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Neurocritical Care Improvement

May 31, 2012

Research on aneurysmal subarachnoid hemorrhage (bleeding found within the membrane layers surrounding the brain) needs more well-designed and large-scale clinical trials to move forward in discovering lifesaving treatment options, said Baylor College of Medicine neurocritical physicians and researchers.

Dr. Jose I. Suarez, professor of neurology, and Dr. Chethan P. Venkatasubba Rao, assistant professor of neurology, both with the division of vascular neurology and neurocritical care at BCM, contributed to a commentary in the current edition of Lancet concerning the results of the MASH 2 clinical trial by Dorhout Mees et al., which can also be found in the current edition.

The study found that intravenous magnesium sulphate did not improve clinical outcome after aneurysmal subarachnoid hemorrhage, also known as aSAH. This disorder has a high morbidity and mortality rate due to elevated intracranial pressure in the first few hours of onset and also because of delayed cerebral ischemia (a condition caused by a reduction in blood flow to an area of the brain that could result in permanent tissue loss or damage), which can occur days or weeks after aSAH.

Both Suarez, who is also chief of stroke and neurocritical care at St. Luke’s Episcopal Hospital, and Rao agree with the study outcome, stating in the commentary, “The results, although disappointing, are nonetheless very pertinent to the management of SAH patients. Concurrent with previous analyses, we agree with the authors that routine intravenous magnesium sulphate infusion cannot be recommended for aSAH. Pervasively glamorous in earlier studies, magnesium sulphate morphed into perfidious paramour in this definitive clinical trial.”

They note that some additional study design features could be taken into account in future research.

People who are suffering from aSAH have a variety of underlying issues that could have affected the outcome. Suarez said these issues and additional testing could be evaluated as indicators to determine the likelihood of good outcome for patients.

Suarez also noted that since delayed cerebral ischemia plays a large role in recovery, the disorder should have been included in this study. How aggressively delayed cerebral ischemia was treated and managed should be reviewed for each case to understand what role it played in the outcome of each patient. He also said other medical complications need to be further studied to determine treatment standards.

Finally, financial constraints affected how certain on-site monitoring and physiological recordings of the effects of intravenous magnesium infusion were carried out.

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