Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage

1. Cerebral Vasospasm Following Aneurysmal
Subarachnoid Hemorrhage
Ade Wijaya, MD – February 2019

2. Outline:
o Anatomy
o Vasospasm
o Delayed Cerebral Ischaemia
o Risk Factors
o Pathophysiology
o Diagnosis
o Treatment
o Summary

3. Anatomy

4. Vasospasm
o Narrowing of cerebral arteries
o Start: 3-5 days – Peak: 5-14 days – Resolve: 2-4 weeks
o If severe or prolonged, ischemia and infarction may follow
Weir B, Grace M, Hansen J, Rothberg C. Time course of vasospasm in man. JNeurosurg. 1978;48:173–8.
Diringer MN, Bleck TP, Claude Hemphill J, 3rd, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the neurocritical care society’s multidisciplinary consensus
conference. Neurocrit Care. 2011;15:211–40. This document contains the most recent recommendations for the care of aSAH patients from the Neurocritical Care Society.
Vergouwen MDI, Vermeulen M, van Gijn J, Rinkel GJE, Wijdicks EF, Muizelaar JP, et al. Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies proposal of a
multidisciplinary research group. Stroke. 2010;41:2391–5. The auhors describe a definition of delayed ischemic deficit to aid with classification in future studies.
Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KTS. Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm. Br J Anaesth. 2012;109:315–29.

5. Delayed Cerebral Ischemia
o Presence of focal neurological deficit or a decrease in the Glasgow Coma Scale
of at least two points
o Last longer than one hour
o Absent immediately after aneurysm occlusion
o No other causes
o Occurs in approximately 30 % of aneurysmal subarachnoid hemorrhage 3–14
days after rupture
Vergouwen MDI, Vermeulen M, van Gijn J, Rinkel GJE, Wijdicks EF, Muizelaar JP, et al. Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies proposal of a
multidisciplinary research group. Stroke. 2010;41:2391–5. The auhors describe a definition of delayed ischemic deficit to aid with classification in future studies.
Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KTS. Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm. Br J Anaesth. 2012;109:315–29.

6. Risk Factors
o Severe SAH evident in CT Scan
o Cigarette smoking
o Hypertension,
o Left ventricular hypertrophy on electrocardiogram
Inagawa T. Risk factors for cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a review of the literature. World neurosurgery. 2016 Jan 1;85:56-76.

7. Pathophysiology
o Inflammatory cells within the intima of the blood vessels causing endothelial
dysfunction and necrosis
o Microglial activation
o Oxidative stress and cortical spreading depression
o Microthrombosis
Durrant JC, Hinson HE. Rescue therapy for refractory vasospasm after subarachnoid hemorrhage. Current neurology and neuroscience reports. 2015 Feb 1;15(2):521.

8. Diagnosis
o Clinical examination
o Transcranial Doppler
o Cerebral digital subtraction angiography (gold standard)
o Computer tomography perfusion
o Xenon-enhanced computed tomography,
o Diffusion-weighted magnetic resonance imaging
o Single-photon emission computed tomography
Mills JN, Mehta V, Russin J, Amar AP, Rajamohan A, Mack WJ. Advanced imaging modalities in the detection of cerebral vasospasm. Neurol Res Int. 2013;2013:415960
Claassen J, Hirsch LJ, Kreiter KT, Du EY, Sander Connolly E, Emerson RG, et al. Quantitative continuous EEG for detecting delayed cerebral ischemia in patients with poor-grade subarachnoid hemorrhage. Clin Neurophysiol. 2004;115:2699–710.
Vespa PM, Nuwer MR, Juhasz C, Alexander M, Nenov V, Martin N, et al. Early detection of vasospasm after acute subarachnoid hemorrhage using continuous EEG ICU monitoring. Electroencephalogr Clin Neurophysiol. 1997;103:607–15.

9. Treatment
Durrant JC, Hinson HE. Rescue therapy for refractory vasospasm after subarachnoid hemorrhage. Current neurology and neuroscience reports. 2015 Feb 1;15(2):521.

10. Summary
o Vasospasm is the most serious complication of aneurysmal SAH
o The main risk factor: severity of SAH on CT scan
o Diagnosis: DSA as gold standard
o Treatment: HHH, intraluminal angioplasty, CCB