Acetaminophen in aSAH to Inhibit Lipid Peroxidation and Cerebral Vasospasm

Inhibition of Lipid Peroxidation and Cerebral Vasospasm by an Acetaminophen-Based Regimen in Patients With Aneurysmal Subarachnoid Hemorrhage

The objective of this study is to determine whether acetaminophen (APAP), N-acetylcysteine (NAC), and APAP in combination with NAC will inhibit lipid peroxidation in aneurysmal subarachnoid hemorrhage (aSAH), utilizing F2-IsoPs as biomarkers for lipid peroxidation.

Study Overview

• Status: Terminated
• Conditions: Aneurysmal Subarachnoid Hemorrhage; Cerebral Vasospasm
• Intervention / Treatment: Drug: Placebos for acetaminophen and N-acetylcysteine; Drug: APAP 1 gm every 6 hours and N-acetylcysteine placebo; Drug: NAC IV infusion at 0.5 gm hourly and APAP placebo; Drug: APAP 1 gm q6 hours, plus NAC IV infusion at 0.5 gm hourly; Drug: APAP 1.5 gm q6 hours, plus NAC IV infusion at 0.5 gm hourly

Detailed Description

Aneurysmal subarachnoid hemorrhage (aSAH) is an often devastating form of stroke with high morbidity and mortality despite advances in surgical management. Approximately 30,000 patients annually suffer aSAH in the U.S. For patients who survive the initial subarachnoid hemorrhage, delayed cerebral vasospasm occurring from days 4-14 is the greatest cause of neurological disability and death. A growing body of evidence incriminates hemoprotein-catalyzed lipid peroxidation as the mediator of the vasospasm.

Hemoglobin released from lysed red cells in the subarachnoid space becomes oxidized, in which state it acts as a pseudoperoxidase and generates the protein radicals that induce lipid peroxidation. F2-isoprostanes formed by this lipid peroxidation are highly potent constrictors of cerebral arterioles. We have demonstrated a more than 5 fold mean increase in F2-isoprostanes in the cerebrospinal fluid of patients with aSAH; this increase is maximal at the time of delayed vasospasm, and the level of increase is a function of the severity of the aSAH. We hypothesize that such vasoconstrictors are major contributors to the vasospasm produced by the hemoproteins, hemoglobin and myoglobin, in diseases in which they are released from their cellular confines.

We have discovered that acetaminophen (APAP) is a potent inhibitor of hemoprotein-catalyzed lipid peroxidation with an IC50 for hemoglobin of 15 uM, which is in the range of plasma levels resulting from therapeutic doses of the drug in humans. Acetaminophen acts by reducing the ferryl-oxo radical form of the heme, and thereby prevents formation of the hemoprotein radical that initiates lipid peroxidation. To assess proof of concept in vivo, we determined the effect of acetaminophen in a rat model of rhabdomyolysis in which renal failure results from intense vasospasm. Acetaminophen blocked lipid peroxidation in this model, and prevented the renal failure with a dose that produced plasma levels in the therapeutic range for humans.

We also have demonstrated that N-acetylcysteine (NAC) will inhibit hemoprotein-catalyzed lipid peroxidation. Moreover, NAC administration increases the levels of glutathione in vivo, and glutathione is a co-substrate for the glutathione peroxidases that can reduce the levels of peroxides in the environment of the aSAH . This is important as acetaminophen is most potent in inhibiting hemoprotein-catalyzed lipid peroxidation when peroxide concentrations are low. This concerted evidence is the basis for a hypothesis that NAC will augment the efficacy of acetaminophen as an inhibitor of hemoprotein-catalyzed lipid peroxidation in aSAH.

These finding provide the rationale for a pilot study seeking proof of the concept that acetaminophen-based regimens can inhibit lipid peroxidation in patients with subarachnoid hemorrhage. Lipid peroxidation will be determined by analysis of F2-isoprostanes in cerebrospinal fluid. If such inhibition is seen, that then would provide a basis for a larger multi-center investigation to assess the effect on clinical endpoints.

This pilot study will determine whether APAP, NAC, and APAP in combination with NAC will inhibit lipid peroxidation in aneurysmal subarachnoid hemorrhage.

• Study Type: Interventional
• Enrollment (Actual): 44
• Phase: Phase 3

Contacts and Locations

Study Locations

• United States
  • Tennessee
    • Nashville, Tennessee, United States, 37232
      • Vanderbilt University Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 20 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Ages ≥ 20
• Fisher Grade III or III + IV SAH based upon admitting CT scan
• Aneurysm secured by either clipping or coiling within 72 hours of SAH
• Intracranial aneurysm confirmed by angiography or CTA
• Presence of ventriculostomy for external ventricular drainage (EVD) prior to randomization

Exclusion Criteria:

• Consent unobtainable
• Enrollment in another interventional study
• Patient is pregnant or lactating
• Known co-morbidities that could affect outcome of this study
• Contraindication to CTA
• Serum creatinine > 1.4
• Documented allergy to iodinated contrast that cannot be adequately treated with premedication
• Documented allergy and/or intolerance to ApAP
• Baseline liver disease
• History of recent alcohol abuse with documented ALT or AST above normal laboratory values
• Documented history of both malnutrition and decreased serum albumin below normal lab values
• Documented abnormal platelet count below normal lab values
• Documented abnormal PT or PTT above normal lab values
• History or evidence of active asthma
• Documented allergy and/or intolerance to N-acetylcysteine
• Currently taking phenytoin, carbamazepine, or phenobarbital
• Currently taking isoniazid (INH, Lanzid, Nydrazid)
• Severe life-threatening complications resulting from standard aneurysm treatments that will likely prevent completion of the study
• Patient unsuitable for the study, in the opinion of the investigator(s)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: Quadruple

Number of Arms

5

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Placebos for acetaminophen and N-acetylcysteine	Drug: Placebos for acetaminophen and N-acetylcysteine; Placebos for acetaminophen and N-acetylcysteine
Active Comparator: Acetaminophen and N-acetylcysteine placebo; Acetaminophen 1 gm every 6 hours and N-acetylcysteine placebo	Drug: APAP 1 gm every 6 hours and N-acetylcysteine placebo; Acetaminophen 1 gm every 6 hours and N-acetylcysteine placebo
Active Comparator: N-acetylcysteine and acetaminophen; N-acetylcysteine IV infusion at 0.5 gm hourly and acetaminophen placebo	Drug: NAC IV infusion at 0.5 gm hourly and APAP placebo; N-acetylcysteine IV infusion at 0.5 gm hourly and acetaminophen placebo
Active Comparator: Acetaminophen 1 Gram and N-acetylcysteine; Acetaminophen 1 gm every 6 hours, plus N-acetylcysteine IV infusion at 0.5 gm hourly	Drug: APAP 1 gm q6 hours, plus NAC IV infusion at 0.5 gm hourly; Acetaminophen 1 gm every 6 hours, plus N-acetylcysteine IV infusion at 0.5 gm hourly
Active Comparator: Acetaminophen 1.5 Gram and N-acetylcysteine; Acetaminophen 1.5 gm every 6 hours, plus N-acetylcysteine IV infusion at 0.5 gm hourly	Drug: APAP 1.5 gm q6 hours, plus NAC IV infusion at 0.5 gm hourly; Acetaminophen 1.5 gm every 6 hours, plus N-acetylcysteine IV infusion at 0.5 gm hourly

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Patients With Vasospasm Based on Magnetic Resonance Angiography (MRA)	Presence of vasospasm measured Magnetic Resonance Angiography (MRA). MRA measures the degree of arterial narrowing, with a higher score indicating more severe vasospasm. An MRA score of 84% sensitivity and 72% specificity is indicative of vasospasm.	8 Days post subarachnoid hemorrhage (SAH) event
Number of Patients With Vasospasm Based on Computed Tomographic Angiography (CTA)	Presence of vasospasm measured by Computed Tomographic Angiography (CTA). CTA scores range from 0 (no vasospasm) to 34, where a score of 10 or more is indicative of vasospasm.	8 Days post subarachnoid hemorrhage (SAH) event
National Institutes of Health Stroke Scale (NIHSS) Score	The scale measures the severity of symptoms associated with patient's stroke. It assesses the severity of impairments related to stroke. The impairments are graded on a 3-4 point scale with scores that range from 0-42. Patients with a higher score have a more severe impairment, and patients with a lower score have a less severe impairment.	8 Days post subarachnoid hemorrhage (SAH) event
Modified Rankin Scale (MRS) Score	The modified Rankin Scale (mRS) is used for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The 7 point ordinal scale ranges from No symptoms (0) to Death (6), with higher scores representing worse outcome.	8 Days post subarachnoid hemorrhage (SAH) event
Glasgow Outcome Scale (GOS) Score	The Glasgow Outcome Scale (GOS) is a scale used to assess recovery of participants with brain damage. The scale has 5 categories: Death (1), Persistent vegetative state (2), Severe disability (3), Moderate disability (4), Good recovery (5).	8 Days post subarachnoid hemorrhage (SAH) event
The Barthel Index Score	The Barthel index measures the extent to which someone can function independently during basic activities of daily living. Scores range from (from 0 to 100), 0 meaning disability and 100 meaning independence, therefore, higher score, better outcome.	8 Days post subarachnoid hemorrhage (SAH) event

Secondary Outcome Measures

Outcome Measure	Time Frame
To determine whether APAP and APAP with NAC will inhibit vasospasm and brain ischemia in aSAH, as assessed by CTA w/perfusion imaging or MRI and diffusion weighted images.	8 +/- days

Collaborators and Investigators

• Sponsor: Vanderbilt University Medical Center
• Collaborators: National Institutes of Health (NIH); National Institute of General Medical Sciences (NIGMS)
• Investigators: Principal Investigator: Matthew Fusco, MD, Vanderbilt University Medical Center

Study record dates

Study Major Dates

• Study Start: April 1, 2007
• Primary Completion (Actual): October 26, 2023
• Study Completion (Actual): October 26, 2023

Study Registration Dates

• First Submitted: December 26, 2007
• First Submitted That Met QC Criteria: December 26, 2007
• First Posted (Estimated): January 3, 2008

Study Record Updates

• Last Update Posted (Actual): April 18, 2025
• Last Update Submitted That Met QC Criteria: March 31, 2025
• Last Verified: March 1, 2025

More Information

Terms related to this study

• Keywords: Lipid; Vasospasm; N-Acetylcysteine; Acetaminophen; Peroxidation
• Additional Relevant MeSH Terms: Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Pathologic Processes; Intracranial Hemorrhages; Hemorrhage; Subarachnoid Hemorrhage; Vasospasm, Intracranial; Anti-Infective Agents; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Sensory System Agents; Antiviral Agents; Analgesics, Non-Narcotic; Analgesics; Antipyretics; Antioxidants; Protective Agents; Expectorants; Respiratory System Agents; Free Radical Scavengers; Antidotes; Acetaminophen; Acetylcysteine; N-monoacetylcystine
• Other Study ID Numbers: NIH P50 GM015431; VUMCIRB060556; P50GM015431 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO