Data_Sheet_1_A network meta-analysis of therapeutic and prophylactic management of vasospasm on aneurysmal subarachnoid hemorrhage outcomes.DOCX

BackgroundVasospasm and cerebral ischemia after aneurysmal subarachnoid hemorrhage are associated with mortality and poor neurological outcomes. We studied the efficacy of all available strategies targeting vasospasm and cerebral ischemia on outcomes in a network meta-analysis.MethodsWe searched EMBASE and MEDLINE databases from 1 January 1990 and 28 November 2021 according to PRISMA guidelines. Randomized controlled trials and longitudinal studies were included. All curative or preventive strategies targeting vasospasm and/or cerebral ischemia were eligible. A network meta-analysis was performed to compare all interventions with one another in a primary (randomized controlled trials only) and a secondary analysis (both trials and longitudinal studies). Mortality by 3 months was the primary outcome. Secondary outcomes were vasospasm, neurological outcome by 3 months, and dichotomized as “good” or “poor” recovery according to each study definition.ResultsA total of 2,382 studies were screened which resulted in the selection of 192 clinical trials (92 (47.9%) and 100 cohorts (52.1%) and the inclusion of 41,299 patients. In randomized controlled studies, no strategy decreased mortality by 3 months. Statins (0.79 [0.62–1]), tirilazad (0.82 [0.69–0.97]), CSF drainage (0.47 [0.29–0.77]), and clazosentan (0.51 [0.36–0.71]) significantly decreased the incidence of vasospasm. Cilostazol was the only treatment associated with improved neurological outcomes by 3 months in the primary (OR 1.16, 95% CI [1.05–1.28]) and secondary analyses (OR 2.97, 95% CI [1.39–6.32]).DiscussionIn the modern era of subarachnoid hemorrhage, all strategies targeting vasospasm failed to decrease mortality. Cilostazol should be confirmed as a treatment to improve neurological outcomes. The link between vasospasm and neurological outcome appears questionable.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=116073, identifier: PROSPERO CRD42018116073.</p

Data_Sheet_2_A network meta-analysis of therapeutic and prophylactic management of vasospasm on aneurysmal subarachnoid hemorrhage outcomes.docx

BackgroundVasospasm and cerebral ischemia after aneurysmal subarachnoid hemorrhage are associated with mortality and poor neurological outcomes. We studied the efficacy of all available strategies targeting vasospasm and cerebral ischemia on outcomes in a network meta-analysis.MethodsWe searched EMBASE and MEDLINE databases from 1 January 1990 and 28 November 2021 according to PRISMA guidelines. Randomized controlled trials and longitudinal studies were included. All curative or preventive strategies targeting vasospasm and/or cerebral ischemia were eligible. A network meta-analysis was performed to compare all interventions with one another in a primary (randomized controlled trials only) and a secondary analysis (both trials and longitudinal studies). Mortality by 3 months was the primary outcome. Secondary outcomes were vasospasm, neurological outcome by 3 months, and dichotomized as “good” or “poor” recovery according to each study definition.ResultsA total of 2,382 studies were screened which resulted in the selection of 192 clinical trials (92 (47.9%) and 100 cohorts (52.1%) and the inclusion of 41,299 patients. In randomized controlled studies, no strategy decreased mortality by 3 months. Statins (0.79 [0.62–1]), tirilazad (0.82 [0.69–0.97]), CSF drainage (0.47 [0.29–0.77]), and clazosentan (0.51 [0.36–0.71]) significantly decreased the incidence of vasospasm. Cilostazol was the only treatment associated with improved neurological outcomes by 3 months in the primary (OR 1.16, 95% CI [1.05–1.28]) and secondary analyses (OR 2.97, 95% CI [1.39–6.32]).DiscussionIn the modern era of subarachnoid hemorrhage, all strategies targeting vasospasm failed to decrease mortality. Cilostazol should be confirmed as a treatment to improve neurological outcomes. The link between vasospasm and neurological outcome appears questionable.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=116073, identifier: PROSPERO CRD42018116073.</p

Time course of TLR-induced production of TNF-α and IL-12 in circulating mDCs from patients with aneurysmal subarachnoid hemorrhage.

<p>Intracellular cytokine measurement was performed in circulating mDCs from SAH patients (N = 21) on days 2, 5 and 10 and from HC (N = 11). The percentages of mDCs expressing TNF-α or IL-12 were assessed after a 3.5-hour <i>ex vivo</i> stimulation with (<b>A</b>) polyIC (TLR-3 agonist), (<b>B</b>) lipopolysaccharide (TLR-4 agonist) or (<b>C</b>) CL097 (TLR-7/8 agonist). The percentage of positive DCs without TLR-stimulation was below 1% (data not shown). The results are presented as percentages of mDCs expressing TNF-α (%TNF-α⁺) or IL-12 (% IL-12⁺). Plots represent median (Interquartile ranges). HC: healthy controls. mDCs: myeloid dendritic cells. SAH: aneurysmal subarachnoid hemorrhage. TNF-α: tumour necrosis factor -α. IL-12: intreleukin-12. * <i>P</i><0.05.</p

Time course of TLR-induced productions of TNF-α and IFN-α in circulating pDCs from patients with aneurysmal subarachnoid hemorrhage.

<p>Intracellular cytokine measurement was performed in circulating pDCs from SAH patients (N = 21) on days 2, 5 and 10 after brain injury and from HC (N = 11). The percentages of pDCs expressing TNF-α or IFN-α were assessed after a 3.5-hour <i>ex vivo</i> stimulation with (<b>A</b>) CL097 (TLR-7/8 agonist) or (<b>B</b>) CpG (TLR-9 agonist). The percentage of positive pDCs without TLR-stimulation was below 1% (data not shown). The results are presented as percentages of pDCs expressing TNF-α (%TNF-α⁺) or IFN-α (%IFN-α⁺). Plots represent median (Interquartile ranges). HC: healthy controls. IFN-α: interferon. pDCs: plasmacytoid dendritic cells. SAH: aneurysmal subarachnoid hemorrhage. TNF-α: tumour necrosis factor -α. *<i>P</i><0.05.</p

Exploratory comparison of mDC and pDC status on day 2 in survivors and non-survivors.

<p>(<b>A</b>) The number of circulating myeloid DCs and plasmacytoid DCs were compared on day 2 between 13 survivors and 8 non-survivors. On day 2, mDCs and pDCs were stimulated <i>ex vivo</i> with polyIC (TLR-3 agonist), lipopolysaccharide (TLR-4 agonist), CL097 (TLR-7/8 agonist) and CpG (TLR-9 agonist) for 3.5 hours. (B) The percentages of mDCs expressing TNF-α or IL-12 and (C) the percentages of pDCs expressing TNF-α or IFN-α were compared between survivors and non-survivors. The percentage of positive DCs without TLR stimulation was below 1% (data not shown). The results are presented as percentages of DCs expressing TNF-α (%TNF-α⁺), IL-12 (%IL-12⁺) or IFN-α (%IFN-α⁺). Plots represent median (Interquartile ranges). * <i>P</i><0.05.</p

Characteristics of the study population.

<p>ARDS: acute respiratory distress syndrome, ICU: intensive care unit, SAH: subarachnoid hemorrhage, SAPS: simplified acute physiological score, WFNS: World Federation of Neurological Surgeons.</p

Gating strategy used to identify blood DC subsets and intracellular cytokines production in DCs in whole blood stimulated with TLR ligands.

<p>Whole blood samples were incubated with TLR3, 4, 7/8 or 9 ligands for 3.5-hour and then stained for identification of myeloid DC (HLA-DR+, Lin-, CD11c+, CD123-) and plasmacytoid DC (HLA-DR+, lin−, CD11c−, CD123+) together with intracellular cytokine production (TNFα, IL-12, IFNα).</p

Time course of circulating mDCs and pDCs numbers in patients with aneurysmal subarachnoid hemorrhage.

<p>Comparison of circulating (A) myeloid DC and (B) plasmacytoid DC counts in SAH patients (N = 21) on days 2, 5 and 10 compared with HC (N = 11). Plots represent median (Interquartile ranges). HC: healthy controls. SAH: aneurysmal subarachnoid hemorrhage. DCs: dendritic cells. * <i>P</i><0.05, ** <i>P</i><0.01.</p

Le Courrier

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Additional file 5: Figure S3. of Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury – a multicentre prospective cohort study and systematic review

Time course of the blood levels of creatinine (A) and urea (B) in patients treated or not with continuous hyperosmolar therapy. (PDF 67 kb