Cisternal MgSO4 Not Beneficial For Clinical Vasospasm

Preventive effect of continuous cisternal irrigation with magnesium sulfate solution on angiographic cerebral vasospasms associated with aneurysmal subarachnoid hemorrhages: a randomized controlled trial.

Takuji Yamamoto MD, Kentaro Mori MD, Takanori Esaki MD, et al. (JNS)

In this single institution prospective randomized controlled study which was done in Japan, the investigators studied the efficacy of continuous direct infusion of MgSO4 solution into the intrathecal cistern in patients with an aneurysmal SAH after surgical clipping. This study included 70 consecutive patients presenting with SAH within 72 hours from ictus from April 2008 to March 2013. They had two groups, first one patients who received MgSO4 treatment protocol and the second control group of patients who did not receive MgSO4 treatment. They used transcranial Doppler (TCD) and cerebral angiography to evaluate the efficacy of intrathecal Mg infusion for preventing cerebral vasospasms (CV) and monitored both Mg2+ serum and Mg2+ CSF to assess the safety of this treatment. Also they used mRS after 3 months to assess the improvements in functional outcome. During clipping, the Liliequist membrane was opened to allow CSF circulation between the supratentorial and infratentorial compartments, and the cisternal drainage tube was placed into the basal cistern and a spinal drainage tube was also inserted. Continuous infusion of MgSO4 solution was performed at 20 ml/hr from day 4 until Day 14 through the cisternal to spinal drainage. A decline in consciousness and bradypnea possibly caused by the sedative effect of Mg were observed in Mg group. The TCD results indicated that velocity in MCA increased more in the control group. A delayed cerebral ischemia identified on CT or MRI scans was observed in 9 patients in the control group and in 5 patients in the Mg group. The clinical outcomes at the 3-month follow-up examination did not significantly differ in these outcomes. They concluded that continuous cisternal infusion with MgSO4 solution reduces the incidence of angiographic CV in patients with aneurysmal SAH, particularly of severe spasms on their angiographic CV scale. However this Mg treatment protocol did not reduce the incidence of delayed cerebral ischemia and did not improve clinical outcomes among the patients.

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Highest Volume Centers Have The Lowest Mortality in Patients with SAH.

High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes

Pandey, Aditya S. MD; Gemmete, Joseph J. MD; Wilson, Thomas J. MD, et al (Neurosurgery)

This study is a cross-sectional retrospective analysis on patient data obtained through the National Inpatient Sample (NIS). Patients included were adults with an ICD9 code diagnosis of subarachnoid hemorrhage at discharge from the hospital. Diagnosis codes of traumatic SAH and SAH due to arteriovenous malformations were excluded to ensure only aneurysmal SAH was analyzed. Patients were sorted into treatment type of clipping versus coiling. The primary outcome measured was mortality. Outcomes were defined as “good” or “bad.” Good outcomes were when the patient was discharged home. Bad outcomes included inpatient mortality, discharge to hospice, or discharge to a long term acute care nursing facility. Hospitals were separated into quintiles based on volume of aneurysmal SAH discharges per year. The authors claim that the highest volume centers had the lowest inpatient mortality and bad outcomes with also a higher level of good outcomes. This statement held true in their study when adjusting for patient co morbidities and level of aggressiveness in treatment.

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