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Cerebral Vasospasm

Cerebral Vasospasm. M. Christopher Wallace M.D. The Toronto Western Hospital, University Health Network University of Toronto Postgraduate Lecture Series Division of Neurosurgery Friday October 20, 2000. Subarachnoid Hemorrhage. Delayed presentation Headache, no deficit

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Cerebral Vasospasm

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  1. Cerebral Vasospasm M. Christopher Wallace M.D. The Toronto Western Hospital, University Health Network University of Toronto Postgraduate Lecture Series Division of Neurosurgery Friday October 20, 2000

  2. Subarachnoid Hemorrhage • Delayed presentation • Headache, no deficit • Minimal subarachnoid blood

  3. Cause of Subarachnoid Hemorrhage?

  4. Post surgical CT

  5. Post-op Angiography

  6. Comparison Angiograms

  7. Post surgical CT’s

  8. History • 1927 Moniz - angiography • 1937 Dandy describes the clipping of intracranial aneurysm • 1949 Robertson described post-mortem lesions after aneurysmal SAH. • Brain 72:150, 1949 • 1951 Ecker & Reimenschneider angiographic spasm

  9. Time Course • After aneurysmal subarachnoid hemorrhage • Delayed onset • Rarely present before Day 3 • Peak Day 6-7

  10. Significance • 1970’s Does it exist? • Time course in humans • Kwak, Niizuma Surg Neurol 11:257, 1979 • Niizuma, Kwak Surg Neurol 11:263, 1979 • Cause of death or disability in 13.5% in co-operative study • J. Neurosurgery 73:18-36, 1990

  11. Vasospasm and SAH • Relationship to the amount of subarachnoid hemorrhage • Fisher CT Grade • I 2/11 angiographic spasm, 0/11 • II 0/7 • III 23/24 clinical vasospasm • Fisher, Kistler, Davis Neurosurgery 6:1 1980

  12. Etiology • Reversible? • Smooth muscle contraction vs morphological change in vascular wall • Weir, Findlay, MacDonald • Demonstration of role of oxyhemoglobin leads to documented contraction of smooth muscle • Delayed thickening of intima and adventitia day 28

  13. Etiology • Fresh serum and platelet rich plasma are vasoreactive • Washed rbc’s are inert • Contractility of rbc’s linked to incubation with plasma • Trapped rbc’s in subarachnoid space • day 7

  14. Treatment of cerebral vasospasm • Diagnosis • Hypervolemic-hypertensive therapy • Calcium channel blockers • Cerebral angioplasty • Intracisternal thrombolytic therapy

  15. Diagnosis • Clinical suspicion: patient/time period • Transcranial doppler • Cerebral angiography • Neurological deficit

  16. Hypervolemic-hypertensive therapy • Prophylactic use of euvolemia in patients with aneurysmal hemorrhage post-therapy • Kosnik & Hunt J Neurosurg 45:148, 1976 • Kassell, Peerless et al Neurosurgery 11:337, 1982 • Reversal of deficit in 43/58 patients • Use of colloids and inotropes • Clinical detection of deficit and angiographic proof of spasm

  17. Calcium channel blockers • Use of nimodipine 60mg q4h x 3 weeks • Reduces morbidity/poor outcomes but does not alter the incidence of angiographic spasm….?mechanism • Allen NEJM 308:619, 1983 • Petruk J Neurosurg 68:505, 1988 • Pickard Br Med J 298:636, 1989

  18. Cerebral angioplasty • Mechanical vs chemical (papaverine) • Early, minimal deficit, radiological contraindications • Permanence • Risk of rupture • ?prophylaxis • Polin et al Neurosurgery 42:1256-1264, 1998 • Eskridge et al Neurosurgery 42:510-516, 1998

  19. Intracisternal thrombolytic therapy • Cisternal clot removal • Laboratory evidence • Prospective study failed to demonstrate efficacy • N=100, high risk patients in main centre (p=0.02) mild/no spasm severe • Placebo 42% 23% • rt-PA 69% 15% • Findlay et al Neurosurgery 37:168-176, 1995

  20. Endothelin and Vasospasm • Isolated from endothelial cells, 1988 • Three isoforms: ET-1, -2, -3, 21 AA • Prepro ET-1 gene, conversion to proendothelin then Big-ET • ET-1 most vasoactive • Vasoconstriction, elevates arterial pressure, bronchoconstriction • Endothelin receptors: ETA, ETB1, ETB2 • Neurosurgery 43:863-876, 1998

  21. Endothelin Receptors ETA • localized to smooth muscle • mediates vasoconstriction ETB1 • Localized to vascular endothelial cells • Mediates endothelium-dependant vasodilation action of ET ETB2 • Similar localization and action to ETA

  22. Endothelin and Vasospasm • Documented in CSF after aneurysmal SAH • Marker vs mediator • Likely not over expression of ET1 • Potential for therapy with selective agonists/antagonists to receptors

  23. Approach to Patient with Delayed Neurological Deficit Post-op • Hemorrhage • Ischemia Vessel occlusion Clipping or coiling error Post temporary clipping

  24. Approach to Patient with Delayed Neurological Deficit Day1-3 • Hyponatremia • Fever • Oxygenation • Hydrocephalus • Medications • Rebleed/unsecured aneurysm

  25. Approach to Patient with Delayed Neurological Deficit Day3-10 • Vasospasm • Vasospasm • Vasospasm • Hydrocephalus • Fever/pneumonia

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