1. Cerebral Vasospasm
• Delayed arterial narrowing that occurs after an
aneurysm has ruptured (subarachnoid hemorrhage)
Management of Cerbral
– starts after 3 days, maximal at 7 days, resolves by 14
Vasospasm in Subarchanoid days
Hemorrhage
• A common cause of morbidity and mortality in
those who survive to reach hospital
– vasospasm doubles the death rate and reduces good
outcomes by 1/3
Cerebral Aneurysms Blood from Ruptured Aneurysm
side
bottom
normal:
ruptured aneurysm:
Cerebral Vasospasm SAH – Differential diagnosis for
delayed neurological deterioration
Before
(normal
arteries)
After
(vasospastic
arteries)
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2. SAH – Who gets vasospasm? SAH – Fisher Scale
67% will have some angiographic spasm by day 7
>25% constriction in 30% of patients
small vessel spasm likely more prevalent…but cannot image!
prevalent…
Worse SAH = Worse vasospasm
50-60% of grade III-IV patients will have >50% narrowing of arteries
50- III-
volume and clearance of subarachnoid clot are key predictive factors
factors
SAH - Fisher Scale Vasospasm – Diagnosis
Clinical exam
new global/focal deficit
all other causes ruled out (metabolic, structural)
Imaging
TCD – peak systolic values, trends
CTA/CTP – can visualize diameter & blood flow
DSA – gold standard
Vasospasm – Treatment Vasospasm – Hemodynamic therapy
General
optimize ICP, temperature, seizure control
critical to avoid hypovolemia, hyponatremia
hypovolemia,
Specific
nimodipine (mechanism?)
hemodynamic therapy
intra-arterial therapy
intra-
future agents: endothelin antagonists, free-radical
free-
scavengers, Mg2+, statins, neuroprotectants…
statins, neuroprotectants…
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3. Vasospasm – Intraarterial Treatment
Vasospasm – Ca2+ channel blockers
Vasodilators
Can treat distal, small vessel spasm, less risk
Less effective, transient, repeat tx required
Raised ICP (papaverine > verapamil/nicardipine)
(papaverine verapamil/nicardipine)
Angioplasty
Very effective, long-lasting effecit
long-
Higher risk, cannot reach distal, small vessels
Not available at all centers
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4. Summary
Vasospasm incidence and morbidity
1.
remains high in SAH patients
Maintain high index of suspicion
2.
Daily clinical exam
Daily TCD
Vasospasm is stroke in evolution!
3.
Early diagnosis and management
Rapid escalation of therapy
Key role for ongoing research
4.
Small vessel spasm, prophylaxis, drug treatment…
treatment…
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