Celia Bradford on Vasospasm after SAH

PREVENTION

AND

MANAGEMENT

Vasospasm After SAH

Prevalence

0.5% of the population will rupture a cerebral aneurysm

25% of these will die

Death is due to

The initial catastrophic bleed

Rebleeding

Cerebral vasospasm

Vasospasm

70% of patients will have angiographic evidence of spasm following the haemorrhage

30% of these cases will have symptomatic spasm

50% of these will have DIND

VASOSPASM

Delayed cerebral vasospasm typically develops

from 4 to 9 days, though earlier (3 days) or late

(3 weeks) vasospasm may be observed

Does spasm = ischemia?

Not necessarily

Many factors contribute to the development of ischemia and infarction,

distal microcirculatory failure,

Poor collateral anatomy,

genetic or physiological variations in cellular ischemic tolerance

Risks for Spasm

Case

50 year old woman

Sudden onset of headache

ED->CTB; SAH. Ruptured AComA aneurysm

Coiling

Progress

EVD inserted for hydrocephalus

Extubated on day 4.

GCS 14 (eyes to voice) but generally drowsy

On day 8 developed left hemiparesis

Intubated

DSA demonstrated severe bilateral ICA spasm

Balloon angioplasty to RICA and MCA

Intraarterial verapamil and papaverine

Progress

Massive doses of noradrenaline and vasopressin to maintain SBP. ICP high. Thio coma

Angio D9... Severe spasm persists refractory to intraarterial verapamil

CTB; diffuse cerebral oedema. ICPs >30

Decompressive craniectomy

Progress

D10;

Despite decompression, ICP remain at 38.

Unsupportable BP

Therapy ceased

Diagnosis

Neuro exam

DSA

TCD

Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class IIa;Level of

Evidence B). (New recommendation)

Warning Signs

CT Perfusion

A=CBF B=CBV

Perfusion imaging can be useful to identify regions of potential brain ischaemia(Class IIa; Level of evidence B)

Management

Management; 6 point plan

1.Nimodipine

2. Euvolemia

3. Induction of Hypertension

4. Mg

5. Cerebral angioplasty and/or selective intra-arterial

vasodilator therapy

6. Stop the boats

Nimodipine

Level 1 Evidence

Euvolemia and Hypertensing

Choice of fluid

SBP aims

Magnesium

Intra-arterial therapy

Management of other complications due to vasospasm

Hyponatremia... Cerebral salt wasting

Role of euvolemia

Fludrocortisone

3% saline

Choice of fluid

Fever

Independent association with high fever after SAH and poor cognitive outcome

Haemoglobin

Controversial

Lower threshold for transfusion in vasospastic patients

Statins

STASH Trial

Other

Urokinase

Lumbar drainage