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Effect of magnesium sulfate therapy on patients with aneurysmal subarachnoid hemorrhage using serum S100B protein as a prognostic marker

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Abstract

Magnesium, one of the essential trace elements, plays important roles in maintaining both normal cellular and body functions. S100 calcium-binding protein B (S100B) has been used as a marker of glial damage in several neurological disorders. Thirty patients with ruptured intracranial aneurysms treated by clip** are included. The patients were randomized within 4 days after the attack of hemorrhage. The patients were divided into two groups with 15 patients in each group. Group I received magnesium infusion within 4 days. Group II is the control group. World Federation of Neurological Surgeons, Fisher, and Glasgow outcome scores are evaluated at an intensive care unit in addition to 3 months clinical follow-up evaluation. Samplings of serum S100B were performed on admission and on postoperative days 1, 3, and 7. There is a statistically significant difference between both groups as regards the second reading of the S100B (day 1 postoperative; P < 0.05). There is no statistically significant difference between both groups as regards outcome at 3 months using clinical status and S100B values. There is a tendency in the magnesium group to have better outcomes. Further studies with more number of patients with subarachnoid hemorrhage are needed to determinate the accuracy of S100B protein as a prognostic marker and of magnesium sulfate as a neuroprotector.

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Authors and Affiliations

  1. Department of Neurosurgery, Alexandria University School of Medicine, Elazarita, Shambeleon Street, Alexandria, Egypt

    Tamer Hassan

  2. Department of Anaesthesia, Alexandria University, Alexandria, Egypt

    Mahmoud Nassar, Sherif Mohammed Elhadi & Wafa Kamel Radi

Authors
  1. Tamer Hassan
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  2. Mahmoud Nassar
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  3. Sherif Mohammed Elhadi
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  4. Wafa Kamel Radi
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Correspondence to Tamer Hassan.

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Comments

Claudius Thomé, Innsbruck, Austria

Hassan et al. have performed a randomized study on the effect of intravenous magnesium sulfate on outcome and S100B levels after aneurysmal subarachnoid hemorrhage (SAH) in a series of 30 patients. S100B was chosen as a surrogate parameter for neurological damage. Patients were included, treated by surgical clip**, and started on an established dose of magnesium or an equal volume of saline within 4 days after SAH. Unfortunately, S100B levels were analyzed in relation to the time point of surgery rather than the time point of SAH, so that it is unclear whether the significantly lower S100B value on the first postoperative day in the magnesium group is a therapeutic effect or merely due to intergroup differences in timing. Vasospasm was present in 3 of 15 treated versus 2 of 15 control patients, but a definition of vasospasm—be it clinically, angiographically, or per TCD—is lacking. There are some methodological flaws like the absence of a power calculation as the small patient numbers would have never allowed meaningful conclusions. Most of these drawbacks can be somewhat overcome by the dedication to perform a randomized study, which is considered the most appropriate means to establish scientific knowledge. One criticism, however, cannot be stressed enough: Favorable outcome of 73% in the magnesium group versus 60% in the control group reaching a P value of 0.43 simply states that there is no difference in outcome! This cannot be interpreted as “a tendency in the magnesium group to have better outcomes” as concluded in the abstract!

Overall, I like the idea of the manuscript to combine a surrogate biomarker with a randomized study design for a potentially neuroprotective agent. Nevertheless, there already is a large amount of data on magnesium sulfate in SAH from six phase II and one phase III randomized-controlled trials, which has been recently reviewed by Suarez et al. (1) The phase III trial with 327 patients revealed no difference in outcome whatsoever (2), which is in line with the results of the present study.

References

1. Suarez JI (2011) Participants in the International Multidisciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Magnesium sulfate administration in subarachnoid hemorrhage. Neurocrit Care 15:302–307.

2. Wong GK, Poon WS, Chan MT, Boet R, Gin T, Ng SC, Zee BC (2010) Plasma magnesium concentrations and clinical outcomes in aneurysmal subarachnoid hemorrhage patients: post hoc analysis of intravenous magnesium sulfate for aneurysmal subarachnoid hemorrhage trial. Stroke 41:1841–1844.

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Hassan, T., Nassar, M., Elhadi, S.M. et al. Effect of magnesium sulfate therapy on patients with aneurysmal subarachnoid hemorrhage using serum S100B protein as a prognostic marker. Neurosurg Rev 35, 421–427 (2012). https://doi.org/10.1007/s10143-011-0368-8

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  • DOI: https://doi.org/10.1007/s10143-011-0368-8

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