Celia Bradford on Vasospasm after SAH

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Celia Bradford talks about prevention and management of vasospasm after subarachnoid haemorrhage. This talk was recorded at Bedside Critical Care Conference 4.

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Celia Bradford on Vasospasm after SAH

  1. 1. Vasospasm After SAH PREVENTION AND M A N AG E M E NT
  2. 2. Prevalence  0.5% of the population will rupture a cerebral aneurysm  25% of these will die  Death is due to  The initial catastrophic bleed  Rebleeding  Cerebral vasospasm
  3. 3. Vasospasm  70% of patients will have angiographic evidence of spasm following the haemorrhage  30% of these cases will have symptomatic spasm  50% of these will have DIND
  4. 4. VASOSPASM  Delayed cerebral vasospasm typically develops from 4 to 9 days, though earlier (3 days) or late (3 weeks) vasospasm may be observed
  5. 5. Does spasm = ischemia?  Not necessarily  Many factors contribute to the development of ischemia and infarction,  distal microcirculatory failure,  Poor collateral anatomy,  genetic or physiological variations in cellular ischemic tolerance
  6. 6. Risks for Spasm
  7. 7. Case  50 year old woman  Sudden onset of headache
  8. 8. ED->CTB; SAH. Ruptured AComA aneurysm
  9. 9. Coiling
  10. 10. Progress  EVD inserted for hydrocephalus  Extubated on day 4.  GCS 14 (eyes to voice) but generally drowsy  On day 8 developed left hemiparesis  Intubated  DSA demonstrated severe bilateral ICA spasm  Balloon angioplasty to RICA and MCA  Intraarterial verapamil and papaverine
  11. 11. Progress  Massive doses of noradrenaline and vasopressin to maintain SBP. ICP high. Thio coma  Angio D9... Severe spasm persists refractory to intraarterial verapamil  CTB; diffuse cerebral oedema. ICPs >30  Decompressive craniectomy
  12. 12. Progress  D10;  Despite decompression, ICP remain at 38.  Unsupportable BP  Therapy ceased
  13. 13. Diagnosis  Neuro exam  DSA  TCD  Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class IIa;Level of Evidence B). (New recommendation)  Warning Signs  CT Perfusion
  14. 14. A=CBF B=CBV
  15. 15. Perfusion imaging can be useful to identify regions of potential brain ischaemia (Class IIa; Level of evidence B)
  16. 16. Management
  17. 17. Management; 6 point plan  1.Nimodipine 2. Euvolemia 3. Induction of Hypertension 4. Mg 5. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy 6. Stop the boats
  18. 18. Nimodipine  Level 1 Evidence
  19. 19. Euvolemia and Hypertensing  Choice of fluid  SBP aims
  20. 20. Magnesium
  21. 21. Intra-arterial therapy
  22. 22. Management of other complications due to vasospasm  Hyponatremia... Cerebral salt wasting  Role of euvolemia  Fludrocortisone  3% saline  Choice of fluid
  23. 23. Fever Independent association with high fever after SAH and poor cognitive outcome
  24. 24. Haemoglobin  Controversial  Lower threshold for transfusion in vasospastic patients
  25. 25. Statins  STASH Trial
  26. 26. Other  Urokinase  Lumbar drainage

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