Application of Magnesium-rich Artificial Cerebrospinal Fluid in Nonaneurysmal Subarachnoid Hemorrhage
Application of Magnesium-rich Artificial Cerebrospinal Fluid in Nonaneurysmal Subarachnoid Hemorrhage
Intracerebral hemorrhage (ICH) is one of the common fatal types of cerebral apoplexy with
 high mortality and disability rates. Hematoma volume and complications of intracerebral
 hemorrhage are major predictors of early death and poor prognosis. The hematoma and its
 metabolites are key therapeutic targets. At present, in order to improve the prognosis of
 patients, cerebrospinal fluid(CSF) replacement with normal saline(NS) is commonly used in
 clinical practice to clear the bloody components, which shows a good clinical effect.
 However, due to the large difference between NS and CSF composition, it is easy to cause
 secondary injury of brain tissue. Therefore, the replacement of artificial CSF with similar
 CSF composition will be more effective in reducing the incidence of complications and improve
 the prognosis of neurological function.

 The Magnesium-rich Artificial Cerebrospinal Fluid(MACSF) designed and developed in the early
 stage of this project which has similar physical and chemical properties to physiological
 CSF, such as ion species, concentration, potential of hydrogen (pH) value and osmotic
 pressure. Animal experiments has confirmed its safety and effectiveness. In this study,
 patients with basal ganglia intracerebral hemorrhage ruptured into the ventricle or
 nonaneurysmal subarachnoid hemorrhage were stratified randomly divided into MACSF group and
 NS group. MACSF and NS were used as replacement fluid for lumbar puncture CSF replacement,
 respectively. By observing and compare two groups of patients of the Modified Rankin Scale
 (mRS) in the day of 14, 30, 60, 90 days after onset; hematoma absorption rate, hemorrhagic
 CSF removal rate; changes of cerebral autoregulation； incidence of complications, such as
 acute obstructive hydrocephalus (AOH) and cerebral vasospasm (CVS); the changes of scores and
 scales about imaging; assessment of neurological function recovery, such as the National
 Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Score (GCS) during
 hospitalization, headache duration and the Visual Analogue Scale (VAS), vomiting duration,
 duration of meningeal irritant, ICU hospitalization duration, total hospitalization duration;
 change of CSF and peripheral blood biochemical indicators. Objective to evaluate MACSF
 replacement therapy in patients with basal ganglia cerebral hemorrhage broken into ventricles
 and nonaneurysmal subarachnoid hemorrhage of the influence of absorption rate and prognosis.
This study is a prospective, interventional and double-blind randomized controlled clinical
 trial. After approval of the clinical registry, patients who meet the standards of inclusion
 and exclusion criteria will be recruited to this study, if they and their relatives are
 willing to join in the study. According to the clinical manifestations of the patients at
 admission and the results of cranial imaging, the patients' conditions were evaluated using
 the modified Fisher score, the World Federation of Neurological Surgeons Scale (WFNSS), the
 max-ICH score (max-ICH), the IVH score (IVHs), the Hijdra Sum Score (Hijdra), the Modified
 Graeb Score (mGS) and other grading criteria. Two groups (NS group and MACSF group) were
 divided into groups using a completely stratified randomization method. This study was a
 double-blind clinical study, and the grouping protocol was managed by the project research
 assistant. After the subject or his/her family members sign the informed consent, the project
 research assistant completed the grouping according to the randomly assigned sequence given
 by the clinical research center of the First Affiliated Hospital of Xi'anJiaotong University.
 The project research assistant records the group and informs the specialist of the type of
 replacement fluid required. The replacement fluid was sent into the ward in a special
 container, and then lumbar puncture and CSF replacement were performed by the operator. The
 replacement liquid used in both groups was identical in appearance, color, temperature, and
 smell. During the whole study, the investigator did not participate in the preparation of the
 replacement liquid, and the subjects and their family members were also unaware of the
 grouping. After the case collection and electronic database records are completed, the
 research assistant will inform the researcher of the group name under the supervision of the
 third party to complete the unblinding, and the researcher shall inform the subjects of the
 group name in written form. For the control group, patients were treated the normal saline
 (0.9% Sodium Chloride Injection) as the replacement fluid. For the intervention group, MACSF
 will be used. The composition and concentration of MACSF is as follows:Na+: 146.2 mEq/L, K+:
 2.7 mEq/L, Mg2+: 4.2 mEq/L, Cl-: 123 mEq/L, HCO3-:23.2 mEq/L, Glucose: 0.75 g/L. MACSF is
 prepared by the staff of Pharmacy Intravenous Admixture Services of First Affiliated Hospital
 of Xi'an Jiaotong University, according to a specific formula in the specific working area.
 The whole procedure follow the aseptic principles strictly. Fresh-made MACSF will be placed
 in a specific container and send to the the patient ward through specific channels.
 Intracranial pressure (ICP) was measured by non-invasive ICP test before lumbar puncture. If
 it is higher than 350cmH2O, a lumbar puncture can be performed 30 minutes after intravenous
 drip of 100ml 20% mannitol. Then, for the patients who signed the informed consent, a CSF
 sample (3ml) was taken before each lumbar puncture CSF replacement and synchronous blood
 samples (6ml) was taken. The blood samples should be drawn into a non-anticoagulant tube and
 a heparin anticoagulant tube respectively. All the samples will be transferred to BioBank of
 the First Affiliated Hospital of Xi'anJiaotong University in a liquid nitrogen tank. After
 re-melted in a water bath of 37°, the blood samples will be centrifuged at 4° for 15min at
 3000r/min, the CSF samples will be centrifuged at 4° for 10min at 1000r/min and then the
 supernatant will be collected and stored at -80°. At the end of this study, the contents of
 oxyhemoglobin (OxyHb), S100 calcium-binding protein β (S100β), neuron-specific enolase(NSE),
 D-dimer (DD), matrix metalloproteinases-9 (MMP-9), Mg2+, Ca2+ in the samples will be detected
 by enzyme linked immunosorbent assay (ELISA) or mass spectrometry. The total amount of
 replacement was generally 30ml, and the replacement was performed once every 2 days. When the
 red cell (RBC) count in CSF is less than 100×10^6/L, the CSF is considered to be cleared. CSF
 replacement is performed up to four times. NIHSS and GCS scores were evaluated daily after
 admission. Cerebral computerized tomography (CT) was performed at least every week after
 admission. If there is new low-density lesions, delayed cerebral infarction (DCI) will be
 diagnosed. Transcranial Doppler(TCD) examination was performed the first three days after
 admission and after each replacement. Cerebral autoregulation (CA) was evaluated by transient
 hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method,
 which describes the changes in cerebral blood fow velocity after a brief compression of the
 ipsilateral common carotid artery. The specific content is described later. CVS will be
 diagnosed by TCD, the diagnostic criteria will be described later. All subjects were followed
 up in the day of 14, 30, 60, 90 days after onset and the mRS was evaluated. Meanwhile, some
 indicators will be used to evaluate the safety of MACSF application, which including
 secondary infection, fluctuation of intracranial pressure and hypermagnesemia. For patients
 or their family members who do not agree to do the CSF replacement, the sample collection can
 be used as a supplementary analysis for this study after they sign the informed consent for
 sample collection.

 The diagnostic criteria and the solutions will be described in the next part.
Inclusion Criteria:

 -  Patient is between 18 and 80 years of old;

 -  Patients with ICH rupture into the ventricle in the primary basal ganglia region or
 non-aneurysmal subarachnoid hemorrhage confirmed by skull imaging examination;

 -  Patient is admitted to hospital within 72 hours after onset;

 -  Informed consent of the patients or their family members, and signed informed consent
 for CSF replacement treatment.

 Exclusion Criteria:

 -  Non-spontaneous intracranial hemorrhage;

 -  Time from onset to admission is longer than 72 hours;

 -  The patient who needs surgical treatment;

 -  Contraindication of lumbar puncture, such as: cerebral hernia, severe intracranial
 hypertension, puncture site inflammation, blood system diseases, etc.;

 -  Patient has other serious diseases, such as heart failure, kidney failure, liver
 failure, etc;

 -  Patient or his/her relatives refuse to accept the above research plan.