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Cerebral Vasospasm

                                                         • Delayed arterial narrowing that occurs afte...
SAH – Who gets vasospasm?                                                  SAH – Fisher Scale


 67% will have some angiog...
Vasospasm – Intraarterial Treatment
Vasospasm – Ca2+ channel blockers

                                     Vasodilators
 ...
Summary
     Vasospasm incidence and morbidity
1.
     remains high in SAH patients

     Maintain high index of suspicion...
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Management Of Cerebral Vasospasm

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Transcript of "Management Of Cerebral Vasospasm"

  1. 1. Cerebral Vasospasm • Delayed arterial narrowing that occurs after an aneurysm has ruptured (subarachnoid hemorrhage) Management of Cerbral – starts after 3 days, maximal at 7 days, resolves by 14 Vasospasm in Subarchanoid days Hemorrhage • A common cause of morbidity and mortality in those who survive to reach hospital – vasospasm doubles the death rate and reduces good outcomes by 1/3 Cerebral Aneurysms Blood from Ruptured Aneurysm side bottom normal: ruptured aneurysm: Cerebral Vasospasm SAH – Differential diagnosis for delayed neurological deterioration Before (normal arteries) After (vasospastic arteries) 1
  2. 2. SAH – Who gets vasospasm? SAH – Fisher Scale 67% will have some angiographic spasm by day 7 >25% constriction in 30% of patients small vessel spasm likely more prevalent…but cannot image! prevalent… Worse SAH = Worse vasospasm 50-60% of grade III-IV patients will have >50% narrowing of arteries 50- III- volume and clearance of subarachnoid clot are key predictive factors factors SAH - Fisher Scale Vasospasm – Diagnosis Clinical exam new global/focal deficit all other causes ruled out (metabolic, structural) Imaging TCD – peak systolic values, trends CTA/CTP – can visualize diameter & blood flow DSA – gold standard Vasospasm – Treatment Vasospasm – Hemodynamic therapy General optimize ICP, temperature, seizure control critical to avoid hypovolemia, hyponatremia hypovolemia, Specific nimodipine (mechanism?) hemodynamic therapy intra-arterial therapy intra- future agents: endothelin antagonists, free-radical free- scavengers, Mg2+, statins, neuroprotectants… statins, neuroprotectants… 2
  3. 3. Vasospasm – Intraarterial Treatment Vasospasm – Ca2+ channel blockers Vasodilators Can treat distal, small vessel spasm, less risk Less effective, transient, repeat tx required Raised ICP (papaverine > verapamil/nicardipine) (papaverine verapamil/nicardipine) Angioplasty Very effective, long-lasting effecit long- Higher risk, cannot reach distal, small vessels Not available at all centers 3
  4. 4. Summary Vasospasm incidence and morbidity 1. remains high in SAH patients Maintain high index of suspicion 2. Daily clinical exam Daily TCD Vasospasm is stroke in evolution! 3. Early diagnosis and management Rapid escalation of therapy Key role for ongoing research 4. Small vessel spasm, prophylaxis, drug treatment… treatment… 4

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