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

Cerebral Vasospasm

Dennis A. Velez, MD

Cerebrovascular/Endovascular Neurosurgery

Dept. of Neurological Surgery

Vanderbilt University


Objectives

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

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

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

Histological changes


Role of hgb oxidation products

Role of Hgb oxidation products


Intracellular signaling

Intracellular signaling


Inflammatory response

Inflammatory Response


Cvs prediction patient specific factors

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

Glasgow Coma Scale


Hunt and hess grading scale

Hunt and Hess Grading Scale


Wfns grading scale

WFNS Grading Scale


Fisher scale

Fisher Scale


Pathological markers

Pathological Markers

  • Endothelin 1

  • Leukocytosis

  • Soluble adhesion molecules

  • Lipid peroxides

  • Cellular proliferation and Growth Factors

  • Hypomagnesemia

  • Genetic markers


Diagnostic neurological imaging

Diagnostic Neurological Imaging

  • DSA/Conventional angiography

  • CT angiography/CT perfusion

  • TCD

  • SPECT

  • DWI/PWI


Cerebral vasospasm

TCD


Cvs treatment options

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

Lumbar Drainage


Head shaking for cvs

Head Shaking for CVS


Intra aortic balloon counterpulsation

Intra-aortic balloon counterpulsation


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