Medical Management of Cerebral Vasospasm

1
Medical Management of Cerebral Vasospasm
S.A.H.

• Mark Angle, M.D.
• MNH / I-2001

2
Cerebral Vasospasm
S.A.H.

• A Syndrome of Delayed Regional Hypoperfusion Post
  Sub-Arachnoid Hemorrhage

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Delayed Ischemic Neurological Deficits ? Onset
4 - 14 days post - SAH ? Focal or global ?
Differential diagnosis 1. Hydrocephalus 2.
Re-hemorrhage 3. Hyponatremia 4. Concurrent
illness 5. Seizure(s) 6. Vasospasm
S.A.H.
4
Pathophysiologyof Vasospasm
S.A.H.
Clot-Derived Oxyhemoglobin

• Local InflammatoryArteritis

• Local / Distal
• Vasoconstricition

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VasomotorDysregulation
S.A.H.

• Early Enhanced Calcium Entry into
• Smooth Muscle
• Late Activation of PKC

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S.A.H.

• Vasospasm
• Modulators
• NO ? cGMP
• Endothelin ? PKC
• Eicosonoids ? cAMP, IP 3

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Cortical Necrosis
S.A.H.

• Critical Hypoperfusion
• Paradoxical Micro vascular Constriction after
  Cortical
• Activation

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Predictors of Vasospasm
S.A.H.

• Thickness of Clot (Fischer)
• Hydrocephalus
• Prior Smoking History
• Prior Hypertension
• (Early Surgical Intervention)
• Intra-Operative Hypotension

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Treatment of Vasospasm
S.A.H.

• Prophylaxis
• Risk Management
• Baro-Therapy
• Vaso-Therapy

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Diagnosis of Vasospasm
S.A.H.

• Symptoms (Delayed Neurological Deficits)
• Angiography DS vs CTA
• TCD
• Perfusion Xe CT, CT perfusion
• Tissue Monitoring
• Spectroscopy
• Microdialysis

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Vasospasm A Systemic Illness?
S.A.H.

• Systemic Inflammatory Response (leukocytosis,
  tachycardia, tachypnea, fever)
• Natriuresis
• Fever

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Vasospasm Prophylaxis
S.A.H.

• Cisternal Drainage
• Immunotherapy
• (steroids)
• Experimental Pharmacotherapy

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Vasospasm Risk Management
S.A.H.

• Nimodipine
• Triple H

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Triple - H
S.A.H.

• Hemodilution
• ? hct 30 - 32
• Hypervolemia
• ? CVP 10 - 12
• Hypertension
• ? ? MAP 20 - 40

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Symptomatic Vasospasm
S.A.H.

• Results of Best Practice
• CVA at 24 hrs. - 40 - 50
• Poor Outcome - 40 - 50

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Milrinone Actions
S.A.H.

• PDE III Inhibitor
• ? ? cAMP
• ? ? cGMP
• Immuno Modulator
• ? ? TNF, IL-6
• ? ? Platelet Adhesion
• ? ? wbc chemopexis
• Cardiac Inotrope

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Vasospasm Treatment Protocol
S.A.H.

• Optimal Medical Management
• Euvolemia
• Normo - Natremia
• Milrinone Trial
• Salvage Hypertension
• Angioplasty