Carlos E. Baccin, MD; James D. Rabinov, MD

KEY FACTS

Terminology
Pre-Procedure
Procedure

TERMINOLOGY

Definitions
- Cerebral vasospasm:Narrowing/constriction of intracranial arteries after subarachnoid hemorrhage (SAH); caused by overcontraction of arterial wall
  - Also known as subarachnoid hemorrhage vasospasm
  - Ruptured intracerebral aneurysm dominant etiology
  - Vasospasm affects 60-70% patients after SAH
    - Symptomatic ischemia in 30%; manifested by
      - Altered level of consciousness/confusion
      - Focal neurological deficit
    - Death/serious disability in 1/3 of patients with SAH
  - Caused by exposure to blood breakdown products
    - Vasospastic reversible stenosis
      - Inflammation
      - Changes in arterial wall
      - Altered level of vasoactive substances
    - Onset usually after day 3 of SAH
      - Maximal severity 4-14 days after SAH
      - Significantly reduced or gone within 3 weeks
  - Risk factors for symptomatic vasospasm
    - Amount of blood on initial head CT scan
    - Age < 50 years
    - Hyperglycemia
    - History of hypertension
    - Larger aneurysm size
    - Intraventricular hemorrhage
    - Cocaine use
- Endovascular options for treatment of vasospasm
  - Balloon angioplasty(PTA)
    - Mostly for large/medium (> 1.5 mm) vessel spasm
    - Proximal intracranial arteries amenable to PTA
      - Internal carotid (ICA)/vertebral/basilar arteries
      - M1 segment of middle cerebral artery (MCA)
      - A1 segment of anterior cerebral artery (ACA)
      - P1 segment of posterior cerebral artery (PCA)
  - Intraarterial pharmacologic infusion
    - For more distal branch vasospasm
    - Vessels not safely treated with angioplasty
- Transcranial Doppler ultrasonography (TCD): Measurement of blood flow velocities in major branches of circle of Willis through intact skull
  - Noninvasive vasospasm evaluation/monitoring
  - 2-4 MHz pulsed-wave Doppler with spectral analysis
  - Measurement supports grading
    - Vasospasm severity
    - Localization of intracranial stenoses/occlusions

PRE-PROCEDURE

Indications
Pre-Procedure Imaging
Getting Started

PROCEDURE

Equipment Preparation
Procedure Steps
Findings and Reporting
Alternative Procedures/Therapies

POST-PROCEDURE

Expected Outcome
Things to Do
Things to Avoid

OUTCOMES

Complications

Selected References

McGuinness B et al: Endovascular management of cerebral vasospasm. Neurosurg Clin N Am. 21(2):281-90, 2010
Pradilla G et al: Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am. 21(2):365-79, 2010
Schmidt U et al: Hemodynamic management and outcome of patients treated for cerebral vasospasm with intraarterial nicardipine and/or milrinone. Anesth Analg. 110(3):895-902, 2010
Webb A et al: The effect of intraventricular administration of nicardipine on mean cerebral blood flow velocity measured by transcranial Doppler in the treatment of vasospasm following aneurysmal subarachnoid hemorrhage. Neurocrit Care. 12(2):159-64, 2010
Jabbour PM et al: Neuroendovascular management of vasospasm following aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 20(4):441-6, 2009
Kwon OY et al: The utility and benefits of external lumbar CSF drainage after endovascular coiling on aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc. 43(6):281-7, 2008
Sayama CM et al: Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurosurg Focus. 21(3):E12, 2006
Hoh BL et al: Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine. Neurosurg Clin N Am. 16(3):501-16, vi, 2005

Related Anatomy

Related Differential Diagnoses

References

Tables

KEY FACTS

Terminology
Pre-Procedure
Procedure

TERMINOLOGY

Definitions
- Cerebral vasospasm:Narrowing/constriction of intracranial arteries after subarachnoid hemorrhage (SAH); caused by overcontraction of arterial wall
  - Also known as subarachnoid hemorrhage vasospasm
  - Ruptured intracerebral aneurysm dominant etiology
  - Vasospasm affects 60-70% patients after SAH
    - Symptomatic ischemia in 30%; manifested by
      - Altered level of consciousness/confusion
      - Focal neurological deficit
    - Death/serious disability in 1/3 of patients with SAH
  - Caused by exposure to blood breakdown products
    - Vasospastic reversible stenosis
      - Inflammation
      - Changes in arterial wall
      - Altered level of vasoactive substances
    - Onset usually after day 3 of SAH
      - Maximal severity 4-14 days after SAH
      - Significantly reduced or gone within 3 weeks
  - Risk factors for symptomatic vasospasm
    - Amount of blood on initial head CT scan
    - Age < 50 years
    - Hyperglycemia
    - History of hypertension
    - Larger aneurysm size
    - Intraventricular hemorrhage
    - Cocaine use
- Endovascular options for treatment of vasospasm
  - Balloon angioplasty(PTA)
    - Mostly for large/medium (> 1.5 mm) vessel spasm
    - Proximal intracranial arteries amenable to PTA
      - Internal carotid (ICA)/vertebral/basilar arteries
      - M1 segment of middle cerebral artery (MCA)
      - A1 segment of anterior cerebral artery (ACA)
      - P1 segment of posterior cerebral artery (PCA)
  - Intraarterial pharmacologic infusion
    - For more distal branch vasospasm
    - Vessels not safely treated with angioplasty
- Transcranial Doppler ultrasonography (TCD): Measurement of blood flow velocities in major branches of circle of Willis through intact skull
  - Noninvasive vasospasm evaluation/monitoring
  - 2-4 MHz pulsed-wave Doppler with spectral analysis
  - Measurement supports grading
    - Vasospasm severity
    - Localization of intracranial stenoses/occlusions

PRE-PROCEDURE

Indications
Pre-Procedure Imaging
Getting Started

PROCEDURE

Equipment Preparation
Procedure Steps
Findings and Reporting
Alternative Procedures/Therapies

POST-PROCEDURE

Expected Outcome
Things to Do
Things to Avoid

OUTCOMES

Complications

Selected References

McGuinness B et al: Endovascular management of cerebral vasospasm. Neurosurg Clin N Am. 21(2):281-90, 2010
Pradilla G et al: Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am. 21(2):365-79, 2010
Schmidt U et al: Hemodynamic management and outcome of patients treated for cerebral vasospasm with intraarterial nicardipine and/or milrinone. Anesth Analg. 110(3):895-902, 2010
Webb A et al: The effect of intraventricular administration of nicardipine on mean cerebral blood flow velocity measured by transcranial Doppler in the treatment of vasospasm following aneurysmal subarachnoid hemorrhage. Neurocrit Care. 12(2):159-64, 2010
Jabbour PM et al: Neuroendovascular management of vasospasm following aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 20(4):441-6, 2009
Kwon OY et al: The utility and benefits of external lumbar CSF drainage after endovascular coiling on aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc. 43(6):281-7, 2008
Sayama CM et al: Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurosurg Focus. 21(3):E12, 2006
Hoh BL et al: Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine. Neurosurg Clin N Am. 16(3):501-16, vi, 2005

KEY FACTS

Terminology

Pre-Procedure

Procedure

TERMINOLOGY

Definitions

PRE-PROCEDURE

Indications

Pre-Procedure Imaging

Getting Started

PROCEDURE

Equipment Preparation

Procedure Steps

Findings and Reporting

Alternative Procedures/Therapies

POST-PROCEDURE

Expected Outcome

Things to Do

Things to Avoid

OUTCOMES

Complications

Selected References

Tables

KEY FACTS

Terminology

Pre-Procedure

Procedure

TERMINOLOGY

Definitions

PRE-PROCEDURE

Indications

Pre-Procedure Imaging

Getting Started

PROCEDURE

Equipment Preparation

Procedure Steps

Findings and Reporting

Alternative Procedures/Therapies

POST-PROCEDURE

Expected Outcome

Things to Do

Things to Avoid

OUTCOMES

Complications

Selected References