Article

Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: a randomized, placebo-controlled, clinical study.

Department of Neurosurgery, University of Wuerzburg, Wuerzburg, Germany.
Critical care medicine (Impact Factor: 6.15). 03/2010; 38(5):1284-90. DOI: 10.1097/CCM.0b013e3181d9da1e
Source: PubMed

ABSTRACT To examine whether the maintenance of elevated magnesium serum concentrations by intravenous administration of magnesium sulfate can reduce the occurrence of cerebral ischemic events after aneurysmal subarachnoid hemorrhage.
Prospective, randomized, placebo-controlled study.
Neurosurgical intensive care unit of a University hospital.
One hundred ten patients were randomized to receive intravenous magnesium sulfate or to serve as controls. Magnesium treatment was started with a bolus of 16 mmol, followed by continuous infusion of 8 mmol/hr. Serum concentrations were measured every 8 hrs, and infusion rates were adjusted to maintain target levels of 2.0-2.5 mmol/L. Intravenous administration was continued for 10 days or until signs of vasospasm had resolved. Thereafter, magnesium was administered orally and tapered over 12 days.
Delayed ischemic infarction (primary end point) was assessed by analyzing serial computed tomography scans. Transcranial Doppler sonography and digital subtraction angiography were used to detect vasospasm. Delayed ischemic neurologic deficit was determined by continuous detailed neurologic examinations; clinical outcome after 6 months was assessed using the Glasgow outcome scale. Good outcome was defined as Glasgow outcome scale score 4 and 5.The incidence of delayed ischemic infarction was significantly lower in magnesium-treated patients (22% vs. 51%; p = .002); 34 of 54 magnesium patients and 27 of 53 control patients reached good outcome (p = .209). Delayed ischemic neurologic deficit was nonsignificantly reduced (9 of 54 vs. 15 of 53 patients; p = .149) and transcranial Doppler-detected/angiographic vasospasm was significantly reduced in the magnesium group (36 of 54 vs. 45 of 53 patients; p = .028). Fewer patients with signs of vasospasm had delayed cerebral infarction.
These data indicate that high-dose intravenous magnesium can reduce cerebral ischemic events after aneurysmal subarachnoid hemorrhage by attenuating vasospasm and increasing the ischemic tolerance during critical hypoperfusion.

1 Bookmark
 · 
147 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage is a cause of considerable morbidity and mortality. Magnesium sulfate has been proposed as a prophylactic intervention for angiographic vasospasm and to improve clinical outcomes. A systematic review was conducted to determine the evidence for the prophylactic use of magnesium sulfate in aneurysmal subarachnoid hemorrhage. Medline, Embase, Cochrane library, clinicaltrials.gov, and controlled-trials.com were searched with a comprehensive search strategy. 2,035 records were identified in the initial search and 1,574 remained after removal of duplicates. Randomized, parallel group, controlled trials of magnesium sulfate in patients with aneurysmal subarachnoid hemorrhage were included. A total of ten studies were included. Review Manager and GRADE software were used to synthesize the results. The summary effect for Glasgow outcome scale and the modified Rankin scale is a risk ratio (RR) of 0.93 [95 % confidence interval (CI) 0.82-1.06]. The RR for mortality is 0.95 [95 % CI 0.76-1.17]. Delayed cerebral ischemia has a RR of 0.54 [95 % CI 0.38-0.75], which is the only outcome with a statistically significant summary effect measure favoring magnesium treatment. Delayed ischemic neurological deficit has a RR of 0.93 [95 % CI 0.62-1.39]. Transcranial doppler vasospasm has a RR of 0.72 [95 % CI 0.51-1.03]. Current evidence does not support the prophylactic use of magnesium sulfate in aneurysmal subarachnoid hemorrhage.
    Neurocritical Care 03/2014; · 3.04 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background The failures of recent studies intended to prevent cerebral vasospasm have moved the focus of research into delayed cerebral ischemia away from cerebral artery constriction towards other mechanisms. Recent accumulating evidence has suggested that early brain injury is also involved in the development of delayed cerebral ischemia, and that hydrogen can prevent early brain injury. Therefore, we have established a combination therapy of intravenous hydrogen infusion and intra-cisternal magnesium sulfate infusion for the treatment of both early brain injury and cerebral vasospasm. The present randomized controlled clinical trial is designed to investigate the effects of this novel therapeutic strategy on the occurrence of cerebral vasospasm, delayed cerebral ischemia, and clinical outcomes after high-grade subarachnoid hemorrhage.Methods This study is a randomized, double-blind, placebo-controlled design to be conducted in two hospitals. A total of 450 patients with high-grade subarachnoid hemorrhage will be randomized to one of three arms: (i) Mg¿+¿H2 group, (ii) Mg group, and (iii) control group. Patients who are assigned to the Mg¿+¿H2 group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous hydrogen-rich fluid infusion (200 mL) twice a day for 14 days. Patients who are assigned to the Mg group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Patients who are assigned to the control group will receive intra-cisternal Ringer solution without magnesium sulfate at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Primary outcome measures will be occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures will be modified Rankin scale score at 3, 6, and 12 months and biochemical markers.DiscussionThe present protocol for a randomized, placebo-controlled study of intravenous hydrogen therapy with intra-cisternal magnesium infusion is expected to establish the efficacy and safety of this therapeutic strategy.Trial registrationUMIN-CTR: UMIN000014696.
    BMC Neurology 09/2014; 14(1):176. · 2.49 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Neurocritical care is a pioneering subspecialty dedicated to the treatment of patients with life-threatening neurological illnesses, postoperative neurosurgical complications, and neurological manifestations of systemic disease. The care of these patients requires specialized neurological monitoring and specific clinical expertise and has generated a body of literature commensurate with the expansion of the field. This article reviews landmark studies over the last 10 years in the management and treatment of common acute neurological illnesses including massive cerebral infarction, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, and status epilepticus.
    The Neurohospitalist. 04/2014; 4(2):102-8.

Full-text (2 Sources)

Download
221 Downloads
Available from
May 17, 2014