2013Protein S100B has proven to be a useful biomarker for cerebral damages. Increased levels of serum and cerebrospinal fluid (CSF) S100B have been shown in patients...
BACKGROUND
Protein S100B has proven to be a useful biomarker for cerebral damages. Increased levels of serum and cerebrospinal fluid (CSF) S100B have been shown in patients suffering subarachnoid hemorrhage (SAH), severe head injury and stroke. In patients with SAH, the course of S100B levels has been correlated with neurological deficits and outcome. Cerebral vasospasm is a major contributor to morbidity and mortality. The primary aim of this study was to investigate the potential of S100B protein as a predictor of cerebral vasospasm in patients with severe SAH.
MATERIALS AND METHODS
Patients with SAH, Fisher grade 3 and 4, were included in the study. Five samples of CSF and serum S100B were collected from each patient. The first sample (baseline sample) was drawn within the first 3 days following ictus and the following four samples, once a day on days 5-8, with day of ictus defined as day 1. Clinical suspicion of cerebral vasospasm confirmed by computed tomography angiography was used to diagnose cerebral vasospasm.
RESULTS
A total of 18 patients were included. Five patients (28%) developed cerebral vasospasm, two (11%) developed ventriculitis. There were no significant differences between S100B for those with and without vasospasm. Serum S100B levels in patients with vasospasm were slightly lower within the first 5 days following ictus, compared to patients without vasospasm. Two out of five patients had elevated and increasing serum S100B prior to vasospasm. Only one showed a peak level of S100B 1 day before vasospasm could be diagnosed. Due to the low number of patients in the study, statistical significance could not be reached.
CONCLUSION
Neither serum nor CSF S100B can be used as predictor of cerebral vasospasm in patients suffering from SAH.
PubMed: 23761779
DOI: 10.3389/fneur.2013.00065