Posttraumatic Cerebral Vasospasm Research Articles

Characterizing the Use of Intrathecal Nicardipine for Post Traumatic Cerebral Vasospasm (P13-7.005)

<h3>Objective:</h3> Characterizing the use of intrathecal nicardipine for post traumatic cerebral vasospasm and treatment-related complications. <h3>Background:</h3> Post traumatic cerebral vasospasm (PTV) is a significant cause of secondary neurologic injury after traumatic brain injury (TBI) and is associated with worse outcomes. There is limited data to guide treatment of PTV. Intrathecal nicardipine (ITn) was shown to improve outcomes and reduce delayed cerebral ischemia in non-traumatic subarachnoid hemorrhage (SAH) patients, but traumatic mechanisms were not well studied. In this retrospective study, we characterize the use of ITn for PTV at a high-volume trauma center. <h3>Design/Methods:</h3> We reviewed all TBI admissions at a high-volume trauma center over a 10-year period. Patients ≥18 years of age requiring external ventricular drain (EVD) placement were included. We collected data regarding injury severity, length of stay, rationale, and timing for initiation of ITn, dosing, frequency and treatment-related complications. <h3>Results:</h3> Seven patients with severe TBI received ITn for radiographic vasospasm (VSP) on surveillance imaging. The average duration of treatment was 6 days. ITn was stopped given radiographic improvement (4), pre-defined decision for 48 hours of treatment (1), after DSA revealed no VSP (1) or identification of ventriculitis (1). Three patients had delayed cerebral ischemia on imaging; however, these were noted before the initiation of ITn. Two patients developed ventriculitis and one patient had brief, elevated intracranial pressure spikes with ITn. <h3>Conclusions:</h3> ITn is rarely used for PTV in this high-volume center. When ordered, it is done for radiographic VSP with variations in practice patterns for dosing, duration and weaning. Given the possible benefit of ITn in non-traumatic SAH patients and otherwise limited treatment options for PTV, understanding ITn use and outcomes in PTV is warranted. <b>Disclosure:</b> Dr. Sigman has nothing to disclose. Dr. Chester has nothing to disclose. Dr. Sciarretta has nothing to disclose. The institution of Dr. Ratcliff has received research support from Nico Corporation. The institution of Dr. Ratcliff has received research support from Sense . Ofer Sadan has received intellectual property interests from a discovery or technology relating to health care.

Abstract P-520: PHYSIOLOGIC RISK FACTORS ASSOCIATED WITH FUNCTIONAL OUTCOMES IN PEDIATRIC POST-TRAUMATIC CEREBRAL VASOSPASM

Aims & Objectives: This study examined the physiologic risk factors associated with post-traumatic cerebral vasospasm and poor outcome in children with acute traumatic brain injury. Methods Prospective single center study of previously health (N=60) children ages 5 days to 15 years of age admitted to hospital for an acute TBI. Data include physiologic (temperature, blood pressure, intracranial pressure, serum glucose) data, seizure and CV activity and genetic sampling over 8 days of hospitalization. Functional outcomes were measured at discharge and at 4-week follow-up using the Glasgow Outcome Scale-Extended, Pediatrics (GOS-E Peds). Results Our study included 26 females (43%) and 34 males (57%) with a mean age was 5.9 years, of which 43% of participants experienced an occurrence of CV (anterior or posterior). A total of 62 CV events were identified (Table 1) with subarachnoid hemorrhage being the most prevalent lesion. CV occurred within the first 48 hours of hospitalization. CV was associated with the number of seizures (p-value = 0.042) when adjusted for injury severity. In addition, CV in the anterior circulation was associated with occurrences of hypotension (p-value = 0.016) and hypothermia (p-value = 0.028). The presence of a physiologic instability also showed proportionally poorer GOS-E eds outcomes at both measurement time points. Conclusions We identified that physiologic instability was associated with post-traumatic CV and poorer outcomes in our TBI patients. Although more research is needed to better define these relationships, clinically the opportunity to improve outcomes in patients with TBI should include the evaluation for post-traumatic CV and management of physiologic instability.

Abstract 53: Cerebral Hemodynamic Changes in Patients with Wartime Traumatic Brain Unjury

Cerebral vasospasm (VSP) is a frequent complication after aneurysmal and traumatic subarachnoid hemorrhage (SAH) and carries significant morbidity and mortality. Traumatic brain injury (TBI) is associated with the severest casualties from Operation Iraqi Freedom and Operation Enduring Freedom. From Oct. 1, 2008 the US Army Medical Department initiated a transcranial Doppler (TCD) ultrasound service for TBI; included patients were retrospectively evaluated for TCD-determined incidence of posttraumatic cerebral vasospasm and intracranial hypertension after wartime TBI. Patients were identified using a computerized registry and a prospective TCD database maintained in the Sentient NeuroCare Services. TCD recordings of mean cerebral blood flow velocities (CBFV) and Pulsatility Indices of the anterior and posterior circulation vessels were recorded using a 2-MHz transducer (Doppler Box, DWL/Compumedics, USA, Germany/Australia). Comprehensive TCD protocol was applied in all cases: if mean CBFV equaled or exceeded 100 cm/sec., 140 cm.sec and 200 cm/sec the TCD signs of mild vasospasm, moderate vasospasm and severe vasospasm respectively were considered present. 122 patients were investigated with daily TCD studies and comprehensive TCD protocol and published diagnostic criteria for VSP and raised intracranial pressure (ICP) were applied. TCD signs of mild, moderate and severe VSP involving anterior circulation vessels were observed in 71%, 42% and 16% of patients, respectively. TCD signs of mild, moderate and severe VSP involving posterior circulation vessels were observed in 57%, 32% and 14% of patients, respectively. TCD signs of intracranial hypertension were recorded in 43%, eight patients (7%) underwent transluminal angioplasty for post-traumatic symptomatic vasospasm treatment. These findings demonstrate that cerebral arterial VSP and intracranial hypertension are frequent and significant complications of combat TBI, therefore daily TCD monitoring is recommended for their recognition and subsequent management. Acknowledgements. The opinions and views expressed herein belong solely to those of the authors. They are not nor should they be implied as being endorsed by the Uniformed Services University of the Health Sciences, Department of the Army, Department of the Navy, Department of Defense or any other branch of the Federal government of the United States. This paper supported in part, by the US Army Medical Research and Material Command’s Telemedicine and Advanced Technology Research Center (Fort Detrick, MD, USA).

Posttraumatic vasospasm and intracranial hypertension after wartime traumatic brain injury

Summary Traumatic brain injury (TBI) is associated with the severest casualties from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). From October 1, 2008 the US Army Medical Department initiated a transcranial Doppler (TCD) ultrasound service for TBI patients; included patients were retrospectively evaluated for TCD-determined incidence of posttraumatic cerebral vasospasm and intracranial hypertension after wartime TBI. Ninety patients were investigated with daily TCD studies and comprehensive TCD protocol and published diagnostic criteria for vasospasm and raised intracranial pressure (ICP) were applied. TCD signs of mild, moderate and severe vasospasms were observed in 37%, 22% and 12% of patients, respectively. TCD signs of intracranial hypertension were recorded in 62.2%, five patients (4.5%) underwent transluminal angioplasty for post-traumatic clinical vasospasm treatment and 16 (14.4%) had cranioplasty. These findings demonstrate that cerebral arterial spasm and intracranial hypertension are frequent and significant complications of combat TBI, therefore daily TCD monitoring is recommended for their recognition and subsequent management.

Post-Traumatic Cerebral Vasospasm Demonstrated by Magnetic Resonance Angiography and Perfusion-Weighted Imaging: A Case Report

Post-Traumatic Cerebral Vasospasm Demonstrated by Magnetic Resonance Angiography and Perfusion-Weighted Imaging: A Case Report

Risk factors for the development of post-traumatic cerebral vasospasm

BACKGROUND Post-traumatic vasospasm is a well-recognized sequela of head injury. The risk factors associated with post-traumatic vasospasm have not been well defined. We studied 119 consecutive patients with head injury to determine the risk factors for post-traumatic vasospasm. METHODS Twenty-nine (27.1%) patients were excluded from the study because of poor insonation ( n = 12) or a hospital stay of less than 72 hours ( n = 17). Seventy (77.8%) of 90 patients suffered severe head injury. Sixteen (17.8%) patients sustained moderate head injury and four (4.4%) patients sustained mild head injury. All patients were monitored with transcranial Doppler (TCD) ultrasonography daily. RESULTS Post-traumatic vasospasm was detected in 32 (35.6%) of 90 patients. Among these patients, 29 (90.6%) had severe head injury, and three (9.4%) had moderate head injury. None of the patients with mild head injury suffered posttraumatic vasospasm. In most cases, the onset of post-traumatic vasospasm began on the fifth day and lasted 1 to 9 days. In 8 (25%) patients, post-traumatic vasospasm began within the first three days of the head injury. Among 32 patients with post-traumatic vasospasm, 10 (31.2%) patients had mild vasospasm, 20 (65.5%) had moderate vasospasm, and 2 (6.3%) had severe post-traumatic vasospasm. Clinical deterioration was documented in two (2.5%) patients. CONCLUSIONS Development of post-traumatic vasospasm correlated only with severe subarachnoid hemorrhage on initial computed tomographic scan. There was an increased incidence of post-traumatic vasospasm in patients with epidural hematomas, subdural hematomas, and intracerebral hemorrhages. The Glasgow Coma Scale (GCS) score on admission was inversely related to the development of post-traumatic vasospasm. In most cases, the period of vasospasm was short and clinical deterioration was rare. Probably, two varieties of post-traumatic vasospasm exist, one that lasts a shorter time and does not correlate with the presence of SAH, and a second that correlates with the presence of SAH, lasts longer, and resembles aneurysmal vasospasm.

Posttraumatic cerebral vasospasm: clinical and morphological presentations.

Head injury is one of the leading causes of morbidity and mortality in the young population. Many factors complicate head injury and worsen an outcome. One of these factors is posttraumatic cerebral vasospasm. We studied 75 patients admitted to the University of Mississippi Medical Center with head injury. Their ages ranged from 14 to 67 years (mean 30 years, SD 11.63). Eighty percent of the patients were men, and 20% were women. Of these patients, 53 (70.6%) suffered severe blunt trauma, and 4 patients suffered gunshot wounds to the head. Four patients had mild head injury, and 14 had moderate head injury. Posttraumatic vasospasm was detected in 24 (32%) patients. Among these patients, 19 (79.2%) had severe closed head injury, 3 patients had moderate head injury, and 2 suffered gunshot wounds. The severity of the patient's respective condition was correlated with the development of posttraumatic cerebral vasospasm: 50% of the patients with Glasgow Coma Scale (GCS) 3-4 developed PTV, and only 30% with GCS 9-11, and none of the patients with GCS > 12 developed PTV. Overall, posttraumatic vasospasm started earlier and had a shorter course than did aneurysmal vasospasm. Morphologically, posttraumatic vasospasm resembled the features of aneurysmal vasospasm. We found increased corrugation of the internal elastic lamina and increased amounts of connective tissue in the subendothelial layer. These findings show that posttraumatic vasospasm, although clinically more mild, demonstrates the same morphological changes as aneurysmal vasospasm.

The importance of traumatic subarachnoid haemorrhage

Post-traumatic cerebral vasospasm is being increasingly recognised as a possibly significant complication after head injury. To assess the relationship between post-traumatic subarachnoid haemorrhage (tSAH) and post-traumatic vasospasm, 63 patients with severe head injury (GCS 3–8) were studied. Forty-seven patients had cerebral contusion on the initial CT scan. In 25 of these (Group I) there were only contusions, while 22 (Group II) also had tSAH. All patients had daily measurements of blood flow velocity in the basal cerebral arteries using transcranial Doppler ultrasound (TCD). The incidence of vasospasm detected by TCD was significantly higher in Group II. Furthermore there were significantly fewer good outcomes (GOS 1 and 2) in this group. These results suggest that the presence of subarachnoid blood in patients with severe head injury is associated with a risk of vasospasm, and with poorer outcome.