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cerebral_vasospasm_treatment

Cerebral Vasospasm Treatment

Cerebral Vasospasm in the large brain-supplying vessels is only partially treatable 1) 2).

Prevention

see Nimodipine for subarachnoid hemorrhage.

Removal of subarachnoid hemorrhage as soon as possible.

Instillation of thrombolytic agents (e.g. urokinase).

Antiinflammatory agents (steroids or NSAIDs).

Treatment

The ultimate goal in the treatment of cerebral vasospasm after subarachnoid hemorrhage is to avoid DIND by reducing ICP, optimizing the rate of cerebral oxygen demand, and improving cerebral blood flow. Given these goals, early aneurysm treatment and ventriculostomy placement for patients with elevated intracranial pressure is a necessity. Early aneurysm treatment allows the treatment team to be more aggressive with further vasospasm treatment over the course of care.

Triple H therapy controversial

IVF +/- Inotropes/vasopressors

CVP 10-12mmHg, PAOP 15-18mmHg, CI 3-3.5 L/min/m2, Hct 30-35%, SBP 160-200 if aneurysm clipped and 120-150 if unclipped

Complications

Pulmonary edema, myocardial ischemia, rebleeding, rupture of new aneurysm, vasogenic edema/hemorrhagic infarction insetting of compromised BBB.

For refractory Triple H therapy

Selective intra-arterial verapamil, papaverine, or nitroprusside or Angioplasty.


Hemodynamic strategies and endovascular procedures may be considered for the treatment of cerebral vasospasm.

To date, the current therapeutic interventions remain ineffective being limited to the manipulation of systemic blood pressure, variation of blood volume and viscosity, and control of arterial carbon dioxide tension.In this scenario, the hormone erythropoietin (EPO), has been found to exert neuroprotective action during experimental SAH when its recombinant form (rHuEPO) is systemically administered. However, recent translation of experimental data into clinical trials has suggested an unclear role of recombinant human EPO in the setting of SAH 3).

Nimodipine

Papaverine

The use of intravascular papaverine as an alternative treatment for reversible vasospasm is associated with various side effects including hemodynamic instability like bradycardia and hypotension. Some recent studies have pointed that washing aneurysmal arteries and subarachnoid space with papaverine may not have many complications and hemodynamic disorders besides preventing aneurysmal vasospasm 4)

Washing with papaverine significantly reduces cerebral blood flow and relieves vasospasm 5).

CSF diversion

A substantial body of evidence supports the idea that CSF diversion could prevent VS, even if this issue is still much debated. External ventricular drainage (EVD) is the recommended procedure for posthemorrhagic hydrocephalus.

Of radiologically confirmed VS in 141 patients treated endovascularly for aneurysmal subarachnoid hemorrhage: 80 underwent EVD for hydrocephalus, 61 did not undergo EVD.

VS occurred in 8.75% of cases (7 patients) in the first groups, while in 22.95% (14 patients) in the second group. In addition, patients not treated with EVD display a prevalence of VS in lower Fisher grades compared to the other group.

This data indicate that CSF drainage reduces the risk of vasospasms in patients with endovascular treatment for aneurysmal SAH 6).

1)
Macdonald RL, Weir BK. A review of hemoglobin and the pathogenesis of cerebral vasospasm. Stroke 1991;22(08):971–982
2)
Pluta RM. Delayed cerebral vasospasm and nitric oxide: review, new hypothesis, and proposed treatment. Pharmacol Ther 2005; 105(01):23–56
3)
Grasso G, Tomasello G, Noto M, Alafaci C, Cappello F. Erythropoietin for the treatment of subarachnoid hemorrhage: A feasible ingredient for a successful medical recipe. Mol Med. 2015 Nov 16. doi: 10.2119/molmed.2015.00177. [Epub ahead of print] PubMed PMID: 26581085.
4)
Rath GP, Mukta H, Prabhakar H, Dash HH, Suri A. Haemodynamic changes after intracisternal papaverine instillation during intracranial aneurysmal surgery. Br J Anaesth. 2006;97:848–50.
5)
Sabouri M, Rahmani P, Rezvani M, Nikbakht H, Rafiee A, Torkashvand M, Eshraghi N, Nourian N, Moradi M. The effect of irrigation of intracisternal papaverine on cerebral blood flow in subarachnoid hemorrhage. Adv Biomed Res. 2013 Jun 29;2:45. doi: 10.4103/2277-9175.114184. eCollection 2013. PubMed PMID: 24516845.
6)
Della Pepa GM, Scerrati A, Albanese A, Marchese E, Maira G, Sabatino G. Protective effect of external ventricular drainage on cerebral vasospasm. A retrospective study on aneurysmal SAH treated endovascularly. Clin Neurol Neurosurg. 2014 Sep;124:97-101. doi: 10.1016/j.clineuro.2014.06.030. Epub 2014 Jun 28. PubMed PMID: 25019459.
cerebral_vasospasm_treatment.txt · Last modified: 2018/08/09 19:37 by administrador