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Medical Management of Cerebral Vasospasm

S.A.H. Medical Management of Cerebral Vasospasm. Mark Angle, M.D. MNH / I-2001. S.A.H. Cerebral Vasospasm:. A Syndrome of Delayed Regional Hypoperfusion Post Sub-Arachnoid Hemorrhage. S.A.H.

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Medical Management of Cerebral Vasospasm

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  1. S.A.H. Medical Management of Cerebral Vasospasm Mark Angle, M.D. MNH / I-2001

  2. S.A.H. Cerebral Vasospasm: A Syndrome of Delayed Regional Hypoperfusion Post Sub-Arachnoid Hemorrhage

  3. S.A.H. Delayed Ischemic Neurological DeficitsOnset 4 - 14 days post - SAH Focal or global Differential diagnosis:1. Hydrocephalus2. Re-hemorrhage3. Hyponatremia4. Concurrent illness5. Seizure(s) 6. Vasospasm

  4. Local InflammatoryArteritis Local / Distal Vasoconstricition S.A.H. Pathophysiologyof Vasospasm Clot-Derived Oxyhemoglobin

  5. S.A.H. VasomotorDysregulation Early: Enhanced Calcium Entry into Smooth Muscle Late: Activation of PKC

  6. S.A.H. Vasospasm Modulators: NO  cGMP Endothelin  PKC Eicosonoids  cAMP, IP 3

  7. S.A.H. Cortical Necrosis • Critical Hypoperfusion • Paradoxical Micro vascular Constriction after Cortical Activation

  8. S.A.H. Predictors of Vasospasm: • Thickness of Clot (Fischer) • Hydrocephalus • Prior Smoking History • Prior Hypertension • (Early Surgical Intervention) • Intra-Operative Hypotension

  9. S.A.H. Treatment of Vasospasm • Prophylaxis • Risk Management • Baro-Therapy • Vaso-Therapy

  10. S.A.H. Diagnosis of Vasospasm: • Symptoms (Delayed Neurological Deficits) • Angiography: DS vs CTA • TCD • Perfusion: Xe CT, CT perfusion • Tissue Monitoring Spectroscopy Microdialysis

  11. S.A.H. Vasospasm: A Systemic Illness? • Systemic Inflammatory Response (leukocytosis, tachycardia, tachypnea, fever) • Natriuresis • Fever

  12. S.A.H. Vasospasm: Prophylaxis • Cisternal Drainage • Immunotherapy (steroids) • Experimental Pharmacotherapy

  13. S.A.H. Vasospasm: Risk Management • Nimodipine • Triple H

  14. S.A.H. “Triple - H” • Hemodilution  hct 30 - 32 • Hypervolemia  CVP 10 - 12 • Hypertension   MAP 20 - 40 %

  15. S.A.H. Symptomatic Vasospasm: Results of “Best Practice”: CVA at 24 hrs. - 40 - 50 % Poor Outcome - 40 - 50 %

  16. S.A.H. Milrinone: Actions • PDE III Inhibitor   cAMP   cGMP • Immuno Modulator   TNF, IL-6   Platelet Adhesion   wbc chemopexis • Cardiac Inotrope

  17. S.A.H. Vasospasm: Treatment Protocol: • Optimal Medical Management • Euvolemia • Normo - Natremia • Milrinone Trial • Salvage Hypertension • Angioplasty

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