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

                              1. McGuinness B et al: Endovascular management of cerebral vasospasm. Neurosurg Clin N Am. 21(2):281-90, 2010
                              2. Pradilla G et al: Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am. 21(2):365-79, 2010
                              3. 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
                              4. 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
                              5. Jabbour PM et al: Neuroendovascular management of vasospasm following aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 20(4):441-6, 2009
                              6. 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
                              7. Sayama CM et al: Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurosurg Focus. 21(3):E12, 2006
                              8. 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
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                              Related Differential Diagnoses
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                              References
                              Tables

                              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

                                                          1. McGuinness B et al: Endovascular management of cerebral vasospasm. Neurosurg Clin N Am. 21(2):281-90, 2010
                                                          2. Pradilla G et al: Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am. 21(2):365-79, 2010
                                                          3. 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
                                                          4. 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
                                                          5. Jabbour PM et al: Neuroendovascular management of vasospasm following aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 20(4):441-6, 2009
                                                          6. 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
                                                          7. Sayama CM et al: Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurosurg Focus. 21(3):E12, 2006
                                                          8. 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