Cerebral vasospasm
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Cerebral Vasospasm. Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University. Objectives. To recognize cerebral vasospasm (CVS) as a treatable complication of aSAH To safely and effectively institute optimal medical management of CVS

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Cerebral Vasospasm

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Cerebral Vasospasm

Dennis A. Velez, MD

Cerebrovascular/Endovascular Neurosurgery

Dept. of Neurological Surgery

Vanderbilt University


Objectives

  • To recognize cerebral vasospasm (CVS) as a treatable complication of aSAH

  • To safely and effectively institute optimal medical management of CVS

  • To recognize the different modalities used to diagnose CVS

  • To learn to identify which patients may benefit from endovascular therapy for CVS


Definition

  • CVS has been defined in various ways:

  • Clinical vasospasm (delayed cerebral ischemia, DCI)

  • Angiographic vasospasm

  • TCD vasospasm

  • Which one is more clinically relevant?


Pathophysiology

  • Prolonged arterial contraction: oxyhemoglobin

  • Structural changes in the arterial wall: arterial hyperplasia, platelet aggregation and edema-luminal narrowing, increased resistance, decreased blood flow

  • Breakdown of blood products: oxyhemoglobin, serotonin, prostaglandins, catecholamines, histamine, angiotensin

  • Inflammatory response: neurogenic and classic inflammation


Histological changes


Role of Hgb oxidation products


Intracellular signaling


Inflammatory Response


CVS Prediction: Patient-specific factors

  • Clinical grade

  • Blood volume and frequency of SAH

  • Size and location of aneurysm(s)

  • Cocaine use

  • Sex

  • Age

  • Smoking

  • Hypertension


Glasgow Coma Scale


Hunt and Hess Grading Scale


WFNS Grading Scale


Fisher Scale


Pathological Markers

  • Endothelin 1

  • Leukocytosis

  • Soluble adhesion molecules

  • Lipid peroxides

  • Cellular proliferation and Growth Factors

  • Hypomagnesemia

  • Genetic markers


Diagnostic Neurological Imaging

  • DSA/Conventional angiography

  • CT angiography/CT perfusion

  • TCD

  • SPECT

  • DWI/PWI


TCD


CVS Treatment Options

  • Triple “H” therapy

  • Albumin 5%/Normal Saline

  • Pressors

  • Hemodilution

  • Nimodipine

  • Statins

  • Lumbar drainage/ Head shaking

  • Endovascular treatment: IA/TBA

  • Intra-aortic balloon counterpulsation (IABC)


Lumbar Drainage


Head Shaking for CVS


Intra-aortic balloon counterpulsation


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