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Table of Contents    
CORRESPONDENCE
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 282-283

Authors' Reply: Magnesium supplementation in intracerebral hematoma: The hope and the hype!


1 Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication11-Jan-2018

Correspondence Address:
Dr. Bal Krishna Ojha
Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.222840

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How to cite this article:
Bhaskar MK, Ojha BK, Verma R. Authors' Reply: Magnesium supplementation in intracerebral hematoma: The hope and the hype!. Neurol India 2018;66:282-3

How to cite this URL:
Bhaskar MK, Ojha BK, Verma R. Authors' Reply: Magnesium supplementation in intracerebral hematoma: The hope and the hype!. Neurol India [serial online] 2018 [cited 2019 Apr 23];66:282-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/1/282/222840




Dear Sir

We would like to convey our sincere thanks to the authors of this letter for showing keen interest in our article [1] and the commentary related to it,[2] and for raising the important point related to the association between the serum level of magnesium, and the hematoma expansion as well as the outcome, in patients with intracranial hemorrhage. The role of magnesium sulphate and its supplementation in stroke has been highlighted in many trials.[3],[4]

The various properties of magnesium sulphate described in literature, namely its N-methyl-D-aspartate receptor (NMDA) blocking effect, its anti-glutamate action, its role in increasing cerebral blood flow, its role in inhibiting intracellular entry of calcium, and its vasodilator effect, have been exploited in trials pertaining to neuroprotection in stroke.[5] The FAST –MAG (field administration of stroke therapy– magnesium) trial studied the neuroprotective effect of magnesium sulphate and evaluated the factors concerned with clinical outcome.[6] The other related study did not convincingly showed the benefit of magnesium sulphate therapy in acute ischemic stroke, although attesting to the safety of magnesium supplementation.[7]

Hematoma expansion is undoubtedly one of the critical determining factors in the outcome of hemorrhagic stroke. In the recent past, much hope has been generated that with the manipulation of the coagulation cascade in patients who have suffered from a primary intracerebral hemorrhage, the expansion of hematoma may be prevented with a consequent good prognosis. The recombinant factor VIIa was initially studied in 399 subjects. The study revealed a reduction in the clot size and concluded that the factor VIIa administered group showed a better clinical outcome.[8] The subsequent high powered large scale study failed to show clinical benefits. This negative study, however, does not close the chapter for the assessment of hemostatic agents in the reduction of primary intracerebral hematoma (ICH).[9]

Recently, a study was published in Neurology, highlighting the effect of low magnesium level on clot expansion in patients who have had a primary ICH. The authors found that those patients who were having a low serum magnesium had a larger initial hematoma volume, a greater incidence of hematoma expansion, and a worse clinical outcome at 90 days. This study was conducted on 290 patients. A low serum magnesium level adversely affected the prognosis, a fact substantiated by a high modified Rankin's scale (with an odds ratio 0.14 [P = 0.11]) after adjustment of other variables.[10]

This confirms the role of magnesium in achieving intracranial hemostasis. However, there are many unresolved issues. The effect of magnesium on the coagulation cascade needs more mechanistic insights.

Our opinion is that more high-powered studies are required to establish the role of magnesium in the achievement of hemostasis and for establishing its correlation with the amount of hematoma volume and clot growth in patients suffering from a primary ICH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhaskar MK, Kumar R, Ojha B, Singh SK, Verma N, Verma R, et al. A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage. Neurol India 2017;65:752-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Mendelow A D. Operation versus non-operative treatment for spontaneous supratentorial intracerebral haemorrhage: Is a change in current clinical practice required? Neurol India 2017;65:759-60.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Cojocaru IM, Cojocaru M, Burcin C, Atanasiu NA. Serum magnesium in patients with acute ischemic stroke. Rom J Intern Med 2007;45:269-73.  Back to cited text no. 3
    
4.
Lampl Y, Gilad R, Geva D, Eshel Y, Sadeh M, et al. Intravenous administration of magnesium sulfate in acute stroke: A randomized double-blind study. Clin Neuropharmacol 2001;24:11-15.  Back to cited text no. 4
    
5.
Van den Bergh WM, Dijkhuizen RM, Rinkel GJ. Potentials of magnesium treatment in subarachnoid haemorrhage. Magnes Res2004;17:301-13.  Back to cited text no. 5
    
6.
Saver JL, Kidwell C, Eckstein M, Starkman S, for the FAST-MAG Pilot Trial Investigators. Prehospital neuroprotective therapy for acute stroke: Results of the field administration of stroke therapy– magnesium (FAST–MAG) pilot trial. Stroke2004; 35:e106-08.  Back to cited text no. 6
    
7.
Singh H, Jalodia S, Gupta M S, Talapatra P, Gupta V, Singh I. Role of magnesium sulfate in neuroprotection in acute ischemic stroke. Ann Indian Acad Neurol 2012;15:177-80.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Recombinant activated factor VII intracerebral hemorrhage trial investigators: Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005;352:777-85.  Back to cited text no. 8
    
9.
Mayer SA, Brun NC, Broderick J, Davis S, Diringer MN, Skolnick BE, et al., Europe/Australasia Novo Seven ICH Trial Investigators: Safety and feasibility of recombinant factor VIIa for acute intracerebral hemorrhage. Stroke 2005;36:74-9.  Back to cited text no. 9
    
10.
Liotta EM, Prabhakaran S, Sangha RS, Bush RA, Long AE, Trevick SA, et al. Magnesium, hemostasis, and outcomes in patients with intracerebral hemorrhage. Neurology 2017;89:813-9.  Back to cited text no. 10
    




 

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