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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

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
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
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
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)
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