Review Article: Inflammation, Vasospasm, and Brain Injury After Subarachnoid Hemorrhage

Hindawi Publishing Corporation
BioMed Research International

Volume 2014, Article ID 384342, 16 pages
http://dx.doi.org/10.1155/2014/384342
Review Article
Inflammation, Vasospasm, and Brain Injury
after Subarachnoid Hemorrhage
Brandon A. Miller,1 Nefize Turan,1 Monica Chau,2 and Gustavo Pradilla1,3
1
Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
Division of Neuropathology, Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
3
Cerebrovascular Research Laboratory, Grady Memorial Hospital, Emory University School of Medicine, 1365 Clifton Road,
NE, Suite B6166, Atlanta, GA, USA
2
Correspondence should be addressed to Gustavo Pradilla; gpradil@emory.edu

Received 14 February 2014; Revised 14 May 2014; Accepted 26 May 2014; Published 3 July 2014
Academic Editor: Aaron S. Dumont
Copyright 2014 Brandon A. Miller et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Subarachnoid hemorrhage (SAH) can lead to devastating neurological outcomes, and there are few pharmacologic treatments
available for treating this condition. Both animal and human studies provide evidence of inflammation being a driving force behind
the pathology of SAH, leading to both direct brain injury and vasospasm, which in turn leads to ischemic brain injury. Several
inflammatory mediators that are elevated after SAH have been studied in detail. While there is promising data indicating that
blocking these factors might benefit patients after SAH, there has been little success in clinical trials. One of the key factors that
complicates clinical trials of SAH is the variability of the initial injury and subsequent inflammatory response. It is likely that
both genetic and environmental factors contribute to the variability of patients post-SAH inflammatory response and that this
confounds trials of anti-inflammatory therapies. Additionally, systemic inflammation from other conditions that affect patients
with SAH could contribute to brain injury and vasospasm after SAH. Continuing work on biomarkers of inflammation after SAH
may lead to development of patient-specific anti-inflammatory therapies to improve outcome after SAH.
1. Introduction
Subarachnoid hemorrhage (SAH) remains a devastating disease, leaving survivors with neurological injuries that range
from subtle cognitive deficits to disabling cerebral infarctions.
While treatment continues to evolve and improve, there are
few therapies that treat the underlying pathological mechanisms of SAH. Additionally, there is no clear explanation
for the heterogeneity among patients with SAH, with some
recovering well and others worsening after their initial ictus.
In this review, we will discuss the evidence supporting the role
of inflammation as a direct mediator of neurological injury
after SAH and a causative factor of post-SAH vasospasm.
We hypothesize that the diffuse inflammatory response after
SAH results in acute and chronic neurological injury and
vasospasm and that patients with more severe inflammatory responses may experience worse outcomes after SAH.
An improved understanding of the inflammatory pathways
activated after SAH will likely lead to novel therapies and

improved patient outcomes.
2. Evidence for Acute Inflammation

after Subarachnoid Hemorrhage
2.1. Detection of Inflammatory Mediators in CSF after SAH.
Several human studies have repeatedly shown elevated
inflammatory mediators within CSF after SAH. While the key
mediators identified may vary across studies, the relationship between elevation, onset of vasospasm, and decreased
neurological outcomes remains a consistent finding [1, 2]. A
study by Polin and colleagues [3] showed that patients who
developed vasospasm after SAH had higher CSF levels of Eselectin, an endothelial cell molecule that induces leukocyte
adherence and extravasation and subsequent tissue injury
in ischemic stroke [46]. These findings are supported by
2
experimental data showing that CSF from patients with
SAH increased rolling and adhesion of leukocytes in an
in vitro mouse model [7]. While there are other studies
showing elevation of E-selectin after SAH [8], some have
failed to detect E-selectin in the CSF of patients with SAH,
even when other inflammatory molecules, such as monocyte
chemoattractant protein-1 (MCP-1), were elevated [9]. Other
cytokines that have been widely cited to play a role in
SAH, such as tumor necrosis factor-alpha (TNF), also show
wide variation in expression when compared across different
studies. For instance, Kikuchi and colleagues found elevated
levels of interleukin- (IL-) 6 and IL-8 but not TNF after
SAH, while other groups have found elevations of TNF
in the CSF after SAH [2, 10, 11]. One recent study found
detectable levels of TNF in only 30% of patients after SAH,
indicating that the inflammatory response after SAH may
be quite heterogeneous [12]. The differences across these
studies may be the result of different CSF collection times
after SAH, alternative methods of detection used, or diverse
patient populations. In addition, cross contamination of CSF
with blood during collection from ventricular or lumbar
sources is rarely accounted for. The volume of blood present
within the subarachnoid space would obviously affect the
levels of cytokines present in CSF, and therefore cytokine
concentration in CSF may reflect the volume of SAH rather
than the magnitude of the inflammatory response within the
brain.
One of the most widely studied molecules in SAH is
endothelin-1 (ET-1), a vasoconstrictor produced by endothelial cells. ET-1 has been detected in CSF from patients with
SAH and can be produced by monocytes isolated from
CSF of SAH patients [13, 14]. ET-1 has been implicated
in the development of vasospasm after SAH [15] and will
be discussed in detail later in this review. As with many
other proinflammatory molecules, the expression of ET-1 is
highly variable: in a study by Fassbender and colleagues,
ET-1 was not found in CSF of control subjects, and only
46% of patients with SAH had detectable levels of ET-1
[13]. Though the averaged results of both groups revealed a
significant increase in ET-1 after SAH, this demonstrates that
not all patients with SAH experience the same inflammatory
response. Furthermore, a study from a different group failed
to detect ET-1 after SAH [16]. This heterogeneity is readily
apparent to clinicians treating SAH, as many patients move
through their posthemorrhage course with few complications, while others experience severe complications such as
vasospasm and cerebral edema, which may both be driven by
an inflammatory response [17, 18].
2.2. Detection of Inflammatory Mediators in Blood after SAH.
In addition to the inflammatory cytokines found within CSF
in patients after SAH, a systemic increase in inflammatory
mediators after SAH is well documented [1, 19, 20]. This
systemic increase in inflammatory cytokines after SAH is
predictive of poor outcome and may be related to a late, rather
than early, inflammatory response [2124]. Other markers
of systemic inflammation, such as high body temperature
and leukocytosis, have also correlated with worse outcomes

after SAH; however, no causal relationship was established
between peripheral inflammation and intracerebral pathology [25, 26]. There is increasing interest in developing inflammatory biomarkers for prognosticating outcome in SAH
though no biomarker study in SAH has been prospectively
validated [27]. It is unclear to what extent the presence of
inflammatory cytokines in plasma is due to intracerebral
processes or how strongly blood cytokine levels correlate with
inflammation within the brain [12]. It is quite possible that
inflammatory cytokines detected in plasma are indicators
of global inflammation throughout the body, as would be
expected in patients who are critically ill after SAH. For
example, both ICAM-1 and E-selectin have been used to
prognosticate outcome in critically ill patients without SAH
[28]. It is also possible that inflammatory cytokines within the
blood contribute to brain injury after SAH; the breakdown
of the blood brain barrier after SAH could allow serum
cytokines to enter the brain parenchyma leading to tissue
injury there.
In planning any trial of anti-inflammatory therapy after
SAH, consideration should be given to when the peak of
inflammation occurs, in order to optimize delivery and
dosing of the therapy. There is evidence that the expression of
certain inflammatory molecules peaks within 24 hours after
hemorrhage onset, with IL-6 being elevated at days 0 to 1 after
SAH [29] though others have shown a peak of IL-6 at day
6 after SAH [30]. Once again, differences between these two
studies may be due to many factors, including the high degree
of variability among inflammatory responses among patients
with SAH [3, 10].
2.3. Inflammation and Aneurysm Formation. Inflammation
may also play a role in aneurysm formation. Several previously discussed inflammatory cytokines, such as TNF and
MCP-1, are thought to play a role in endothelial injury and
remodeling based on evidence from both human and animal
studies [31, 32]. A recent clinical study found increased
cyclooxygenase within the walls of ruptured and unruptured
aneurysms [33] and the same group has shown that aspirin
may reduce the rate of aneurysm rupture due to its antiinflammatory properties [34, 35]. E-selectin has also been
found at elevated levels in the walls of aneurysms [36]. Additionally, environmental factors that contribute to a proinflammatory state may contribute to aneurysm formation [37]. A
detailed discussion of the contribution of inflammation to
aneurysm formation is outside the scope of this review and
was reviewed recently elsewhere [38].
3. Evidence for Inflammation

in Animal Models of SAH
Animal models have been utilized to establish a causative
relationship between inflammation and brain injury after
SAH. Several animal models for SAH exist, each with
their own advantages and drawbacks [39]. Common models
include blood injection into the basal cisterns of animals or
endovascular perforation, both of which produce vasospasm
and an inflammatory response [4042]. As in human SAH
2
experimental data showing that CSF from patients with
SAH increased rolling and adhesion of leukocytes in an
in vitro mouse model [7]. While there are other studies
showing elevation of E-selectin after SAH [8], some have
failed to detect E-selectin in the CSF of patients with SAH,
even when other inflammatory molecules, such as monocyte
chemoattractant protein-1 (MCP-1), were elevated [9]. Other
cytokines that have been widely cited to play a role in
SAH, such as tumor necrosis factor-alpha (TNF), also show
wide variation in expression when compared across different
studies. For instance, Kikuchi and colleagues found elevated
levels of interleukin- (IL-) 6 and IL-8 but not TNF after
SAH, while other groups have found elevations of TNF
in the CSF after SAH [2, 10, 11]. One recent study found
detectable levels of TNF in only 30% of patients after SAH,
indicating that the inflammatory response after SAH may
be quite heterogeneous [12]. The differences across these
studies may be the result of different CSF collection times
after SAH, alternative methods of detection used, or diverse
patient populations. In addition, cross contamination of CSF
with blood during collection from ventricular or lumbar
sources is rarely accounted for. The volume of blood present
within the subarachnoid space would obviously affect the
levels of cytokines present in CSF, and therefore cytokine
concentration in CSF may reflect the volume of SAH rather
than the magnitude of the inflammatory response within the
brain.
One of the most widely studied molecules in SAH is
endothelin-1 (ET-1), a vasoconstrictor produced by endothelial cells. ET-1 has been detected in CSF from patients with
SAH and can be produced by monocytes isolated from
CSF of SAH patients [13, 14]. ET-1 has been implicated
in the development of vasospasm after SAH [15] and will
be discussed in detail later in this review. As with many
other proinflammatory molecules, the expression of ET-1 is
highly variable: in a study by Fassbender and colleagues,
ET-1 was not found in CSF of control subjects, and only
46% of patients with SAH had detectable levels of ET-1
[13]. Though the averaged results of both groups revealed a
significant increase in ET-1 after SAH, this demonstrates that
not all patients with SAH experience the same inflammatory
response. Furthermore, a study from a different group failed
to detect ET-1 after SAH [16]. This heterogeneity is readily
apparent to clinicians treating SAH, as many patients move
through their posthemorrhage course with few complications, while others experience severe complications such as
vasospasm and cerebral edema, which may both be driven by
an inflammatory response [17, 18].
2.2. Detection of Inflammatory Mediators in Blood after SAH.
In addition to the inflammatory cytokines found within CSF
in patients after SAH, a systemic increase in inflammatory
mediators after SAH is well documented [1, 19, 20]. This
systemic increase in inflammatory cytokines after SAH is
predictive of poor outcome and may be related to a late, rather
than early, inflammatory response [2124]. Other markers
of systemic inflammation, such as high body temperature
and leukocytosis, have also correlated with worse outcomes

after SAH; however, no causal relationship was established
between peripheral inflammation and intracerebral pathology [25, 26]. There is increasing interest in developing inflammatory biomarkers for prognosticating outcome in SAH
though no biomarker study in SAH has been prospectively
validated [27]. It is unclear to what extent the presence of
inflammatory cytokines in plasma is due to intracerebral
processes or how strongly blood cytokine levels correlate with
inflammation within the brain [12]. It is quite possible that
inflammatory cytokines detected in plasma are indicators
of global inflammation throughout the body, as would be
expected in patients who are critically ill after SAH. For
example, both ICAM-1 and E-selectin have been used to
prognosticate outcome in critically ill patients without SAH
[28]. It is also possible that inflammatory cytokines within the
blood contribute to brain injury after SAH; the breakdown
of the blood brain barrier after SAH could allow serum
cytokines to enter the brain parenchyma leading to tissue
injury there.
In planning any trial of anti-inflammatory therapy after
SAH, consideration should be given to when the peak of
inflammation occurs, in order to optimize delivery and
dosing of the therapy. There is evidence that the expression of
certain inflammatory molecules peaks within 24 hours after
hemorrhage onset, with IL-6 being elevated at days 0 to 1 after
SAH [29] though others have shown a peak of IL-6 at day
6 after SAH [30]. Once again, differences between these two
studies may be due to many factors, including the high degree
of variability among inflammatory responses among patients
with SAH [3, 10].
2.3. Inflammation and Aneurysm Formation. Inflammation
may also play a role in aneurysm formation. Several previously discussed inflammatory cytokines, such as TNF and
MCP-1, are thought to play a role in endothelial injury and
remodeling based on evidence from both human and animal
studies [31, 32]. A recent clinical study found increased
cyclooxygenase within the walls of ruptured and unruptured
aneurysms [33] and the same group has shown that aspirin
may reduce the rate of aneurysm rupture due to its antiinflammatory properties [34, 35]. E-selectin has also been
found at elevated levels in the walls of aneurysms [36]. Additionally, environmental factors that contribute to a proinflammatory state may contribute to aneurysm formation [37]. A
detailed discussion of the contribution of inflammation to
aneurysm formation is outside the scope of this review and
was reviewed recently elsewhere [38].
3. Evidence for Inflammation

in Animal Models of SAH
Animal models have been utilized to establish a causative
relationship between inflammation and brain injury after
SAH. Several animal models for SAH exist, each with
their own advantages and drawbacks [39]. Common models
include blood injection into the basal cisterns of animals or
endovascular perforation, both of which produce vasospasm
and an inflammatory response [4042]. As in human SAH

studies, there is considerable variability between subjects
when inflammatory responses are quantified [43, 44]. Animal
studies of SAH have found evidence of inflammation in
all intracerebral compartments: CSF, brain parenchyma, and
vasculature [4549].
Animal studies have been used to link inflammation,
cerebral edema, and cell death after SAH. The anesthetic
isoflurane has been shown to reduce TNF production,
leukocyte adhesion molecule expression, and blood brain
barrier permeability after experimental SAH [50, 51]. The
results of these studies are promising but do not prove
whether decreased TNF levels in affected tissue are a
cause or result of decreased leukocyte infiltration. There is,
however, evidence of TNF having a direct role on neuronal
injury after SAH. Recently, blockade of TNF was shown to
reduce apoptosis in the hippocampus after SAH [52]. This
corresponds well to the extensive literature demonstrating
a role for TNF in neuronal apoptosis in other forms of
neurological injury [53]. However, the antiapoptotic effects
of TNF blockade were not uniform throughout the brain,
and a pre-rather than posttreatment paradigm was utilized
in this study [52]. Furthermore, there is not even a consensus
that neuronal death occurs in SAH, with some groups
reporting no neuronal apoptosis after SAH while others
observe neuronal death throughout the brain after SAH [54
56]. Regardless of whether or not neuronal death occurs after
SAH, there are other pathological events that could explain
neurological dysfunction after SAH, such as synaptic injury,
loss of long term potentiation, and white matter injury [57].
Both synaptic loss and white matter injury are mediated
by inflammation in models of other neurological diseases;
however, more work is needed to understand the precise role
of inflammation on cell death and injury after SAH [58, 59].
Animal models of SAH have also found evidence for
inflammation playing a role in injury outside of the brain. In
a study using endovascular perforation as a model of SAH in
rats, systemic anti-inflammatory treatment was able to reduce
lung injury after SAH [60]. This is relevant to SAH treatment
as many patients experience cardiopulmonary complications
as part of a systemic reaction to SAH [61]. Animal models
of SAH have played an essential role in linking inflammation
to vasospasm after SAH and will be discussed in more detail
below.
4. The Role of Inflammation

in Vasospasm after SAH
4.1. Induction of Vasospasm with Proinflammatory Agents.
Early clinical studies showing a correlation between
vasospasm and fever in the absence of infection established a
link between inflammation and vasospasm [7786]. Several
proinflammatory agents such as talc (crystallized hydrous
magnesium sulfate) [87, 88], latex, polystyrene, and dextran
beads [89, 90], lipopolysaccharide (LPS) [91], and tenascin-C
[92] have been administered intracisternally to show that
vasospasm can occur in the absence of blood. These studies
provided proof that vasospasm is not dependent on red
blood cells (RBCs) or hemoglobin (Hgb) and confirmed the
role of inflammation in the development of vasospasm.
3
4.2. Inflammatory Molecules Linked to Development of
Vasospasm. Among inflammatory molecules linked to cerebral vasospasm, the selectin family, which consists of three
members: E-selectin, platelet- (P-) selectin, and leukocyte(L-) selectin, has been extensively studied. These molecules
facilitate leukocyte binding and migration through vascular endothelium towards injured tissue. L-selectin and Eselectin are constitutively expressed on cell surfaces whereas
P-selectin expression requires activation by histamine or
thrombin [93]. E-selectin is elevated in the CSF of SAH
patients with higher concentrations seen in patients who
develop moderate or severe vasospasm [3]. Inhibition of
E-selectin with an inhibitory antibody [62] and E-selectin
tolerization via intranasal administration have decreased
vasospasm in rodent SAH models [63]. However, not all
data point to selectins having deleterious effects after SAH:
while P-selectin levels were higher in patients with SAH
who developed cerebral ischemia after SAH, L-selectins were
higher in patients who did not develop delayed ischemia
[23, 94].
Integrins are cell surface proteins that facilitate cell-cell
adhesion and interaction. The main integrins involved
in leukocyte adhesion and migration are lymphocyte
function-associated antigen 1 (LFA-1) and Mac-1 integrin
(CD11b/CD18). Systemically administered anti-LFA-1 and
Mac-1 monoclonal antibodies reduce vasospasm in rat [64],
rabbit [65], and primate [66] SAH models. Immunoglobulin
superfamily proteins, such as ICAM-1, play a role in
leukocyte adhesion and are upregulated in patients who
develop clinical vasospasm [3] as well as in rabbit [70]
and canine SAH models [47]. Anti-ICAM-1 monoclonal
antibodies were shown to decrease femoral artery vasospasm
and inhibit infiltration of macrophages and neutrophils into
blood vessel adventitia in a rodent model [95] and reduce
vasospasm in a rabbit model of SAH [71].
Key proinflammatory cytokines elevated in experimental
models and patients with vasospasm include IL-1B, IL-6, IL8, TNF, and MCP-1. IL-6 has been shown to peak early
after SAH, suggesting that it may be an early marker for
predicting vasospasm development [9, 11, 47, 96101]. TNF
levels in poor-grade SAH patients were shown to correlate
with severity of vasospasm [68] and serum MCP-1 levels were
associated with predicting negative outcome but not severity
of vasospasm [21]. Cytokine inhibitor CNI-1493 [72], antiIL-6 antibodies [102], anti-IL-1B antibodies [67], and TNF
inhibitors [103] have all been shown to attenuate vasospasm
in animal models.
Several studies have examined intracellular signaling
pathways activated during inflammation and their role
in vasospasm. Mitogen-activated protein-kinase (MAPK)
and nuclear factor kappa-B (NfB) intracellular signaling
pathways are crucial in generating inflammatory immune
responses [104]. Jun N-terminal kinase 1 (JNK1) and JNK2,
which are part of MAPK family, are activated in the cerebral
vasculature after experimental SAH and their inhibition
reduces vasospasm [105, 106]. Inhibition of JNK was also
effective at reversing the vasoconstrictive effects of tenascinC in a rat model of SAH [92]. Poly (ADP-ribose) polymerase
(PARP) is a nuclear enzyme that regulates adhesion molecule
4
expression and neutrophil recruitment during inflammation
[107]. In a rabbit model of SAH, Satoh and colleagues showed
PARP activation within the smooth muscle and adventitia of
blood-exposed vessels and that PARP inhibition decreased
the severity of vasospasm [108].
The complement pathway of antibacterial proteins also
affects vasospasm after SAH. Complement depletion by
treatment with cobra venom [109] and prevention of complement activation with nafamostat mesilate, a serine protease
inhibitor, reduced vasospasm in experimental models [90,
110] and human subjects [111, 112]. Moreover, expression of
the membrane attack complex (MAC) is increased in a rat
model of SAH and can be responsible for lysis of extravasated
erythrocytes and release of hemoglobin after SAH [113].
Recently, the lectin complement pathway (LCP) has also
shown to be activated after SAH, and LCP activity has been
linked to SAH severity and vasospasm in humans [114].
Oxidative signaling and oxidative stress are effectors
of the immune response in many central nervous system
diseases [115], and it is likely that the balance of oxidative
stress and antioxidants influences response to and recovery
from SAH. Haptoglobin is a serum protein composed of
tetramer of two and two chains. Its main action is to bind
free hemoglobin and facilitate its uptake and clearance. This
has a net effect of reducing oxidative stress caused by free
hemoglobin [116, 117]. Three phenotypes of haptoglobin (Hp)
have been identified in humans: Hp 1-1, Hp 2-1, and Hp 2-2
[118]. In humans, the haptoglobin proteins with -2 subunits
have been associated with higher rates of vasospasm compared to haptoglobin 1-1 [119]. Similarly, genetically modified Hp 2-2 mice experience increased macrophage infiltration in the subarachnoid space, more severe vasospasm, and
worse functional outcome after SAH [120]. Recently, Hp 2-2
phenotype was associated with neurological deterioration but
not cerebral infarction or unfavorable outcome in one clinical
SAH study [121]; however, another recent study did find worse
clinical outcomes in patients with the 2-2 phenotype [122].
Ongoing work in this area will further clarify the role of
haptoglobin phenotype in SAH.
Endothelium-derived relaxing factor or nitric oxide (NO)
is synthesized enzymatically by three main nitric oxide
synthase (NOS) isoforms, endothelial (eNOS), neuronal
(nNOS), and macrophage inducible NOS (iNOS) [123].
Under physiologic conditions, NO affects signaling pathways
for vasodilation and cytoprotection among many others [123,
124]. The function of eNOS can be altered in many disease
states such as atherosclerosis, hypertension, and diabetes
mellitus, in which case eNOS starts to produce superoxide
anion (O2 ) instead of NO, an alteration defined as eNOS
uncoupling [125]. Increased eNOS and iNOS expression
were detected in mice after SAH, and this physiological
response to SAH is decreased in proinflammatory Hp 22 transgenic mice compared with Hp 1-1 mice [126, 127].
In an animal model of SAH, simvastatin was shown to
recouple eNOS and improve outcome after SAH [128]. On the
other hand, genetic elimination of eNOS in knockout mice
reduces the incidence of vasospasm and reduces oxidative
stress as measured by superoxide production but has no effect
on iNOS [129]. eNOS knockout mice also exhibit reduced

Zn2+ release after SAH, which was associated with reduced
microthrombi formation and neuronal degeneration in the
same experiment.
Endothelins, which are potent vasoconstrictors and
proinflammatory mediators expressed by vascular endothelial cells and vascular smooth muscle cells [130], are thought
to contribute to tissue inflammation and cerebral edema.
Several studies have documented increased ET-1 levels in
SAH patients with symptomatic vasospasm and that the
amount of blood within the cisterns correlated with the
level of ET-1 in CSF [73, 76, 131]. However, other studies
have failed to find significant elevation of ET-1 after SAH
or a correlation between ET-1 levels and vasospasm [16, 73].
Inhibition of ET-1 by administration of anti-ET-1 monoclonal antibodies [132], anti-ET receptor antibodies [74, 133],
ET activation enzyme inhibitors [134], and levosimendan
(which antagonizes the ET receptor) [135] was effective in
decreasing vasospasm in some [74, 133] but not all studies
[135, 136]. Transgenic mice overexpressing ET-1 experienced
more pronounced vasospasm and cerebral edema and an ETA receptor antagonist decreased vasospasm and edema in the
same study [137].
4.3. Trials of Anti-Inflammatory Agents for Treatment of
Vasospasm. As subarachnoid blood is thought to generate
much of the acute inflammation in SAH, faster clearance of
subarachnoid clot could potentially improve outcomes after
SAH. This theory has been tested, and intrathecal administration of thrombolytic agents has decreased vasospasm
and improved outcomes in primates [138] and humans [139
143] after SAH. A meta-analysis showed a beneficial effect
of thrombolytic treatment, with absolute risk reductions of
14.4%; however, the results of the analysis were limited due to
predominance of nonrandomized studies [144]. In a recent
clinical study by Yamamoto et al., cisternal irrigation therapy
using tissue plasminogen activator in patients who underwent surgical clipping of ruptured intracranial aneurysms
decreased serum inflammatory markers, reduced the incidence of ischemic lesions, and was associated with better
neurological outcome [145]. Kim and colleagues recently
demonstrated that cisternal irrigation with papaverine, a
phosphodiesterase inhibitor and potent vasodilator, was similar in effectiveness compared to the thrombolytic urokinase,
both of which decreased incidence of vasospasm [146].
Corticosteroids are potent anti-inflammatories and have
been used in several human SAH trials. Experimental administration of high-dose methylprednisolone has been shown
to reduce angiographic vasospasm and ameliorate arterial
wall abnormalities in dog models [147149]. Human clinical
studies by Chyatte and colleagues [150] showed that highdose methylprednisolone treatment improved neurological
outcomes, reduced mortality, and delayed cerebral ischemia.
A multicenter study of intravenous hydrocortisone administration after SAH showed improved mental status, speech,
and motor function at 1 month after treatment [151]. However,
another randomized controlled trial of hydrocortisone did
not show any effect on neurological outcome after SAH
[152]. On the other hand, hydrocortisone has been shown
to support hypervolemic therapy by attenuating natriuresis

[153], inducing hypervolemia, and improving the efficiency
of hypervolemic therapy [154]. However, a large double
blind randomized control trial demonstrated a beneficial
effect of methylprednisolone in functional outcome one year
after SAH but no effect on vasospasm [155]. These studies
underscore the fact that outcomes in SAH are not solely
dependent upon the development of vasospasm.
Nonsteroidal anti-inflammatory drugs (NSAIDs) also
have potent anti-inflammatory properties, mediated in part
by inhibition of cyclooxygenase expression, which reduces
prostaglandin synthesis [156]. NSAID administration significantly reduced the severity of vasospasm in an animal
model of SAH; however, the mode of NSAID treatment in
this model, 30 minutes before and 3 hours after SAH, is not
applicable to human trials [157]. Ibuprofen inhibits femoral
artery vasospasm and decreases periadventitial monocytes
and macrophages after, in a rodent model of SAH, and can
increase cerebrovascular diameter in monkeys and rabbits
[158160]. Chyatte and colleagues also demonstrated that
ibuprofen prevented ultrastructural changes in the cerebral
vessel walls of dogs after blood injection [149]. The nonsteroidal anti-inflammatory drugs parecoxib and celecoxib
have also shown promise as treatment options for vasospasm
[161163]. As these drugs are relatively safe and well studied in
humans, they hold promise for clinically applicable treatment
options for vasospasm.
Immunosuppressants such as cyclosporine cause T-cell
dysfunction by inhibiting interleukin-2 (IL-2) transcription
[164] and have been tested in experimental SAH with varied
success [165, 166]. Clinical studies with cyclosporine are
also varied, showing no beneficial effect of cyclosporine in
the outcome patients with severe SAH [167], but showing
improved outcome in patients who underwent early clipping after SAH when combined with nimodipine [168170].
Tacrolimus (FK-506), a newer immunosuppressant, did not
prevent vasoconstriction and lymphocytic infiltrations in
experimental SAH models [171173].
Statins are 3-hydroxy-3-methylglutaryl coenzyme A
reductase inhibitors clinically used as cholesterol-reducing
agents. Their ability to reduce the expression of proinflammatory cytokines and inhibit leukocyte integrins confers their
potent anti-inflammatory activity [174, 175]. Preconditioning
of rats with atorvastatin has been shown to reduce the
level of ET-1 while attenuating vasospasm, which could be
a mechanism of antivasospastic effects of statins after SAH
[176]. Simvastatin treatment before or after SAH was also
shown to attenuate cerebral vasospasm and neurological
deficits, possibly via endothelial nitric oxide upregulation
[177], and decrease perivascular granulocyte migration [40].
Several clinical studies have shown that statins decrease
serum ICAM-1 levels in hypercholesterolemic patients [174,
175, 178180], which could explain the experimental findings
associated with decreased leukocyte migration. However,
clinical studies with statins have yielded mixed results. While
one study showed improved 14-day functional outcomes
and cerebral vasospasm in patients receiving statins prior
to their SAH [181], more recent studies [182, 183] did not
find significant differences in the severity of angiographic
or clinical vasospasm or neurologic outcomes of patients
5
receiving statins after SAH. Another case-control study
showed that oral atorvastatin treatment decreased vasospasm
and cerebral ischemia but did not lead to significant functional improvement 1 year after SAH [184]. In a phase-II
randomized controlled trial enrolling 80 patients with SAH,
patients treated with oral pravastatin 72 hours after SAH had
a 32% reduction in vasospasm incidence, and vasospasmrelated neurologic deficits and mortality were decreased by
83% and 75%, respectively [185]. Subsequently, pravastatin
was also effective at sustaining the improved neurological
outcome at 6 months after the treatment [186]. A Cochrane
review of clinical trials on statins after SAH concluded
that, in the only clinical trial that met criteria, although
simvastatin improved vasospasm, mortality, and functional
outcome, these benefits were not statistically significant [187].
Currently, clinical trials including simvastatin in aneurysmal subarachnoid hemorrhage (STASH) trial are ongoing
(http://clinicaltrials.gov/show/NCT00731627).
Nitric oxide (NO) depletion contributes to the pathogenesis of cerebral vasospasm after SAH [188, 189]. Therefore,
several NO donors have been investigated for treatment of
vasospasm. Intrathecal NO supplementation via controlledreleased polymers was shown to prevent vasospasm in rat
and rabbit models of SAH [190, 191] and delayed polymer
implantation 24 or 48 hours after SAH has been shown
to be still effective at ameliorating vasospasm [191]. Several
other studies have also shown that selective intracerebral
NO injection, [192] intraventricular NO injection [193],
and systemic nitrite infusions can improve the severity or
decrease the incidence of vasospasm in experimental and
clinical studies [189]. Intravenous sodium nitrate (NaNO2 )
was also shown to reduce the degree of vasospasm and
nitrite, nitrate, and S-nitrosothiols concentrations in CSF
were found to be increased compared to controls in primate
model of SAH [194]. L-citrulline is an amino acid that
when converted to L-arginine increases nitric oxide (NO)
production by NO synthase (NOS), leading to vasodilation
[195]. L-citrulline administration has been shown to prevent posthemorrhagic cerebral vasospasm in the transgenic
Hp 2-2 model of SAH, improve neurological function as
determined by PGA (posture, grooming, and ambulation)
scores, and reverse the decrease in upregulation of iNOS and
eNOS expression in Hp 2-2 animals compared with baseline
levels in mice [126]. Besides vasodilation, NO supplementation can have anti-inflammatory effects through modulating
leukocyte-endothelial cell interactions in the acute inflammatory response. Inhibitors of NO production increase leukocyte adherence [196], and NO modulates oxidative stress
[197] and microvascular permeability [198, 199]. The antiinflammatory effects of NO through prevention of leukocyte
adhesion have been linked with its ability to inactivate the
superoxide anion [200]. Besides ameliorating vasospasm,
whether NO donors including citrulline can help recoupling
of eNOS, decrease the inflammatory infiltration, and decrease
neuronal apoptosis requires further investigation. Other NO
donors such as sodium nitroprusside and nitroglycerin are
not considered as potential candidates due to their side
effects such as dose-limiting hypotension, cyanide toxicity,
and tolerance development [201].
6
Clazosentan, a synthetic endothelin receptor antagonist
(ETRA), has been investigated as a potential treatment
for vasospasm after subarachnoid hemorrhage [202]. In
the CONSCIOUS-1 trial, an intravenous infusion of clazosentan 5 mg/h decreased vasospasm but the study was
not powered to detect changes in morbidity and mortality
[203]. In CONSCIOUS-2, a phase-III randomized controlled
trial, including 1,157 patients, clazosentan infusion up to
14 days after hemorrhage did not reduce vasospasm-related
morbidity and mortality or improve functional outcome
[75]. A meta-analysis of randomized controlled trials for
ETRAs for the treatment of vasospasm, including 5 trials
with 2601 patients, showed that ETRAs decreased incidence
of angiographic vasospasm; however, they did not improve
functional outcome, vasospasm-related cerebral infarction,
or mortality [204]. As a result, the use of ETRAs in patients
with SAH was not proven to be beneficial [204]. These studies
reinforce that vasospasm alone cannot be accounted for the
neurological deficits and functional outcome after SAH and
treatment strategies that only target improving or preventing
vasospasm are not likely to succeed.
Cilostazol is a selective phosphodiesterase III inhibitor
that is used to treat ischemic peripheral vascular disease and
exhibits anti-inflammatory properties including inhibiting
microglial activation [205, 206]. Oral cilostazol administration prevented vasospasm in a rat model of SAH [207] and
reduced endothelial damage in a canine model of SAH [208].
Clinical studies have demonstrated effectiveness of cilostazol
in decreasing incidence and severity of vasospasm [209,
210]. A multicenter randomized clinical trial of cilostazol
has shown a decrease in angiographic vasospasm but no
improvement in outcomes 6 months after SAH [211].
5. The Role of Inflammation in Early

Brain Injury and Delayed Neurological
Deterioration after SAH
While there is no doubt that inflammation occurs after
SAH, a link must be made between inflammation and poor
outcomes after SAH for it to be considered an important
therapeutic target. As demonstrated by several of the trials
discussed above, vasospasm is not the only determinant of
outcome after SAH. It is likely that inflammation plays multiple roles after SAH, mediating vasospasm as tissue damage
as well as leading to regeneration or recovery as has been
shown in other neurological conditions [212]. Alternately,
the inflammatory cytokines detected in the CSF and blood
after SAH could be results, rather than causative factors, of
brain injury after SAH. There is a vast literature in ischemic
stroke that ties the inflammatory response to deleterious
effects such as edema and neuronal loss. Many experimental
studies in stroke have shown blood brain barrier breakdown
to be mediated by inflammatory cytokines [213] and that
inhibiting inflammation reduces cerebral edema and neurological injury [214, 215]. Proinflammatory cytokines such
as TNF, IL-1, IL-6, and leukocyte adhesion molecules have
been associated with worse outcomes in ischemic stroke
[216]. However, despite the vast literature on inflammation in

ischemic stroke, there have been no successful clinical trials
using anti-inflammatory agents.
Recently, the term early brain injury has been used to
describe the mechanisms of acute neurologic deterioration
after SAH [217]. Early brain injury includes cell death, cerebral edema, and neuronal dysfunction that occur after SAH.
Although vasospasm is a major cause of clinical deterioration
after SAH, recent thinking has focused on the fact that
vasospasm is not the only phenomenon contributing to poor
patient outcomes after SAH [218, 219]. A key example of this
is that nimodipine, the only pharmaceutical treatment shown
to improve outcomes in SAH, appears to manifest its effects
without affecting the rate of vasospasm [220, 221]. Many
patients also undergo neurological deterioration in a delayed
fashion after SAH. This can be due to cerebral vasospasm,
which typically peaks 7 to 14 days after SAH, but also occurs
in the absence of vasospasm. This subacute neurological
decline is referred to as delayed neurological deterioration
and can be mediated by several events including delayed
ischemia (with or without vasospasm), seizures, and fevers
[222]. The terms delayed neurological deterioration (DND)
and delayed cerebral ischemia (DCI) are often used interchangeably, but it should be noted that DCI is just one of the
causes of DND [223]. Additionally, it is likely that the events
of early brain injury occur along a continuum with DND and
are likely mediated by many of the same factors.
As in ischemic stroke, there is no accepted use of antiinflammatory treatments for improving outcome after SAH.
As discussed earlier, corticosteroids have been used to block
inflammation after SAH, but there is no clear therapeutic
benefit of this strategy [224]. However, there is experimental evidence from animal studies showing that blocking
inflammatory pathways can improve both blood brain barrier
breakdown and neuronal survival after SAH [219, 225]. In one
study utilizing a rat model of SAH, there was a reduction in
TNF production, cerebral edema, and apoptosis in response
to a blockade of a sulfonylurea receptor that is upregulated
after SAH [45].
Clinically, the presence of cell death, cerebral edema,
and vasospasm all contribute to poor outcomes after SAH.
Though it is difficult to measure cell loss in humans, there
is evidence for hippocampal neuronal loss after SAH based
on MRI imaging, and elevated neurofilament levels in CSF
correlate with functional outcome after SAH, indicating a link
between axonal breakdown and clinical outcome [226, 227].
As in ischemic stroke, proinflammatory cytokines have
gained attention as biomarkers for outcome in SAH, and the
recent literature is well reviewed by Lad and colleagues [228].
Genetic differences in inflammatory cytokine expression and
haptoglobin phenotype (discussed previously) have also been
used to prognosticate outcome in patients with SAH, without
definitive results [69]. Human genetic studies have also
shown a benefit of lower TNF levels for recovery after SAH
[229]. This points to a possible dual role for inflammation in
both acute injury and recovery, as has been proposed in other
neurological diseases [230]. There is already experimental
support for this dual role of inflammation in SAH, as the
cytokine MCP-1 that has been associated with poor outcomes
Table 1: Key inflammatory molecules implicated in the pathology of SAH.

Molecule
Function
Roles in animal studies
Selectins
Leukocyte adhesion
Inhibition of selectins
decreases vasospasm
[62, 63]
Integrins
Leukocyte adhesion
TNF
Proinflammatory
cytokine produced by
leukocytes
Blocking reduces
vasospasm [6466]
Induces neuronal apoptosis
after SAH [52]; blockade
reduces vasospasm [67]
MCP-1
Macrophage
chemoattractant
Promotes repair of
aneurysms [69]
ICAM-1
Leukocyte adhesion
Interleukins Mediate leukocyte

interactions
Increased in animal SAH

studies [47, 70]; blockade
reduces vasospasm [71]
Blockade reduces
vasospasm [72]
Endothelin-1 Potent
vasoconstrictor
Inhibition reduces
vasospasm [73, 74]
Roles in human studies

Higher levels in CSF correlate
to vasospasm in some studies
[3], found in walls of ruptured
aneurysms [36]
Higher levels seen in patients
with vasospasm [3]
Found in CSF in patients after
SAH and correlates with
vasospasm after SAH [68]
Found in CSF after SAH and
associated with poor outcomes
but not vasospasm [9, 21]
Peak early in SAH [9, 11]

Produced by monocytes from
SAH patients [13, 14], with no
proved benefit in clinical trials
[75]
6. Discussion
Evidence from both clinical and animal studies indicates
that inflammation contributes to aneurysm formation, brain
injury, and vasospasm after SAH and that many of the
same molecules contribute to vasospasm and brain injury
after SAH (Figure 1, Table 1). Much of the data from human
studies linking inflammation to worse outcomes after SAH
is correlative and studies examining different inflammatory
molecules at different time points after SAH make it difficult to make direct comparisons (Table 1). However, taken
together, human and animal studies suggest that a higher
inflammatory burden contributes to the pathophysiology
of SAH. This would suggest anti-inflammatory treatment to
be a robust treatment strategy for SAH, as in other diseases.
For example, the possibility that aspirin could reduce chronic
inflammation within the walls of aneurysms and decrease the
risk of rupture [34, 35] is akin to the paradigm of human cardiovascular disease in which the anti-inflammatory actions of
aspirin and statins may protect against cardiovascular disease
[122, 232, 233]. Unfortunately, this strategy has not borne
out reliably in clinical trials. One potential reason for this
is that animal studies of homogenous populations may not
be an accurate model of SAH in humans where individual
responses to a given insult could be quite variable.
Clinicians who care for patients with SAH understand
that there is a wide range of physiologic responses to SAH,
even in patients who present with the same initial grade of
hemorrhage. While this is doubtlessly influenced by many
factors (such as SAH blood volume), the intensity of an
Inflammatory
selectins;
factors:
integrins;
TNF;
MCP-1;
ICAM-1;
interleukins
Variable expression in patients with

SAH [2, 1012]
Also associated with vascular injury
[31]
Used to prognosticate outcome in
critically ill patients without SAH
[28]
Peak at variable times in human
studies [29, 30]
Increased in patients with

SAH [3]
and vasospasm after SAH has recently been used to promote

repair of experimental aneurysms [21, 231].
Comments
Variable expression in patients with
SAH [3, 8, 9], used to prognosticate
outcome in critically ill patients
without SAH [28]
Highly variable expression after

SAH and may not correlate with
vasospasm [13, 16, 76]
Tissue inflammation and

injury
Aneurysmal
SAH
Vasospasm
Figure 1: Schematic of a coronal projection of a ruptured cerebral

aneurysm and contributing factors that result in cerebral vasospasm
after SAH and delayed ischemic injury. Many inflammatory factors
are hypothesized to contribute to brain injury and vasospasm after
SAH. The interface between subarachnoid blood, brain parenchyma,
and the cerebral vasculature is the likely location for induction of
inflammatory cascades that lead to brain injury and vasospasm after
SAH.
individuals inflammatory response to SAH may also determine if a patient develops delayed clinical deterioration or
vasospasm. While this could be influenced by factors such as
haptoglobin genotype [122], there are probably other genetic
and environmental factors that influence patients production
of, and tolerance to, a post-SAH inflammatory response.
Evidence from animal studies has shown that inflammatory stimuli can both exacerbate and reduce vasospasm,
depending on the intensity of the stimulus [234]. A recent
8
clinical study implied that preexisting atherosclerotic disease
could have a protective effect on patients who suffer SAH,
possibly by modifying neuroinflammation [233, 235, 236].
In the future, treatment for SAH may involve tailoring
therapy to match the timing and intensity of an individual
patients inflammatory response. In order for this approach
to be implemented, successful validation of inflammatory
biomarkers and outcome measures for SAH would need to
be developed.
7. Conclusion
The immune response within (and possibly outside of) the
CNS is clearly a driving force behind many of the pathological
events of SAH, including both vasospasm and early brain
injury. Though much experimental and clinical work has
linked increased inflammation to poor outcome after SAH,
there is still no proven anti-inflammatory treatment that can
be offered to patients who have suffered SAH. The volume of
research on inflammation and SAH is rapidly expanding and
will likely lead to new clinical trials, development of biomarkers, and hopefully anti-inflammatory treatments for SAH.
Though anti-inflammatory treatments will likely improve the
lives of patients with SAH, it must be remembered that
neuroinflammation has beneficial effects as well and could
also play a role in recovery after SAH.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
Acknowledgments
Brandon A. Miller received NIH R25 Fellowship Award
and AANS/CNS Robert J. Dempsey Cerebrovascular Section
Award.
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BioMed Research International

Correspondence should be addressed to Gustavo Pradilla; gpradil@emory.edu

activated after SAH will likely lead to novel therapies and

2. Evidence for Acute Inflammation

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3. Evidence for Inflammation

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3. Evidence for Inflammation

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4. The Role of Inflammation

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5. The Role of Inflammation in Early

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Table 1: Key inflammatory molecules implicated in the pathology of SAH.

Roles in animal studies

Interleukins Mediate leukocyte

Increased in animal SAH

Roles in human studies

Peak early in SAH [9, 11]

Variable expression in patients with

Increased in patients with

and vasospasm after SAH has recently been used to promote

Highly variable expression after

Tissue inflammation and

Figure 1: Schematic of a coronal projection of a ruptured cerebral

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of PhysiologyHeart and Circulatory Physiology, vol. 297, no. 5,

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vivo nitric oxide suppression, American Journal of Physiology

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