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Cerebral Vasospasm

Cerebral Vasospasm. Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University. Objectives. To recognize cerebral vasospasm (CVS) as a treatable complication of aSAH To safely and effectively institute optimal medical management of CVS

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Cerebral Vasospasm

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  1. Cerebral Vasospasm Dennis A. Velez, MD Cerebrovascular/Endovascular Neurosurgery Dept. of Neurological Surgery Vanderbilt University

  2. Objectives • To recognize cerebral vasospasm (CVS) as a treatable complication of aSAH • To safely and effectively institute optimal medical management of CVS • To recognize the different modalities used to diagnose CVS • To learn to identify which patients may benefit from endovascular therapy for CVS

  3. Definition • CVS has been defined in various ways: • Clinical vasospasm (delayed cerebral ischemia, DCI) • Angiographic vasospasm • TCD vasospasm • Which one is more clinically relevant?

  4. Pathophysiology • Prolonged arterial contraction: oxyhemoglobin • Structural 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

  5. Histological changes

  6. Role of Hgb oxidation products

  7. Intracellular signaling

  8. Inflammatory Response

  9. CVS Prediction: Patient-specific factors • Clinical grade • Blood volume and frequency of SAH • Size and location of aneurysm(s) • Cocaine use • Sex • Age • Smoking • Hypertension

  10. Glasgow Coma Scale

  11. Hunt and Hess Grading Scale

  12. WFNS Grading Scale

  13. Fisher Scale

  14. Pathological Markers • Endothelin 1 • Leukocytosis • Soluble adhesion molecules • Lipid peroxides • Cellular proliferation and Growth Factors • Hypomagnesemia • Genetic markers

  15. Diagnostic Neurological Imaging • DSA/Conventional angiography • CT angiography/CT perfusion • TCD • SPECT • DWI/PWI

  16. TCD

  17. CVS Treatment Options • Triple “H” therapy • Albumin 5%/Normal Saline • Pressors • Hemodilution • Nimodipine • Statins • Lumbar drainage/ Head shaking • Endovascular treatment: IA/TBA • Intra-aortic balloon counterpulsation (IABC)

  18. Lumbar Drainage

  19. Head Shaking for CVS

  20. Intra-aortic balloon counterpulsation

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