Celia Bradford on Vasospasm after SAH
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![Page 1: Celia Bradford on Vasospasm after SAH](https://reader034.fdocuments.net/reader034/viewer/2022042817/559cb4881a28abf7048b4747/html5/thumbnails/1.jpg)
PREVENTION
AND
MANAGEMENT
Vasospasm After SAH
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Prevalence
0.5% of the population will rupture a cerebral aneurysm
25% of these will die
Death is due to
The initial catastrophic bleed
Rebleeding
Cerebral vasospasm
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Vasospasm
70% of patients will have angiographic evidence of spasm following the haemorrhage
30% of these cases will have symptomatic spasm
50% of these will have DIND
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VASOSPASM
Delayed cerebral vasospasm typically develops
from 4 to 9 days, though earlier (3 days) or late
(3 weeks) vasospasm may be observed
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Does spasm = ischemia?
Not necessarily
Many factors contribute to the development of ischemia and infarction,
distal microcirculatory failure,
Poor collateral anatomy,
genetic or physiological variations in cellular ischemic tolerance
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Risks for Spasm
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Case
50 year old woman
Sudden onset of headache
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ED->CTB; SAH. Ruptured AComA aneurysm
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Coiling
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Progress
EVD inserted for hydrocephalus
Extubated on day 4.
GCS 14 (eyes to voice) but generally drowsy
On day 8 developed left hemiparesis
Intubated
DSA demonstrated severe bilateral ICA spasm
Balloon angioplasty to RICA and MCA
Intraarterial verapamil and papaverine
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Progress
Massive doses of noradrenaline and vasopressin to maintain SBP. ICP high. Thio coma
Angio D9... Severe spasm persists refractory to intraarterial verapamil
CTB; diffuse cerebral oedema. ICPs >30
Decompressive craniectomy
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Progress
D10;
Despite decompression, ICP remain at 38.
Unsupportable BP
Therapy ceased
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Diagnosis
Neuro exam
DSA
TCD
Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class IIa;Level of
Evidence B). (New recommendation)
Warning Signs
CT Perfusion
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A=CBF B=CBV
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Perfusion imaging can be useful to identify regions of potential brain ischaemia(Class IIa; Level of evidence B)
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Management
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Management; 6 point plan
1.Nimodipine
2. Euvolemia
3. Induction of Hypertension
4. Mg
5. Cerebral angioplasty and/or selective intra-arterial
vasodilator therapy
6. Stop the boats
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Nimodipine
Level 1 Evidence
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Euvolemia and Hypertensing
Choice of fluid
SBP aims
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Magnesium
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Intra-arterial therapy
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Management of other complications due to vasospasm
Hyponatremia... Cerebral salt wasting
Role of euvolemia
Fludrocortisone
3% saline
Choice of fluid
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Fever
Independent association with high fever after SAH and poor cognitive outcome
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Haemoglobin
Controversial
Lower threshold for transfusion in vasospastic patients
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Statins
STASH Trial
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Other
Urokinase
Lumbar drainage