Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery...
-
Upload
phyllis-harper -
Category
Documents
-
view
214 -
download
0
Transcript of Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery...
![Page 1: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/1.jpg)
Dennis A. Velez, MDCerebrovascular/Endovascular Neurosurgery
Dept. of Neurological SurgeryVanderbilt University
![Page 2: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/2.jpg)
ObjectivesTo recognize cerebral vasospasm (CVS) as a
treatable complication of aSAHTo safely and effectively institute optimal
medical management of CVSTo recognize the different modalities used to
diagnose CVSTo learn to identify which patients may
benefit from endovascular therapy for CVS
![Page 3: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/3.jpg)
DefinitionCVS has been defined in various ways: Clinical vasospasm (delayed cerebral
ischemia, DCI)Angiographic vasospasmTCD vasospasmWhich one is more clinically relevant?
![Page 4: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/4.jpg)
PathophysiologyProlonged arterial contraction: oxyhemoglobinStructural 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
![Page 5: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/5.jpg)
Histological changes
![Page 6: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/6.jpg)
Role of Hgb oxidation products
![Page 7: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/7.jpg)
Intracellular signaling
![Page 8: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/8.jpg)
Inflammatory Response
![Page 9: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/9.jpg)
CVS Prediction: Patient-specific factors
Clinical gradeBlood volume and frequency of SAHSize and location of aneurysm(s)Cocaine useSexAgeSmokingHypertension
![Page 10: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/10.jpg)
Glasgow Coma Scale
![Page 11: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/11.jpg)
Hunt and Hess Grading Scale
![Page 12: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/12.jpg)
WFNS Grading Scale
![Page 13: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/13.jpg)
Fisher Scale
![Page 14: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/14.jpg)
![Page 15: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/15.jpg)
Pathological MarkersEndothelin 1LeukocytosisSoluble adhesion moleculesLipid peroxidesCellular proliferation and Growth FactorsHypomagnesemiaGenetic markers
![Page 16: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/16.jpg)
Diagnostic Neurological ImagingDSA/Conventional angiographyCT angiography/CT perfusionTCDSPECTDWI/PWI
![Page 17: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/17.jpg)
![Page 18: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/18.jpg)
![Page 19: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/19.jpg)
TCD
![Page 20: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/20.jpg)
![Page 21: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/21.jpg)
![Page 22: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/22.jpg)
CVS Treatment OptionsTriple “H” therapyAlbumin 5%/Normal SalinePressorsHemodilutionNimodipineStatinsLumbar drainage/ Head shakingEndovascular treatment: IA/TBAIntra-aortic balloon counterpulsation (IABC)
![Page 23: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/23.jpg)
![Page 24: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/24.jpg)
![Page 25: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/25.jpg)
![Page 26: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/26.jpg)
![Page 27: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/27.jpg)
Lumbar Drainage
![Page 28: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/28.jpg)
Head Shaking for CVS
![Page 29: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/29.jpg)
![Page 30: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/30.jpg)
![Page 31: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/31.jpg)
![Page 32: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/32.jpg)
![Page 33: Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University.](https://reader038.fdocuments.net/reader038/viewer/2022110211/56649efc5503460f94c0fc09/html5/thumbnails/33.jpg)
Intra-aortic balloon counterpulsation